Holidays May Not Be Needed

Commentary With more and more joint replacements being performed every year, the number of complications is also on the rise, including periprosthetic joint infection (PJI), which is a major cause of morbidity and mortality in patients undergoing total joint arthroplasty1. This increasing trend underscores the pressing need to optimize PJI management strategies, such as the role of an antibiotic holiday. Two-stage exchange arthroplasty for the surgical treatment of chronic PJI continues to be popular around the globe and remains the treatment of choice in the Americas2–4. Despite this widespread adoption, there is ongoing debate regarding specific perioperative protocols, particularly the necessity of an antibiotic holiday. The paper by Fraval et al. addresses a key issue that many clinicians are still debating and trying to understand. The use of an antibiotic holiday prior to the second stage is a common strategy intended to ensure that the infection has been cleared, which is often confirmed with a laboratory after the second week of the holiday. However, there is little evidence supporting this treatment plan in the literature. Moreover, the lack of standardized protocols across institutions adds to the uncertainty surrounding its efficacy. The literature investigating the utility of an antibiotic holiday versus continuous antibiotic therapy has been heterogeneous, with few direct comparisons of the 2 treatments and with most studies designed to address an unrelated aim. Fraval et al. present an excellent, broad scoping review that comprehensively maps the evidence for an antibiotic holiday in patients undergoing 2-stage exchange revision surgery for chronic PJI in total knee and hip arthroplasty. They reviewed 243 studies to determine if outcomes are improved with this practice compared with continuous antibiotic therapy. However, the quality of the evidence may have been limited by the abundance of individual case series with multiple confounding variables and great heterogeneity, as well as by the very small number of direct comparative studies, with only a few investigations directly differentiating both strategies. As noted by the authors, this variability in study designs makes it difficult to draw firm conclusions, underscoring the need for robust prospective clinical trials. The conclusions of the review may also have been weakened by the heterogeneity of the included studies, which had a wide variety of protocols, especially in terms of the surgical intervals and the definitions of the antibiotic holiday and treatment success. These inconsistencies make it challenging to establish universally accepted best practices for PJI management. The manuscript stands out for its thorough methodology. The use of the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) guidelines adds solid credibility to the paper, and it is clear that the authors invested considerable effort into selecting and analyzing the studies carefully. The comparisons of failure rates between the antibiotic holiday and continuous therapy groups provide valuable insights that can guide clinicians in making better decisions and optimizing their treatment protocols. Their findings demonstrate that the evidence for an antibiotic holiday in PJI treatment does not convincingly support its use and that an antibiotic holiday may unnecessarily prolong the interval between the first and second stages, which may cause functional impairment to worsen due to a longer term with a spacer5. This highlights a critical clinical consideration: whether an extended between-stage interval, due to an antibiotic holiday, could negatively affect patient mobility and overall recovery. The review by Fraval et al. is also extremely useful for planning rigorous prospective clinical trials that are designed to quantify the effect of an antibiotic holiday and the duration of the between-stage interval in patients treated with 2-stage revision for chronic PJI in hip and knee arthroplasty. Without any doubt, this paper will make a solid contribution to the discussion on optimizing PJI management. Its findings should prompt further high-quality studies aimed at refining treatment protocols and ultimately improving patient outcomes.