Antibiotic treatment can be safely stopped in asymptomatic patients with prosthetic joint infections despite persistent elevated C-reactive protein values

Treatment of Prosthetic Joint Infection with Debridement, Antibiotics and Irrigation with Implant Retention - a Narrative Review

Prosthetic joint infection usually requires combined medical and surgical therapy. While revision surgery is widely considered to be the gold standard surgical procedure, debridement, antibiotics and irrigation with implant retention is a very appealing alternative. There is however great controversy regarding its real worth with success rates ranging from 0% to over 90%. A number of different patient and host related variables as well as specific aspects of surgical and medical management have been described as relevant for the final outcome. Along this paper, the authors will provide the readers with a critical narrative review of the currently available literature while trying to provide concise and practical treatment recommendations regarding adequate patient selection criteria, proper surgical technique and optimal antibiotic therapy.

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

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.

[Duration of antibiotic therapy in bone infection and biological or radiological data]

Modalities of bone infection therapeutic follow-up are controversial, notably for biological and radiological parameters. We have proposed six weeks of antibiotic therapy for all patients presenting with bone infection, since July 2005. Therefore, biological and radiological exams performed during the treatment were not taken into account when determining the duration of antibiotherapy. This protocol allows determining the usefulness of these biological and radiological parameters.

METHODS

All patients presenting with bone infection, from July 2005 to July 2008, were included. Inflammatory biological parameters such as C-reactive protein (CRP) and sedimentation rate were analyzed, and values were considered as normal when less than 10 mg/L and less than 15 mm respectively. All available CT- and MR imaging were analyzed by the same referent radiologist.

RESULTS

Eighty-seven patients presenting with bone infection received antibiotic therapy for a mean [SD] 42 ± 0.3 days. Cure was reported in 82 patients (94%) with a mean follow-up after antibiotic therapy of 36 ± 9 months, five patients relapsed. CRP was available in 66 cases by the end of antibiotic therapy, it was normal in 40/64 of patients with favorable outcome (62%) and in one case of unfavorable outcome. The sedimentation rate was available in 22 cases, and normal in seven cases of favorable outcome (32%). By the end of antibiotic therapy, CT-scan showed active bone infection for 15/23 of patients with favorable outcome (65%), while MR imaging suggested the same diagnosis in 8/14 cases (57%).

CONCLUSION

Biological parameters and radiological findings are inadequate to determine the duration of antibiotic therapy in bone infection.