Management of Periprosthetic Joint Infection with Amikacin-Only Sensitive Enterobacteriaceae

Surgical Management Decision

The surgical approach depends critically on timing and clinical presentation, with the Infectious Diseases Society of America (IDSA) guidelines recommending surgical intervention combined with intravenous amikacin therapy 1, 2, 3
Debridement and Implant Retention (DAIR) criteria include duration of symptoms <3 weeks, prosthesis age <30 days, well-fixed prosthesis on imaging, absence of sinus tract, and organism susceptible to oral biofilm-active agents 4, 5, 6
If DAIR criteria are not met, proceed with prosthesis removal via two-stage exchange, which is the gold standard in North America for established PJI 5, 6
During surgery, obtain 3-6 intraoperative tissue samples for aerobic and anaerobic culture 1, 3, 6

The IDSA guidelines recommend intravenous amikacin dosing for 4-6 weeks following definitive surgical intervention 1, 2, 3
Consider adding a second agent if any susceptibility exists, with the IDSA guidelines noting that addition of aminoglycoside is optional for Pseudomonas and Enterobacter species 1, 2

The IDSA guidelines recommend 4-6 weeks of intravenous therapy after DAIR or two-stage exchange 1, 2, 3
An antibiotic-free interval of 2-6 weeks is typical between stages of two-stage exchange 5

The IDSA guidelines recommend indefinite chronic oral antimicrobial suppression for Enterobacteriaceae, with preferred treatment being Cotrimoxazole 1 double-strength tablet PO twice daily 7, 8, 9
Alternative treatment includes β-lactam oral therapy based on in vitro susceptibilities 7, 8, 9

Mandatory consultations include orthopedic surgery for surgical decision-making, infectious disease for antimicrobial optimization, and consider plastic surgery if soft tissue coverage is needed 4, 5, 6, 7, 8
The ultimate surgical decision should be made by the orthopedic surgeon with appropriate infectious disease consultation 4

Clinical monitoring includes daily assessment of renal function and watching for signs of renal irritation 6
Laboratory monitoring includes serial inflammatory markers, such as CRP, and adjusting dosage based on levels and renal function 1, 8, 10