Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement

Abstract

Experience with debridement and prosthesis retention in early prosthetic joint infections (PJI) due to Staphylococcus aureus is scarce. The present study aimed to evaluate the outcome and predictors of failure. Patients prospectively registered with an early PJI due to S. aureus and 2 years of follow-up were reviewed. Demographics, co-morbidity, type of implant, clinical manifestations, surgical treatment, antimicrobial therapy and outcome were recorded. Remission was defined when the patient had no symptoms of infection, the prosthesis was retained and C-reactive protein (CRP) was ≤ 1 mg/dL. Univariate and multivariate analysis were performed. Fifty-three patients with a mean ± SD age of 70 ± 10.8 years were reviewed. Thirty-five infections were on knee prosthesis and 18 were on hip prosthesis. The mean ± SD duration of intravenous and oral antibiotics was 10.6 ± 6.7 and 88 ± 45.9 days, respectively. After 2 years of follow-up, 40 (75.5%) patients were in remission. Variables independently associated with failure were the need for a second debridement (OR 20.4, 95% CI 2.3-166.6, p 0.006) and a CRP > 22 mg/dL (OR 9.8, 95% CI 1.5-62.5, p 0.01). The onset of the infection within the 25 days after joint arthroplasty was at the limit of significance (OR 8.3, 95% CI 0.8-85.6, p 0.07). Debridement followed by a short period of antibiotics is a reasonable treatment option in early PJI due to S. aureus. Predictors of failure were the need for a second debridement to control the infection a CRP > 22 mg/dL and the infection onset within the first 25 days after joint arthroplasty.

Prosthetic Joint Infection

“…However, the number of patients with MRSA PJI remaining at risk after treatment was very small, so it is difficult to know whether the rate of failure after treatment of these individuals would not also be significant. Other studies using combination therapy with rifampin and fluoroquinolone for S. aureus PJI have reported short-term treatment success rates ranging from 62 to 75% (355,369), compared to a rate of 36% in an older study without rifampin (127). The short-term treatment success rate may be up to 80% when rifampin combination therapy is used in properly selected patients (125).…”

“…The longer duration of oral combination therapy is predicated on the often larger amount of soft tissue infection in knee arthroplasty infections. Some clinicians use a fluoroquinolone combined with rifampin even during the initial phase of therapy (63,355,369), a practice supported by both IDSA and International Consensus Meeting documents (60,251). This has not been directly compared to the use of an initial period of intravenous antimicrobials.…”

Linezolid plus Rifampin as a Salvage Therapy in Prosthetic Joint Infections Treated without Removing the Implant

“…In the last 15 years, the combination of rifampin with other antibiotics (e.g., fluoroquinolones) has demonstrated a 70 to 90% success rate (1,3,11,21). Failure has been associated with at least one of the following: (i) the type of isolated microorganism (16), mainly methicillin-resistant staphylococci and enterococci, (ii) the need for more than 1 debridement to control the infection, (iii) a high C-reactive protein concentration at the moment of diagnosis (21), and (iv) the antibiotic or combination of antibiotics administered (5). The management of patients who fail while they are on treatment has not yet been well-defined.…”

Can periprosthetic hip joint infections be successfully managed by debridement and prosthesis retention?

“…However, the purpose of the present study was to evaluate only studies reporting on hip joint infections. Several well-designed studies with a higher level of evidence report about DAIR including both THA and total knee arthroplasty (TKA) cases, whereas a differentiation of the results between both primary surgeries is not possible [15][16][17][18][19][20][21][22][23][24][25][26][27][28] . Similar to that, other studies present data only about small case series [29][30][31] .…”

“…Some authors recommend a duration of antibiotic treatment for 6 mo for TKA-PJIs and 3 mo for THA-PJIs when treated with DAIR [4] . In some recent studies, it has been reported that a shorter course of antibiotics might be also an alternative in DAIR treatment [21,23,28,37] . This confusion regarding the optimal duration of antibiotic therapy is also evident in the present literature review.…”