HTML Fulltext


Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD


Title:
Antibiotic Treatment and Timing

Liaisons:
Camilo Restrepo MD

Leaders:
Steven Schmitt MD (US), David Backstein MD (International)

Delegates:
Bryan T Alexander PharmD, Maja Babic MD, Barry D. Brause MD, John L Esterhai MD, Robert P. Good MD, Peter H Jørgensen MD, Paul Lee MB, BCh, FRCS, Camelia Marculescu MD, Claudio Mella MD, Carsten Perka MD, Aidin Eslam Pour MD, Harry E Rubash MD, Tomoyuki Saito MD, Rolando Suarez MD, Robert Townsend MD, I Remzi Tözün MD, Michel PJ Van den Bekerom MD

Vol 1, Num S1, September 2014

 

   

Question 1: Can oral antibiotic therapy be used instead of intravenous for the initial treatment of periprosthetic joint infection (PJI) following resection?

Consensus: There is evidence to support pathogen-specific, highly bioavailable oral antibiotic therapy as a choice for the treatment of PJI.

Delegate Vote: Agree: 79%, Disagree: 11%, Abstain: 1% (Strong Consensus)


Question 2: Is oral antibiotic therapy appropriate after an initial IV antibiotic course?

Consensus: There is evidence that pathogen-specific, highly bioavailable oral antibiotic therapy is an appropriate choice for the treatment of PJI after an initial IV antibiotic regimen.

Delegate Vote: Agree: 98%, Disagree: 1%, Abstain: 1% (Strong Consensus)


Question 3: What is the ideal length of antibiotic treatment following removal of the infected implant?

Consensus: There is no conclusive evidence regarding the ideal duration of antibiotic therapy. However, we recommend a period of antibiotic therapy between 2 to 6 weeks.

Delegate Vote: Agree: 93%, Disagree: 5%, Abstain: 2% (Strong Consensus)


Question 4: How should the length of antibiotic treatment be determined? (Inflammatory markers, clinical signs, etc).

Consensus: There is no conclusive evidence on how to determine the length of antibiotic therapy. A combination of clinical signs and symptoms and biochemical markers may be employed. There is the need for a marker that can determine the optimal timing for reimplantation.

Delegate Vote: Agree: 96%, Disagree: 3%, Abstain: 1% (Strong Consensus)


Question 5: Should there be an antibiotic holiday period prior to reimplantation?

Consensus: There is no conclusive evidence supporting a holiday period following discontinuation of antibiotic treatment and prior to reimplantation surgery as a means of ensuring eradication of infection.

Delegate Vote: Agree: 74%, Disagree: 22%, Abstain: 4% (Strong Consensus)


Question 6: Does the use of rifampin in conjunction with IV antibiotic therapy following removal of the infected implant lead to a more rapid and definitive eradication of staphylococcal infection (particularly methicillin-resistant Staphylococcus aureus [MRSA])?

Consensus: There is no evidence to support the use of rifampin in conjunction with IV antibiotic therapy as a more adequate treatment option than either agent used alone following implant removal.

Delegate Vote: Agree: 77%, Disagree: 18%, Abstain: 5% (Strong Consensus)


Question 7: What is the optimal time to start rifampin treatment?

Consensus: There is no conclusive evidence regarding the best time to start rifampin treatment. Good oral intake and adequate administration of a primary antimicrobial agent should be well-established before starting rifampin. Potential side effects and drug interactions should be addressed prior to the start and at the conclusion of therapy.

Delegate Vote: Agree: 83%, Disagree: 11%, Abstain: 6% (Strong Consensus)


Question 8: How long should antibiotic treatment be given following a single-stage exchange arthroplasty performed for PJI?

Consensus: There is no conclusive evidence regarding the ideal duration of antibiotic therapy for a single-stage exchange arthroplasty. We recommend that parenteral antibiotic be given for 2 to 6 weeks following single-stage exchange arthroplasty, with consideration for longer-term oral antibiotic therapy.

Delegate Vote: Agree: 87%, Disagree: 10%, Abstain: 3% (Strong Consensus)


Question 9: Is there a role for intra-articular local antibiotic treatment after reimplantation? If so, what are the indications?

Consensus: There is no conclusive evidence to support the use of intra-articular local antibiotic therapy. Further evidence is needed to support the use of intra-articular local antibiotic therapy.

Delegate Vote: Agree: 95%, Disagree: 4%, Abstain: 1% (Strong Consensus)


Question 10: What is the optimal antibiotic treatment for culture-negative PJI?

Consensus: There is no conclusive evidence on the optimal antibiotic treatment for patients with culture-negative PJI. We recommend a broad spectrum antibiotic regimen covering gram-negative and gram-positive organisms (including MRSA) as well as anaerobic organisms. In patients with suspected fungal infection, coverage against common fungi should be considered.

Delegate Vote: Agree: 91%, Disagree: 8%, Abstain: 1% (Strong Consensus)


Question 11: Is joint aspiration necessary prior to reimplantation?

Consensus: There is no conclusive evidence to support mandatory joint aspiration prior to reimplantation. It may be useful in selected cases. We recommend against infiltration of any liquids into the affected joint and reaspiration in patients with an initial dry aspirate.

Delegate Vote: Agree: 89%, Disagree: 8%, Abstain: 3% (Strong Consensus)