Antibiotic Holiday in 2-Stage Exchange for Periprosthetic Joint Infection

BACKGROUND: The use of a 2-stage exchange remains a common management strategy for periprosthetic joint infection (PJI). The use of an "antibiotic holiday" before the second stage to confirm the clearance of infection is often employed, but there is little evidence to guide this practice. The aim of this review was to systematically map the literature reporting on the use of an antibiotic holiday as part of a 2-stage revision for chronic PJI and to answer the question: is there a role for an antibiotic holiday in patients undergoing 2-stage exchange arthroplasty for PJI? METHODS: Given the heterogeneity of the literature on this topic, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-compliant scoping review was conducted. Two reviewers developed and refined the search strategy and study eligibility criteria and pilot-tested the data charting form prior to data extraction. Data were analyzed descriptively. RESULTS: Three databases were screened, with 504 full-text articles retrieved for review after screening 2,579 titles and abstracts. Of these, 243 were included for data charting. Most studies (238 of 243; 97.9%) were case series, and the remaining 5 (2.1%) were cohort studies that incorporated a direct comparison between continuous therapy and an antibiotic holiday. Most case series (202 of 238; 84.9%) utilized an antibiotic holiday. The proportion of patients who experienced treatment failure in the continuous therapy group (271 of 2,074 patients; 13.1%) was lower than that in the antibiotic holiday group (2,843 of 17,329 patients; 16.4%; p < 0.001). There was a greater proportion of studies with a between-stage interval of <3 months among case series utilizing continuous antibiotic therapy (66.7%) compared with those utilizing an antibiotic holiday (27.2%; p < 0.001). CONCLUSIONS: There is no proven superiority of an antibiotic holiday during a 2-stage exchange to treat chronic PJI. Due to the need to extend the duration of the interval between the first and second stages in order to accommodate an antibiotic holiday, patients may be subjected to unnecessary prolongation of their treatment duration without an improvement in outcome. LEVEL OF EVIDENCE: Therapeutic Level IV . See Instructions for Authors for a complete description of levels of evidence.