Clinical outcome and risk factors for failure in late acute prosthetic joint infections treated with debridement and implant retention

Highlights

• Late acute prosthetic joint infection (PJI) treated with surgical debridement and implant retention have a high failure rate.

• The exchange of mobile components during surgical debridement is the most potent predictor for treatment success.

• There are several preoperative patient related variables that increase the risk for failure.

• Treatment strategies for late acute PJIs should be individualized and optimized according to the preoperative risk for failing.

Summary

Objectives

Debridement, antibiotics and implant retention (DAIR) is the recommended treatment for all acute prosthetic joint infections (PJI), but its efficacy in patients with late acute (LA) PJI is not well described.

Methods

Patients diagnosed with LA PJI between 2005 and 2015 were retrospectively evaluated. LA PJI was defined as the development of acute symptoms (≤ 3 weeks) occurring ≥ 3 months after arthroplasty. Failure was defined as: (i) the need for implant removal, (ii) infection related death, (iii) the need for suppressive antibiotic therapy and/or (iv) relapse or reinfection during follow-up.

Results

340 patients from 27 centers were included. The overall failure rate was 45.0% (153/340). Failure was dominated by Staphylococcus aureus PJI (54.7%, 76/139). Significant independent preoperative risk factors for failure according to the multivariate analysis were: fracture as indication for the prosthesis (odds ratio (OR) 5.4), rheumatoid arthritis (OR 5.1), age above 80 years (OR 2.6), male gender (OR 2.0) and C-reactive protein > 150 mg/L (OR 2.0). Exchanging the mobile components during DAIR was the strongest predictor for treatment success (OR 0.35).

Conclusion

LA PJIs have a high failure rate. Treatment strategies should be individualized according to patients’ age, comorbidity, clinical presentation and microorganism causing the infection.

Introduction

Prosthetic joint infections (PJI) can be subdivided into early post-surgical, chronic and late acute infections, the latter being considered to be mostly hematogenous of origin.¹ These subdivisions have been introduced to identify patients in whom the infected prosthesis can be debrided and retained (in case of acute infections) and to identify those in whom the infected prosthesis should be removed (in case of chronic infections). Despite these well-recognized categories of PJIs in literature, specific data on the clinical outcome of patients with a late acute infection is scarce. Several studies indicate that late acute PJIs have a higher failure rate compared to early acute (post-surgical) infections, especially when the infection is caused by Staphylococcus aureus (S. aureus).2, 3, 4, 5, 6, 7, 8 Some studies show higher failure rates in late acute PJIs caused by other microorganisms than S. aureus as well,^9–10 but this has been discarded by others.11, 12, 13 Current guidelines recommend the same surgical (debridement and implant retention (DAIR)) and antimicrobial strategy for both early and late acute infections,¹⁴ but late acute PJIs may require a different treatment approach. More evidence on the clinical outcome and identification of risk factors for failure in a larger cohort of patients is important to optimize treatment for this specific patient group. Therefore, we performed a large multicenter observational study to describe clinical outcome and risk factors for failure in late acute PJI treated with DAIR. We hypothesized that late acute PJIs have a high failure rate, especially when caused by S. aureus.