2020 Mark Coventry Award: Microorganism-directed oral antibiotics reduce the rate of failure due to further infection after two-stage revision hip or knee arthroplasty for chronic infection: a multicentre randomized controlled trial at a minimum of two years

Abstract

Aims The aim of this study was to determine if a three-month course of microorganism-directed oral antibiotics reduces the rate of failure due to further infection following two-stage revision for chronic prosthetic joint infection (PJI) of the hip and knee. Methods A total of 185 patients undergoing a two-stage revision in seven different centres were prospectively enrolled. Of these patients, 93 were randomized to receive microorganism-directed oral antibiotics for three months following reimplantation; 88 were randomized to receive no antibiotics, and four were withdrawn before randomization. Of the 181 randomized patients, 28 were lost to follow-up, six died before two years follow-up, and five with culture negative infections were excluded. The remaining 142 patients were followed for a mean of 3.3 years (2.0 to 7.6) with failure due to a further infection as the primary endpoint. Patients who were treated with antibiotics were also assessed for their adherence to the medication regime and for side effects to antibiotics. Results Nine of 72 patients (12.5%) who received antibiotics failed due to further infection compared with 20 of 70 patients (28.6%) who did not receive antibiotics (p = 0.012). Five patients (6.9%) in the treatment group experienced adverse effects related to the administered antibiotics severe enough to warrant discontinuation. Conclusion This multicentre randomized controlled trial showed that a three-month course of microorganism-directed, oral antibiotics significantly reduced the rate of failure due to further infection following a two-stage revision of total hip or knee arthroplasty for chronic PJI. Cite this article: Bone Joint J 2020;102-B(6 Supple A):3–9.

Think Twice before Prescribing Antibiotics for That Swollen Knee: The Influence of Antibiotics on the Diagnosis of Periprosthetic Joint Infection

“…In addition to a thorough history and physical examination, the diagnosis of PJI often relies on serological tests and radiographic evaluation [ 6 ]. In particular, isolating the infecting microorganism from cultures of fluid or tissue within the joint remains the cornerstone for diagnosis and targeted antibiotic therapy, which has been shown to increase the chances of treatment success [ 7 ]. This also provides valuable prognostic information for patients and guides perioperative counseling [ 8 ].…”

What is the appropriate extended duration of antibiotic prophylaxis after two-stage revision for chronic PJI?

“…Some studies have concluded that following stage II reimplantation, the use of two to three days of standard antibiotic prophylaxis can achieve infection control rates equivalent to four to six weeks of antibiotic use, 18-20 but studies with higher levels of evidence have found that extending antibiotic treatment to three months was beneficial for infection control. 7,8 The RCTs showed that extended antibiotics should be used, thus raising a new question: if antibiotics use needs to be extended, for how long should they be used? Therefore, our study divided patients into a short course of extended antibiotic treatment (mean 20.17 days (SD 5.30)) and a long course of extended antibiotic treatment (mean 45.02 days (SD 15.03)) and found infection control rates of 95.3% and 92.7% for the short course and long course groups, respectively, with no statistically significant difference (p = 0.676, Fisher’s exact test).…”

“…The overall infection control rate was 94.3% (99/105) in this study, which was at a high level compared to previous studies. 8,17,21,22 This may be related to the comprehensive use of tissue culture technology, 23 ultrasonic lysis technology, and metagenomic next-generation sequencing 24,25 to improve pathogen identification. The high detection rate of pathogens and clear drug susceptibility in the involved cases made the application of antibiotics more appropriate.…”

“…Randomized controlled studies (RCTs) have shown that antibiotics for three months after stage II reimplantation surgery can help reduce the recurrence rate of infection. 7,8 However, there is also the view that if pathology and culture in reimplantation surgery confirm no infection, it should be considered aseptic surgery, and the extended use of antibiotics may render pathogens resistant to antibiotics and adversely affect the patient’s intestinal flora, as well as liver and kidney function. 9-11 Focusing on whether antibiotics are needed after stage II surgery, all of the aforementioned studies were designed to compare standard antibiotic prophylaxis (two to three days) with long course antibiotics (six to 12 weeks) after reimplantation surgery.…”

Flucloxacillin bone and soft tissue concentrations assessed by microdialysis in pigs after intravenous and oral administration

“…29 Furthermore, recent studies have shown that administration of postoperative oral antibiotics to patients undergoing revision surgery resulted in lower rates of infection. 30 , 31 The sparse evidence that exists recommends that a broad-spectrum antibiotic should be included in the perioperative prophylaxis along with flucloxacillin. 32 …”