To DAIR or not to DAIR: Decision-making in the management of acute prosthetic joint infection � A narrative review

Abstract

Prosthetic joint infections are much-feared complications of joint arthroplasty that require complex multidisciplinary treatment. Although prosthesis removal is usually needed, the performance of debridement, antibiotics, and implant retention (DAIR) is an attractive alternative in well-selected patients with acute infection. Whether or not to indicate DAIR in a given situation is not a straightforward decision, despite validated algorithms and published guidelines. The odds of eradicating the infection and retaining an arthroplasty that is functional and painless are influenced by multiple variables regarding not only type of infection but also causative microorganism, antimicrobial treatment, surgical procedure, and the patient's condition and baseline characteristics. In this narrative review, we go over current recommendations, and algorithms, along with reported rates of success and risk factors of failure, and we will balance the decision to perform DAIR against other alternatives.

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

“…The treatment goals in PJIs are to eradicate infection and maintain pain-free joint function. 3,14 Options include prolonged suppressive antibiotics, DAIR, one-and two-stage revisions, resection arthroplasty, arthrodesis and amputation. Chronic suppressive antibiotic therapy is a conservative approach to PJI, usually reserved for patients who are unfit for or refuse further surgical management, and has poor success rates.…”

“…Increased theatre time, blood loss, surgical difficulty and bone loss associated with implant removal and potential damage to surrounding soft tissues add to a procedure with significant morbidity, prolonged hospitalisation and costs to both patient and healthcare systems. 3,14,18 When applied to selective patients, DAIR has shown itself as a cost-effective option in treating PJI while maintaining implants and the surrounding soft tissue envelope. DAIR is associated with an overall decreased surgical demand on both the surgeon and patient, reduced hospital stay and improved functional outcomes when successful.…”

“…Debridement, antibiotics and implant retention is indicated in early postoperative and acute haematogenous infections with a stable, well-fixed prosthesis. Some sources regard early postoperative infections as occurring within one to three months of the index procedure 29,36 and acute haematogenous infections with symptoms no longer than three to four weeks, 3,19 while others suggest DAIR is a viable option in all cases of PJI with a well-fixed prosthesis, regardless of implant age, 28 that is susceptible to anti-biofilm agents. 35…”

“…1,2 With escalating joint arthroplasty procedures, increased periprosthetic joint infections (PJIs) are expected. 3 The incidence of PJI is estimated at 0.5-2%, with knee arthroplasty at 0.8-1.9% and hip arthroplasty at 0.3-1.7%. 4,5 PJI is a devastating complication of total joint arthroplasty and significantly increases the burden on the patient, the surgeon and the healthcare system.…”

“…7 Eradicating a PJI while retaining a viable and functional prosthesis remains a challenge due to multiple variables, including patient condition, the infective organism, surgical approach and antimicrobial use. 3 Debridement, antibiotics and implant retention (DAIR) has been identified as a viable treatment choice in PJI when applied to selected patients, and its use has shown a significantly increasing trend of approximately 0.9-3.4% over a ten-year period. 8 This review discusses the use of DAIR for PJI and highlights its potential benefits and pitfalls.…”