Is DAIR Still an Effective Way to Eradicate Acute Prosthetic Joint Infections? Our Experience in the Jordanian Royal Medical Services

Background: Prosthetic joint infections is estimated to occur in 1-2% of primary total joint arthroplasty. Debridement, antibiotics, irrigation and retention of prosthesis (DAIR) is the traditional treatment for acute prosthetic joint infections.

Objective: To determine risk factors of treatment failure in subjects managed with debridement, antibiotics, irrigation and retention of prosthesis for acute prosthetic joint infections.

Methods: Our prospective, double blind and randomized investigation included 70 subjects, of both sexes, aged 63-72 years, who were managed with debridement, antibiotics, irrigation and retention of prosthesis for total hip or total knee arthroplasty acute prosthetic joint infections at Prince Hashim military hospital and Queen Alia military hospital, Jordan, during the period October 2017-October 2020. The observation period was 3 years. Therapy success was defined as absence of infection following 3 years, retention of the prosthesis and no further antibiotics therapy. Prosthetic joint infection was defined based on one or more of: a) growth of the same microorganism in minimum 2 cultures; b) one positive culture and a purulent synovial fluid upon debridement; c) negative culture and minimum 2 of purulent synovial fluid upon debridement. A successful outcome was defined as no clinical and laboratory evidence of infection (serum C-reactive protein less than 10 mg/L) at 3 years. Subjects with chronic, suppressive antibiotics or with prosthesis removal were considered therapy failure. Parameters statistically and remarkably discrepant between success and failure groups were investigated with logistic regression. P less than 0.05 were considered statistically significant.

Results: Amount of 46 subjects (65.7%) had no infection during the period of observation. Factors correlated with therapy failure were: history of Rheumatoid Arthritis, delayed infection (more than 1.5 years following arthroplasty), ESR at presentation of more than 50 mm/h and infection induced by coagulase-negative Staphylococcus. Symptoms duration of less than 5 days was associated with a better outcome. The use of Gentamicin sponges was statistically remarkably more in the success group and the use of beads was more in the failure group in the univariate but not in the logistic regression. Less surgical interventions were needed in the group managed with sponges than in the group managed with beads. Prosthetic joint infection induced by coagulase-negative Staphylococcus was associated with a less success rate and streptococcal infections were associated with an increased success rate.

Conclusion: Rheumatoid arthritis, duration of symptoms of more than 5 days, ESR of more than 50 mm/h, delayed infection (more than 1.5 years following the index arthroplasty) and coagulase-negative Staphylococcus infections reduce the rate of a successful debridement, antibiotics, irrigation and retention of prosthesis therapy.