Addressing important evidence gaps in the management of prosthetic joint infection: clinician attitudes and equipoise

Hip or knee replacement is complicated by deep infection (Prosthetic joint infection [PJI]) in 1%–2% of cases, causing morbidity, high healthcare costs, and productivity loss.1, 2 In 2020, 112 000 knee and hip replacements were done in Australia.3 Treatment typically requires lengthy antibiotic courses and one or more operations, with variable cure rates (30%–70%, mean 50% after 24 months).4 There is a pressing need to establish more effective surgical and antibiotic strategies. In a previous survey, we identified key clinician priorities for future randomized controlled trials (RCTs) of PJI.5 A critical obstacle in researching PJI treatments is the lack of equipoise among experts. Hence, we designed a survey to assess current practices and equipoise in PJI treatment among physicians and surgeons, aiming to identify variations and inform future RCTs. The survey consisted of four clinical scenarios and 25 questions (Table S1) and was distributed to infectious diseases physicians and/or clinical microbiologists (IDP/CM) and orthopaedic surgeons via mailing lists of Australasian Society of Infectious Diseases (n = 800), and arthroplasty societies in Australia (n = 127), UK (n = 162) and Canada (n = 130) in July 2022. Respondents who managed fewer than 10 PJIs annually were excluded. A total of 294 clinicians responded. After excluding 14% for managing fewer than 10 cases yearly, 68% were IDP/CM and 31% orthopaedic surgeons (Table S2). Overall, 45% worked in Australia, 20% in the UK, 10% in Canada, 10% in the USA, 7% in NZ, and the remaining 9% in other countries. The preferred surgical strategy for the management of late acute PJI was DAIR (67%), followed by two-stage (28%) and one-stage revision arthroplasty (5%) (Table S2). This differed depending on the specialty of the respondent: 85% of orthopaedic surgeons preferred DAIR as compared to 59% of the IDP/CM, and 36% of the IDP/CM preferred two-stage revision versus 9% of orthopaedic surgeons (P < 0.001 for both). DAIR remained the most preferred method for late acute PJI by Australian IDP/CM (61%), but a greater proportion of Australian respondents preferred two-stage revision as compared to their peers from the UK (35% vs. 7%, respectively, P = 0.07). For the chronic PJI scenario, the most preferred surgical intervention strategy was two-stage revision arthroplasty (62%), followed by one-stage revision arthroplasty (22%), ‘Kiwi procedure’ (a loosely cemented one-stage leaving the possibility open for a second stage in the future – 10%), and DAIR (2%). The proportion of IDP/CM who preferred two-stage revision (73%) was higher than that of orthopaedic surgeons (41%) (Table S3). Opinions of surgeons varied by country: 68% of Australian surgeons preferred two-stage revision as compared to 15% of UK surgeons (P = 0.001). Similarly, 81% of Australian IDP/CM preferred two-stage revision as compared to 29% of the UK IDP/CM (P = 0.001). For early post-operative staphylococcal PJI managed with DAIR, 36% preferred to switch to oral antibiotics after 6 weeks of IV antibiotics, 33% after 2 weeks of IV antibiotics, and 27% opted to switch at the time of clinical stability. Canada was the country with the highest proportion of respondents who preferred 6 weeks of IV prior to oral switch (70%), followed by the USA (63%) and Australia (42%). For a similar clinical scenario, 67% of the respondents would include rifampicin as part of the antibiotic treatment regimen (74% of IDP/CM and 56% of orthopaedic surgeons). ‘Other countries’ was the group with the highest proportion of respondents recommending rifampicin (93%), versus 60% of Australian respondents. Regarding the preferred antibiotic duration post second stage, 42%, 27% and 14% of the respondents stated that they would continue antibiotics for 72 h, 7 days and 12 weeks, respectively. A greater proportion of the orthopaedic surgeons continued antibiotics for 12 weeks as compared to IDP/CM (22% vs. 9%). Regarding equipoise for future randomized trials, the majority (79%) were comfortable assigning late acute PJI to either DAIR or revision (Table S3). Similarly, 91% were comfortable assigning chronic PJI to an initial management strategy of one versus two-stage revision arthroplasty as part of an approved RCT, and 86% were comfortable assigning acute staphylococcal PJI treated with DAIR to regimens with or without rifampicin. Regarding the antibiotic treatment duration after second stage for chronic PJI, 84% would be comfortable assigning the patient to either of the ≤7 days or 12 weeks of antibiotic treatment arms. This study revealed significant variation in PJI treatment practices across countries and specialties, yet a majority supported randomizing PJI patients in RCTs to identify optimal management strategies. Practice variation in PJI treatment was more evident in antibiotic use than in surgical approaches, despite OVIVA and PIANOFORTE trials.6, 7 While these studies suggested early oral switch could be effective, two-thirds of respondents still preferred a minimum two-week course of IV antibiotics for acute staphylococcal PJI treated with DAIR. The reasons behind the low uptake of trial results are not elaborated in this study, but previous work has shown there is a 15–20 year gap between the publication of high quality studies and change in clinical practice.8 The use of rifampicin in PJI treatments varied globally, with European respondents often considering it standard despite conflicting evidence from previous research.9, 10 IDP/CM generally advocated for more aggressive surgical methods, such as two-stage revisions for PJI, unlike orthopaedic surgeons who prefer single-stage revisions, reflecting variations influenced by regional practices, notably in the UK where two-stage revisions are less common.11 Most respondents were open to randomizing late acute PJI patients to DAIR or revision surgery but emphasized the need for clear DAIR definitions in RCTs. In summary, there is large practice variation in PJI management, and strong equipoise for the conduct of RCTs addressing surgical and antibiotic management strategies. We thank respondents of this survey for their time. Open access publishing facilitated by The University of Newcastle, as part of the Wiley - The University of Newcastle agreement via the Council of Australian University Librarians. Burcu Isler: Formal analysis; writing – original draft; writing – review and editing. Natalie Niessen: Data curation; formal analysis; methodology; project administration; writing – review and editing. David Campbell: Data curation; writing – review and editing. Andrew D. Toms: Data curation; writing – review and editing. Nick Daneman: Data curation; writing – review and editing. Laurens Manning: Conceptualization; data curation; investigation; methodology; supervision; writing – review and editing. Joshua S. Davis: Conceptualization; data curation; formal analysis; investigation; methodology; supervision; writing – original draft; writing – review and editing. Table S1. Summary of the clinical scenarios included in the survey and associated questions Table S2. Characteristics and responses of survey participants, n (%) Table S3. Equipoise of respondents regarding proposed RCTs (n [%]) Please note: The publisher is not responsible for the content or functionality of any supporting information supplied by the authors. Any queries (other than missing content) should be directed to the corresponding author for the article.

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