Should rifampin be routinely included in the treatment of staphylococcal infections involving retained prosthetic joints?

Rifampin has excellent penetration of biofilms in vitro (1). According to the Infectious Disease Society of America (IDSA) guidelines, it should be used in combination with another anti-staphylococcal antibiotic in the treatment of staphylococcal prosthetic joint infections for 3-6 months following debridement of a retained prosthesis (level A1 recommendation) (2).

Although a small randomized-controlled trial between ciprofloxacin and ciprofloxacin-rifampin reported a dramatic 100% cure rate in patients treated with the combination regimen (vs 58% with ciprofloxacin alone) (3), its small sample size (n=24) with its high drop-out rate, beg for a larger study comparing a more conventional anti-staphylococcal drug regimen such as a beta-lactam or vancomycin with and without rifampin. In the meantime, be on the alert for rifampin-induced drug resistance, hepatotoxicity, and frequent CYP450 drug interactions (e.g. warfarin) when used in combination with other anti-staphylococcal drugs (1).

 

References

  1. Forrest GN, Tamura K. Rifampin combination therapy for nonmycobacterial infections. Clin Microbiol Rev. 2010;23(1):14-34.
  2. Osmon DR, Berbari EF, Berendt AR, et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1-e25.
  3. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279(19):1537-1541.

 

Contributed by Sam Slavin, Harvard Medical Student, Boston, MA.

Should rifampin be routinely included in the treatment of staphylococcal infections involving retained prosthetic joints?

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