To heal or harm: A systematic review of the role of fluoroquinolones in periprosthetic joint infections

Abstract

Background Fluoroquinolones (FQs) are currently recommended for the treatment of periprosthetic joint infections (PJIs) caused by staphylococci and Gram-negative bacteria (GNB) in patients undergoing debridement, antibiotics and implant retention (DAIR). In recent decades, reports of serious adverse events associated with FQ use have led to official regulatory recommendations for their restricted use. This review aims to describe the evidence for, and discuss the risks and benefits of, FQ use for PJI. Methods A comprehensive search of MEDLINE and EMBASE up to October 2024 was conducted using pre-defined criteria to identify studies addressing (i) the efficacy of FQs in treating staphylococcal and GNB-PJI, and (ii) serious adverse events associated with FQs. A narrative synthesis of the results was performed. Results No randomized controlled trials were identified. A total of 19 retrospective studies were reviewed to assess the efficacy of FQs in treating staphylococcal and GNB-PJI, though the sample sizes in these studies were relatively small. Fifty-seven studies, mostly large retrospective epidemiological cohorts, were found evaluating adverse events associated with FQ treatment. Conclusions There is evidence supporting the use of FQ monotherapy for GNB-PJI and FQ combined with rifampin for staphylococcal PJIs following DAIR over other antimicrobial regimens. There is evidence that FQs are associated with an increased risk of tendinopathy, prolonged QTc interval, peripheral neuropathy and dysglycaemia, however the absolute risk is low. When FQs are used in the treatment of PJIs, an individualized risk assessment and close monitoring during treatment are recommended.