Inadequate empirical antibiotics following debridement for orthopedic infections do not increase therapy failures

TL;DR

Using narrower-spectrum antibiotics after surgery for bone infections doesn't lead to worse outcomes compared to broader ones.

Contribution

Shows that inaccurate initial antibiotics don't increase therapy failure in orthopedic infections.

Findings

No difference in therapy failure between accurate and inaccurate empirical antibiotics.

Narrower-spectrum antibiotics are sufficient for mild to moderate infections.

Delay in targeted treatment does not increase risk of negative outcomes.

Abstract

Introduction: Empirical antibiotics should only target the most likely pathogens if antibiotic stewardship is being heeded. However, there is a drive for broader-spectrum empirical antibiotics in orthopedic infections due to the concern of therapeutic failure if a regimen fails to target subsequently identified pathogens. Methods: Retrospective case-control study with surgically managed orthopedic infections from July 2018 to June 2024 with a minimum follow-up of 6 months. Patients were stratified by the initial empirical treatment of either accurate empirical choice or inaccurate empirical choice. Results: Of 482 infection episodes, 79 antibiotic regimens (43 broad-spectrum; 9 %) were used with a median postoperative duration of 42 d (interquartile range 19–45 d); 290 infection episodes (60 %) were correctly targeted. In 192 cases (40 %), the initial empirical choice was inaccurate, with a median switching time to a targeted treatment of 4 d. There was no difference between accurate and inaccurate empirical treatment in terms of ultimate failures (18/290 vs. 15/192; Pearson
χ2
test,
p=0.49
), overall adverse events of therapy (15 % vs. 7 %,
p=0.11
), duration of hospital stay (median 9 d vs. 9 d,
p=0.96
), or supplementary surgical debridement (median 0 vs. 0 intervention,
p=0.58
). In multivariate logistic regression analysis, the duration of an inaccurate antibiotic treatment failed to alter the risk of “failures” (odds ratio 0.9, 95 % confidence interval 0.8–1.1). Conclusions: A delay in commencing targeted antibiotics does not increase the risk of a negative outcome. Narrower-spectrum empirical regimens are appropriate for clinically mild to moderate infections as a broader spectrum does not provide any clinical advantage.

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