Safety Profile of Seven-Day Intra-articular Antibiotic Irrigation for the Treatment of Chronic Periprosthetic Joint Infection: A Prospective Randomized Phase II Comparative Study

Bryan D Springer; Carlos A Higuera-Rueda; Brian C de Beaubien; Kevin D Warner; Andrew H Glassman; Hari K Parvataneni; Nicolas S Piuzzi

doi:10.1016/j.arth.2024.03.069

Safety Profile of Seven-Day Intra-articular Antibiotic Irrigation for the Treatment of Chronic Periprosthetic Joint Infection: A Prospective Randomized Phase II Comparative Study

J Arthroplasty. 2024 Apr 9:S0883-5403(24)00313-9. doi: 10.1016/j.arth.2024.03.069. Online ahead of print.

Authors

Bryan D Springer¹, Carlos A Higuera-Rueda², Brian C de Beaubien³, Kevin D Warner⁴, Andrew H Glassman⁵, Hari K Parvataneni⁶, Nicolas S Piuzzi⁷

Affiliations

¹ OrthoCarolina, Hip and Knee Center, Charlotte, North Carolina.
² Department of Orthopaedic Surgery, Cleveland Clinic Florida, Weston, Florida.
³ Department of Orthopaedics, Covenant Medical Center, Saginaw, Michigan.
⁴ Covenant Medical Center, Saginaw, Michigan.
⁵ Department of Orthopaedics, The Ohio State University Wexner Medical Center, Columbus, Ohio.
⁶ Florida Orthopedic Institute, Gainesville, Florida.
⁷ Department of Orthopaedic Surgery, Cleveland Clinic Foundation, Cleveland, Ohio.

PMID: 38604274
DOI: 10.1016/j.arth.2024.03.069

Abstract

Background: Systemic intravenous antimicrobials yield poor outcomes during treatment of periprosthetic joint infection due to the inability to obtain minimum biofilm eradication concentrations. This study evaluated the safety of a novel method of optimized local delivery of intra-articular antibiotics (IAAs).

Methods: This was a Phase II, multicenter, prospective randomized trial evaluating safety of a rapid (seven-day) two-stage exchange arthroplasty with IAA irrigation compared to standard two-stage exchange. The Experimental Group received irrigation using 80 mg tobramycin daily with a 2-hour soak, followed by hourly irrigation using 125 mg vancomycin with a 30-minute soak via an intramedullary irrigation device. The Control Group received an antibiotic-loaded cement spacer with vancomycin (average 8.4 g) and tobramycin (average 7.1 g, total 16 g antibiotics). Both groups received 12 weeks of systemic antibiotics following Stage 2. Safety measures included adverse events, peak vancomycin/tobramycin serum concentrations (Experimental Group), blood transfusion, and mortality. There were thirty-seven patients randomized to the Experimental Group and 39 to control. There was no difference in baseline demographics or comorbidities.

Results: There were no antibiotic medication-related adverse events and 2 serious adverse events related to antibiotic instillation. Of 188 vancomycin peak measurements, 69% had detectable serum level concentrations, with all concentrations well below the maximum acceptable trough threshold of 20 μg/mL. Of the 103 tobramycin peak measurements, 45% had detectable levels, with all below the maximum acceptable peak threshold of 18 to 24 μg/mL. There was no difference in blood transfused per subject (Experimental: 655 mL versus Control: 792 mL; P = .4188). There were two (2) deaths in the Experimental Group and four (4) in the control.

Conclusions: The use of IAA is safe with minimal systemic antibiotic exposure. There was no difference in the rates or severity of serious adverse events between groups. Further research is being conducted to examine treatment efficacy.

Keywords: biofilm; hip PJI; knee PJI; periprosthetic joint infection; revision arthroplasty; two-stage exchange.