November 23, 2022
Can We Stop Antibiotics Early for Retained Implant Prosthetic Joint Infections?By Aldon Li, MD, FIDSA
IDSA guidelines on the management of prosthetic joint infections (PJI) suggest prescribing a prolonged duration of intravenous (IV) antibiotic therapy of 2-6 weeks in patients with PJI after debridement of the infected area with implant retention, followed by an extended oral antibiotic regimen for 3 months in hip infections or for 6 months in knee infections, then followed by an optional indefinite, lifelong oral suppressive antibiotic.
This treatment strategy of debridement, antibiotics, and implant retention (DAIR) was examined further in a recent study in Open Forum Infectious Diseases. The authors conducted a retrospective review of adults with hip or knee PJI who received DAIR with an antibiotic strategy aligning with IDSA guidance to identify risk of treatment failure in relation to antibiotic duration and antibiotic choice.
During the study period of 10 years, treatment failure occurred in 65 of the 247 total cases (hip infections, 39%; knee infections, 61%) with 55% of failures occurring in the first year after surgery. Gram-positive organisms (Staphylococcus and Streptococcus species) were the causative pathogen in 195 (78%) cases, and 57 (23%) cases experienced a concurrent bacteremia. More than 91% of total cases involved the use of IV antibiotics followed by oral antibiotics, and < 1% of total cases involved the use of oral antibiotics only.
The authors found no significant association in treatment failure between a 4-week versus 6-week course of IV antibiotic therapy.
Although an increased risk of failure occurred in cases treated with 90 days of oral antibiotics versus a 1-year duration, no differences in treatment failure were found in cases treated with 1 year of oral antibiotics versus a 5-year duration.
In cases with Staphylococcus species isolated as the causative pathogen, no association in treatment failure occurred in cases treated with or without a fluroquinolone, but rifampin use decreased the risk of treatment failure in patients with knee infections only.
This study adds to a growing body of literature finding an early switch from IV to oral antibiotics is noninferior to the standard longer IV antibiotic duration in deep-seated infections. Also, given the 2012 IDSA guidelines revealed that the recommendation regarding the use of indefinite suppressive antibiotic therapy was not unanimous among the panel members, this study provides data suggesting suppressive antibiotics longer than one year may be unnecessary.
