Short Against Long Antibiotic Therapy for Infected Orthopedic Sites

Short Against Long Antibiotic Therapy for Infected Orthopedic Sites

The investigators will perform two concomitant RCTs, depending on the presence of infected osteosynthesis material at enrolment:

- SALATIO 1. Infected implant not removed (or new material inserted): Randomization 6 vs. 12 weeks (+/- 5 days) of total antibiotic therapy counted since the first debridement for infection. Early switch to oral targeted therapy.

- SALATIO 2. Infected implant without residual material (definitive removal or within the interval of a two-stage exchange): Randomization 3 vs. 6 weeks (+/- 5 days) of total antibiotic therapy counted since the first debridement for infection. Early switch to oral targeted therapy.

The optimal duration of postoperative, systemic antibiotic therapy for implant-related orthopedic infections, with or without implant removal, is unknown.

Retrospective studies suggest that a maximum duration of 6 weeks is not inferior to longer administrations; even if the infected implants are kept in place or during a one-stage exchange. Prospective-randomized trials (RCT) suggest that even shorter durations, such 3 or 4 weeks, are possible, when the implant is removed. Likewise, in prospective studies, 6 or 8 weeks of systemic antibiotics are not inferior to the current 12 weeks during DAIR (debridement, antibiotic and implant retention), or during the one-stage exchange; except for one single RCT suggesting a better outcome for 12 weeks in the substrata of arthroplasty infections undergoing the DAIR procedure.

However, these RCTs concern selected branches of orthopedic surgery; especially prosthetic joint infections. The investigators intend to expand these evaluations to all fields of orthopedic and hand surgery. The only exceptions would be spine surgery, for which a multicenter, separate RCT is already under way (SASI-trials). The second exception would be the treatment of implant-free diabetic foot infections, for which two RCTs are underway.

Inclusion Criteria:

• Age ≥ 18 years on admission
• Orthopedic bone and implant infections including musculoskeletal grafts
• Intraoperative debridement with any surgical technique
• 12 months of scheduled follow-up from hospitalization
• Bacterial orthopedic infections of any nature
• First or second episode of infection

Exclusion Criteria:

• Mycobacterial, fungal, nocardial, and Actinomyces infections
• Purely soft tissue infections
• Non-resected cancer in the infection site
• Purely intrasynovial infections (native joint septic arthritis)
• More than three debridements performed for infection
• Absence of at least one surgical intraoperative debridement
• Spine infections (investigated in another trial)10
• Diabetic foot infections (investigated in another trial)7
• Documented endocarditis according to the Duke criteria
• At least 2 prior infection episodes at the actual infection site