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. 2025 Dec 22;10(4):e25.00259.
doi: 10.2106/JBJS.OA.25.00259. eCollection 2025 Oct-Dec.

Dual Antibiotic Prophylaxis with Addition of Doxycycline Does Not Lower Periprosthetic Infection Rate in Primary Directed Anterior Total Hip Replacement: A Cohort Study on 7,917 Patients

Sebastian Simon  1   2 , Selma Tobudic  3 , Jennyfer A Mitterer  1   2   4 , Stephanie Huber  1   2 , Sujeesh Sebastian  1 , Susana Gardete-Hartmann  1 , Christian Woisetschlaeger  5 , Jochen G Hofstaetter  1   5   6
Affiliations

Dual Antibiotic Prophylaxis with Addition of Doxycycline Does Not Lower Periprosthetic Infection Rate in Primary Directed Anterior Total Hip Replacement: A Cohort Study on 7,917 Patients

Sebastian Simon et al. JB JS Open Access. .

Abstract

Background: Periprosthetic joint infections (PJI) caused by Cutibacterium spp. are frequently observed in total hip arthroplasty (THA) using the direct anterior approach (DAA). The microbiological spectrum of PJI after DAA differs from that of a lateral based approach. The aim of this study was to compare a dual-antibiotic (AB)-prophylaxis with cefuroxime (CEF) and doxycycline (DOX) to mono-AB-prophylaxis with CEF alone in DAA THA.

Methods: A total of 4,430 primary THAs receiving CEF prophylaxis were compared with 3,487 THAs receiving CEF+DOX prophylaxis. The institutional AB-prophylaxis was changed from cefuroxime 1.5-3 g (CEF group) alone to cefuroxime 1.5-3 doxycycline 300 mg (CEF+DOX group). A multivariable binary logistic regression analysis to evaluate the association between CEF vs. CEF+DOX and the occurrence of PJI (according to the International Consensus Meeting 2018) was performed with dropping 3 months before and after the change (covariates: American Society of Anesthesiologists, Charlson Comorbidity -Index, age, body mass index [BMI], smoking status, and diabetes mellitus [DM]). The primary outcome was the incidence of PJI following THA after a minimum follow-up of 1 year, with an accompanying analysis of the microbiological spectrum.

Results: In total, 7,917 (age: 65.8 (65.5; 66.0) years; female: 61.2%; male: 38.8%) THA were analyzed for this study. After a median follow-up of 4.3 years (interquartile-range: 2.0-6.2), no significant difference in the incidence of septic revision was observed between the CEF and CEF+DOX therapy with an infection rate of 1.3% and 1.0%, respectively (p = 0.172). The septic-free revision rate at 1 year was 99.0% in the CEF group and 99.1% in the CEF+DOX group (p = 0.541). Due to the longer follow-up, the CEF group experienced more THA with aseptic loosening compared to the CEF+DOX group. The type of AB prophylaxis was not associated with a clinically relevant higher risk of PJI (odds ratio [OR] = 1.03; 95% CI: 0.99-1.07; p = 0.052). Only BMI demonstrated a significant association with PJI (OR = 1.12; 95% CI: 1.09-1.16; p < 0.001). In the CEF+DOX group, Cutibacterium avidum was more frequent (15.7% vs. 8.1%) and Cutibacterium Acnes was less frequent (9.8% vs. 12.3%) compared with the CEF group (p = 0.143 and p = 0.809, respectively).

Conclusion: This study showed no superiority in the rate of PJI between CEF+DOX and CEF alone in DAA THA. DOX does not prevent Cutibacterium-positive PJIs. There are factors other than AB prophylaxis that influence the risk of PJI.

Level of evidence: Diagnostic Level III. See Instructions for Authors for a complete description of levels of evidence.

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Conflict of interest statement

Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJSOA/B52).

Figures

Fig. 1
Fig. 1
Septic-free survival after 90 days, 1a, 2a, and 3a (95%-CI); a (years), monotherapy with CEF and dual therapy with CEF and DOX. CEF = cefuroxime, CI = confidence interval, and DOX = doxycycline.
See this image and copyright information in PMC

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