Dual Antibiotic Prophylaxis with Addition of Doxycycline Does Not Lower Periprosthetic Infection Rate in Primary Directed Anterior Total Hip Replacement: A Cohort Study on 7,917 Patients.

Abstract

Periprosthetic joint infections (PJI) caused by <i>Cutibacterium</i> spp. are frequently observed in total hip arthroplasty (THA) using the direct anterior approach (DAA). The microbiological spectrum of PJI after DAA differs from that of a lateral based approach. The aim of this study was to compare a dual-antibiotic (AB)-prophylaxis with cefuroxime (CEF) and doxycycline (DOX) to mono-AB-prophylaxis with CEF alone in DAA THA. A total of 4,430 primary THAs receiving CEF prophylaxis were compared with 3,487 THAs receiving CEF+DOX prophylaxis. The institutional AB-prophylaxis was changed from cefuroxime 1.5-3 g (CEF group) alone to cefuroxime 1.5-3 doxycycline 300 mg (CEF+DOX group). A multivariable binary logistic regression analysis to evaluate the association between CEF vs. CEF+DOX and the occurrence of PJI (according to the International Consensus Meeting 2018) was performed with dropping 3 months before and after the change (covariates: American Society of Anesthesiologists, Charlson Comorbidity -Index, age, body mass index [BMI], smoking status, and diabetes mellitus [DM]). The primary outcome was the incidence of PJI following THA after a minimum follow-up of 1 year, with an accompanying analysis of the microbiological spectrum. In total, 7,917 (age: 65.8 (65.5; 66.0) years; female: 61.2%; male: 38.8%) THA were analyzed for this study. After a median follow-up of 4.3 years (interquartile-range: 2.0-6.2), no significant difference in the incidence of septic revision was observed between the CEF and CEF+DOX therapy with an infection rate of 1.3% and 1.0%, respectively (p = 0.172). The septic-free revision rate at 1 year was 99.0% in the CEF group and 99.1% in the CEF+DOX group (p = 0.541). Due to the longer follow-up, the CEF group experienced more THA with aseptic loosening compared to the CEF+DOX group. The type of AB prophylaxis was not associated with a clinically relevant higher risk of PJI (odds ratio [OR] = 1.03; 95% CI: 0.99-1.07; p = 0.052). Only BMI demonstrated a significant association with PJI (OR = 1.12; 95% CI: 1.09-1.16; p < 0.001). In the CEF+DOX group, <i>Cutibacterium avidum</i> was more frequent (15.7% vs. 8.1%) and <i>Cutibacterium Acnes</i> was less frequent (9.8% vs. 12.3%) compared with the CEF group (p = 0.143 and p = 0.809, respectively). This study showed no superiority in the rate of PJI between CEF+DOX and CEF alone in DAA THA. DOX does not prevent <i>Cutibacterium</i>-positive PJIs. There are factors other than AB prophylaxis that influence the risk of PJI. Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.