Antibiotic Treatment and Timing of Reimplantation

PJI is traditionally treated with intravenous (IV) antibiotics in order to obtain the minimum inhibitory concentration in the shortest time possible. Once this goal is met and there is clinical evidence of improvement, some IV antibiotic regimens can be switched to oral regimens. There is scarce literature reporting on the use of oral (combined or single) antibiotic therapy for the treatment of PJIs without an initial IV regimen [1–5]. Most of these studies were conducted in cases where the prosthesis was retained. There is one study in which no oral or prolonged IV regimen was used after debridement and the use of an antibiotic-impregnated cement spacers led to a 87% eradication rate [6]. No literature conclusively supports the use of only oral (combined or single) antibiotic therapy prior to reimplantation. The recently-published guidelines of the Infectious Diseases Society of America (IDSA) [7] suggest that pathogen-specific, highly bioavailable oral therapy (e.g. linezolid or fluoroquinolones) may be an alternative as initial therapy for some cases of PJI. Concerns against the routine use of appropriate oral agents in the treatment of PJI largely comprise questions of patient medication compliance and the long-term use of medication therapy with less intensive efficacy and toxicity monitoring.