Table 3. Antimicrobial Treatment of Periprosthetic Joint Infection.

Microorganism	Antibiotic (dose), check pathogen susceptibility	Duration	Followed by
Staphylococcus spp.
Oxacillin-/methicillin-susceptible	Cefazolin (3×2 g, i.v.)*+Rifampin (2×450 mg, p.o.)	2 wk	According to susceptibility, Levofloxacin (2×500 mg, p.o.) or Cotrimoxazol (3×960 mg, p.o.) or Doxycyclin (2×100 mg, p.o.) +Rifampin(2×450 mg, p.o.)
Oxacillin-/methicillin-resistant	Vancomycin (2×1 g, i.v.)†+Rifampin (2×450 mg. p.o.)	2 wk	Same combination as above for oxacillin-/methicillin-susceptible staphylococci
Rifampicin-resistant§	Vancomycin (2×1 g, i.v.)†	2 wk	Long-term suppression for ≥1 yr, depending on susceptibility (e.g., with cotrimoxazol, doxycycline or clindamycin)
Streptococcus spp.	Penicillin G (4×5 million U, i.v.)* or Ceftriaxon (1×2 g, i.v.)	2 wk	Amoxicillin (3×1,000 mg, p.o.) or Levofloxacin (2×500 mg, p.o.) (consider suppression for 1 year)
Enterococcus spp.
Penicillin-susceptible	Ampicillin (4×2 g, i.v.)*+Gentamicin (2×60-80 mg, i.v.)‡	2–3 wk	Amoxicillin (3×1,000 mg, p.o.)
Penicillin-resistant§	Vancomycin (2×1 g, i.v.)† or +Gentamicin (2×60-80 mg, i.v.)‡	2–4 wk	Linezolid (2×600 mg, p.o.), maximum 4 wk
Vancomycin-resistant	Individual; removal of the implant or life-long suppression necessary
Gram-negative bacteria
Enterobacteriaceae (Escherichia coli, Klebsiella, Enterobacter, etc.)	Ciprofloxacin (2×750 mg, p.o.)
Nonfermenters (Pseudomonas aeruginosa, Acinetobacter spp.)	Piperacillin/tazobactam (3×4.5 g, i.v.) or Meropenem (3×1 g, i.v.) or Ceftazidim (3×2 g, i.v.)+Gentamicin (1×240 mg, i.v.)	2–3 wk	Ciprofloxacin (2×750 mg, p.o.)
Ciprofloxacin-resistant§	Depending on susceptibility: meropenem (3×1 g), colistin (3×3 million U) and/or fosfomycin (3×5 g), i.v.		Oral suppression
Anaerobes
Gram-positive anaerobes (Propionibacterium, Peptostreptococcus, Finegoldia magna)	Penicillin G (4×5 million U, i.v.)* or Ceftriaxon (1×2 g, i.v.)+Rifampin (2×450 mg, p.o.)	2 wk	Levofloxacin (2×500 mg, p.o.) or Amoxicillin (3×1,000 mg, p.o.)+Rifampin (2×450 mg, p.o.)
Gram-negative anaerobes (Bacteroides)	Clindamycin (3×600 mg, i.v.)	2 wk	Metronidazol (3×500 mg, p.o.)
Candida spp.
Fluconazole-susceptible§	Caspofungin (1×50 mg, 1st day: 70 mg; i.v.)	2 wk	Fluconazole (1×400 mg, suppression for ≥1 year; p.o.)
Fluconazole-resistant§	Individual (e.g., with voriconazole 2×200 mg, p.o.); removal of the implant or long-term suppression

Total duration of therapy: 12 weeks, usually 2 weeks intravenously, followed by oral route.

Laboratory testing 2 times/weekly: leukocytes, C-reactive protein, creatinine/estimated glomerular filtration rate, liver enzymes (AST/SGOT and ALT/SGPT).

Dose-adjustment according to renal function and body weight (<40 kg or >100 kg); the dosages needed renal adjustment are in bold.

i.v.: intravenously; p.o.: per oral.

Rifampin is administered only after the new prosthesis is implanted, wounds are dry and drains are removed; in patients aged >75 years, the rifampicin dose should be reduced to 2×300 mg, p.o.

^*In case of anaphylaxis (such as Quincke's edema, bronchospasm, anaphylactic shock) or cephalosporin allergy: vancomycin (21 g, i.v.).

^†Check vancomycin trough concentration (take blood before next dose) at least 1 time/week; therapeutic range, 15–20 µg/mL.

^‡Give only, if gentamicin high-level (HL) is tested susceptible (consult your microbiology laboratory). In gentamicin HL-resistant enterococci: gentamicin is exchanged with ceftriaxone (1×2 g, i.v.).

^§Difficult-to-treat.