From the Guidelines
Rifampin should not be used as a routine treatment in Staphylococcus periprosthetic joint infection (PJI) after a single-stage exchange, as the removal of all foreign material in this setting reduces the need for biofilm-active agents like rifampin, and the risk of rifampin toxicity is not minimal 1.
Key Considerations
- In single-stage exchange, the focus is on removing the infected prosthesis and replacing it with a new one, which reduces the biofilm load and the need for biofilm-active agents like rifampin.
- The use of rifampin is generally recommended in cases where there is a high risk of biofilm formation, such as in debridement and implant retention (DAIR) procedures or in cases where the prosthesis cannot be removed 1.
- The risk of rifampin toxicity, including hepatotoxicity and drug interactions, must be carefully considered, especially in patients with underlying liver disease or those taking other medications that interact with rifampin 1.
- Alternative antimicrobial regimens, such as those including fluoroquinolones or other oral antibiotics, may be considered based on the susceptibility of the infecting organism and the patient's clinical condition 1.
Clinical Context
In clinical practice, the decision to use rifampin in Staphylococcus PJI after a single-stage exchange should be made on a case-by-case basis, taking into account the individual patient's risk factors, the susceptibility of the infecting organism, and the potential benefits and risks of rifampin therapy. Shared decision-making with the patient and a multidisciplinary team approach are essential in managing these complex infections 1.
From the Research
Use of Rifampin in Staphylococcus Periprosthetic Joint Infections
- The use of rifampin in the treatment of staphylococcal periprosthetic joint infections (PJI) is supported by several studies 2, 3, 4, 5, 6.
- Rifampin has been shown to be effective against staphylococcal bacteria and has the ability to penetrate and disrupt biofilms, making it a crucial antibiotic in the management of PJI 2.
- The combination of rifampin with other antibiotics, such as β-lactams and vancomycin, has been shown to enhance bacterial eradication and improve patient outcomes 2, 3.
- However, the use of rifampin is not without challenges, including the potential for drug interactions and the development of resistance 2, 3, 4.
Single-Stage Exchange
- The use of rifampin in cases where the implant is exchanged during revision surgery is less clear 6.
- A multicenter observational cohort study found no statistically significant difference in failure rates between patients receiving rifampin and those not receiving rifampin after a single-stage exchange 6.
- However, a subanalysis of chronic PJIs treated by 2-stage exchange arthroplasty demonstrated a lower failure rate in cases treated with rifampin 6.
Factors Associated with Rifampin Resistance
- Several factors have been associated with the emergence of rifampin resistance, including male sex, ≥ 3 previous surgical revisions, PJI treatment with high initial bacterial load, and inadequate rifampin therapy 4.
- Extensive surgical debridement and adequate antibiotic therapy are needed to prevent the emergence of rifampin resistance 4.
Outcome of Debridement, Antibiotics, and Implant Retention
- A systematic review and meta-analysis found that the use of rifampicin may only prevent a small fraction of all treatment failures in staphylococcal hip and knee PJI after debridement, antibiotics, and retention of the implant (DAIR) 5.
- The pooled success rate was 69% for Staphylococcus aureus hip PJI, 54% for S aureus knee PJI, 83% for coagulase-negative staphylococci (CNS) hip PJI, and 73% for CNS knee PJI 5.