Should we use rifampicin in periprosthetic joint infections caused by staphylococci when the implant has been exchanged? A multicentre observational cohort study

Abstract Background Previous studies demonstrated the efficacy of a rifampicin-based regimen in the treatment of acute staphylococcal periprosthetic joint infections (PJI) treated with surgical debridement. However, evidence is lacking to support use of rifampicin in cases where the implant is exchanged during revision. Methods We included all consecutive cases of staphylococcal PJIs treated from January 2013 to December 2018 with revision surgery into this international, retrospective, multicentre observational cohort study. PJI was defined according to the EBJIS diagnostic criteria. A relapse or reinfection during follow-up, the need for antibiotic suppressive therapy, the need for implant removal and PJI related death were defined as clinical failure. Cases without reimplantation or a follow up < 12 months were excluded. Results A total of 375 cases were included in the final analysis, including 124 one-stage-exchanges (33.1%) and 251 two-stage-exchanges (66.9%). Of those, 101 cases failed (26.9%). There was no statistically significant difference in failure of patients receiving rifampicin 22.5% (42/187) and not receiving rifampicin 31.4% (59/188; p=0.051). A subanalysis of chronic PJIs treated by two-stage exchange arthroplasty demonstrated a lower failure rate in cases treated with rifampicin (15%) compared to the no-rifampicin-group (35.5%; p=0.005). In this subgroup, the use of rifampicin and an antibiotic holiday of more than 2 weeks were independent predictors for clinical success (odds ratio [OR] 0.36, [95% CI 0.15–0.88] and OR 0.19 [95% CI 0.04–0.90], respectively). Conclusion Combination treatment with rifampicin increases treatment success in patients with chronic staphylococcal PJI treated with two-stage exchange arthroplasty.