Clinical use of linezolid in periprosthetic joint infections - a systematic review

Introduction: The most common causative organism in periprosthetic joint infections (PJIs) is Gram-positive bacteria that are increasingly drug resistant. In these cases the use of linezolid may be warranted. However, there are conflicting reports regarding its role in antibiotic treatment of PJIs. The aim of this review is to gather and analyze clinical results and treatment details on linezolid in patients with PJIs. Methods: In August 2019, a comprehensive literature search using MEDLINE (Pubmed and Ovid) and Cochrane Library was performed. A total of 504 records were screened, and a total of 16 studies including 372 patients treated with linezolid for a PJI were included in this review based on the PRISMA criteria and after quality analysis using the MINOR score and Newcastle-Ottawa scale, as well as assessing level of evidence. Pooling analysis as well as descriptive analysis was performed. Results: Based on the results from the studies included, infection control was achieved in 80 % (range 30 %-100 %) of patients after a mean follow-up period of 25 (range 2-66) months. The mean duration of treatment was 58 d intravenous and orally at a median dose of 600 mg bis in die (b.i.d.) (range 400-900 b.i.d.). A combination therapy with rifampicin was used in 53 % of patients. MRSA (methicillin-resistant Staphylococcus aureus) infections were present in 29 % and resistant CoNS (coagulase-negative Staphylococcus) in 46 %. Adverse effects occurred in 33 % of cases, mostly anemia, thrombocytopenia and gastrointestinal complaints leading to treatment discontinuation in 9 %. However, great heterogeneity was found with respect to surgical treatment, diagnosis of infection and indication for linezolid. Discussion: Linezolid is an appropriate option for treatment of resistant Gram-positive organisms in PJIs. Most commonly 600 mg b.i.d. is used, and a combination with rifampicin appears feasible although one must consider individual increases in doses in these cases. However, adverse effects are common and there are limited data for long-term use and optimal antibiotic combinations or individual doses.