Prosthetic joint infection eradication outcomes for DAIR (debridement, antibiotics, and implant retention) procedure according to culture etiology.

Abstract

Prosthetic joint infection (PJI) is a rare but devastating complication following total hip and knee arthroplasty. While two-stage revision remains the gold standard, debridement, antibiotics, and implant retention (DAIR) offers a less morbid alternative for select patients. The aim of this study was to assess how microbiologic etiology affects DAIR success, with emphasis on fungal, antibiotic-resistant, and culture-negative PJIs, and to identify pathogen-specific predictors that may guide treatment decisions. A single-center retrospective review was conducted of 173 culture-positive and culture-negative PJIs treated with DAIR between January 2016 and June 2025. Inclusion criteria followed modified Musculoskeletal Infection Society (MSIS) guidelines. Demographics, comorbidities, and microbiologic data were collected. Treatment success was defined as infection eradication without recurrence or need for further surgical intervention, per Delphi consensus. Logistic regression analyses were performed to evaluate associations between treatment success and microbiologic characteristics, as well as between fungal PJI and patient comorbidities. Overall, infection eradication was achieved in 66.5% of cases. Fungal pathogens were significantly associated with DAIR failure compared to non-fungal organisms (Odds Ratio [OR] 0.06, 95% Confidence Interval [CI] 0.011-0.31, P = 0.001). Culture-negative infections were nearly four times more likely to achieve eradication (OR 3.91, 95% CI 1.43-10.69, P = 0.008). Antibiotic-resistant and gram-positive pathogens were associated with lower success, whereas polymicrobial infections did not differ significantly from single-organism infections (P value = 0.92). Fungal PJIs comprised 8% of cases and exhibited a higher comorbidity burden (median Charlson Comorbidity Index [CCI] 4 vs 2, P = 0.0496). Fungal organisms and antibiotic-resistant pathogens were associated with lower rates of infection eradication, underscoring the importance of pathogen-specific risk stratification when considering DAIR. These findings suggest that alternative surgical strategies or heightened surveillance may be warranted in patients with high-risk organisms.