Adjunctive Rifampin Following Debridement and Implant Retention for Staphylococcal Prosthetic Joint Infection: Is it Effective if not Combined With a Fluoroquinolone?

Key Question: Does adjunctive rifampin improve cure rates when combined with non-fluoroquinolone antibiotics for the treatment of staphylococcal prosthetic joint infections (PJIs) managed with debridement and implant retention (DAIR)?

Key Findings:

• Fluoroquinolone-rifampin combination therapy was associated with higher cure rates compared to other regimens (OR 2.68, 95% CI 1.43-5.02).
• Non-fluoroquinolone rifampin combinations were not associated with improved cure rates compared to regimens without rifampin (OR 1.22, 95% CI 0.79-1.88).

Clinical Implications:

• Adding rifampin to non-fluoroquinolone antibiotics may not improve cure rates for staphylococcal PJIs treated with DAIR.
• Fluoroquinolone-rifampin combination therapy may lead to better outcomes compared to other regimens.

Strengths:

• Systematic review and meta-analysis of 8 studies
• Findings consistent with results of 2 RCTs
• No evidence of publication bias for key comparison of fluoroquinolone-rifampin vs. regimens without rifampin

Limitations:

• Most studies were retrospective and subject to confounding
• Heterogeneity between studies in rifampin dosing
• Possibility of publication bias exaggerating benefit of fluoroquinolone-rifampin combinations
• Fluoroquinolone-rifampin may have been used in healthier patients predisposed to better outcomes (confounding by indication)