Antimicrobial strategies and multidisciplinary care in prosthetic joint infections

Abstract

Prosthetic joint infection (PJI) is one of the most devastating complications after joint arthroplasty. Treatment is complex, often requiring repeated surgery, prolonged antimicrobial therapy, and close collaboration between multiple medical specialties. Despite advances in surgical techniques and antibiotic treatment, relapse rates remain substantial and many treatment strategies are still based on limited clinical evidence.

This thesis explores three key domains in the management of PJI. First, the effectiveness of multidisciplinary team (MDT) care for complex bone and joint infections was evaluated. High implementation rates of MDT decisions were observed, while non-implementation of surgical recommendations was associated with poorer clinical outcomes. Second, antimicrobial strategies for acute PJI treated with debridement, antibiotics, and implant retention (DAIR) were studied. This included the development of the RiCOTTA trial, investigating whether targeted monotherapy may be an effective alternative to rifampicin-based combination therapy in staphylococcal PJI, and a prospective study evaluating oral treatment options for Gram-negative PJI. Third, international practice variation in suppressive antimicrobial therapy (SAT) was analyzed. Based on these findings, new definitions and risk classifications for SAT are proposed. Furthermore, in selected patients, lower-dosed SAT may be effective, and suppressive therapy may not always need to be continued lifelong, as treatment discontinuation after approximately 1 to 3 years appears safe.

Overall, this thesis supports a more individualized, evidence-based, and multidisciplinary approach to PJI care.