title: The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study.
abstract: 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.
  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.
  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).
  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.
authors.affiliation: 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).
authors.forename: Jaime
authors.initials: J
authors.lastname: Lora-Tamayo
authors.affiliation: Department of Infectious Diseases, Gustave Dron Hospital of Tourcoing, France.
authors.forename: Éric
authors.initials: É
authors.lastname: Senneville
authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Department of Infectious Diseases, Hospital Universitario de Bellvitge, IDIBELL, Barcelona, Spain.|Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom.
authors.forename: Alba
authors.initials: A
authors.lastname: Ribera
authors.affiliation: Department of Infectious Diseases, Hôpital Universitaire Bretonneau, Tours, France.|Centre de Référence pour les Infections Ostéo-Articulaires Complexes du Grand Ouest (CRIOGO).
authors.forename: Louis
authors.initials: L
authors.lastname: Bernard
authors.affiliation: Centre correspondant de prise en charge des Infections Ostéo-articulaires Complexes du Grand Sud-Ouest, CHU Bordeaux.
authors.forename: Michel
authors.initials: M
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authors.affiliation: Centre de Référence des Infections Ostéo-Articulaires Complexes, Groupe Hospitalier Diaconesses Croix Saint Simon, Paris, and.
authors.forename: Valérie
authors.initials: V
authors.lastname: Zeller
authors.affiliation: Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford, United Kingdom.
authors.forename: Ho Kwong
authors.initials: HK
authors.lastname: Li
authors.affiliation: Centre de Référence pour les Infections Ostéo-Articulaires Complexes du Grand Ouest (CRIOGO).|Department of Infectious Diseases, Rennes University Hospital, Rennes, France.
authors.forename: Cédric
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authors.affiliation: Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland, Liestal.
authors.forename: Martin
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authors.lastname: Clauss
authors.affiliation: Department of Infectious Diseases, Hôpitaux Universitaires Genève, Switzerland.
authors.forename: Ilker
authors.initials: I
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authors.affiliation: Hospital of Traumatology and Orthopedics, Riga, Latvia.
authors.forename: Dace
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authors.affiliation: Department of Infectious and Tropical Diseases, Hôpital de la Croix-Rousse, Hospices Civils de Lyon, France.
authors.forename: Tristan
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authors.lastname: Ferry
authors.affiliation: Department of Infectious Diseases, Hospital Universitario Donostia, San Sebastián, Spain.
authors.forename: José Antonio
authors.initials: JA
authors.lastname: Iribarren
authors.affiliation: Department of Infectious Diseases, Saint Vincent's Public Hospital, Melbourne, Victoria, Australia.
authors.forename: Trisha N
authors.initials: TN
authors.lastname: Peel
authors.affiliation: Department of Infectious Diseases, University Hospital of Bern, Switzerland.
authors.forename: Parham
authors.initials: P
authors.lastname: Sendi
authors.affiliation: Infectious Diseases Department, University Clinical Center, Maribor, Slovenia.
authors.forename: Nina Gorišek
authors.initials: NG
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authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Infectious Diseases Department, Hospital Universitari Vall d'Hebron, Universitat Autònoma de Barcelona.
authors.forename: Dolors
authors.initials: D
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authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (Ibis), University of Seville, University Hospitals Virgen Macarena y Virgen del Rocío, and.
authors.forename: María Dolores
authors.initials: MD
authors.lastname: Del Toro
authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Department of Infectious Diseases, Hospital Universitario Marqués de Valdecilla, Santander, Spain.
authors.forename: Marta
authors.initials: M
authors.lastname: Fernández-Sampedro
authors.affiliation: Center for Orthopedics, Trauma Surgery and Spinal Cord Injury, Heidelberg University Hospital, Germany.
authors.forename: Ulrike
authors.initials: U
authors.lastname: Dapunt
authors.affiliation: Helsinki University Hospital, Finland.
authors.forename: Kaisa
authors.initials: K
authors.lastname: Huotari
authors.affiliation: Department of Infectious Diseases, John Hunter Hospital, Newcastle, New South Wales, Australia.
authors.forename: Joshua S
authors.initials: JS
authors.lastname: Davis
authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Clinical Unit of Infectious Diseases, Microbiology and Preventive Medicine, Institute of Biomedicine of Seville (Ibis), University of Seville, University Hospitals Virgen Macarena y Virgen del Rocío, and.
authors.forename: Julián
authors.initials: J
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authors.affiliation: Departments of Orthopedic Surgery and Biomedical Engineering, University of Groningen, University Medical Center Groningen, The Netherlands.
authors.forename: Danielle
authors.initials: D
authors.lastname: Neut
authors.affiliation: Department of Infectious Diseases, Fiona Stanley Hospital, Western Australia.
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authors.initials: BM
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authors.affiliation: Department of Microbiology and Infectious Diseases, Concord Hospital, New South Wales, Australia.
authors.forename: Thomas
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authors.affiliation: Service for Bone Infections, Valdoltra Orthopaedic Hospital, Ankaran, Slovenia.
authors.forename: Rihard
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authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Department of Infectious Diseases, Hospital Clínic, Barcelona, Spain.|ESCMID Study Group for Implant-Associated Infections (ESGIAI).
authors.forename: Alex
authors.initials: A
authors.lastname: Soriano
authors.affiliation: Department of Internal Medicine, Hospital de El Bierzo, Ponferrada.
authors.forename: Alberto
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authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Unit of Infectious Diseases, Hospital de Cruces, Barakaldo, and.
authors.forename: Laura
authors.initials: L
authors.lastname: Guío
authors.affiliation: Unit of Infectious Diseases, Department of Internal Medicine, Hospital Universitario La Paz, Madrid, Spain.
authors.forename: Alicia
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authors.affiliation: Unit of Infectious Diseases, Department of Internal Medicine, Santa Casa de Misericórdia de São Paulo, Brazil.
authors.forename: Mauro J C
authors.initials: MJC
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authors.affiliation: Unit of Infectious Diseases, Department of Internal Medicine, Hospital Universitario Lucus Augusti, Lugo, Spain.
authors.forename: M José G
authors.initials: MJG
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authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Unit of Infectious Diseases, Hospital Universitari de la Santa Creu I Sant Pau, Institut d'Investigació Biomèdica Sant Pau, Universitat Autònoma de Barcelona.
authors.forename: Natividad
authors.initials: N
authors.lastname: Benito
authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Department of Internal Medicine, Hospital Son Espases, Palma de Mallorca, and.
authors.forename: Melchor
authors.initials: M
authors.lastname: Riera
authors.affiliation: Unit of Infectious Diseases, Hospital Universitari Mútua de Terrassa, Spain.
authors.forename: Lucía
authors.initials: L
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authors.affiliation: Department of Infectious Diseases, Northern Health, Victoria and University of Melbourne, Northern Clinical School, Australia.
authors.forename: Craig A
authors.initials: CA
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authors.affiliation: Department of Clinical Microbiology, IIS-Fundación Jiménez Díaz, Madrid.
authors.forename: Jaime
authors.initials: J
authors.lastname: Esteban
authors.affiliation: Department of Infectious Diseases, Hospital del Mar, Barcelona, Spain.
authors.forename: Juan Pablo
authors.initials: JP
authors.lastname: Horcajada
authors.affiliation: Department of Clinical Microbiology, Beaumont Hospital, Dublin, Ireland.
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authors.lastname: O'Connell
authors.affiliation: Department of Orthopedics and Rehabilitation, Humanitas Research Hospital, Milano, Italy.
authors.forename: Matteo
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authors.affiliation: Department of Orthopedics, OrhopediClinic, Semmelweis University, Budapest, Hungary.
authors.forename: Gábor
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authors.affiliation: 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).
authors.forename: Rafael San
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authors.forename: José María
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authors.forename: Nathalie
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authors.forename: Séverine
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authors.affiliation: Centre de Référence pour les Infections Ostéo-Articulaires Complexes du Grand Ouest (CRIOGO).|Department of Infectious Diseases, Hôpital Universitaire La Miletrie, Poitiers, France.
authors.forename: Gwenäel Le
authors.initials: GL
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authors.affiliation: Interdisciplinary Septic Surgical Unit, Kantonsspital Baselland, Liestal.
authors.forename: Werner
authors.initials: W
authors.lastname: Zimmerli
authors.affiliation: Red Española de Investigación en Patología Infecciosa (REIPI).|Department of Infectious Diseases, Hospital Universitario de Bellvitge, IDIBELL, Barcelona, Spain.
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mesh_terms: D000368:Aged; D000900:Anti-Bacterial Agents / Q000008:administration & dosage / Q000627:therapeutic use; D001170:Arthritis, Infectious / Q000188:drug therapy* / Q000382:microbiology / Q000401:mortality / Q000628:therapy*; D018441:Biofilms / Q000187:drug effects; D003646:Debridement; D005260:Female; D006801:Humans; D038622:Internationality; D008297:Male; D011379:Prognosis; D016459:Prosthesis-Related Infections / Q000188:drug therapy / Q000382:microbiology / Q000401:mortality / Q000628:therapy*; D012189:Retrospective Studies; D012293:Rifampin / Q000008:administration & dosage / Q000627:therapeutic use; D016879:Salvage Therapy; D013290:Streptococcal Infections / Q000188:drug therapy / Q000628:therapy*; D013292:Streptococcus agalactiae / Q000302:isolation & purification; D017211:Treatment Failure; D047090:beta-Lactams / Q000008:administration & dosage / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D047090:beta-Lactams; D012293:Rifampin
keywords: DAIR; biofilm; bone and joint infection; rifampin.