Research Summary

Does a Longer Antibiotic Holiday Improve Outcomes in Two-Stage Exchange for Chronic PJI?

Anthony Calabro, MA

Key Highlights

  • In chronic hip periprosthetic joint infection (PJI), infection control was higher with a long antibiotic holiday compared with a short holiday (100% vs 80%).
  • In chronic knee PJI, infection control was similar between long and short antibiotic holiday groups (95.2% vs 83.3%).
  • Functional recovery, based on Harris Hip Score and Knee Society Scores, improved significantly after reimplantation, with no differences between groups.
  • Overall infection control rate was 92.0%, higher than reported in some prior literature.

In this retrospective cohort, investigators assessed whether the length of an antibiotic-free period (“antibiotic holiday”) affects infection control after two-stage exchange for chronic periprosthetic joint infection (PJI). A 3-month holiday or longer improved outcomes in hip cases, suggesting a potential role for prolonging this interval in selected patients.

Periprosthetic joint infection remains one of the most severe complications of arthroplasty, with success rates for two-stage exchange reported at 72% to 91%. The protocol typically includes implant removal, debridement, placement of an antibiotic-loaded spacer, systemic antibiotics, and later reimplantation. Between stages, patients undergo an antibiotic-free period to monitor infection activity, but optimal duration is unclear. This study aimed to clarify whether extending the antibiotic holiday improves infection eradication.

The study retrospectively included 75 patients treated at a single center from 2012 to 2021. All underwent long-interval two-stage exchange (LITE) with articulating spacers. After 6 weeks or more of targeted antibiotics, patients were stratified into a short antibiotic holiday group (< 3 months, SAH) or a long antibiotic holiday group (≥ 3 months, LAH). Reimplantation occurred after markers such as C-reactive protein and erythrocyte sedimentation rate stabilized. Patients were followed for 2 years or longer. Outcomes included infection control, complications, and functional recovery measured by the Harris Hip Score (HHS) and Knee Society Score (KSS).

Among 42 hip cases (15 SAH, 27 LAH), infection control was significantly better in the LAH group (27/27, 100%) compared with the SAH group (12/15, 80%; P = .016). In the 33 knee cases (12 SAH, 21 LAH), infection control did not differ significantly (20/21, 95.2% vs 10/12, 83.3%; P = .238). Kaplan–Meier survival analysis confirmed these findings, and Cox regression indicated a lower risk of recurrence or uncontrolled infection with LAH (HR, 0.103; 95% CI, 0.012–0.881). Functional outcomes improved substantially after reimplantation in both groups, with mean HHS rising from 37–38 preoperatively to 77–79 and mean KSS rising from 44–48 to 81–82, with no intergroup differences. The overall infection control rate across all patients was 92.0% (69/75).

The study has several limitations. Its retrospective, single-center design introduces potential bias, and the modest sample size (n = 75) yielded a calculated study power of 0.75, below the conventional 0.8 threshold. Subgroup analyses, particularly for knee PJI, may have been underpowered. Additionally, results may not be generalizable to settings using static spacers or differing antibiotic regimens. The authors note that future multicenter prospective studies are needed to confirm the optimal antibiotic holiday duration.

“A ≥ 3-month antibiotic holiday, without compromising postoperative functional recovery, may enhance infection control rates after two-stage exchange for chronic hip PJI using joint spacers,” the authors concluded.

Reference
Ding H, Yuan X, Chen Y, et al. Infection control rate in two-stage exchange for chronic periprosthetic joint infection: a retrospective cohort study focusing on antibiotic-free period. BMC Infect Dis. 2025;25(1):523. Published 2025 Apr 14. doi:10.1186/s12879-025-10919-1