JBJI Journal of Bone and Joint Infection JBJI J. Bone Joint Infect. 2206-3552 Ivyspring Göttingen, Germany 10.7150/jbji.24285 Treatment of Prosthetic Joint Infection with Debridement, Antibiotics and Irrigation with Implant Retention - a Narrative Review Sousa Ricardo 1 2 Abreu Miguel Araújo 3 2 Department of Orthopaedics, Centro Hospitalar do Porto, Porto, Portugal Grupo TrofaSaude - Hospital em Alfena, Valongo, Portugal Department of Infectious Diseases, Centro Hospitalar do Porto, Porto, Portugal 08 06 2018 3 3 108 117 Copyright: © 2018 Ricardo Sousa 2018 This work is licensed under the Creative Commons Attribution 4.0 International License. To view a copy of this licence, visit https://creativecommons.org/licenses/by/4.0/ This article is available from https://jbji.copernicus.org/articles/3/108/2018/jbji-3-108-2018.html The full text article is available as a PDF file from https://jbji.copernicus.org/articles/3/108/2018/jbji-3-108-2018.pdf

<p class="p p-first" id="__p3">Prosthetic joint infection usually requires combined medical and surgical therapy. While revision surgery is widely considered to be the gold standard surgical procedure, debridement, antibiotics and irrigation with implant retention is a very appealing alternative.</p><p id="__p4">There is however great controversy regarding its real worth with success rates ranging from 0% to over 90%. A number of different patient and host related variables as well as specific aspects of surgical and medical management have been described as relevant for the final outcome.</p><p class="p p-last" id="__p5">Along this paper, the authors will provide the readers with a critical narrative review of the currently available literature while trying to provide concise and practical treatment recommendations regarding adequate patient selection criteria, proper surgical technique and optimal antibiotic therapy.</p>

 References Dzaja I, Howard J, Somerville L, Lanting B. Functional outcomes of acutely infected knee arthroplasty: a comparison of different surgical treatment options. Can J Surg. 2015;58(6):402–7. [PMC free article] Grammatopoulos G, Bolduc ME, Atkins BL, Kendrick BJL, McLardy-Smith P, Murray DW, Functional outcome of debridement, antibiotics and implant retention in periprosthetic joint infection involving the hip: a case-control study. Bone Joint J; 2017. p. 99. -B(5): 614-22. Sherrell JC, Fehring TK, Odum S, Hansen E, Zmistowski B, Dennos A. et al. The Chitranjan Ranawat Award: fate of two-stage reimplantation after failed irrigation and debridement for periprosthetic knee infection. Clin Orthop Relat Res. 2011;469(1):18–25. [PMC free article] Gardner J, Gioe TJ, Tatman P. Can this prosthesis be saved?: implant salvage attempts in infected primary TKA. Clin Orthop Relat Res. 2011;469(4):970–6. [PMC free article] Gristina AG, Costerton JW. Bacterial adherence and the glycocalyx and their role in musculoskeletal infection. Orthop Clin North Am. 1984;15(3):517–35. Tzeng A, Tzeng TH, Vasdev S, Korth K, Healey T, Parvizi J. et al. Treating periprosthetic joint infections as biofilms: key diagnosis and management strategies. Diagn Microbiol Infect Dis. 2015;81(3):192–200. Costerton JW, Stewart P, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science. 1999;284(5418):1318–22. Gbejuade HO, Lovering AM, Webb JC. The role of microbial biofilms in prosthetic joint infections. Acta Orthop. 2015;86(2):147–58. [PMC free article] Romano C, Logoluso N, Drago L, Peccati A, Romano D. Role for irrigation and debridement in periprosthetic infections. J Knee Surg. 2014;27(4):267–72. Romano CL, Manzi G, Logoluso N, Romano D. Value of debridement and irrigation for the treatment of peri-prosthetic infections. A systematic review. Hip Int. 2012;22(Suppl 8):S19–24. Triantafyllopoulos GK, Soranoglou V, Memtsoudis SG, Poultsides LA. Implant retention after acute and hematogenous periprosthetic hip and knee infections: Whom, when and how? World J Orthop. 2016;7(9):546–52. [PMC free article] Azzam KA, Seeley M, Ghanem E, Austin MS, Purtill JJ, Parvizi J. Irrigation and debridement in the management of prosthetic joint infection: traditional indications revisited. J Arthroplasty. 2010;25(7):1022–7. Holmberg A, Thorhallsdottir VG, Robertsson O, W-Dahl A, Stefansdottir A. 75% success rate after open debridement, exchange of tibial insert, and antibiotics in knee prosthetic joint infections. Acta Orthop. 2015;86(4):457–62. [PMC free article] Grammatopoulos G, Kendrick B, McNally M, Athanasou NA, Atkins B, McLardy-Smith P. et al. Outcome Following Debridement, Antibiotics, and Implant Retention in Hip Periprosthetic Joint Infection-An 18-Year Experience. J Arthroplasty. 2017;32(7):2248–55. Rodriguez D, Pigrau C, Euba G, Cobo J, Garcia-Lechuz J, Palomino J. et al. Acute haematogenous prosthetic joint infection: prospective evaluation of medical and surgical management. Clin Microbiol Infect. 2010;16(12):1789–95. Zimmerli W, Trampuz A, Ochsner PE. Prosthetic-joint infections. N Engl J Med. 2004;351(16):1645–54. Buller LT, Sabry FY, Easton RW, Klika AK, Barsoum W. The preoperative prediction of success following irrigation and debridement with polyethylene exchange for hip and knee prosthetic joint infections. J Arthroplasty. 2012;27(6):857–64.e1. -4. Byren I, Bejon P, Atkins BL, Angus B, Masters S, McLardy-Smith P. et al. One hundred and twelve infected arthroplasties treated with 'DAIR' (debridement, antibiotics and implant retention): antibiotic duration and outcome. J Antimicrob Chemother. 2009;63(6):1264–71. [PMC free article] Estes CS, Beauchamp CP, Clarke HD, Spangehl MJ. A two-stage retention debridement protocol for acute periprosthetic joint infections. Clin Orthop Relat Res. 2010;468(8):2029–38. [PMC free article] Fehring TK, Odum SM, Berend KR, Jiranek WA, Parvizi J, Bozic KJ. et al. Failure of irrigation and debridement for early postoperative periprosthetic infection. Clin Orthop Relat Res. 2013;471(1):250–7. [PMC free article] Kuiper JW, Vos SJF, Saouti R, Vergroesen DA, Graat HCA, Debets-Ossenkopp YJ. et al. Prosthetic joint-associated infections treated with DAIR (debridement, antibiotics, irrigation, and retention): analysis of risk factors and local antibiotic carriers in 91 patients. Acta Orthop. 2013;84(4):380–6. [PMC free article] Tornero E, Morata L, Martinez-Pastor JC, Bori G, Climent C, Garcia-Velez DM. et al. KLIC-score for predicting early failure in prosthetic joint infections treated with debridement, implant retention and antibiotics. Clin Microbiol Infect. 2015;21(8):786.e9–e17. Westberg M, Grogaard B, Snorrason F. Early prosthetic joint infections treated with debridement and implant retention: 38 primary hip arthroplasties prospectively recorded and followed for median 4 years. Acta Orthop. 2012;83(3):227–32. [PMC free article] Osmon DR, Berbari EF, Berendt AR, Lew D, Zimmerli W, Steckelberg JM. et al. Diagnosis and management of prosthetic joint infection: clinical practice guidelines by the Infectious Diseases Society of America. Clin Infect Dis. 2013;56(1):e1–e25. Gehrke T, Parvizi J. Proceedings of the International Consensus Meeting on Periprosthetic Joint Infection. https://www.efort.org/wpcontent/uploads/2013/10/Philadelphia_Consensus.pdf. 2013. Betz M, Abrassart S, Vaudaux P, Gjika E, Schindler M, Billieres J. et al. Increased risk of joint failure in hip prostheses infected with Staphylococcus aureus treated with debridement, antibiotics and implant retention compared to Streptococcus. Int Orthop. 2015;39(3):397–401. Zmistowski BM, Manrique J, Patel R, Chen AF. Recurrent Periprosthetic Joint Infection After Irrigation and Debridement With Component Retention Is Most Often Due to Identical Organisms. J Arthroplasty. 2016;31(9 Suppl):148–51. Salgado CD, Dash S, Cantey JR, Marculescu CE. Higher risk of failure of methicillin-resistant Staphylococcus aureus prosthetic joint infections. Clin Orthop Relat Res. 2007;461:48–53. Siddiqui MM, Lo NN, Ab Rahman S, Chin PL, Chia Sl, Yeo SJ. Two-year outcome of early deep MRSA infections after primary total knee arthroplasty: a joint registry review. J Arthroplasty. 2013;28(1):44–8. Bradbury T, Fehring TKF, Taunton M, Hanssen A, Azzam K, Parvizi J. et al. The fate of acute methicillin-resistant Staphylococcus aureus periprosthetic knee infections treated by open debridement and retention of components. J Arthroplasty. 2009;24(6 Suppl):101–4. Joulie D, Girard J, Mares O, Beltrand E, Legout L, Dezeque H. et al. Factors governing the healing of Staphylococcus aureus infections following hip and knee prosthesis implantation: a retrospective study of 95 patients. Orthop Traumatol Surg Res. 2011;97(7):685–92. Lora-Tamayo J, Murillo OF, Iribarren JA, Soriano A, Sanchez-Somolinos M, Baraia-Etxaburu JM. et al. A large multicenter study of methicillin-susceptible and methicillin-resistant Staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis. 2013;56(2):182–9. Hsieh PH, Lee MS, Hsu K-Y, Chang Y-H, Shih H-N, Ueng SW. Gram-negative prosthetic joint infections: risk factors and outcome of treatment. Clin Infect Dis. 2009;49(7):1036–43. Peel TN, Cheng AC, Choong PFM, Buising KL. Early onset prosthetic hip and knee joint infection: treatment and outcomes in Victoria, Australia. J Hosp Infect. 2012;82(4):248–53. Aboltins CA, Dowsey MM, Buising KL, Peel TN, Daffy JR, Choong PFM. et al. Gram-negative prosthetic joint infection treated with debridement, prosthesis retention and antibiotic regimens including a fluoroquinolone. Clin Microbiol Infect. 2011;17(6):862–7. Rodriguez-Pardo D, Pigrau C, Lora-Tamayo J, Soriano A, del Toro MD, Cobo J. et al. Gram-negative prosthetic joint infection: outcome of a debridement, antibiotics and implant retention approach. A large multicentre study. Clin Microbiol Infect. 2014;20(11):911–9. Veltman ES, Vos FJ, Meis JF, Goosen JH. Debridement, antibiotics and implant retention in early postoperative infection with Pseudomonas aeruginosa. J Infect. 2015;70(3):307–9. Zmistowski B, Fedorka CJ, Sheehan E, Deirmengian G, Austin MS, Parvizi J. Prosthetic joint infection caused by gram-negative organisms. J Arthroplasty. 2011;26(6 Suppl):104–8. Ricciardi W, Giubbini G, Laurenti P. Surveillance and Control of Antibiotic Resistance in the Mediterranean Region. Mediterr J Hematol Infect Dis; 2016. p. 8. (1) [PMC free article] Livermore DM. Current Epidemiology and Growing Resistance of Gram- Negative Pathogens. Korean J Intern Med. 2012;27(2):128–42. [PMC free article] de Sanctis J, Teixeira L, van Duin D, Odio C, Hall G, Tomford JW. et al. Complex prosthetic joint infections due to carbapenemase-producing Klebsiella pneumoniae: a unique challenge in the era of untreatable infections. Int J Infect Dis. 2014;25:73–8. [PMC free article] Kheir MM, Tan TL, Higuera C, George J, Della Valle CJ, Shen M. et al. Periprosthetic Joint Infections Caused by Enterococci Have Poor Outcomes. J Arthroplasty 2016; Sep 28. [Epub ahead of print] doi: 10.1016/j.arth.2016.09.017. [Google Scholar] Rasouli MR, Tripathi MS, Kenyon R, Wetters N, Della Valle CJ, Parvizi J. Low rate of infection control in enterococcal periprosthetic joint infections. Clin Orthop Relat Res. 2012;470(10):2708–16. [PMC free article] Tornero E, Senneville E, Euba G, Petersdorf S, Rodriguez-Pardo D, Lakatos B. et al. Characteristics of prosthetic joint infections due to Enterococcus sp. and predictors of failure: a multi-national study. Clin Microbiol Infect. 2014;20(11):1219–24. Duijf SV, Vos FJ, Meis JF, Goosen JH. Debridement, antibiotics and implant retention in early postoperative infection with Enterococcus sp. Clin Microbiol Infect. 2015;21(5):e41–2. Odum SM, Fehring TK, Lombardi AV, Zmistowski BM, Brown NM, Luna JT. et al. Irrigation and debridement for periprosthetic infections: does the organism matter? J Arthroplasty. 2011;26(6 Suppl):114–8. Lora-Tamayo J, Senneville E, Ribera A, Bernard L, Dupon M, Zeller V. et al. The Not-So-Good Prognosis of Streptococcal Periprosthetic Joint Infection Managed by Implant Retention: The Results of a Large Multicenter Study. Clin Infect Dis. 2017;64(12):1742–52. Marculescu CE, Cantey JR. Polymicrobial prosthetic joint infections: risk factors and outcome. Clin Orthop Relat Res. 2008;466(6):397–404. [PMC free article] Tornero E, Garcia-Oltra E, Garcia-Ramiro S, Martinez-Pastor JC, Bosch J, Climent C. et al. Prosthetic joint infections due to Staphylococcus aureus and coagulase-negative staphylococci. Int J Artif Organs. 2012;35(10):884–92. Aboltins C, Dowsey MM, Peel T, Lim WK, Parikh S, Stanley P. et al. Early prosthetic hip joint infection treated with debridement, prosthesis retention and biofilm-active antibiotics: functional outcomes, quality of life and complications. Intern Med J. 2013;43(7):810–5. Choong PF, Dowsey MM, Carr D, Daffy J, Stanley P. Risk factors associated with acute hip prosthetic joint infections and outcome of treatment with a rifampinbased regimen. Acta Orthop. 2007;78(6):755–65. Cochran AR, Ong KL, Lau E, Mont MA, Malkani AL. Risk of Reinfection After Treatment of Infected Total Knee Arthroplasty. J Arthroplasty. 2016;31(9 Suppl):156–61. Kim JH, Chun SK, Yoon YC, Lakhotia D, Shon WY. Efficacy of Debridement for Early Periprosthetic Joint Infection after Hip Arthroplasty. Hip Pelvis. 2014;26(4):227–34. [PMC free article] Klouche S, Lhotellier L, Mamoudy P. Infected total hip arthroplasty treated by an irrigation-debridement/component retention protocol. A prospective study in a 12-case series with minimum 2 years' follow-up. Orthop Traumatol Surg Res. 2011;97(2):134–8. Koyonos L, Zmistowski B, Della Valle CJ, Parvizi J. Infection control rate of irrigation and debridement for periprosthetic joint infection. Clin Orthop Relat Res. 2011;469(11):3043–8. [PMC free article] Vilchez F, Martinez-Pastor JC, Garcia-Ramiro S, Bori G, Tornero E, Garcia E. et al. Efficacy of debridement in hematogenous and early post-surgical prosthetic joint infections. Int J Artif Organs. 2011;34(9):863–9. Zhang C, Yan CH, Chan PK, Ng FY, Chiu KY. Polyethylene Insert Exchange Is Crucial in Debridement for Acute Periprosthetic Infections following Total Knee Arthroplasty. J Knee Surg. 2017;30(1):36–41. Fukagawa S, Matsuda S, Miura H, Okazaki K, Tashiro Y, Iwamoto Y. High-dose antibiotic infusion for infected knee prosthesis without implant removal. J Orthop Sci. 2010;15(4):470–6. Geurts JA, Janssen DM, Kessels AGH, Walenkamp GH. Good results in postoperative and hematogenous deep infections of 89 stable total hip and knee replacements with retention of prosthesis and local antibiotics. Acta Orthop. 2013;84(6):509–16. [PMC free article] Peel TN, Buising KL, Dowsey MM, Aboltins CA, Daffy JR, Stanley PA. et al. Outcome of debridement and retention in prosthetic joint infections by methicillin-resistant staphylococci, with special reference to rifampin and fusidic acid combination therapy. Antimicrob Agents Chemother. 2013;57(1):350–5. [PMC free article] Puhto AP, Syrjala H. Short-course antibiotics for prosthetic joint infections treated with prosthesis retention. Clin Microbiol Infect. 2012;18(11):1143–8. Chung JY, Ha CW, Park YB, Song YJ, Yu KS. Arthroscopic debridement for acutely infected prosthetic knee: any role for infection control and prosthesis salvage? Arthroscopy. 2014;30(5):599–606. Waldman BJ, Hostin E, Mont MA, - MMF, Hungerford DS. Infected total knee arthroplasty treated by arthroscopic irrigation and debridement. J Arthroplasty. 2000;15(4):430–6. Kalteis T, Lehn N, Schroder H-J, Schubert T, Zysk S, Handel M. et al. Contaminant seeding in bone by different irrigation methods: an experimental study. J Orthop Trauma. 2005;19(9):591–6. Munoz-Mahamud E, Garcia S, Bori G, Martinez-Pastor JC, Zumbado JA, Riba J. et al. Comparison of a low-pressure and a high-pressure pulsatile lavage during debridement for orthopaedic implant infection. Arch Orthop Trauma Surg. 2011;131(9):1233–8. Anglen JO, Apostoles S, Christensen G, Gainor B. The efficacy of various irrigation solutions in removing slime-producing Staphylococcus. J Orthop Trauma. 1994;8(5):390–6. Bartoszewicz M, Rygiel A, Krzeminski M, Przondo-Mordarska A. Penetration of a selected antibiotic and antiseptic into a biofilm formed on orthopedic steel implants. Ortop Traumatol Rehabil. 2007;9(3):310–8. Moussa FW, Gainor BJ, Anglen JO, Christensen G, Simpson WA. Disinfecting agents for removing adherent bacteria from orthopaedic hardware. Clin Orthop Relat Res. 1996 Aug;(329):255–62. Smith DC, Maiman R, Schwechter EM, Kim SJ, Hirsh DM. Optimal Irrigation and Debridement of Infected Total Joint Implants with Chlorhexidine Gluconate. J Arthroplasty. 2015;30(10):1820–2. Schwechter EM, Folk D, Varshney AK, Fries BC, Kim SJ, Hirsh DM. Optimal irrigation and debridement of infected joint implants: an in vitro methicillin-resistant Staphylococcus aureus biofilm model. J Arthroplasty. 2011;26(6 Suppl):109–13. [PMC free article] Bjarnsholt T, Alhede M, Jensen PO, Nielsen AK, Johansen HK, Homoe P. et al. Antibiofilm Properties of Acetic Acid. Adv Wound Care (New Rochelle) 2015;4(7):363–72. [PMC free article] Williams RL, Ayre WN, Khan WS, Mehta A, Morgan-Jones R. Acetic Acid as Part of a Debridement Protocol During Revision Total Knee Arthroplasty. LID - S0883-5403(16)30652-0 [pii] LID - 10.1016/j.arth.2016.09.010 [doi] J Arthroplasty; 2016. Whiteside LA, Peppers M, Nayfeh TA, Roy ME. Methicillin-resistant Staphylococcus aureus in TKA treated with revision and direct intra-articular antibiotic infusion. Clin Orthop Relat Res. 2011;469(1):26–33. [PMC free article] Whiteside LA, TA N, LaZear R, Roy ME. Reinfected revised TKA resolves with an aggressive protocol and antibiotic infusion. Clin Orthop Relat Res. 2012;470(1):236–43. [PMC free article] Whiteside LA, Roy ME. One-stage Revision With Catheter Infusion of Intraarticular Antibiotics Successfully Treats Infected THA. Clin Orthop Relat Res. 2017;475(2):419–29. [PMC free article] Tintle SM, Forsberg JA, Potter BK, Islinger RB, Andersen RC. Prosthesis retention, serial debridement, and antibiotic bead use for the treatment of infection following total joint arthroplasty. Orthopedics; 2009. p. 32. (2) Tornero E, Morata L, Martinez-Pastor JC, Angulo S, Combalia A, Bori G. et al. Importance of selection and duration of antibiotic regimen in prosthetic joint infections treated with debridement and implant retention. J Antimicrob Chemother. 2016;71(5):1395–401. Zimmerli W, Widmer AF, Blatter M, Frei R, Ochsner PE. Role of rifampin for treatment of orthopedic implant-related staphylococcal infections: a randomized controlled trial. Foreign-Body Infection (FBI) Study Group. JAMA. 1998;279(19):1537–41. Lora-Tamayo J, Murillo O, Iribarren JA, Soriano A, Sanchez-Somolinos M, Baraia-Etxaburu JM. et al. A large multicenter study of methicillin-susceptible and methicillin-resistant Staphylococcus aureus prosthetic joint infections managed with implant retention. Clin Infect Dis. 2013;56(2):182–94. Morata L, Senneville E, Bernard L, Nguyen S, Buzele R, Druon J. et al. A Retrospective Review of the Clinical Experience of Linezolid with or Without Rifampicin in Prosthetic Joint Infections Treated with Debridement and Implant Retention. Infect Dis Ther. 2014;3(2):235–43. [PMC free article] Vilchez F, Martinez-Pastor JC, Garcia-Ramiro S, Bori G, Macule F, Sierra J. et al. Outcome and predictors of treatment failure in early post-surgical prosthetic joint infections due to Staphylococcus aureus treated with debridement. Clin Microbiol Infect. 2011;17(3):439–44. Achermann Y, Eigenmann K, Ledergerber B, Derksen L, Rafeiner P, Clauss M, Factors associated with rifampin resistance in staphylococcal periprosthetic joint infections (PJI): a matched case-control study. Infection; 2013. p. 41. (2) Grossi O, Asseray N, Bourigault C, Corvec S, Valette M, Navas D. et al. Gram-negative prosthetic joint infections managed according to a multidisciplinary standardized approach: risk factors for failure and outcome with and without fluoroquinolones. J Antimicrob Chemother. 2016;71(9):2593–7. Tanaka G, Shigeta M, Komatsuzawa H, Sugai M, Suginaka H, Usui T. Effect of the growth rate of Pseudomonas aeruginosa biofilms on the susceptibility to antimicrobial agents: beta-lactams and fluoroquinolones. Chemotherapy. 1999;45(1):28–36. Lora-Tamayo J, Euba G, Cobo J, Horcajada JP, Soriano A, Sandoval E. et al. Short- versus long-duration levofloxacin plus rifampicin for acute staphylococcal prosthetic joint infection managed with implant retention: a randomised clinical trial. Int J Antimicrob Agents. 2016;48(3):310–6. Piso RJ, Elke R. Antibiotic treatment can be safely stopped in asymptomatic patients with prosthetic joint infections despite persistent elevated C-reactive protein values. Infection. 2010;38(4):293–6. Bejon P, Byren I, Atkins BL, Scarborough M, Woodhouse A, McLardy-Smith P. et al. Serial measurement of the C-reactive protein is a poor predictor of treatment outcome in prosthetic joint infection. J Antimicrob Chemother. 2011;66(7):1590–3. Jimenez-Garrido CA-Ohoo, Gomez-Palomo JM, Rodriguez-Delourme I, Duran-Garrido FJ, Nuno-Alvarez E, Montanez-Heredia E. The Kidney, Liver, Index surgery and C reactive protein score is a predictor of treatment response in acute prosthetic joint infection. Int Orthop. 2018;42(1):33–8. Lowik CAM, Jutte PC, Tornero E, Ploegmakers JJW, Knobben BAS, de Vries AJ, Predicting Failure in Early Acute Prosthetic Joint Infection Treated With Debridement, Antibiotics, and Implant Retention: External Validation of the KLIC Score. J Arthroplasty; 2018. Mar 27. pii: S0883-5403(18)30299-7. doi: 10.1016/j.arth.2018.03.041. Moojen DJ, Zwiers JH, Scholtes VAB, Verheyen CCPM, Poolman RW. Similar success rates for single and multiple debridement surgery for acute hip arthroplasty infection. Acta Orthop. 2014;85(4):383–8. [PMC free article] Brimmo O, Ramanathan D, Schiltz NK, Pillai AL, Klika AK, Barsoum WK. Irrigation and Debridement Before a 2-Stage Revision Total Knee Arthroplasty Does Not Increase Risk of Failure. J Arthroplasty. 2016;31(2):461–4. [PMC free article] Wang X, Sadovskaya I, Leterme D, Watier D, Chokr A, Zhu Za. et al. A comparative study of antibodies against proteins extracted from staphylococcal biofilm for the diagnosis of orthopedic prosthesis-related infections in an animal model and in humans. Diagn Microbiol Infect Dis. 2013;75(2):124–9. Parvizi J, Alijanipour P, Barberi EF, Hickok NJ, Phillips KS, Shapiro IM. et al. Novel developments in the prevention, diagnosis, and treatment of periprosthetic joint infections. J Am Acad Orthop Surg. 2015;23(Suppl):S32–43. Costa F, Maia S, Gomes J, Gomes P, Martins MC. Characterization of hLF1-11 immobilization onto chitosan ultrathin films, and its effects on antimicrobial activity. Acta Biomater. 2014;10(8):3513–21. Sousa R, Silva M, Sousa A, Esteves J, Neves P, Seabra-Lopes J. et al. Treatment of Prosthetic Joint Infections with Debridement and Implant Retention -results of prospectively aplying a predetermined protocol [in portuguese] Rev Port Ortop Traumatol. 2017;25(I):16–27. [Google Scholar]