Antibiotic Therapy in 2-Stage Revision for Periprosthetic Joint Infection: A Systematic Review

Patients undergoing total joint arthroplasty (TJA) are at risk for developing periprosthetic joint infection (PJI). To treat PJI, orthopaedic surgeons can perform 1-stage or 2-stage revision arthroplasty. Although 2-stage revision yields superior long-term outcomes, the optimal antibiotic therapy duration and route of administration between stages remain uncertain. In this systematic review, we aimed to identify if variations in antibiotic therapy, duration, and administration during 2-stage hip or knee revision arthroplasty affect PJI eradication rates and surgical outcome measures.

A literature search was performed using the PubMed and Google Scholar databases to identify all original reports from January 2000 to June 2021 involving 2-stage revision arthroplasty to treat PJI. Studies were included if they specified antibiotic duration, an intravenous (IV) route of antibiotic administration, type of antibiotic, and 2-stage revision PJI eradication rate and had a mean or median follow-up of at least 2 years after the second-stage operation. Included studies were classified into 3 groups based on the length of IV antibiotic therapy after prosthesis explantation: prolonged IV antibiotic therapy of 4 to 6 weeks, shortened IV antibiotic therapy of ≤2 weeks, and shortened course of IV antibiotic therapy followed by 6 to 12 weeks of oral antibiotics.

Nine studies were included. Three studies utilizing a prolonged IV antibiotic therapy had PJI eradication rates of 79% to 96%. Four studies using a shortened IV antibiotic therapy showed PJI eradication rates of 88% to 100%. Finally, 2 studies utilizing a shortened course of IV antibiotic therapy with oral antibiotics had PJI eradication rates of 95% and 97%. There was no significant difference in eradication rates across IV antibiotic duration strategies, despite a diverse array of cultured microorganisms across the studies.

Although the numbers are small, this systematic review suggests that prolonged IV antibiotic duration, shortened IV antibiotic duration, and shortened IV antibiotic duration supplemented with oral antibiotics confer similar PJI eradication rates after hip or knee arthroplasty.

Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.