Suppressive Antibiotic Therapy after Debridement, Antibiotics, and Implant Retention (DAIR) is Well-Tolerated Without Inducing Resistance: A Multicenter Study

Background Suppressive antibiotic therapy (SAT) after total joint arthroplasty (TJA) debridement, antibiotics, and implant retention (DAIR) maximizes reoperation-free survival. Our aims were to evaluate SAT after DAIR of acutely infected primary TJA regarding: 1) adverse drug reaction (ADR)/intolerance; 2) reoperation for infection; and 3) antibiotic resistance. Methods Patients who underwent total knee arthroplasty (TKA) or total hip arthroplasty (THA) DAIR for acute PJI at two academic medical centers from 2015 to 2020 were identified (n = 115). Data were collected on patient demographics, infecting organisms, antibiotics, ADR/intolerances, reoperations, and antibiotic resistances. Median SAT duration was 11 months. Stepwise multivariate logistic regressions were used to identify covariates significantly associated with outcomes of interest. Results There were 11.1% and 16.3% of TKA and THA DAIR patients, respectively, who had ADR/intolerance to SAT. Patients prescribed trimethoprim/sulfamethoxazole (TMP-SMZ) (P = 0.0014) or combination antibiotic therapy (P = 0.0169) after TKA DAIR had increased risk of ADR/intolerance. There was no difference in reoperation-free survival between TKA (83.3%) and THA (65.1%) DAIR (P = 0.5900) at mean 2.8-year follow-up. Risk of reoperation for infection was higher among TKA Staphylococcus aureus infections (P = 0.0004) and lower with increased SAT duration (P < 0.0450). The optimal duration of SAT was nearly 2 years. No cases of antibiotic resistance developed due to SAT. Conclusion One should consider SAT after TJA DAIR due to improved reoperation-free survival and favorable safety profile. Prolonged SAT did not induce antibiotic resistance. Use TMP-SMZ with caution because of the increased likelihood of ADR/intolerance.