A prospective multicentre study of 82 prosthetic joint infections treated with a standardised debridement and implant retention (DAIR) protocol followed by 6 weeks of antimicrobial therapy: favourable results
Restricted accessResearch articleFirst published online January, 2025
A prospective multicentre study of 82 prosthetic joint infections treated with a standardised debridement and implant retention (DAIR) protocol followed by 6 weeks of antimicrobial therapy: favourable results
Prosthetic joint infection (PJI) is a much-feared complication in total joint arthroplasty. Debridement, antibiotics, irrigation and implant retention (DAIR) is often the preferred treatment in acute PJIs, but with varying results. The primary aim of this study was to evaluate the outcome of a high quality DAIR procedure performed according to a consistently applied surgical protocol in early postoperative and acute haematogenous PJIs in hip and knee, and secondary to study risk factors associated with failure.
Methods:
We performed a prospective multicentre study to evaluate the effect of a standardised protocol-based surgical management (DAIR) emphasising a thorough debridement, followed by 6 weeks of antimicrobial therapy. Empiric parenteral antimicrobial treatment was administered until the results of susceptibility tests were available. No suppressive antimicrobial therapy was given after the 6-week treatment-period. Primary outcome measure was infection control at the 2-year follow-up.
Results:
A total of 99 patients from 8 Norwegian hospitals were found eligible and included in the study, and 82 patients were finally analysed. 69 of 82 patients (84% [CI, 76–92%]) were successfully treated with this treatment protocol. We found a reduced success rate when patients were treated with a DAIR procedure following an infected revision arthroplasty compared with an infected primary arthroplasty (11/17 (65 %) versus 58/65 (89 %), respectively (p = 0.02).
Conclusions:
The success rate of a standardised DAIR procedure with a 6-week antimicrobial treatment was good in PJI following primary arthroplasties. The success rate following PJI in revision arthroplasty was poor, and other treatment options should be considered.
LearmonthIDYoungCRorabeckC.The operation of the century: total hip replacement. Lancet2007; 370: 1508–1519.
2.
KelmerGStoneAHTurcotteJ, et al. Reasons for revision: primary total hip arthroplasty mechanisms of failure. J Am Acad Orthop Surg2021; 29: 78–87.
3.
KloucheSSarialiEMamoudyP.Total hip arthroplasty revision due to infection: a cost analysis approach. Orthop Traumatol Surg Res2010; 96: 124–132.
4.
BradburyTFehringTKTauntonM, et al. The fate of acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty2009; 24(Suppl.): 101–104.
5.
ZimmerliWWidmerAFBlatterM, et al. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA1998; 279: 1537–1541.
6.
Lora-TamayoJMurilloOIribarrenJA, et al. A large multicenter study of methicillin-susceptible and methicillin-resistant Staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis2013; 56: 182–194.
7.
FehringTKOdumSMBerendKR, et al. Failure of irrigation and debridement for early postoperative periprosthetic infection. Clin Orthop Relat Res2013; 471: 250–257.
8.
Di BenedettoPDi BenedettoEDSalviatoD, et al. Acute periprosthetic knee infection: is there still a role for DAIR?Acta Biomed2017; 88(2S): 84–91.
9.
ShohatNGoswamiKTanTL, et al. Increased failure after irrigation and debridement for acute hematogenous periprosthetic joint infection. J Bone Joint Surg Am2019; 101: 696–703.
10.
KuiperJWWillinkRTMoojenDJ, et al. Treatment of acute periprosthetic infections with prosthesis retention: review of current concepts. World J Orthop2014; 5: 667–676.
11.
FlierlMACulpBMOkrojKT, et al. Poor outcomes of irrigation and debridement in acute periprosthetic joint infection with antibiotic-impregnated calcium sulfate beads. J Arthroplasty2017; 32: 2505–2507.
12.
OttesenCSTroelsenASandholdtH, et al. Acceptable Success rate in patients with periprosthetic knee joint infection treated with debridement, antibiotics, and implant retention. J Arthroplasty2019; 34: 365–368.
13.
TsukayamaDTEstradaRGustiloRB.Infection after total hip arthroplasty. A study of the treatment of one hundred and six infections. J Bone Joint Surg Am1996; 78: 512–523.
14.
KarlsenØEBorgenPBragnesB, et al. Rifampin combination therapy in staphylococcal prosthetic joint infections: a randomized controlled trial. J Orthop Surg Res2020; 15: 365.
15.
ArgensonJNArndtMBabisG, et al. Hip and knee section, treatment, debridement and retention of implant: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty2019; 34(2S): S399–S419.
16.
VilchezFMartínez-PastorJCGarcía-RamiroS, et al. Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement. Clin Microbiol Infect2011; 17: 439–444.
17.
BarberánJAguilarLCarroquinoG, et al. Conservative treatment of staphylococcal prosthetic joint infections in elderly patients. Am J Med2006; 119: 993. e7–10.
18.
Wouthuyzen-BakkerMSebillotteMHuotariK, et al. Lower success rate of debridement and implant retention in late acute versus early acute periprosthetic joint infection caused by Staphylococcus spp. Results from a matched cohort study. Clin Orthop Relat Res2020; 478: 1348–1355.
19.
ByrenIBejonPAtkinsBL, et al. One hundred and twelve infected arthroplasties treated with ‘DAIR’ (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother2009; 63: 1264–1271.
20.
BongartzTHalliganCSOsmonDR, et al. Incidence and risk factors of prosthetic joint infection after total hip or knee replacement in patients with rheumatoid arthritis. Arthritis Rheum2008; 59: 1713–1720.
21.
HolmbergAThórhallsdóttirVGRobertssonO, et al. 75% success rate after open debridement, exchange of tibial insert, and antibiotics in knee prosthetic joint infections. Acta Orthop2015; 86: 457–462.
22.
AboltinsCDowseyMPeelT, et al. Good quality of life outcomes after treatment of prosthetic joint infection with debridement and prosthesis retention. J Orthop Res2016; 34: 898–902.
23.
BryanAJAbdelMPSandersTL, et al. Irrigation and debridement with component retention for acute infection after hip arthroplasty: improved results with contemporary management. J Bone Joint Surg Am2017; 99: 2011–2018.
24.
GurenEFigvedWFrihagenF, et al. Prosthetic joint infection-a devastating complication of hemiarthroplasty for hip fracture. Acta Orthop2017; 88: 383–389.
25.
del ToroMDNietoIGuerreroF, et al. Are hip hemiarthroplasty and total hip arthroplasty infections different entities? The importance of hip fractures. Eur J Clin Microbiol Infect Dis2014; 33: 1439–1448.
TorneroEGarcía-OltraEGarcía-RamiroS, et al. Prosthetic joint infections due to Staphylococcus aureus and coagulase-negative staphylococci. Int J Artif Organs2012; 35: 884–892.
28.
LeeJKangCILeeJH, et al. Risk factors for treatment failure in patients with prosthetic joint infections. J Hosp Infect2010; 75: 273–276.
29.
PeelTNBuisingKLDowseyMM, et al. Outcome of debridement and retention in prosthetic joint infections by methicillin-resistant staphylococci, with special reference to rifampin and fusidic acid combination therapy. Antimicrob Agents Chemother2013; 57: 350–355.
30.
ChaussadeHUçkayIVuagnatA, et al. Antibiotic therapy duration for prosthetic joint infections treated by debridement and implant retention (DAIR): similar long-term remission for 6 weeks as compared to 12 weeks. Int J Infect Dis2017; 63: 37–42.
31.
ScheperHvan der WalRJPMahdadR, et al. Effectiveness of different antimicrobial strategies for staphylococcal prosthetic joint infection: results from a large prospective registry-based cohort study. Open Forum Infect Dis2022; 9: ofac474.
32.
BullerLTSabryFYEastonRW, et al. The preoperative prediction of success following irrigation and debridement with polyethylene exchange for hip and knee prosthetic joint infections. J Arthroplasty2012; 27: 857–864.e1–4.
33.
ChoiHRKwonYMFreibergAA, et al. Periprosthetic joint infection with negative culture results: clinical characteristics and treatment outcome. J Arthroplasty2013; 28: 899–903.
34.
PuhtoAPPuhtoTSyrjalaH.Short-course antibiotics for prosthetic joint infections treated with prosthesis retention. Clin Microbiol Infect2012; 18: 1143–1148.
35.
Lora-TamayoJEubaGCoboJ, et al. Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. Int J Antimicrob Agents2016; 48: 310–316.
36.
LesensOFerryTForestierE, et al. Should we expand the indications for the DAIR (debridement, antibiotic therapy, and implant retention) procedure for Staphylococcus aureus prosthetic joint infections? A multicenter retrospective study. Eur J Clin Microbiol Infect Dis2018; 37: 1949–1956.
