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Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection

Javad Parvizi MD, FRCS
Thorsten Gehrke MD

Oral Antibiotic Therapy

Patrick O'Toole MD

Douglas Osmon MD (US), Alex Soriano DO (International)

Jan-Erik Berdal MD, Mathias Bostrum, Rafael Franco-Cendejas MD, DeYoung Huang PhD, Charles Nelson, F Nishisaka, Brian Roslund, Cassandra D Salgado, Robert Sawyer MD, John Segreti MD, Eric Senneville PhD, Xian Long Zhang

Vol 1, Num S1, September 2014



This panel has reviewed the indication and duration of oral antibiotics for periprosthetic joint infection (PJI) in the following situations:
1) Acute (early or late) PJI treated with debridement without implant removal and exchange of the modular components, whenever modular components can be safely removed. In general, these infections do not require suppressive antibiotic therapy (SAT).
2) Indications for the use of SAT include:
a) Patients who refuse surgical treatment.
b) Patients who cannot be surgically treated because of a high surgical risk due to comorbidities.
c) Patients treated with inadequate surgery such as: 1) debridement without implant removal in late chronic PJI or 2) debridement without implant removal in acute (early or late) PJI but without exchanging the modular components.
d) Patients who undergo optimal surgical treatment in acute PJI but receive suboptimal antibiotic treatment in the following situations: 1) not receiving rifampin in PJI due to Staphylococcus spp, 2) PJI due to methicillin-resistant S. aureus (MRSA), 3) not receiving a fluoroquinolone in gram-negative infections, and 4) fungal infections.
e) Patients in whom it is suspected that the infection is not eradicated according to clinical, laboratory, or imaging data.

Question 1: What are the appropriate oral antibiotic or antibiotic combinations following adequate surgical treatment for acute (early or late) PJI in which the implant has been retained?

Consensus: Regimens containing rifampicin, when feasible, should be used in gram-positive PJI and fluoroquinolones in gram-negative PJI. There is no consensus as to when rifampicin should be started.

Delegate Vote: Agree: 87%, Disagree: 7%, Abstain: 6% (Strong Consensus)

Question 2: How long should antibiotic treatment in acute PJI treated with debridement and retention of the implant be?

Consensus: The duration of intravenous and oral treatment is a question that remains unsolved and there is no clinical trial comparing different durations of antibiotic treatment.

Delegate Vote: Agree: 85%, Disagree: 11%, Abstain: 4% (Strong Consensus)

Question 3: What is the role of antibiotic combinations for treatment of PJI managed without adequate surgical intervention?

Consensus: We do not recommend administration of antibiotics and open debridement alone without removing the implant in chronic PJI.

Delegate Vote: Agree: 84%, Disagree: 14%, Abstain: 2% (Strong Consensus)

Question 4: How long should suppressive therapy be administered?

Consensus: There is no consensus about the length of time that patients should receive suppressive antibiotic therapy; however, there is consensus that treatment should be individualized.

Delegate Vote: Agree: 94%, Disagree: 4%, Abstain: 2% (Strong Consensus)

Question 5: What antibiotics could be useful for suppressive treatment based on type of organism?

Consensus: There is no consensus regarding appropriate antibiotics for suppression therapy. The antibiotic should be chosen according to the susceptibility pattern of the isolated microorganism, preferably obtained from deep samples by joint aspiration or surgical debridement. The list of potential antibiotics and their doses is provided.

Delegate Vote: Agree: 97%, Disagree: 3%, Abstain: 0% (Strong Consensus)

    Table 1: Main oral antibiotics for treating prosthetic joint infections.
    BA=bioavailability. PB=protein binding.
    *Referring to clavulanate.
    **When taken with an empty stomach.
    ***Always use in combination therapy.
    ****Not available in the United States.