Prosthetic joint-associated infections treated with DAIR (debridement, antibiotics, irrigation, and retention)

Abstract

Background and purpose For prosthetic joint-associated infection (PJI), a regimen of debridement, antibiotics, irrigation, and retention of the prosthesis (DAIR) is generally accepted for acute infections. Various risk factors associated with treatment success have been described. The use of local antibiotic carriers (beads and sponges) is relatively unknown. We retrospectively analyzed risk factors in a cohort of patients from 3 hospitals, treated with DAIR for PJI.Patients and methods 91 patients treated with DAIR for hip or knee PJI in 3 Dutch centers between 2004 and 2009 were retrospectively evaluated. The mean follow-up was 3 years. Treatment success was defined as absence of infection after 2 years, with retention of the prosthesis and without the use of suppressive antibiotics.Results 60 patients (66%) were free of infection at follow-up. Factors associated with treatment failure were: a history of rheumatoid arthritis, late infection (> 2 years after arthroplasty), ESR at presentation above 60 mm/h, and infection caused by coagulase-negative Staphylococcus. Symptom duration of less than 1 week was associated with treatment success. The use of gentamicin sponges was statistically significantly higher in the success group, and the use of beads was higher in the failure group in the univariate analysis, but these differences did not reach significance in the logistic regression analysis. Less surgical procedures were performed in the group treated with sponges than in the group treated with beads.Interpretation In the presence of rheumatoid arthritis, duration of symptoms of more than 1 week, ESR above 60 mm/h, late infection (> 2 years after arthroplasty), and coagulase-negative Staphylococcus PJI, the chances of successful DAIR treatment decrease, and other treatment methods should be considered.

Treatment of acute periprosthetic infections with prosthesis retention: Review of current concepts

“…Unfortunately, to date, no comparative studies between different strategies are available and therefore no hard recommendations regarding which one to use can be made. For every strategy different studies are published with results ranging from poor to excellent (21% to 90% success rate) [49,[52][53][54] . All of them are retrospective case-series, which are often quite heterogeneous regarding inclusion, exact treatment and outcomes.…”

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] .…”

“…Various risk factors have been described that are associated with occurrence of PJI, such as rheumatoid arthritis, diabetes mellitus, malignancy, obesity, and use of immunosuppressive drugs [15,20,[32][33][34] . Revision surgery also increases the conclusions.…”

“…Periprosthetic joint infections (PJI) still remain a hazardous complication after primary and revision THA. A regimen of debridement, irrigation, prosthesis retention, and antibiotic therapy is generally accepted for acute infections without complicating factors such as significant comorbidity, not intact soft tissues surrounding the prosthesis or loosening of the prosthesis [15] . The aim of the present review was to investigate whether it is possible to treat these infections by prosthesis retention.…”

“…67.50% Westberg et al [14] Debridement, pulsatile lavage, risk of PJI [17,33,34] . Factors that have been associated with a worse outcome of PJI treatment including both THA and TKA involve infections caused by Staphylococcus species [15] , and more specifically by Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA) [17,[35][36][37] , polymicrobial PJI [20] , intra-articular purulence [15] , retention of exchangeable components [20] , and longer time between initial arthroplasty and PJI diagnosis [16,20,36,38] . Despite the aforementioned known risk factors the ideal treatment procedure is difficult to choose due to the definition of the infection itself.…”