Abstract
Aim
There is a theoretical advantage for immediate postoperative start of rifampicin after debridement, antibiotics and implant retention (DAIR). Anti-biofilm treatment may be mostly needed during the first postoperative days in order to prevent new biofilm formation. However, there are concerns with regard to development of rifampicin resistance if rifampicin is started too early. Rifampicin monotherapy will rapidly result in rifampicin resistance, but this may not occur when prescribed as part of combination antimicrobial therapy and after thorough surgical debridement. We hypothesized that in this setting the probability of development of rifampicin resistance is very low. We evaluated the frequency of development of rifampicin resistance in patients with acute staphylococcal PJI who were treated with DAIR followed by immediate postoperative start of rifampicin in combination with a betalactam or glycopeptide.
Method
During 2003–2014, all patients with an acute staphylococcal PJI were treated with five days of high-dose rifampicin (600mg bid) in combination with at least 6 weeks of betalactam or glycopeptide antibiotics, both started immediately postoperative after DAIR. Clinical outcome and development of rifampicin resistance in patients who failed were monitored. Susceptibility testing for rifampicin was performed by Vitek 2 (Biomerieux). Until 2014, Clinical and Laboratory Standards Institute (CLSI) criteria for rifampicin resistance were applied (S ≤ 1), from 2014 EUCAST criteria (S ≤ 0.06) were applied.
Results
Forty-one patients with acute staphylococcal hip (22) of knee (19) PJI were included. Comorbidities were rheumatoid arthritis (22%), diabetes (10%), a tumor prosthesis due to malignancy (34%) and corticosteroid use (27%). Fifteen patients (37%) developed a failure after DAIR. Eight failures were caused by the same staphylococcal species as the initial PJI (six Staphylococcus aureus, two Coagulase-negative staphylococci). In all failures, rifampicin susceptibility of the isolate had not changed. One patient was started on chronic suppressive treatment (not including rifampicin) and had a prosthetic joint removal 18 months later. In this patient, one out of five positive cultures with S. aureus from the removed prosthesis showed a rifampicin resistant strain. In all failures, mean duration between the initial DAIR and failure was 208 days (range 7–636 days).
Conclusions
Immediate postoperative start of high-dose rifampicin in combination with betalactam or glycopeptide did not result in rifampicin resistant staphylococci among patient who had a failure with the same staphylococci. These results strongly indicate that immediate postoperative start of rifampicin is safe. Larger studies are needed to prove the clinical benefit of this strategy.
