Combined antibiotic therapy spacers either commercial or handmade are superior to monotherapy – a microbiological analysis at the second stage of revision

Abstract

Background: Antibiotic-loaded spacers are often used during two-stage exchange for periprosthetic joint infections (PJIs) both for its mechanical properties and as a means of local antibiotic delivery. Purpose: The main goal of this study is to compare the efficacy of different options of antibiotic(s) in spacers concerning the rate of positive cultures at the second stage. Patients and Methods: We retrospectively evaluated two-stage exchange procedures for infected hip or knee arthroplasty performed between 2012 and 2018 in which adequate (at least four deep tissue samples) culture results in both stages were available. The type of spacer and antibiotics used, in addition to several other patient, infection and treatment-related variables, were registered and correlated to microbiological findings in the second stage. Results: Fifty-eight cases were included with a 19.0 % (11/58) overall rate of positive cultures during reimplantation. With a mean follow-up of 46 months, failure rate was significantly higher at 63.6 % (7/11) in cases with positive cultures at reimplantation compared to 4.3 % (2/47) for those with negative cultures during reimplantation (p< 0.001). The need for additional surgeries was also significantly higher (odds ratio (OR) 122.67, confidence interval (CI) 95 % 11.30–1331.32, p< 0.001). Multivariable analysis revealed antibiotics in the spacers were the main independent prognostic risk factor associated with positive cultures at the second stage with an advantage for combined antibiotics. Monotherapy is associated with failure with an OR of 16.99. Longer time between surgeries did not have statistical significance (p= 0.05), and previous surgical treatment for PJI, presence of difficult-to-treat microorganism(s), duration of systemic antibiotic therapy or even treatment within a dedicated septic team were not shown to be independent risk factors. Among combined antibiotic spacers, there were no significant differences between the rate of positive cultures during the second stage, comparing commercially available vancomycin/gentamicin spacers to hand-mixed vancomycin/meropenem manufactured spacers (8.3 % [2/24] vs. 15.0 % [3/20], p= 0.68). Conclusions: Results show that combined antibiotic therapy spacers are advantageous when compared to gentamicin monotherapy as they produce significantly lower rates of subsequent positive cultures during the second stage. Hand-mixed high-dose vancomycin/meropenem spacers seem to perform just as well as prefabricated commercially available vancomycin/gentamicin options. Level of Evidence: Therapeutic level III.