PROSTHETIC JOINT INFECTION

TREATMENT GUIDANCE

• Normal renal and hepatic function is assumed – adjust doses if necessary refer to SPC • Always document the indication and planned duration for in the medical notes and on medicine chart • All suggested regimes should be tailored according to sensitivities from microbiology and should be prescribed after consideration of co-morbidities and potential hypersensitivity, adverse effects and interactions. • For unusual pathogens or discussion of complicated cases please email [email protected] • For OHPAT referral please use referral guidance and email both [email protected] and [email protected]

PROCEDURE ANTIMICROBIAL DURATION OF IV DURATION OF TOTAL DURATION COMMENT

THERAPY IN THERAPY ORAL THERAPY OF IV AND ORAL Surgeon to discuss THEATRE AN D AFTER THERAPY longer durations FIRST 48 HOURS IV THERAPY with infection team Debridement , Refer to 1-2 weeks (excluding 8 weeks 8-12 weeks (can be Minimum total

Antibiotics and Orthopaedic SAB’s) reduced on advice duration: 2-3 months Implant Surgical + from ID) Retention Prophylaxis oral * (DAIR) Guidance Two stage: long (insert link to 6 weeks post explanation None 6 weeks If cul tures pos t-

interval updated usually followed by (NB. Total duration implantation are

Explanation document) free period and does not have to be POSITIVE discuss followed by then implantation all IV. Confirm plan further antibiotic implantation 6- Always review for IVOST with ID therapy with 8 weeks later microbiology team) infection team One stage results at 48 4 weeks 8 weeks 12 weeks Minimum total

hours post explanation and + duration: 3 months implantation surgery: oral rifampicin*

Two stage: If NO gram 4 weeks 8 weeks 12 weeks Minimum total short interval. negative + duration: 3months

Explanation bacteria grown oral rifampicin*

followed by on cultures then implantation STOP ciprofloxacin

* add only if rifampicin sensitive staphylococcus. Start a few days after IV so that bacterial load has been reduced IV ANTIBIOTICS ORAL ANTIBIOTICS Adjust doses for renal and liver function NB: All ORAL agents are chosen due to bone/tissue penetration. Flucloxacillin is NOT a suitable IVOST option VANCOMYCIN – Calculate dose as per guida nce or calculator Treatment dose to be given on ward and aim for pre dose level of 15-20mg/l Adjust doses for renal and liver function Confirmed MRSA or confirmed MSSA but patient penicillin allergic – 100mg BD MRSA and MSSA cover FLUCLOXACILLIN – 2g QDS Confirmed MSSA (SODIUM FUSIDATE) – 500mg TDS

Never prescribe a s monotherapy and always check for intera ctions TEICOPLANIN – Teicopla nin 800mg IV(400mg if <40kg) given in theatre then dosing Statins s hould be stopped for duration of thera py as per MHRA wa rning will continue on ward as 3 x weekly maintenance dose as per guidance (link) MRSA cover as per sensitivities Confirmed MRSA or MSSA and patient going home via OHPAT service Toxicity and blood level monitoring should be done as per guidance CO-TRIMOXAZOLE – 960mg BD MRSA cover as per sensitivities

DAPTOMYCIN – dos e 10mg/kg OD (unlicensed dose) and monitoring as per guidance RIFAMPICIN - 450mg BD Monitor CK prior to starting and then weekly, stop statins if possible for duration of Never prescribe as monotherapy and always check for interactions thera py If co-prescribed with vancomycin do not start until vancomycin levels are As an alternative to vancomycin or teicoplanin on advice of infection specialist only thera peutic DO NOT co-prescribe with . CIPROFLOXACIN – 400mg BD MRSA and MSSA cove r only if sensitive. IV only required if in theatre or on ward and NBM Empiric gram negative cover – but see note in table above re review at 48 hours – 450mg TDS to QDS MSSA and MRSA cover only if sensitive

GENTAMICIN – Calculate dose as per guidance or calculator LINEZOLID – Only on advice of Infection Specialist Treatment dose to be given on ward and blood sample sent between 6 – 14 hours DO NOT co-prescribe with rifampicin. Refer to prescribing and monitoring from beginning of IV a dminis tra tion guidance

PRISTINAMYCIN (unlicensed) – Only on advice of Infection Specialist Refer to prescribing guidance Developed by: Microbiology, ID, Pharmacy Approved by AMG: May 2020 Amended: Sept 2017 – rifampicin/linezolid interaction CIPROFLOXACIN – 500-750mg bd gram negative cover Review: May 2023 Oct 2017 – rifampicin/vancomycin (750mg bd if Pseudomonas confirmed or if elevated BMI)