Unit of Infectious Diseases, Department of Internal Medicine, Hospital Universitario 12 de Octubre, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain.
Red Española de Investigación en Patología Infecciosa (REIPI).
Clin Infect Dis. 2017 Jun 15;64(12):1742-1752. doi: 10.1093/cid/cix227.
BACKGROUND.: Streptococci are not an infrequent cause of periprosthetic joint infection (PJI). Management by debridement, antibiotics, and implant retention (DAIR) is thought to produce a good prognosis, but little is known about the real likelihood of success.
METHODS.: A retrospective, observational, multicenter, international study was performed during 2003-2012. Eligible patients had a streptococcal PJI that was managed with DAIR. The primary endpoint was failure, defined as death related to infection, relapse/persistence of infection, or the need for salvage therapy.
RESULTS.: Overall, 462 cases were included (median age 72 years, 50% men). The most frequent species was Streptococcus agalactiae (34%), and 52% of all cases were hematogenous. Antibiotic treatment was primarily using β-lactams, and 37% of patients received rifampin. Outcomes were evaluable in 444 patients: failure occurred in 187 (42.1%; 95% confidence interval, 37.5%-46.7%) after a median of 62 days from debridement; patients without failure were followed up for a median of 802 days. Independent predictors (hazard ratios) of failure were rheumatoid arthritis (2.36), late post-surgical infection (2.20), and bacteremia (1.69). Independent predictors of success were exchange of removable components (0.60), early use of rifampin (0.98 per day of treatment within the first 30 days), and long treatments (≥21 days) with β-lactams, either as monotherapy (0.48) or in combination with rifampin (0.34).
CONCLUSIONS.: This is the largest series to our knowledge of streptococcal PJI managed by DAIR, showing a worse prognosis than previously reported. The beneficial effects of exchanging the removable components and of β-lactams are confirmed and maybe also a potential benefit from adding rifampin.
链球菌并非假体周围关节感染（PJI）的罕见病因。保留清创、抗生素和植入物的清创、抗生素、和植入物保留（DAIR）治疗被认为具有良好的预后，但对于其实际成功率知之甚少。
本研究为 2003 年至 2012 年期间进行的一项回顾性、观察性、多中心、国际研究。符合条件的患者患有链球菌 PJI，采用 DAIR 治疗。主要终点是失败，定义为与感染相关的死亡、感染复发/持续存在或需要挽救性治疗。
共有 462 例病例纳入研究（中位年龄 72 岁，50%为男性）。最常见的菌种为无乳链球菌（34%），所有病例中有 52%为血源性。抗生素治疗主要使用β-内酰胺类药物，37%的患者使用利福平。444 例患者的结局可评估：在清创后中位 62 天，187 例（42.1%；95%置信区间，37.5%-46.7%）发生失败；无失败的患者中位随访 802 天。失败的独立预测因素（风险比）为类风湿关节炎（2.36）、术后晚期感染（2.20）和菌血症（1.69）。成功的独立预测因素为可更换部件的更换（0.60）、早期使用利福平（治疗的前 30 天内每天使用 0.98）和较长时间的治疗（≥21 天）β-内酰胺类药物，单独使用（0.48）或与利福平联合使用（0.34）。
这是我们所知的最大系列关于链球菌 PJI 采用 DAIR 治疗的研究，结果显示预后比以前报道的更差。可更换部件和β-内酰胺类药物的有益作用得到证实，并且添加利福平可能也有潜在益处。
