Treatment Duration in Bacterial Prosthetic Joint Infections: A Narrative Review of Current Evidence.

Background/

Objectives

The optimal duration of antibiotic therapy for bacterial prosthetic joint infections (PJI) remains a topic of considerable debate. Current recommendations are often based on limited evidence and expert consensus. Emerging data suggest that shorter antibiotic courses may be as effective as prolonged treatments in select cases. Shortening the duration of therapy offers several advantages, including a reduced risk of bacterial resistance, fewer adverse events, and cost savings. However, this approach must be carefully balanced with the individual patient's risk of treatment failure. This narrative review aims to synthesize current evidence regarding the duration of antibiotic therapy in PJIs, according to surgical strategies-DAIR (debridement, antibiotics, and implant retention), one-stage exchange, two-stage exchange, and resection without reimplantation-and to identify parameters that may guide individualized and potentially shortened regimens.

Methods

We conducted a comprehensive search of PubMed, Embase, and Cochrane Library databases through January 2025, including observational studies, randomized controlled trials, and international guidelines. Reference lists of key articles were also screened.

Results

Studies on DAIR suggest that longer regimens (e.g., 8-12 weeks) are necessary, especially in staphylococcal infections, as confirmed by the DATIPO trial, which showed higher failure rates with 6 weeks compared to 12 weeks. Evidence on one-stage exchange is limited but increasingly suggests that 6 weeks may be sufficient in selected patients; however, no dedicated trial has confirmed this. In two-stage exchange, small retrospective series report successful outcomes with short antibiotic therapy combined with local antibiotics, but randomized trials show trends favoring longer regimens. For patients treated with permanent resection arthroplasty, arthrodesis, or amputation, antibiotic durations are highly variable, with few robust data. Across all strategies, most studies are limited by methodological weaknesses, including small sample sizes, retrospective design, lack of microbiological stratification, and heterogeneous outcome definitions.

Conclusions

Despite growing interest in shortening antibiotic durations in PJIs, high-quality evidence remains limited. Until additional randomized trials are available-particularly in one- and two-stage exchange settings-12 weeks remains the safest reference duration for most patients, especially those with retained hardware. Future studies should incorporate stratification by infection type, causative organism, and host factors to define tailored and evidence-based antibiotic strategies.