The effect of extended postoperative oral antibiotic prophylaxis on the reinfection risk following two-stage exchange arthroplasty for hip and knee periprosthetic joint infection: a systematic review and meta-analysis

TL;DR

Extended postoperative oral antibiotics reduce reinfection risk after joint replacement surgery, especially for hip cases.

Contribution

This study provides the first meta-analysis showing that extended postoperative oral antibiotic prophylaxis reduces reinfection risk after two-stage exchange arthroplasty.

Findings

EPOAP significantly reduced reinfection risk overall (RR: 0.52).

Hip arthroplasty showed significant reduction (RR: 0.37), while knee arthroplasty was borderline nonsignificant (RR: 0.64).

Most reinfections involved antibiotic-resistant organisms.

Abstract

This study aimed to conduct a systematic review and meta-analysis to assess the impact of extended postoperative oral antibiotic prophylaxis (EPOAP) on the risk of reinfection following two-stage exchange arthroplasty for hip and knee periprosthetic joint infection (PJI).

A comprehensive search of PubMed, Embase, and the Cochrane Library was conducted on January 11, 2025. Studies reporting reinfection rates in patients receiving EPOAP after two-stage exchange arthroplasty, compared to those who did not, were included. A random-effects model was used to calculate pooled risk ratios (RRs) and subgroup analyses were performed based on the duration of EPOAP use (> 2 weeks vs. ≤2 weeks) and the joint site (hip or knee).

Five studies, including four retrospective cohort studies and one randomized controlled trial, with a total of 486 knees and 444 hips, were included. The meta-analysis demonstrated that EPOAP significantly reduced the risk of reinfection following two-stage exchange arthroplasty (pooled RR: 0.52; 95% confidence interval [CI]: 0.35, 0.75; p = 0.0006). Subgroup analyses yielded similar findings, with significant reductions in reinfection risk for EPOAP duration > 2 weeks (pooled RR: 0.51; 95% CI: 0.34, 0.78; p = 0.002), hip arthroplasty (pooled RR: 0.37; 95% CI: 0.20, 0.70; p = 0.002), while knee arthroplasty showed a borderline nonsignificant reduction (pooled RR: 0.64; 95% CI: 0.39, 1.04; p = 0.07). Only one cohort study reported a decreased risk of reinfection with EPOAP use ≤ 2 weeks. Two studies assessed adverse events related to EPOAP. No complications were observed among 22 patients in one cohort study, whereas 6 of 22 patients (27%) in an RCT experienced mild gastrointestinal or dermatologic reactions that led to treatment discontinuation. Additionally, another cohort study reported that 16 of 24 reinfection cases (67%) involved organisms resistant to EPOAP.

This meta-analysis suggests that EPOAP is associated with a reduced risk of reinfection following two-stage exchange arthroplasty for hip arthroplasty, while further research is warranted for knee cases. This approach may improve patient outcomes and help optimize post-operative antibiotic management.

The online version contains supplementary material available at 10.1186/s12891-025-09410-4.

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