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Truth in DAIR: Duration of therapy and the use of quinolone/rifampin-based regimens after debridement and implant retention for periprosthetic Joint Infections

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Authors/contributors
Abstract
Background The optimal duration of antibiotic therapy after debridement and implant retention (DAIR) for periprosthetic joint infections (PJIs) is debated. Furthermore, the best antibiotic regimens for staphylococcal PJI are also unclear. In this study, we evaluated the impact of antibiotic therapy duration on the risk of failure. We assessed the utility of rifampin-based regimens for staphylococcal PJI managed with DAIR. Methods We performed a retrospective cohort study of patients 18 years and older diagnosed with hip and knee PJI who underwent DAIR between January 1, 2008 and 31 December 31, 2018 at Mayo Clinic, USA. The outcome was failure of DAIR. For statistical analysis, joint-stratified Cox regression models adjusted for age, sinus tract, symptom duration, and primary/revision arthroplasty were performed. Results We examined 247 cases of PJI with a median follow-up of 4.4 years (interquartile range [IQR], 2.3–7) after DAIR. The estimated 5-year cumulative incidence of failure was 28.1% (n = 65). There was no association between the duration of intravenous (IV) antibiotics (median 42 days; IQR, 38–42) and treatment failure (P = .119). A shorter duration of subsequent oral antibiotic therapy was associated with a higher risk of failure (P = .005; eg, 90-day vs 1-year duration; hazard ratio [HR], 3.50; 95% confidence interval [CI], 1.48–8.25). For staphylococcal knee PJI, both the use and longer duration of a rifampin-based regimen were associated with a lower risk of failure (both P = .025). There was no significant association between fluoroquinolone (FQ) use and failure (HR, 0.62; 95% CI, .31–1.24; P = .172). Conclusions The duration of initial IV antibiotic therapy did not correlate with treatment failure in this cohort of patients. Rifampin use is recommended for staphylococcal knee PJI. There was no apparent benefit of FQ use in staphylococcal PJI.
Publication
Open Forum Infectious Diseases
Date
2022-09-02
DOI
10.1093/ofid/ofac363
URL
https://academic.oup.com/ofid/article/doi/10.1093/ofid/ofac363/6649571
Link
Notes

Key Question: What is the optimal duration of intravenous and oral antibiotic therapy for prosthetic joint infections treated with debridement, antibiotics, and implant retention (DAIR)? What antibiotic regimens are best for staphylococcal infections treated with DAIR?

Findings:

  • Duration of IV antibiotics (median 42 days) was not associated with risk of DAIR failure.
  • Shorter duration of oral antibiotics was associated with higher failure risk, but no differences seen with longer durations beyond 1 year.
  • For staphylococcal infections, rifampin-based regimens reduced failure risk compared to non-rifampin regimens. Longer duration of rifampin therapy was associated with lower failure risk, especially for knee infections.
  • No significant difference in failure rates between fluoroquinolone-based and non-fluoroquinolone oral regimens.

Clinical Implications:

  • Duration of IV antibiotics beyond 4-6 weeks may not be necessary for DAIR treatment.
  • Oral antibiotics should be continued for at least 1 year after DAIR.
  • Rifampin-based regimens are recommended for staphylococcal prosthetic joint infections, with longer durations (>3 months) providing additional benefit.

Strengths:

  • Relatively large sample size
  • Adjusted analysis accounted for confounders
  • Long median follow-up time

Limitations:

  • Retrospective design
  • Potential confounding by indication for choice of antibiotics
  • Heterogeneous antibiotic regimens used
  • Adherence to oral antibiotics not ensured

Level of Evidence: Moderate

Rationale: This was a retrospective cohort study which provides moderate level evidence. The analysis adjusted for relevant confounders. However, the non-randomized design and potential residual confounding limit the strength of evidence.

Citation
1.
Tai DBG, Berbari EF, Suh GA, Lahr BD, Abdel MP, Tande AJ. Truth in DAIR: Duration of therapy and the use of quinolone/rifampin-based regimens after debridement and implant retention for periprosthetic Joint Infections. Open Forum Infectious Diseases. 2022;9(9):ofac363.
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