Background/Objectives: In staphylococcal implant infections, there is often discussion about the optimal postoperative timing of the introduction of rifampicin in the postoperative period with open wounds. Methods: We reviewed all adult patients with residual staphylococcal implant infections between January 2014 and May 2024. We analyzed the delay to rifampicin use in relation to therapeutic failures, infection recurrences, and development of ultimate rifampicin resistance. Results: Among 103 independent infection episodes, 47 (46%) contained the pathogen S. aureus, and the remainder were different coagulase-negative staphylococci. The median number of surgical interventions was one, and the median duration of postsurgical systemic antibiotic treatment was 84 days (interquartile range (IQR), 42–84 d). The median daily dose of oral rifampicin was 900 mg, and the median delay in its introduction was 5 days (IQR, 3–8 d). Overall, 18% of patients experienced an adverse event related to rifampicin (mostly gastrointestinal), requiring treatment to be stopped. The incidences of clinical failures and of microbiologically identical recurrences were 27% and 10%, respectively. The risk of rifampin resistance among any new staphylococcal infection or colonization during a median follow-up of 1.9 years was 1%. In the multivariate Cox regression analysis, the delay in rifampicin administration, its dose, or its duration failed to alter outcomes. Conclusions: In our retrospective cohort of staphylococcal orthopedic implant infections, the timing of rifampicin introduction failed to alter clinical and microbiological outcomes.

Background/Objectives: In staphylococcal implant infections, there is often discussion about the optimal postoperative timing of the introduction of rifampicin in the postoperative period with open wounds. Methods: We reviewed all adult patients with residual staphylococcal implant infections between January 2014 and May 2024. We analyzed the delay to rifampicin use in relation to therapeutic failures, infection recurrences and development of ultimate rifampicin resistance. The “last Staphylococcus” represented any clinical sample at the end of the individual period. Results: Among 103 independent infection episodes, the pathogens were S. aureus in 47 episodes (46%) and the remainder were different coagulase-negative staphylococci. The median number of surgical interventions was 1 and the median duration of postsurgical systemic antibiotic treatment was 84 days (interquartile range (IQR), 42-84 d). The median daily dose of oral rifampicin was 900 mg, the median delay of its introduction 5 days (IQR, 3-8 d). Overall, 13% experienced an adverse event related to rifampicin (mostly gastrointestinal), requiring its stopping. The incidences of Clinical Failures and of Microbiologically identical Recurrences were 27% and 10%, respectively. The risk of rifampin-resistance among the “last Staphylococcus” isolates was 1%. This single case occurred in an infected knee to which rifampicin was introduced after a delay of eight days. In multivariate Cox regression analysis, the delay of rifampicin administration, its dose or its duration all failed to alter outcomes. Conclusions: In our retrospective cohort of staphylococcal orthopedic implant infections, the timing of rifampicin introduction failed to alter clinical and microbiological outcomes.

Introduction: Empirical antibiotics should only target the most likely pathogens if antibiotic stewardship is being heeded. However, there is a drive for broader-spectrum empirical antibiotics in orthopedic infections due to the concern of therapeutic failure if a regimen fails to target subsequently identified pathogens. Methods: Retrospective case-control study with surgically managed orthopedic infections from July 2018 to June 2024 with a minimum follow-up of 6 months. Patients were stratified by the initial empirical treatment of either accurate empirical choice or inaccurate empirical choice. Results: Of 482 infection episodes, 79 antibiotic regimens (43 broad-spectrum; 9 %) were used with a median postoperative duration of 42 d (interquartile range 19–45 d); 290 infection episodes (60 %) were correctly targeted. In 192 cases (40 %), the initial empirical choice was inaccurate, with a median switching time to a targeted treatment of 4 d. There was no difference between accurate and inaccurate empirical treatment in terms of ultimate failures (18/290 vs. 15/192; Pearson χ² test, p=0.49), overall adverse events of therapy (15 % vs. 7 %, p=0.11), duration of hospital stay (median 9 d vs. 9 d, p=0.96), or supplementary surgical debridement (median 0 vs. 0 intervention, p=0.58). In multivariate logistic regression analysis, the duration of an inaccurate antibiotic treatment failed to alter the risk of “failures” (odds ratio 0.9, 95 % confidence interval 0.8–1.1). Conclusions: A delay in commencing targeted antibiotics does not increase the risk of a negative outcome. Narrower-spectrum empirical regimens are appropriate for clinically mild to moderate infections as a broader spectrum does not provide any clinical advantage.