An update on surgical and antimicrobial therapy for acute periprosthetic joint infection: new challenges for the present and the future

Abstract

Periprosthetic joint infection (PJI) is a devastating complication that can occur following any arthroplasty procedure. Approximately half of these infections develop within the first year after arthroplasty, mainly in the first 1 to 3 months. These infections are known as early PJI. It is widely accepted that many early PJIs can be successfully managed by debridement, irrigation, and prosthetic retention, followed by a course of biofilm-effective antibiotics (debridement, antibiotics, implant retention procedure), but candidate patients should meet the requirements set down in Zimmerli’s algorithm. The best antibiotic regimen for acute PJI treated without implant removal remains uncertain. Rifampin-containing regimens, when feasible, are recommended in gram-positive infections, and fluoroquinolones in gram-negative cases. The duration, dosage, and administration route of antibiotics and the use of combined therapy are matters that requires further clarification, as the current level of evidence is low and most recommendations are based on experimental data, studies in small series, and expert experience.

Keywords:

• acute periprosthetic joint infection
• antibiotic treatment
• debridement
• fluoroquinolones
• rifampin

Acknowledgements

This review was translated from Spanish to English by C Cavallo.

Financial & competing interests disclosure

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

No writing assistance was utilized in the production of this manuscript.

Key issues

• The goal of treatment of a periprosthetic joint infection (PJI) is to cure the infection, to prevent recurrence and achieve a pain-free and functional joint; however, the three objectives cannot always be achieved and PJI management must be individualized.

• Most acute PJIs can be managed successfully without removal of the implant, provided that an aggressive and prompt debridement, antibiotics, implant retention (DAIR) procedure has been performed. DAIR approach should only be considered in acute infections under conditions summarized by Zimmerli’s algorithm.

• DAIR procedure should be done as soon as possible if the basal status of the patient allows the intervention.

• Empirical antimicrobial therapy should be started once tissue specimens have been collected. β-Lactams and glycopeptides are the most common empirical antibiotics used despite their poor activity against bacterial biofilms.

• Directed antimicrobial therapy should be individualized for each patient. Regimens containing rifampin, when feasible, should be used in gram-positive PJIs and fluoroquinolones in gram-negative PJI.

• The global length of antimicrobial therapy is controversial, although available data suggest that prolonging antibiotic treatment for more than 3 months does not improve the outcome of acute PJIs treated with DAIR.

• Antimicrobial treatment of PJIs is becoming more challenging because of the increasing prevalence of antimicrobial resistance among gram-positive and gram-negative microorganisms.

• After the failure of a well-performed DAIR procedure, it is unlikely that repeated incision and debridement would be able to control the infection; therefore, implant removal should be considered.

Notes

^†Patients are graded corresponding to a number of factors, including the presence of neutropenia, low CD4 T-cell count or age >80 years.

^‡The local extremity is graded corresponding to the presence of local chronic active infection, soft-tissue loss or the presence of a fistula or subcutaneous abscess, among other factors.

PJI: Periprosthetic Joint Infection.