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Table 3 Targeted antimicrobial therapy based on microorganisms [20,21,22,23,24,25,26]

From: A protocol for periprosthetic joint infections from the Northern Infection Network for Joint Arthroplasty (NINJA) in the Netherlands

Microorganism

Antibiotic

Dosagea

Durationc

S. aureus or flucloxacillin-sensitive coagulase-negative Staphylococci (CoNS)

Flucloxacillin

2.000 mg loading dose, followed by 12.000 mg/24 h continuous infusion IV

1–2 wks

plus

  

Rifampinb

450 mg b.i.d. oral

1–2 weeks

followed by:

  

Moxifloxacin or

400 mg q.d. oral

10–11 weeks

Levofloxacin

500 mg b.i.d. oral

 

plus

  

Rifampinb

450 mg b.i.d. oral

10–11 weeks

Methicillin resistent S. aureus or flucloxacillin coagulase-negative Staphylococci (CoNS)

Vancomycin

20 mg/kg loading dose, followed by 30 mg/kg/24 h continuous infusion (with adjustments based on blood level monitoring)

1–2 weeks

plus

  

Rifampinb

450 mg b.i.d. oral

1–2 weeks

followed by:

  

Moxifloxacin or

400 mg q.d. oral

10–11 weeks

Levofloxacin

500 mg b.i.d. oral

10–11 weeks

plus

  

Rifampinb

450 mg b.i.d. oral

10–11 weeks

In the case of chinolon resistance:

  

Clindamycin or

600 mg t.i.d. oral

10–11 weeks

Minocyclin or

100 mg b.i.d. (first dose 200 mg) oral

10–11 weeks

Co-trimoxazole

960 mg t.i.d. oral

10–11 weeks

All in combination with Rifampinb

450 mg b.i.d. oral

10–11 weeks

In the case of linezolid, use only as monotherapy (not combined with rifampin)

600 mg b.i.d. oral

max. 6 weeks, then switch to alternative

Streptococci

Benzylpenicillin

2 million units loading dose, followed by 12 million units/24 h continuous infusion IV

2 weeks

or

  

Ceftriaxone

2.000 mg once daily IV or 2.000 mg loading dose, followed by 2.000 mg/24 h continuous infusion IV

2 weeks

 ± Rifampin [20]b

450 mg b.i.d. oral

12 weeks

followed by:

  

Amoxicillin

750–1000 t.i.d. mg oral

10 weeks

 ± Rifampin [20]b

450 mg b.i.d. oral

10 weeks

Enterococci (amoxicillin-sensitive)

Amoxicillin

2.000 mg loading dose, followed by 12.000 mg/24 h continuous infusion IV

4 weeks

plus

  

Ceftriaxone

2.000 mg b.i.d. IV or 2.000 mg loading dose, followed by 4.000 mg/24 h continuous infusion

4 weeks

followed by:

  

Amoxicillin

750–1000 mg t.i.d. oral

8 weeks

Enterococci (amoxicillin-resistant)

Vancomycin

20 mg/kg loading dose, followed by 30 mg/kg/24 h continuous infusion (with adjustments based on blood level monitoring)

6 weeks

plus

  

Gentamicin#

3 mg/kg q.d. IV (with adjustments based on blood level monitoring)

2 weeks

followed by:

  

Linezolid§

600 mg b.i.d. oral (preferably with blood level monitoring)

6 weeks

Enterobacteriaceae (e.g. E. coli, Klebsiella, Proteus)

Ceftriaxone

2.000 mg once daily IV or 2.000 mg loading dose, followed by 2.000 mg/24 h continuous infusion

1–2 weeks

followed by:

  

Ciprofloxacin

750 mg b.i.d. oral

10–11 weeks

In case of ciprofloxacin resistance:

  

Cotrimoxazole

960 mg t.i.d. oral

10–11 weeks

Nonfermenters (e.g. Pseudomonas aeruginosa)

Ceftazidime

2.000 mg t.i.d. IV or 2.000 mg loading dose, followed by 6.000 mg/24 h continuous infusion IV

1–2 weeks

plus

  

Ciprofloxacin

400 mg t.i.d. IV (or directly 750 mg b.i.d. oral)

1–2 weeks

followed by:

  

Ciprofloxacin

750 mg b.i.d. oral

10–11 weeks

Cutibacterium acnes (Propionibacterium acnes)

Benzylpenicillin

2 million units loading dose, followed by 12 million units/24 h continuous infusion IV

1–2 weeks

or

  

Ceftriaxone

2.000 mg once daily IV or 2.000 mg loading dose, followed by 2.000 mg/24 h continuous infusion

1–2 weeks

followed by:

  

Amoxicillin

750–1000 mg t.i.d. oral

10–11 weeks

or

  

Clindamycin

600 mg t.i.d. oral

10–11 weeks

Corynebacterium species

Vancomycin

20 mg/kg loading dose, followed by 30 mg/kg/24 h continuous infusion (with adjustments based on blood level monitoring)

1–2 weeks

followed by:

  

Cotrimoxazole

960 mg t.i.d. oral

10–11 weeks

or

  

Clindamycin

600 mg t.i.d. oral

10–11 weeks

or

  

Minocyclin

200 mg loading dose, followed by 100 mg b.i.d oral

10–11 weeks

If resistant for the above:

  

Vancomycin

20 mg/kg loading dose, followed by 30 mg/kg/24 h continuous infusion (with adjustments based on blood level monitoring)

6 weeks

or

  

Dalbavancin

1500 mg once every two weeks

6 weeks (3x)

followed by:

  

Linezolidd

 600 mg b.i.d. oral

6 weeks

Candidal species (fluconazol-sensitive)

Caspofungin

70 mg IV loading dose, followed by 50 mg q.d. if < 80 kg, and 70 mg q.d. if > 80 mg

2–4 weekse

followed by:

  

Fluconazole

800 mg loading dose, followed b 400 mg q.d. oral

5 months

In the case of 2-stage revision:

  

500 mg conventional amfotericin B or 200 mg liposomal amfotericin B in cement spacerf

  
  1. aThe above doses are based on adequate kidney function and a normal weight/BMI. In the case of deviating values, contact the hospital pharmacist for dosing advice
  2. bOnly start with a dry wound and proven susceptibility. The addition of rifampin in a streptococcal infection is advised in a DAIR where the mobile components cannot be replaced.
  3. cTotal treatment duration 3 months (except for Candida)
  4. dDo not prescribe longer than 4 weeks, unless therapeutic drug monitoring is performed.
  5. e4 weeks in the case of a DAIR, 2 weeks in the case of extraction of the prosthesis
  6. fThis dosage should only be used in the temporary cement spacer and not in the fixation cement (There are not sufficient clinical data to guarantee the stability of the cement.)