One hundred and twelve infected arthroplasties treated with 'DAIR' (debridement, antibiotics and implant retention): antibiotic duration and outcome

I Byren, P Bejon, B L Atkins, B Angus, S Masters, P McLardy-Smith, R Gundle, A Berendt, I Byren, P Bejon, B L Atkins, B Angus, S Masters, P McLardy-Smith, R Gundle, A Berendt

Abstract

Objectives: We describe treatment failure rates by antibiotic duration for prosthetic joint infection (PJI) managed with debridement, antibiotics and implant retention (DAIR).

Methods: We retrospectively collected data from all the cases of PJI that were managed with DAIR over a 5 year period. Surgical debridement, microbiological sampling, early intravenous antibiotics and prolonged oral follow-on antibiotics were used.

Results: One hundred and twelve cases of PJI were identified. Twenty infections (18%) recurred during a mean follow-up of 2.3 years. The mean duration of antibiotic use was 1.5 years. Failure was more common after arthroscopic debridement, for previously revised joints and for Staphylococcus aureus infection. There were 12 failures after stopping antibiotics and 8 while on antibiotics [hazard ratio (HR) = 4.3, 95% confidence interval (CI) 1.4-12.8, P = 0.01]. However, during the first 3 months of follow-up, there were eight failures after stopping antibiotics and two while on antibiotics (HR = 7.0, 95% CI 1.5-33, P = 0.015). The duration of antibiotic therapy prior to stopping did not predict outcome.

Conclusions: PJI may be managed by DAIR. The risk of failure with this strategy rises after stopping oral antibiotics, but lengthening antibiotic therapy may simply postpone, rather than prevent, failure.

Figures

Figure 1
Figure 1
Kaplan–Meier plot of time to treatment failure for all patients, showing all follow-up data available.
Figure 2
Figure 2
Kaplan–Meier plots for time to failure are shown for (a) the presence or absence of S. aureus infection, (b) primary versus previously revised implant, (c) arthroscopic versus open debridement and (d) length of intravenous (iv) antibiotic use. The x-axes show days since DAIR and the y-axes show the proportion without treatment failure. The numbers at risk at each timepoint are shown beneath each plot.
Figure 3
Figure 3
Kaplan–Meier plot of time to treatment failure for patients on oral antibiotics (HR = 1) and patients stopping oral antibiotics (where day of stopping is day 0, HR = 4.3, 95% CI 1.4–12.8, P = 0.01).
Figure 4
Figure 4
Kaplan–Meier plot of time to treatment failure for patients at the start of the DAIR protocol and patients stopping oral antibiotics (where day of stopping is day 0), divided according to the length of use of oral antibiotics prior to stopping: P = 0.11; 181–360 days oral suppression, HR = 9.1 (95% CI 0.9–90), P = 0.058; and >360 days oral suppression, HR = 5.1 (95% CI 1.4–19), P = 0.013.

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