Laurens Manning1, Sarah Metcalf2, Michael Dymock3, Owen Robinson4, Benjamin Clark5, Renjy Nelson6, David L Paterson7, Piers Yates8, Mark Loewenthal9, David Dewar10, Paul Huggan11, Joshua S Davis12. 1. Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Murdoch, Western Australia; Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia; Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia. Electronic address: laurens.manning@uwa.edu.au. 2. Department of Infectious Diseases, Christchurch Hospital, New Zealand. 3. Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, Western Australia, Australia. 4. Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia; Department of Infectious Diseases, Royal Perth Hospital, Perth, Western Australia, Australia; PathWest Laboratory Medicine, Perth, Western Australia, Australia; College of Science, Health, Engineering and Education, Murdoch University, Western Australia, Australia. 5. Department of Infectious Diseases, Fiona Stanley Hospital, Perth, Western Australia. 6. Infectious Diseases Department, Royal Adelaide Hospital, Adelaide, South Australia; Faculty of Health and Medical Sciences, University of Adelaide, South Australia. 7. University of Queensland Centre for Clinical Research, Royal Brisbane and Womens Hospital Campus, Brisbane, Queensland, Australia. 8. Medical School, University of Western Australia, Harry Perkins Research Institute, Fiona Stanley Hospital, Murdoch, Western Australia; Department of Orthopaedic Surgery, Fiona Stanley Hospital, Perth, Western Australia, Australia. 9. Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, NSW, Australia. 10. School of Medicine and Public Health, University of Newcastle, NSW, Australia; Department of Orthopaedic Surgery, John Hunter Hospital, Newcastle, NSW, Australia. 11. Waikato District Health Board, Hamilton, New Zealand. 12. Department of Infectious Diseases, John Hunter Hospital, Newcastle, NSW, Australia; Global and Tropical Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia.
Abstract
BACKGROUND: Peri-prosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. Determining the optimal duration of intravenous (IV) antibiotics for PJI managed with debridement and implant retention (DAIR) is a research priority. METHODS: Patients undergoing DAIR for early and late-acute PJI of the hip or knee were randomised to receive 2 (short-course) or 6 (standard-course) weeks of IV antibiotics, with both groups completing 12 weeks of antibiotics in total. The primary endpoint of this pilot, open-label, randomised trial was a 7-point ordinal desirability of outcome ranking (DOOR) score, which accounted for mortality, clinical cure and treatment adverse events at 12 months. Duration of IV treatment was used as a tiebreaker, with shorter courses ranked higher. Outcome adjudication was performed by expert clinicians blinded to the allocated intervention (Australia and New Zealand Clinical Trials Registry ACTRN12617000127303). RESULTS: 60 patients were recruited; 31 and 29 were allocated to short- and standard-course treatment, respectively. All had an evaluable outcome at 12 months and were analysed by intention-to-treat. Clinical cure was demonstrated in 44 (73%) overall; 22 (71%) in the short-course group and 22 (76%) in the standard-care group (P=0.77). Using the DOOR approach, the probability that short- was better than standard-course treatment was 59.7% (95% confidence interval 45.1-74.3). CONCLUSIONS: In selected patients with early and late-acute PJI managed with DAIR, shorter courses of IV antibiotics may be appropriate. Due to small sample size, these data accord with, but do not confirm, results from other international trials of early transition to oral antibiotics.
BACKGROUND: Peri-prosthetic joint infection (PJI) is a devastating complication of joint replacement surgery. Determining the optimal duration of intravenous (IV) antibiotics for PJI managed with debridement and implant retention (DAIR) is a research priority. METHODS: Patients undergoing DAIR for early and late-acute PJI of the hip or knee were randomised to receive 2 (short-course) or 6 (standard-course) weeks of IV antibiotics, with both groups completing 12 weeks of antibiotics in total. The primary endpoint of this pilot, open-label, randomised trial was a 7-point ordinal desirability of outcome ranking (DOOR) score, which accounted for mortality, clinical cure and treatment adverse events at 12 months. Duration of IV treatment was used as a tiebreaker, with shorter courses ranked higher. Outcome adjudication was performed by expert clinicians blinded to the allocated intervention (Australia and New Zealand Clinical Trials Registry ACTRN12617000127303). RESULTS: 60 patients were recruited; 31 and 29 were allocated to short- and standard-course treatment, respectively. All had an evaluable outcome at 12 months and were analysed by intention-to-treat. Clinical cure was demonstrated in 44 (73%) overall; 22 (71%) in the short-course group and 22 (76%) in the standard-care group (P=0.77). Using the DOOR approach, the probability that short- was better than standard-course treatment was 59.7% (95% confidence interval 45.1-74.3). CONCLUSIONS: In selected patients with early and late-acute PJI managed with DAIR, shorter courses of IV antibiotics may be appropriate. Due to small sample size, these data accord with, but do not confirm, results from other international trials of early transition to oral antibiotics.
Authors: Don Bambino Geno Tai; Elie F Berbari; Gina A Suh; Brian D Lahr; Matthew P Abdel; Aaron J Tande Journal: Open Forum Infect Dis Date: 2022-07-25 Impact factor: 4.423