Acute Prosthetic Joint Infection Research Articles

High Rates of Treatment Failure and Amputation in Modular Endoprosthesis Prosthetic Joint Infections Caused by Fungal Infections With Candida.

Fungal prosthetic joint infections (PJIs) are rare yet severe events associated with high rates of recurrent infection. Although bacterial PJIs associated with megaprostheses are known to be associated with higher rates of recurrence and amputation, little is known about fungal PJIs near megaprostheses. In patients with fungal megaprosthesis PJIs from one institutional registry, We asked: (1) what were the most common microorganisms isolated? (2) What were the reoperation-, revision-, and amputation-free survival rates 1 and 2 years after surgery? We conducted a retrospective analysis of megaprostheses in our institutional database. Between 2000 and 2022, 86 patients with a diagnosis of PJI after megaprosthesis implantation were surgically treated at our institution. We considered patients with microbiological cultures that were positive for fungal organisms and who had a minimum follow-up of 2 years from the initial treatment for PJI. Ten patients with fungal megaprosthesis PJIs were included. Although four patients had a follow-up shorter than 2 years, all reached one of the study endpoints at that earlier interval, and therefore were included. All included patients were treated between 2016 and 2022, and the diagnosis of PJI was made in accordance with the 2011 Musculoskeletal Infection Society criteria. Patients were treated with either debridement, antibiotics, and implant retention (DAIR), DAIR-plus (debridement, antibiotics, modular implant component exchange, and stem retention), or one-stage or two-stage revision. In general, DAIR was used for acute PJIs, while DAIR-plus was performed in patients with chronic PJIs who were deemed medically unfit to endure the high morbidity associated with removal of the stems. In cases of prior unsuccessful DAIR-plus or patients with fewer comorbidities, one-stage or two-stage revision was the main treatment approach. The median age at diagnosis was 67 years (range 32 to 84 years), 5 of 10 patients were female, and the median BMI was 31 kg/m2 (range 20 to 43 kg/m2). The median follow-up was 26 months (range 1 to 54 months). A Kaplan-Meier survival analysis was performed to calculate reoperation-, revision-, and amputation-free survival at 1 and 2 years from the index surgery for PJI. The two most common organisms were Candida albicans (5 of 10 patients) and C.parapsilosis (3 of 10). Six of 10 patients had coinfection with a bacterial organism. One-year reoperation-free and revision-free survival were 35% (95% CI 9% to 64%) and 42% (95% CI 11% to 71%), respectively. Two-year reoperation-free and revision-free survival were 12% (95% CI 1% to 40%) and 14% (95% CI 1% to 46%), respectively. Amputation-free survival was 74% (95% CI 30% to 93%) at the 1-year interval and 40% at the 2-year interval (95% CI 7% to 73%). At the final follow-up interval, four patients had undergone amputations and four were being administered chronic antifungal suppression. Megaprosthesis fungal PJIs are rare but devastating. Arthroplasty surgeons should consider treatment efficacy, which appears to be low across surgical strategies, and the patient's capacity to withstand it. A lower decision threshold for performing amputation may be considered in patients who require rapid infection control to initiate immunosuppressive treatments. Future studies should aim to compare the surgical and clinical outcomes of fungal PJIs with those of other etiologies while controlling for potential variables. Efforts should be made to establish multi-institutional collaborations to achieve larger study samples. Level IV, therapeutic study.

Debridement, Antibiotics and Implant Retention: A Systematic Review of Strategies for Treatment of Early Infections after Revision Total Knee Arthroplasty.

The purpose of this review is to provide a systematic and comprehensive overview of the available literature on the treatment of an early prosthetic joint infection (PJI) after revision total knee arthroplasty (TKA) and provide treatment guidelines. This systematic review was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines. The search was conducted using the electronic databases of PubMed, Trip, Cochrane, Embase, LILACS and SciElo. After the inclusion of the relevant articles, we extracted the data and results to compose a treatment algorithm for early and acute PJI after revision TKA. After applying the in- and exclusion criteria, seven articles were included in this systematic review focusing on debridement, antibiotics and implant retention (DAIR) for PJI following revision TKA, of which one was prospective and six were retrospective. All studies were qualified as level IV evidence. The current literature suggests that DAIR is a valid treatment option for early infections after revision TKA with success rates of 50-70%. Repeat DAIR shows success rates of around 50%. Further research should be aimed at predicting successful (repeat/two-stage) DAIRs in larger study populations, antibiotic regimes and the cost effectiveness of a second DAIR after revision TKA.

Clinical and laboratory predictors for prosthetic joint infection within the first postoperative days following primary total hip and knee arthroplasty

PurposeTo identify clinical and laboratory predictors for low- and high-grade prosthetic joint infection (PJI) within the first postoperative days following primary total hip/knee arthroplasty (THA/TKA).MethodsInstitutional bone and joint infection registry of a single osteoarticular infection referral centre was reviewed to identify all osteoarticular infections treated between 2011 and 2021. Among them were 152 consecutive PJI (63 acute high-grade PJI, 57 chronic high-grade PJI, and 32 low-grade PJI) who also had primary THA/TKA performed at the same institution, which were retrospectively analyzed with multivariate logistic regression and covariables.ResultsFor each additional day of wound discharge, persistent wound drainage (PWD) predicted PJI in the acute high-grade PJI group with odds ratio (OR) 39.4 (p = 0.000, 95%CI 1.171–1.661), in the low-grade PJI group with OR 26.0 (p = 0.045, 95%CI 1.005–1.579), but not in the chronic high-grade PJI group (OR 16.6, p = 0.142, 95%CI 0.950–1.432). The leukocyte count product of pre-surgery and POD2 >100 predicted PJI in the acute high-grade PJI group (OR 2.1, p = 0.025, 95%CI 1.003–1.039) and in the chronic high-grade PJI group (OR 2.0, p = 0.018, 95%CI 1.003–1.036). Similar trend was also seen in the low-grade PJI group, but was not statistically significant (OR 2.3, p = 0.061, 95%CI 0.999–1.048).ConclusionsThe most optimal threshold value for predicting PJI was observed only in the acute high-grade PJI group, where PWD >three days after index surgery yielded 62.9% sensitivity and 90.6% specificity, whereby the leukocyte count product of pre-surgery and POD2 >100 showed 96.9% specificity. Glucose, erythrocytes, hemoglobin, thrombocytes, and CRP showed no significant value in this regard.

Acute Prosthetic Joint Infections with Poor Outcome Caused by Staphylococcus Aureus Strains Producing the Panton-Valentine Leukocidin.

The aim of this study was to investigate whether the presence of Staphylococcus aureus (SA) producing the Panton-Valentine leukocidin (PVL) affects the outcome of Prosthetic Joint Infection (PJI). Patients with acute and chronic PJI sustained by SA were prospectively enrolled at the orthopedic unit of "Casa di Cura Santa Maria Maddalena", from January 2019 to October 2021. PJI diagnosis was reached according to the diagnostic criteria of the International Consensus Meeting on PJI of Philadelphia. Synovial fluid obtained via joint aspirations was collected in order to isolate SA. The detection of PVL was performed via real-time quantitative PCR (RT-qPCR). The outcome assessment was performed using the criteria of the Delphi-based International Multidisciplinary Consensus. Twelve cases of PJI caused by SA were included. Nine (75%) cases were acute PJI treated using debridement, antibiotic and implant retention (DAIR); the remaining three (25%) were chronic PJI treated using two-stage (n = 2) and one-stage revision (n = 1), respectively. The SA strains that tested positive for PVL genes were 5/12 (41.6%,). Treatment failure was documented in three cases of acute PJI treated using DAIR, all supported by SA-PVL strains (p < 0.045). The remaining two cases were chronic PJI treated with a revision arthroplasty (one and two stage, respectively), with a 100% eradication rate in a medium follow-up of 24 months. Although a small case series, our study showed a 100% failure rate in acute PJI, probably caused by SA PVL-producing strains treated conservatively (p < 0.04). In this setting, toxin research should guide radical surgical treatment and targeted antibiotic therapy.

Debridement, antimicrobials, and implant retention in the treatment of late acute and early acute Staphylococcus aureus prosthetic joint infections

Background Staphylococcus aureus is the most common microbe in prosthetic joint infections (PJIs). Debridement, antimicrobials, and implant retention (DAIR) are often-recommended treatment modality for acute PJIs, even though it has had relatively poor outcomes in some studies. In this study, we wanted to examine treatment results with a multidisciplinary team in a specialised centre and obtain further information for treatment decisions in acute Staphylococcus aureus PJIs. Methods All consecutive haematogenous late acute and postoperative early acute hip and knee Staphylococcus aureus PJIs treated with DAIR during 2011–2016 were included in this retrospective study. DAIR within three weeks from symptom onset and the exchange of modular parts were required. Results Eighty-five acute Staphylococcus aureus PJIs were treated with DAIR in 83 patients: 28 late acute and 57 early acute PJIs. The late acute PJI patients were older and had malignancies more often than the early acute PJI patients. Bacteraemia was present in 50.6% of Staphylococcus aureus PJI patients, more often in late acute (73.1%) than in early acute (40.4%) patients (p = .006). The implant was retained in 80.0%: 89.3% of the late acute and 75.4% of the early acute PJIs. In 17 joints, DAIR failed and the joint had to be removed. Fourteen of these joints were successfully replaced. One infection-related death occurred. The one-year all-cause mortality rate was 3.6%. Suppressive antimicrobial treatment was given to 22 (26.5%) patients. Conclusions Reasonably good treatment results for acute Staphylococcus aureus PJIs are achievable by DAIR in a specialised centre with a strict treatment protocol and a multidisciplinary team. If the DAIR fails, a two-stage exchange is usually still possible, with good results.

Failed 2-Stage Revision Knee Arthroplasty for Periprosthetic Joint Infection—Patient Characteristics and Outcomes

BackgroundChronic prosthetic joint infection (PJI) is most frequently treated with 2-stage revision in conjunction with antibiotic treatment. The aims of this study were 1) to investigate the characteristics of patients who have recurrent infection following 2-stage revision for PJI and 2) to identify risk factors associated with treatment failure. MethodsA multicenter retrospective review of 90 total knee arthroplasty (TKA) patients who underwent 2-stage revision for treatment of PJI from March 1, 2003 to July 31, 2019, and had recurrent PJI was conducted. The minimum follow-up was 12 months (median follow up of 2.4 years). Microorganisms, subsequent revision, PJI control status, and final joint status were collected. The infection-free survival after initial 2-stage revision was plotted utilizing the Kaplan–Meier method. ResultsMean survival time to reinfection was 21.3 months (range, 0.3 to 160.5). There were 14 recurrent infections that were acute PJIs treated with debridement, antibiotics, and implant retention (DAIR), while 76 were chronic and treated with repeat 2-stage revision. The most common pathogen identified for both index and recurrent PJI was coagulase-negative Staphylococci. Pathogen persistence was observed in 14 (22.2%) of recurrent PJIs. In total, 61 (67.8%) patients possessed a prosthetic reimplantation at their most recent follow-up, and 29 (35.6%) patients required intervention following repeat 2-stage. ConclusionOverall, 31.1% of the patients obtained infection control after treatment of a failed 2-stage revision due to PJI. The high rate of pathogen persistence and the relatively low survival time to recurrence suggests a need to more closely monitor PJIs cases within 2 years.

The Risk of Acute Infection Following Intra-Articular Corticosteroid Injection During Total Knee Manipulation Under Anesthesia

BackgroundManipulation under anesthesia (MUA) is an established option for improving motion in patients presenting with early stiffness following total knee arthroplasty (TKA). Intra-articular corticosteroid injections (IACI) are sometimes administered adjunctively, yet literature examining their efficacy and safety remains limited. Study DesignRetrospective, Level IV. MethodsA total of 209 patients (TKA = 230) were retrospectively examined to determine the incidence of prosthetic joint infections within 3 months following manipulation with IACI. Approximately 4.9% of initial patients had inadequate follow-up where the presence of infection could not be determined. Range of motion was assessed in patients who had follow-up at or beyond one year (n = 158) and was recorded over multiple time points. ResultsNo infections (0 of 230) were identified within 90 days of receiving IACI during TKA MUA. Before receiving TKA (preindex), patients averaged 111° of total arc of motion and 113° of flexion. Following index procedures, just prior to manipulation (pre-MUA), patients averaged 83° and 86° of total arc and flexion motion, respectively. At final follow-up, patients averaged 110° of total arc of motion and 111° of flexion. At six weeks following manipulation, patients had gained a mean of 25° and 24° of their total arc and flexion motion found at 1 year. This motion was preserved through a 12-month follow-up period. ConclusionAdministering IACI during TKA MUA does not harbor an elevated risk for acute prosthetic joint infections. Additionally, its use is associated with substantial increases in short-term range of motion at six weeks following manipulation, which remain preserved through long-term follow-up.

Biofilm formation is associated with poor outcome in prosthetic joint infections caused by Staphylococcus lugdunensis

Background Staphylococcus lugdunensis has been described as a pathogen of increasing importance in prosthetic joint infections (PJI). Our aim was to describe the clinical presentation of PJI caused by S. lugdunensis, and to correlate the biofilm-forming ability of the bacterial isolates to clinical outcome. Method S. lugdunensis isolates from PJI episodes during 2015–2019 were included and analysed for biofilm formation using a microtiter plate assay. Medical records from the corresponding patients were reviewed. Results We identified 36 patients with PJI caused by S. lugdunensis during the study period. Early postoperative PJIs were most frequent (n = 20, 56%). Surgical intervention was performed in a majority of the patients (n = 33, 92%), and the dominating type of antibiotic treatment was a combination of rifampicin and ciprofloxacin (n = 27, 75%). The treatment success-rate was 81% (n = 29). All isolates causing PJI were able to form biofilm in vitro. Biofilm formation was significantly stronger in isolates causing relapsing vs non-relapsing PJI (mean OD550 3.1 ± 0.23 vs 1.14 ± 0.73 p = .001) and strong biofilm formation was also associated with late acute hematogenic PJI (mean OD550 1.8 ± 0.93 vs. 0.93 ± 0.81, p = .01). Conclusion Strong biofilm production in S. lugdunensis isolates was associated with relapse in PJI.

Wound drainage after arthroplasty and prediction of acute prosthetic joint infection: prospective data from a multicentre cohort study using a telemonitoring app.

Background: Differentiation between uncomplicated and complicated postoperative wound drainage after arthroplasty is crucial to prevent unnecessary reoperation. Prospective data about the duration and amount of postoperative wound drainage in patients with and without prosthetic joint infection (PJI) are currently absent. Methods: A multicentre cohort study was conducted to assess the duration and amount of wound drainage in patients after arthroplasty. During 30postoperative days after arthroplasty, patients recorded their wound status in a previously developed wound care app and graded the amount of wound drainage on a 5-point scale. Data about PJI in the follow-up period were extracted from the patient files. Results: Of the 1019included patients, 16patients (1.6 %) developed a PJI. Minor wound drainage decreased from the first to the fourth postoperative week from 50 % to 3 %. Both moderate to severe wound drainage in the third week and newly developed wound drainage in the second week after a week without drainage were strongly associated with PJI (odds ratio (OR) 103.23, 95 % confidence interval (CI) 26.08 to 408.57, OR 80.71, 95 % CI 9.12 to 714.52, respectively). The positive predictive value (PPV) for PJI was 83 % for moderate to heavy wound drainage in the third week. Conclusion: Moderate to heavy wound drainage and persistent wound drainage were strongly associated with PJI. The PPV of wound drainage for PJI was high for moderate to heavy drainage in the third week but was low for drainage in the first week. Therefore, additional parameters are needed to guide the decision to reoperate on patients for suspected acute PJI.

Incidence, functional outcomes and cure rate of hematogenous infection in a 2,498 Total Knee Arthroplasties cohort

PurposeThe primary aim of the present study is to report the late acute hematogenous (LAH) prosthetic joint infection (PJI) cure rate following Total knee arthroplasty (TKA) treated by means of debridement, antibiotics, and implant retention (DAIR) in a long-term follow-up. The secondary purpose is to report the functional outcomes at that follow-up and to compare them with a non-infected group.Material and MethodsThis study cohort consists of 2,498 TKA performed from September 2005 to April 2010 that had a minimum follow-up of 10 years. The diagnosis of PJI and classification into LAH was done in accordance with the Zimmerli criteria. The primary outcome was the failure rate, defined as death before the end of antibiotic treatment, a further surgical intervention for treatment of infection, life-long antibiotic suppressive treatment or chronic infection. The Knee Society Score (KSS) was used to evaluate clinical outcomes.ResultsTen patients were diagnosed with acute hematogenous PJI during the study period (0.4%). All of them were managed with DAIR, which was performed by a knee surgeon and/or PJI surgeon. The failure rate was 0% at the 8.5-year (SD, 2.4) follow-up mark. The KSS score was 82.1 vs. 84.1 (p n.s.) at final follow-up.ConclusionAlthough the literature suggests that TKA DAIR for LAH periprosthetic joint infection is associated with high rates of failure, the results presented here suggest a high cure rate with good functional outcomes.Level of evidenceLevel II, prospective cohort study.

Redo DAIR: The Game Is Seldom Worth the Candle.

Debridement, antibiotics and implant retention (DAIR) remains a commonly utilized technique in the treatment of acute prosthetic joint infections despite its inconsistent outcomes. The performance of a second DAIR after a failed first debridement is controversial as outcomes are uncertain and the final prognosis in the event of failure may be unfavorable. This study analyzes 84 cases of acute prosthetic (hip & knee) joint infection treated with DAIR between 2011 and 2020 at the same institution. In 12 failed cases, a second DAIR was performed, whose success rate was significantly lower than that of the first procedure (8% [95% CI, 0-38] vs. 57% [46-68]). Moreover, the ultimate outcome of the second failed DAIRs was unfavorable with eradication of the infection being achieved in none of the patients. Due to the high likelihood of failure and the potentially grim final prognosis following a second debridement, removal of the components should be considered.

A Comparison of Outcomes of Culture positive and Culture negative Acute Knee Prosthetic Joint Infection following Debridement, Antibiotics and Implant Retention (DAIR).

We aim to compare the outcome of culture-positive (CP PJI) and culture-negative (CN PJI) acute knee prosthetic joint infection (PJI) following debridement, antibiotics and implant retention (DAIR) with polyethylene insert exchange. We also aim to analyze the factors associated with the successful outcome of DAIR and the influence of failed DAIR on the outcome of subsequent two-stage revision arthroplasty. We performed a retrospective review of 36 consecutive patients who underwent DAIR for acute PJI between January 2013 and January 2018. The patient's demographic data, McPherson grade, surgical details, laboratory and microbiology data were retrieved from the medical records. All the patients have been followed up for a minimum of 3years or until re-operation, revision or death and any complications, incidence of DAIR failure, revision and mortality were noted. The mean follow-up was 4.9 ± 2.4years. Among the 36 patients, 16 had CP PJI and 20 had CN PJI. Among the 16 patients with CP PJI, 8 patients had success with DAIR and 8 patients had a recurrence of infection (50%) at a mean of 21months (range, 2weeks to 55months). Among the 20 patients with CN PJI, 14 patients had success with DAIR and 6 patients had a recurrence of infection [30% (6/20)] at a mean of 69months (range, 13-221months) (p < .05). The Kaplan-Meir survival analysis showed survivorship did not vary significantly between both groups (p > .05). Univariate regression analysis showed symptom duration of more than one month found to be significantly associated with the DAIR failure. There was no difference in failure rate after DAIR between age, Charlson comorbidity index, early postoperative versus acute hematogenous group and type of organism grown. Ten out of 14 DAIR failures were successfully managed with two-stage revision surgery with no recurrence of infection till the final follow-up. In the remaining 4 patients, one underwent re-debridement, two underwent arthrodesis and one was left with an antibiotic cement spacer. DAIR with polyethylene exchange will give comparable results irrespective of the culture positivity. Symptom duration of more than 30days for DAIR is significantly associated with DAIR failure. DAIR failures can be successfully managed with two-stage revision.

Accuracy of a Novel Preoperative Failure Risk Model for Debridement Antibiotics and Implant Retention (DAIR) in Acute Prosthetic Joint Infection.

Given the variable success of the debridement, antibiotics and implant retention (DAIR) procedure in patients with acute prosthetic joint infection (PJI), an accurate selection of candidates is critical. In this study, we set about calculating the predictive value of a novel algorithm for predicting outcome following DAIR developed by Shohat et al. Sixty-four patients who underwent debridement for (early and late) acute PJI in a tertiary-level university hospital were selected, and the aforementioned algorithm was retrospectively applied. Patients with model scores of 40–50%, 50–60%, 60–70%, 70–80% and 80–90% displayed success rates of 33.34%, 41.18%, 57.9%, 78.27% and 100%, respectively. The receiver operating characteristic curve showed an area under the curve of 0.69. The calibration intercept value was 0, and the calibration slope value was 1. Failure rates were significantly higher for the following variables: revision surgery (p = 0.012) index surgery for reasons other than osteoarthritis (p = 0.01), and C-reactive protein level >30 mg/L (p = 0.042). This analysis demonstrated that the Shohat algorithm is associated with an optimal calibration value and a moderate predictive value for failure of a DAIR procedure in patients with acute PJI. Its validation is recommended before it can be routinely applied in daily practice.

Bacteremia in Patients Undergoing Debridement, Antibiotics, and Implant Retention Leads to Increased Reinfections and Costs.

BackgroundDebridement, antibiotics, and implant retention (DAIR) is a common treatment for acute prosthetic joint infection (PJI). The effects of concurrent bacteremia at the time of DAIR are poorly understood. This study sought to determine whether patients with bacteremia at the time of DAIR have higher reinfection rates.Material and methodsA retrospective review of a national database was performed. Patients treated with DAIR (hip or knee arthroplasty) after a diagnosis of PJI were identified. DAIR patients who also had a diagnosis of bacteremia were matched to patients without bacteremia by comorbidities and Charlson Comorbidity Index score. The primary outcome was reinfection or continued infection at 90 days and 6, 12, and 24 months after DAIR. Ninety-day Medicare charges were compared between groups. Survival probabilities were used for survival comparisons.ResultsA total of 9945 patients underwent DAIR after a diagnosis of PJI. Seven hundred seven patients underwent DAIR with an associated diagnosis of bacteremia. Three hundred thirty-four DAIR patients with bacteremia were successfully matched to patients without bacteremia by age, gender, and comorbidities. DAIR survivorship was significantly worse in those with bacteremia at 90 days (51.5% vs 65.9%) and 6 (43.1% vs 60.5%), 12 (36.5% vs 56.0%), and 24 months (32.6% vs 53.3%) after DAIR. The 90-day costs of DAIR were significantly greater in PJI patients with bacteremia (mean: $14,722 standard deviation: $4086 vs mean: $8,052, standard deviation: $4,153, P < .01).ConclusionsPatients undergoing DAIR with bacteremia are at an increased risk of reinfection or continued infection. Ninety-day costs are significantly increased (over 50%) in patients with bacteremia vs those without bacteremia.

Does a New Antibiotic Scheme Improve the Outcome of Staphylococcus aureus-Caused Acute Prosthetic Joint Infections (PJI) Treated with Debridement, Antibiotics and Implant Retention (DAIR)?

One of the most commonly used treatments for acute prosthetic joint infection (PJI) is DAIR (debridement, antibiotics and implant retention), which comprises the debridement and the retention of the implant, followed by antibiotic treatment. The efficacy of DAIR remains unclear, as the literature has demonstrated variable success rates, ranging from 26% to 92%. The Staphylococcus aureus is one of the most closely related causative microorganisms, especially with acute and late-acute PJI; it has been identified as one of the most significant predictors of DAIR failure. The current guidelines consider the use of vancomycin as the therapy of choice, but it requires the close control of possible side effects. The aim of this study is to determine if a new combination of antibiotics (a highly bactericidal initial combination followed by an antibiofilm scheme) decreases the failure of DAIR-treated acute prosthetic joint infection (PJI) caused by Staphylococcus aureus. A retrospective analysis of cases of orthopedic infections during a nine-year period (2011–2019) was performed. A total of 45 acute PJI cases caused by S. aureus were diagnosed. The results of two antibiotic schemes were compared: a novel scheme comprising 5 days of daptomycin (10 mg/kg/24 h) + cloxacillin (2 g/6 h) followed by levofloxacin (500 mg/24 h) + rifampicin (600 mg/24 h), versus a traditional, less bactericidal scheme of vancomycin (1000 mg/12 h) plus rifampicin (600 mg/24 h) or levofloxacin (500 mg/24 h) plus rifampicin (600 mg/24 h). Twenty-two out of the twenty-four patients treated with the new scheme (91.6%) were free of infection after 24.8 months of mean follow-up, whereas fourteen out of twenty-one patients (66.6%) were free of infection after 46.6 months of follow-up. This difference was statistically significant (p = 0.036). Demographic comparisons demonstrated homogeneous features, except the Charlson score, which was higher in the novel scheme group (p = 0.047). The combination of high-dose daptomycin and cloxacillin, followed by levofloxacin plus rifampicin, together with surgical treatment, shows better results when compared with other antibiotic schemes for treating acute PJI caused by S. aureus in which DAIR was performed.

Does a 2-Stage Debridement Result in Higher Rates of Implant Retention Compared With Single Debridement Alone?

We retrospectively reviewed 89 patients with acute prosthetic joint infection treated with debridement, antibiotics, and implant retention (DAIR) or 2-DAIR. Patients had <3 weeks of symptoms and met Musculoskeletal Infection Society criteria for infection. Sixty-three patients were treated with DAIR, whereas 26 patients were managed using a 2-DAIR protocol where patients underwent initial debridement, antibiotic bead placement, and subsequent return to the operating room at an average of 16.3 days for repeat debridement and modular component exchange. Patients received a 6-week course of intravenous antibiotics and 3 months of oral antibiotics for suppression. Demographics, comorbidities, implant retention rates, and complications were compared between the groups. The McPherson host type and infection type classification system were used to categorize patients in both the DAIR and 2-DAIR groups. Regression analysis was performed to control postoperative vs acute hematogenous infection, procedure, and comorbidities. The McPherson host types and infection types were not different between DAIR and 2-DAIR patients, P= .728 and P= .061, respectively. There was no difference in the overall implant retention rate between DAIR and 2-DAIR (63.49% vs 69.23%, P= .605). The average days to reinfection was significantly longer for the 2-DAIR cohort compared with DAIR (271.3 vs 165.3, P= .024) in patients who failed treatment. However, when controlling for infection, microorganism, index procedure, and comorbidities, there was no difference in days to reinfection (P= .679). There were no differences in complications, 90-day readmission, or revision rates between the groups. A staged debridement for acute prosthetic joint infection did not improve the rates of infection control. Randomized trials are needed to define indications and potential benefits of 2-DAIR.

Outcomes of Debridement, Antibiotics and Implant Retention (DAIR) for Periprosthetic Joint Infection in a High-Volume Arthroplasty Centre.

Prosthetic joint infection (PJI) following total knee arthroplasty (TKA) and total hip arthroplasty (THA) can be a devastating diagnosis. Debridement, antibiotics and implant retention (DAIR) is a preferred treatment modality for acute PJI. A retrospective analysis of infected primary arthroplasties to evaluate the success of DAIR and factors influencing its outcomes. We retrospectively reviewed all patients who underwent DAIR for PJI at our unit between 2010 and 2018. Patients who underwent revision surgery as an index procedure, arthroscopic washout and those with less than two years of follow-up were excluded. Treatment failure was defined as revision arthroplasty for recurrence of infection within 2years of the index procedure. Chi-square and Fischer's exact test were used to compare between patient factors and DAIR outcomes. Kaplan-Meier survival curve and log-rank test were used to analyse implant survivorship following DAIR. Of the sixty patients (40 knees, 20 hips) who underwent DAIR, eighteen (13 knees, 5 hips) required revision arthroplasty within 2years accounting for a success rate of 70%. Predictive factors for revision were American Society of Anaesthesiologist (ASA) score of greater than 2 (p = 0.021), BMI > 35 (p = 0.046), C Reactive protein (CRP) > 200mg/L (p = 0.007) and Staphylococcus aureus growth (p = 0.012). The five-year survival rate for DAIR was 70%, which remained constant after two years from DAIR. Success rate of DAIR in PJI was 70% which was comparable to similar studies in the literature. ASA > 2, BMI > 35, CRP > 200 and staphylococcus aureus growth were predictors for DAIR failure. Implant survival rate and duration were better following DAIR in early-onset PJI.

Risk Factors of DAIR Failure and Validation of the KLIC Score: A Multicenter Study of Four Hundred Fifty-Five Patients.

Background: Debridement, antibiotic agents, and implant retention (DAIR) is a currently accepted approach for the treatment of early prosthetic joint infections (PJI). The success of a DAIR procedure has shown variable results throughout the published literature. Scoring systems such as the Kidney, Liver, Index surgery, Cemented prosthesis, and C-reactive protein value (KLIC) score for the selection of patients that are likely to benefit from DAIR have proved to be helpful in decision making. Our study aims to further validate the KLIC score using a large external multicentric cohort and to evaluate other risk factors for failure. Patients and Methods: A retrospective analysis of patients with an early acute PJI who were treated with DAIR and recorded in a database of eight Spanish university hospitals was performed. According to pre-operative variables of the KLIC study, patients were categorized into five groups: group A, ≤2 points; group B, 2.5-3.5 points; group C, 4-5 points; group D, 5.5-6.5 points; and group E, ≥7 points. Failure rates were compared between groups at 60 days and after 60 days of DAIR. Further variables for risk of failure were also analyzed. Results: A total of 455 patients with early acute PJI were included in the analyses. At 60 days, patients presenting with pre-operative elevated C-reactive protein serum levels, Staphylococcus aureus, and polymicrobial infections were associated with failure. Failure rates recorded were 12% for group A (n = 210), 18% for group B (n = 83), 26% for group C (n = 89), 24% for group D (n = 66), and 0% for group E (n = 7). Univariable analysis between consecutive groups of the KLIC score showed no differences for failure before 60 days of the DAIR procedure. Scheduled surgery and having the procedure performed by a specialized unit were also identified as important factors for DAIR success. Conclusions: Our results suggest the KLIC score was not useful for predicting failure in our cohort. Furthermore, our results indicate a specialized unit should conduct DAIR procedures.

239. Sex Differences in Prosthetic Joint Infection

BackgroundMale sex has been demonstrated to be a non-modifiable risk factor for prosthetic joint infection (PJI) incidence in multiple studies. Given the known anatomical, genetic, and immunological differences between sexes, we compared the clinical characteristics of PJI among men and women. MethodsA retrospective cohort of total hip and knee arthroplasty PJIs from 2009 to 2019 were identified using a single institution PJI database. Included cases met the 2013 MSIS criteria. Microbiology, acuity (defined by implant age and symptom days), and surgical outcomes were collected. Success was defined as no further PJI surgery at two years. Continuous variables were tested with either Student’s t test or Mann-Whitney U test. Categorical variables were tested with either Chi-squared test or Fisher’s exact test.ResultsWe identified 1052 PJI patients, of whom 463 (44.0%) were women. In univariate analysis of the total cohort, women were younger (68.1 ± 11.2 vs 66.1 ± 11.8 years, p=0.01), had higher BMI (30.8 ± 7.78 vs 29.8 ± 6.0, p=0.04), and had a higher culture-negative rate (14.5% vs 9.0%, p < 0.01) than men, but no difference was noted in Charlson Comorbidity Index (Table 1). Among hip PJIs, women were likelier than men to present with acute PJI (15.9% vs 8.7%, p=0.03). There were no differences in debridement, antibiotics, and implant retention (DAIR) utilization (48.2% vs 44.1%, p=0.067), and overall treatment success (72.1% vs 71.6%, p=0.9), nor in any subanalysis of acute, hip, or knee PJIs. ConclusionAlthough females may present differently when diagnosed with PJI, overall outcomes and outcomes with respect to acuity and type of septic revision did not clearly differ in this single-center cohort. Further research in larger cohorts, including additional biomarkers and socioeconomic variables, may further elucidate relationships between sex and PJI characteristics including culture-negativity and symptom acuity.Disclosures All Authors: No reported disclosures

Chronic Antibiotic Suppression for Nonstaphylococcal Prosthetic Joint Infections Treated with Debridement or Implant Retention

Background: Early postoperative and acute prosthetic joint infection (PJI) may be managed with debridement, antibiotics, and implant retention (DAIR). Among patients with nonstaphylococcal PJI, an initial 4–6-week course of intravenous or highly bioavailable oral antibiotics is recommended in the Infectious Diseases Society of America (IDSA) guidelines, with disagreement among committee members on the need for subsequent chronic oral antimicrobial suppression (CAS). We aimed to characterize patients with nonstaphylococcal PJI who received CAS and to compare them to those who did not receive CAS. Methods: This retrospective cohort study included patients admitted to Veterans’ Affairs (VA) hospitals from 2003 to 2017 who had a PJI caused by nonstaphylococcal bacteria, underwent DAIR, and received 4–6 weeks of antimicrobial treatment. PJI was defined by Musculoskeletal Infection Society (MSIS) 2011 criteria. CAS was defined as at least 6 months of oral antibiotics following initial treatment of the PJI. Patients were followed for 5 years after debridement. We used χ2 tests and t tests were used to compare patients who received CAS with those who did not receive CAS. Results: Overall, 561 patients had a nonstaphylococcal PJI treated with DAIR, and 80.6% of patients received CAS. The most common organisms causing PJI were streptococci. We detected no significant differences between patients who received CAS and those who did not receive CAS, except that modified Acute Physiology and Chronic Health Evaluation (mAPACHE) scores were higher among patients who did not receive CAS (Table 1). Conclusion: Patients not on CAS were more severely ill (by mAPACHE) than those on CAS. Otherwise, the 2 groups were not different. This finding was contrary to our hypothesis that patients with multiple comorbidities or higher mAPACHE scores would be more likely to get CAS. A future analysis will be conducted to assess treatment failure in both groups. We hope to find a specific cohort who may benefit from CAS and hope to deimplement CAS in others who may not benefit from it.Funding: NoDisclosures: None