Amputation
����Amputation should be the last option considered but may be
appropriate in selected cases. Except in emergent cases, referral to a
center with specialist experience in the management of PJI is advised
before amputation is carried out (Figures 2-4) (B-III).
PJI following debridement and retention of the prosthesis
STAPHYLOCOCCAL PJI
����Treat with 2-6 weeks of a pathogen-specific intravenous antimicrobial
(Table 2) in combination with rifampin 300-450 mg orally BID followed
by rifampin plus a companion oral drug for a total of 3 months for a
THA infection and 6 months for a TKA infection (A-I).
����Manage total elbow, total shoulder and total ankle infections with the
same protocols as THA infections (C-III).
����Recommended oral companion drugs for rifampin include ciprofloxacin
(A-I) or levofloxacin (A-II).
����Secondary companion drugs to be used if in vitro susceptibility,
allergies, intolerances or potential intolerances support the use
of an agent other than a quinolone include but are not limited to
co-trimoxazole (A-II), minocycline, doxycycline (C-III) or oral first
generation cephalosporins such as cephalexin or antistaphylococcal
penicillins such as dicloxacillin (C-III).
��If rifampin cannot be used due to allergy, toxicity or intolerance, treat with
��
4-6 weeks of pathogen-specific intravenous antimicrobial therapy (B-III).
��Monitoring of outpatient IV antimicrobial therapy should follow published
��
guidelines [Tice AD et al. Clin Infect Dis 2004; 38:1651-72.] (A-II).
����Indefinite chronic oral antimicrobial suppression with cephalexin,
dicloxacillin, co-trimoxazole or minocycline may follow the above
regimen based on in vitro susceptibility, allergies or intolerances
(Table 3) (B-III).
����Rifampin alone is NOT recommended for chronic suppression, and
rifampin combination therapy is not generally recommended.
����Clinical and laboratory monitoring for efficacy and toxicity is advisable.
����The decision to offer chronic suppressive therapy must take into
account the individual circumstances of the patient including:
������ the ability to use rifampin in the initial phase of treatment
������ the potential for progressive implant loosening and loss of bone stock
������ the hazards of prolonged antibiotic therapy.
5
