Prosthetic Joint Infection

Today we discussed prosthetic joint infection (Recent review here)
UPDATE AUG 20 - NEJM Review Recently Published here.


Treatment options include:

• 2 stage revision -- removal of hardware, insertion of spacer with ~6weeks antibiotics before re-implantation. Highest chance for cure, significant morbidity
  
• 1 stage revision -- removal of hardware, debridement and re-implanataion with concomitant antibiotics. Less morbidiy, less chance of cure
  
• Debridement, Antibiotics and Retention -- chance of failure, little morbidity
  
• Palliation -- i.e. chronic suppressive antibiotics
  

We spent some time discussing debridement and retention (original JAMA article here, review here). In general this can be considered for MSSA, MRSA and CNST prosthetic joint infections provided:

• Relatively short duration of illness
• No loosening of the prosthesis
• Healthy overlying tissues
  
• Full OR debridement occurs
• The organism is susceptible to quinolones and rifampin (and the patient can tolerate both)

In general there is a two week induction with beta-lactam + rifampin or vancomycin + rifampin followed to ~ 3 months for THR and 6 months for TKR with levofloxacin or moxifloxacin with rifampin 450 PO BID. Treatment is continued past 3 (or 6) months if the CRP/ESR fails to normalize. Failure would be recurrent infection, intractable pain, loosening, drug intolerance.

Also -- here is a review of the use of combination rifampin with other antibiotics for the treatment of Staphyloccal infections.