Amputation
ÎÎAmputation 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
ÎÎTreat 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).
ÎÎManage total elbow, total shoulder and total ankle infections with the
same protocols as THA infections (C-III).
ÎÎRecommended oral companion drugs for rifampin include ciprofloxacin
(A-I) or levofloxacin (A-II).
ÎÎSecondary 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).
ÎIf rifampin cannot be used due to allergy, toxicity or intolerance, treat with
Î
4-6 weeks of pathogen-specific intravenous antimicrobial therapy (B-III).
ÎMonitoring of outpatient IV antimicrobial therapy should follow published
Î
guidelines [Tice AD et al. Clin Infect Dis 2004; 38:1651-72.] (A-II).
ÎÎIndefinite 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).
ÎÎRifampin alone is NOT recommended for chronic suppression, and
rifampin combination therapy is not generally recommended.
ÎÎClinical and laboratory monitoring for efficacy and toxicity is advisable.
ÎÎThe 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
