DEBRIDEMENT, ANTIBIOTICS, AND IMPLANT RETENTION FOR THE MANAGEMENT OF PROSTHETIC JOINT INFECTIONS IN A REAL-LIFE SETTING

Aim To describe epidemiology and outcome of prosthetic joint infections (PJIs) treated with debridement, antibiotics and implant retention (DAIR) in a real-life setting. Methods Observational retrospective study on all patients undergoing DAIR for PJI at a high-volume referral centre for bone and joint infections, from 2011 to 2022. Patients were followed for at least 24 months after DAIR or until clinical failure. Treatment failure was defined as the occurrence of one of the following: death, need for antibiotic suppression, need for further unplanned surgery to control infection. Results Ninety-four patients were included, 56 (60%) were males, median age was 65 years (IQR 51-75), median Charlson index was 3 (IQR 2-5); the hip was involved in 57/94 cases and 26/94 patients had a custom-made or a mega-prosthesis. Most patients had an early (n=33) or an acute late (n=33) infection; however, in 28 cases the infection was classified as delayed. A sinus tract was present in 29/94 cases (31%). The DAIR procedure was carried out within the recommended timeframe (< 30 days from implant or < 3 weeks from symptoms onset) in 59/94 (62%) cases. Change of modular components was carried out in 61/94 (64%) cases. Etiology of PJI was unknown before DAIR in 44/94 (47%); overall, an etiological diagnosis was reached in 72/94 cases (77%), polymicrobial infections were 20 (21%). The most frequent pathogens were coagulase-negative staphylococci (n=26), S.aureus (n=21), Enterobacterales (n=16) and P.aeruginosa (n=7); culture negative infections were 22/94 (23%). All patients received antibiotic therapy (intravenous only in 36/94, intravenous followed by an oral regimen in 54/94, oral only in 4/94), median duration of antibiotic treatment was 63 days (IQR 36-97), empiric antibiotic regimen was not active toward the etiological agent in 18/94 cases. Overall, 38/94 (40%) patients experienced a treatment failure after a median of 48 days (IQR 17-288) from DAIR; failure occurred during antibiotic treatment in 28/38 cases and after the discontinuation of antibiotics in 10/38. Reason for failure were prosthesis removal (n=32), amputation (n=3), death (n=2). Conclusion DAIR is a widely accepted surgical treatment for early and acute late PJI, with an overall success rate of approximately 70%. In our real-life study DAIR was carried out even in case of chronic infection, in presence of a sinus tract and the timing of surgery was suboptimal in more than 30% of cases; consequently, the overall success rate was low (60%). Guidelines for the DAIR procedure are urgently needed.