Timing of debridement, antibiotics, and implant retention (DAIR) for early post-surgical hip and knee prosthetic joint infection (PJI) does not affect 1-year re-revision rates: data from the Dutch Arthroplasty Register

Ende, B van der; Oldenrijk, Jakob van; Reijman, Max; Croughs, P; Steenbergen, L.N. van; Verhaar, J.A.; Bos, P.K.

doi:10.5194/jbji-6-329-2021

Cited by 17 publications

(14 citation statements)

References 19 publications

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“…All 16 patients in our cohort underwent surgical intervention for the 18 PJIs. For the treatment of acute PJI with DAIR, the literature reports success rates of 83%-90% [19][20][21]. However, in our cohort, 2/14 (14.28%) patients undergoing DAIR had treatment success, and only 5/18 (27.77%) of all of the joints had successful PJI management.…”

Section: Discussioncontrasting

confidence: 54%

Outcomes of Concurrent Endocarditis and Periprosthetic Joint Infection: A Retrospective Case Series of 16 Patients

Humphrey¹,

Marchwiany²,

Salimy³

et al. 2022

Cureus

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IntroductionConcurrent diagnosis of periprosthetic joint infection (PJI) of total hip arthroplasty (THA) or total knee arthroplasty (TKA) with infectious endocarditis is a devastating clinical scenario infrequently documented in the literature. To date, no studies have fully described the orthopedic and infectious outcomes of patients with these concurrent diagnoses. The purpose of this study was to conduct a case series of patients with these diagnoses and document the orthopedic and infectious outcomes so that surgeons may effectively counsel patients regarding the gravity of the condition and the expected course of treatment. MethodsThis study is a retrospective case series using patient data from five hospitals within an academic healthcare system in the northeastern United States. Cases of concurrent endocarditis and THA or TKA PJI with a minimum of one-year follow-up were identified from January 2000 to January 2021. Basic statistics such as means, standard deviations, and percentages were used to identify trends within our series. Kaplan-Meier survivorship curves with log-rank tests were performed to determine if there were any differences in twoyear mortality and joint survival (defined as needing explant) between patients who had cardiac surgery prior to surgical management for their PJI and those who had surgical management for PJI prior to cardiac surgery. ResultsA total of 18 joints in 16 patients with endocarditis and concurrent TKA or THA PJI were identified. All PJIs were managed surgically, with 14/18 (77.77%) of joint infections initially being managed by debridement, antibiotics, and implant retention (DAIR) and 4/18 (22.22%) of joint infections initially being managed by explant. Within the first six months of PJI diagnosis, 25% (4/16) of patients died of complications related to their infection, and one additional patient died of bacteremia just over a year after the initial PJI diagnosis. Of the 18 PJIs, 72.23% (13/18) had treatment failure, defined as any outcome equal to or worse than requiring chronic suppressive antibiotics for the infection. Due to low statistical power, we were not able to identify any differences in two-year mortality from PJI diagnosis (p=0.311) or joint survival (in terms of requiring explant) (p=0.420) depending on whether cardiac surgery or DAIR was performed first. ConclusionsConcurrent infectious endocarditis and prosthetic joint infection is associated with high morbidity and mortality. Patients with these concurrent infections should be counseled that not only the associated mortality rate is high, but also the surgical treatment of their PJI has a high rate of treatment failure, including an explant following an initial DAIR, an explant with retained spacer, or a requirement of lifelong antibiotic suppression.

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Section: Discussioncontrasting

confidence: 54%

Outcomes of Concurrent Endocarditis and Periprosthetic Joint Infection: A Retrospective Case Series of 16 Patients

Humphrey¹,

Marchwiany²,

Salimy³

et al. 2022

Cureus

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“…19,20 No consensus has been reached over cemented versus uncemented implants, with some sources citing cemented implants as having a greater failure risk. 19,34 Hip arthroplasty shows higher success rates for DAIR over knee arthroplasty, 1,20 but shoulder arthroplasty shows a DAIR success rate of 75%, in keeping with hip and knee cohorts. 20…”

Section: Implant Factorsmentioning

confidence: 85%

“…Nevertheless, DAIR remains a favourable option in patients with an average duration of symptoms of less than three weeks. 7,16,19,31 The time from index surgery or implant age is a heavily debated topic, with some literature suggesting that DAIR should only be performed if the duration from the index surgery is less than one month, 7 whereas others have suggested that this time frame could be extended to three months 3,8,16,19,34 or even a year. 18 It has been suggested that when the implant is well fixed and the PJI is caused by a less virulent organism in an otherwise viable joint, the implant age is not significant.…”

Section: Timingmentioning

confidence: 99%

“…16,19,31 Patient factors such as advanced age (> 80 years), male sex, obesity (body mass index [BMI] > 30 kg/m 2 ) and compromised immune status secondary to disease or steroid use have also been identified as risk factors for DAIR failure. 15,19,26,34 Lastly, a high American Society of Anaesthesiology (ASA) score, elevated ESR (> 40 mm/h) and elevated C-reactive protein (CRP); (> 65 mg/L) on presentation are also predictors of failure. 2,15,18,26,35 A multidisciplinary team, ideally including specialist nurses, therapists, infectious disease physicians and plastic surgeons in addition to the orthopaedic team, is recommended to treat the PJI, optimise any associated comorbidities, manage reversible conditions, exclude any concurrent extrinsic infections and assist with postoperative rehabilitation.…”

Section: Patient Factorsmentioning

confidence: 99%

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Truth or DAIR? A review of debridement, antibiotics and implant retention

2022

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Debridement, antibiotics and implant retention (DAIR) is a viable treatment option in early postoperative and acute haematogenous periprosthetic joint infections (PJIs) with a stable implant. Despite lower success rates compared to one- and two-stage revisions, DAIR maintains satisfactory outcomes in selected patient groups and, if successful, has similar functional outcomes to primary arthroplasty. DAIR remains an attractive treatment option, providing satisfactory outcomes with decreased healthcare costs, reduced surgical burden on the patient and shorter hospital stays. With success rates of 37-90%, various factors need to be considered when deciding on DAIR as the appropriate treatment option for PJI. The risk of DAIR failure needs to be weighed against the potential benefits of DAIR success. Factors that increase success rates include an open DAIR procedure performed for a low-virulence, antibiotic-sensitive organism, within a short duration between symptom onset and/or index surgery and DAIR. The procedure involves intraoperative exchange of mobile components and copious wound irrigation, followed by an appropriate antibiotic regimen for a minimum of six weeks that can be administered either intravenously or orally in a well-optimised host, without significant soft tissue defects or contraindications to surgery. Factors increasing the risk for DAIR failure include chronic/late PJIs with resistant organisms, especially methicillin-resistant Staphylococcus aureus (MRSA) in poor hosts with significant comorbidities, such as chronic obstructive pulmonary disease (COPD), liver cirrhosis, rheumatoid arthritis, advanced age > 80 years, patients with fracture indications for arthroplasty and those who cannot tolerate rifampicin- and fluoroquinolone-based antibiotic regimens. Unfortunately, there is no definitive factor to serve as an indication of whether DAIR will be successful, but with recent data showing that a failed DAIR procedure does not lower success in future staged revisions, then even in the face of a 50% success rate, DAIR can maintain its role as an initial treatment option in the management of PJIs

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“…7 Some current studies demonstrate the DAIR performance within three months of surgery has acceptable success rates. For instance, De Vries et al 12 achieved an 84% rate of component retention. However, these authors mentioned the fundamental role of a stable component, an identified and treatable organism, symptoms for less than three weeks, and intact soft parts.…”

Section: New Conceptsmentioning

confidence: 99%

Infección en prótesis total de rodilla. ¿Cuándo retener los componentes? Una nueva propuesta

Rodriguez,

Silva

2023

Revista Chilena de Ortopedia y Traumatología

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Timing of debridement, antibiotics, and implant retention (DAIR) for early post-surgical hip and knee prosthetic joint infection (PJI) does not affect 1-year re-revision rates: data from the Dutch Arthroplasty Register

Cited by 17 publications

References 19 publications

Outcomes of Concurrent Endocarditis and Periprosthetic Joint Infection: A Retrospective Case Series of 16 Patients

Outcomes of Concurrent Endocarditis and Periprosthetic Joint Infection: A Retrospective Case Series of 16 Patients

Truth or DAIR? A review of debridement, antibiotics and implant retention

Infección en prótesis total de rodilla. ¿Cuándo retener los componentes? Una nueva propuesta

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