Oral and IV Antibiotic Administration After Single-Stage Revision Shoulder Arthroplasty: Study of Survivorship and Patient-Reported Outcomes in Patients without Clear Preoperative or Intraoperative Infection

Most periprosthetic infections (PJI) shoulder are caused by Cutibacterium.

Infections by these organisms do not give rise to the usual signs typical of infections with other organisms, such as fevers, erythema, swelling, elevated white count, elevated markers of inflammation, and abnormal results on frozen section of tissue samples. Instead, shoulder PJI from Cutibacterium often present as otherwise unexplained pain and stiffness after a previously successful arthroplasty. As a result, the diagnosis of Cutibacterium PJI cannot be reliably made at the time of surgery, but must wait until the results of intraoperative cultures are available days or weeks after the revision procedure. Therefore the surgeon must make a decision regarding the use, type, and route of antibiotic treatment at the time of surgery before the culture results are known.

The potential advantages to starting IV antibiotics prior to hospital discharge in patients with a high suspicion for PJI include potentially increased efficacy of the IV therapy in infection eradication and establishment of a peripherally inserted central catheter (PICC) prior to discharge. Disadvantages include the risks associated with insertion of a PICC. Potential advantages of using oral antibiotics for patients with a low suspicion for PJI include lower cost and convenience. Disadvantages of oral therapy include concerns about consistency of administration and achievement of the desired antibiotic serum levels.

In this study of 92 patients without purulence or sinus tracts having single-stage revision for failed shoulder arthroplasty, the authors determined the infection-free survival, revision-free survival, complications, and patient-reported outcomes for patients selected by the surgeon to receive oral or intravenous (IV) antibiotics after revision arthroplasty. IV antibiotics were administered if the surgeon had a high index of suspicion for infection, and oral antibiotics were given if there was a low suspicion. Variables considered for IV antibiotics included young age, male sex, prior infection, humeral component loosening, osteolysis, synovitis and high levels of Cutibacterium on the unprepared skin of the shoulder. Antibiotic therapy was modified based on intraoperative culture results.

In this study, surgeons correctly predicted the presence or absence of PJI (as indicated by multiple positive cultures of specimens from the revision surgery) in 72% of the 92 cases. Subsequent re-revision surgery was required in 17 (18%) of the patients; 8 of these 17 patients had ≥2 positive cultures at re-revision.

Infection-free survival, revision-free survival, and patient-reported outcomes were similar in high-risk patients placed on IV antibiotics and low-risk patients placed on oral antibiotics, even though the bacterial loads at surgery for the IV group were significantly higher than those for the oral antibiotic group.

Patients requiring a change from oral to IV antibiotics based on positive cultures had similar survivorship compared with those initially treated with IV antibiotics.

While they had different preoperative and intraoperative characteristics, the IV and oral antibiotic groups had similar postoperative Simple Shoulder Test (SST), American Shoulder and Elbow Surgeons (ASES), and satisfaction scores. Patients demonstrated a median decrease in the VAS pain score of 4 points and a median improvement in the SST score of 3 points, both of which surpass the minimum clinically important difference for these instruments.

Patients receiving IV antibiotics had a higher rate of antibiotic-related adverse events.

Post-revision antibiotic therapy was associated with an infection-free survival rate of 91% at a mean of >4 years of follow-up.

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