Suppressive Antibiotic Therapy for Spinal Hardware Infection: A Retrospective Cohort Study

Suppressive Antibiotic Therapy for Spinal Hardware Infection: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Suppressive Antibiotic Therapy for Spinal Hardware Infection: A Retrospective Cohort Study Adil Choudhry, James B Doub, Uzoamaka A Eke This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7120988/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Mar, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted 10 You are reading this latest preprint version Abstract Background: Spinal hardware infection (SHI) is one of the most devastating complications of spine surgery with challenging and undefined antibiotic treatment modalities. Methods: Retrospective cohort study of patients ≥18 years of age who underwent surgery for the treatment of SHI at a university center between 1 st January2015, to 1 st January 2020. The aim was to determine the appropriate duration of suppressive antibiotic therapy (SAT) for SHI based on recurrent infection rate on SAT, rate of adverse drug reaction (ADR) from SAT, and rate of antibiotic resistance to SAT in patients with SHI. Results: The median age of the 82 patients who met eligibility criteria for the study was 61 years (53.2–72.5), 55% were female, 59.8% had multimorbidity and 53.7% had early infection . Staphylococcus aureus was the most common cultured organism (37.8%) and 29 (35.4%) of patients had bacteremia. 54 (65.8%) received SAT with a median duration of 52 weeks (12 to 191 weeks). 12 (14.5%) had recurrence, while 8 (9.7%) developed recurrence on SAT. Neither SAT nor SAT duration (52 weeks) was associated with recurrence in early or late infection, regardless of hardware status. There was a non-significant higher recurrence rate with partial hardware revision, 7.3% (OR 6.30 [0.70–57.07]) and full hardware retention, 6.1% (OR 3.62 [0.39–33.30]) compared to complete hardware removal, (1.2%). ADR occurred in 6 (11.1%) of patients on SAT and in 11 (13.6%) of patents while on intravenous therapy, with no significant difference (mid-p exact 95% CI [0.32–1.80], p = 0.82). Only one case of drug resistance occurred with SAT. Conclusion: In patients who underwent surgery for SHI, neither the use of SAT nor SAT duration had any impact on recurrence of SHI regardless of SHI onset or hardware status. The rate of ADR with SAT was comparable to ADR with intravenous antibiotics and the rate of development of drug resistance was low. A randomized control trial is urgently needed to determine the role of SAT and its optimal application in the treatment of SHI. Suppressive antibiotic therapy Spinal hardware infection Surgical site infection Antimicrobial resistance Adverse drug reaction Antibiotic treatment duration Background Spinal hardware infection (SHI) is one of the most devastating complications of spine surgery due to the costs and morbidity associated with conventional treatments. SHI has a reported incidence of 3–20% ( 1 , 2 ). However, as the number of spinal fusion surgeries performed in the US more than doubled in the last two decades, SHI is expected to become even more of a substantial problem ( 3 , 4 ). SHI can be broadly classified as early (presenting within 30 days of surgery) or delayed (appearing months to years after surgery) ( 5 , 6 ). The clinical presentation, mechanism of infection, microbiology and treatment modality typically varies in early compared to delayed SHI ( 1 , 7 ). The proposed pathogenesis of SHI includes intraoperative seeding, contiguous microbial spread from wounds, metal fretting nd hematogenous seeding ( 8 ). In delayed SHI, metal wear and corrosion damage can lead to inflammation, allowing for indolent bacteria, such as coagulase negative Staphylococci and Propionibacterium acnes that are present to flourish, leading to symptoms. On the other hand, in early SHI, more virulent pathogens such as Staphylococcus aureus (S. aureus) , aerobic Streptococci and enteric gram negatives are implicated, causing symptoms to occur much sooner ( 1 , 8 , 9 ) Treatment of SHI is complicated due to the presence of hardware and subsequently the presence of microbial biofilm that conventional antibiotics have poor ability to eradicate ( 10 , 11 ). Ideally, treatment involves implant removal and debridement, followed by antibiotic therapy, usually for a minimum of 6 weeks. However, implant removal is not always feasible, especially in early SHI due to spinal instability. Hence, in early SHI, the most employed treatment modality is debridement, implant retention and then an initial long course of antibiotics for 6 weeks followed by suppressive antibiotic therapy (SAT). The goal of SAT in this setting is to prevent relapse or recurrence of infection due to the retained hardware and incomplete source control. SAT has been shown to achieve 2-year cure rates similar to implant removal plus antibiotic therapy (80%), versus cure rate of 33% without SAT ( 7 ). On the other hand, SAT has not been shown to be as successful in delayed SHI, where implant removal is almost always needed to effect cure, with treatment failures as high as 50–60% when the implant is retained ( 1 , 7 ). SAT has traditionally involved the use of an oral antibiotic that is active against the isolated pathogen/s, deemed tolerable to the patient with potentially minimal side effects, although new long-acting intravenous infusions, such as dalbavancin have begun to have a role in treating these types of infections as well ( 12 ). However, the optimal duration of SAT for SHI is poorly defined. In addition, there is a paucity of data on SAT outcome with regards to adverse drug reactions (ADR), tolerability and SAT antibiotic resistance development. Consequently, in this study, our aim was to determine the appropriate duration of SAT for SHI based on recurrent infection rate on SAT, rate of ADR, and rate of development of antibiotic resistance to SAT in patients with SHI. Materials and Methods Study Design and setting : This was a retrospective cohort study of patients 18 years of age or older, who underwent surgical intervention for the treatment of SHI at the University of Maryland Medical Center (UMMC) in Baltimore between January 1st, 2015, to January 1st, 2020. The study was approved by the Institutional Review Board of the University of Maryland School of Medicine. (HP-00101883). Informed consent to participate was deemed unnecessary according to the University of Maryland, Baltimore (UMB) Institutional Review Board (IRB) and national regulations, 45 CFR 46.104(d). The UMB IRB reviewed the research protocol (HP-00101883) and determined it to be exempt under 45 CFR 46.104(d). Patients were identified using the EPIC electronic medical record database based on International Statistical Classification of Diseases and Related Health Problems (ICD-10) and Current Procedural Terminology (CPT) codes. Data pulled electronically was manually reviewed for accuracy of study entry based on the definition of spinal hardware infection. Manual review of individual charts was conducted and recorded based on patient comorbidities, demographic factors, onset of SHI, utilization of SAT, duration of SAT, microbiology, antimicrobials utilized, hardware revision status (all hardware removed with no hardware present, partial revision where some or all original hardware is replaced, or full hardware retention, where all original hardware is retained), recurrent infection, adverse reaction to antimicrobials and development of antibiotic resistance. Definitions of variables and primary outcomes : SHI was defined as any patient with spinal hardware who presented with any local wound changes around hardware not limited to pain, swelling, redness, drainage, or hardware exposure, that was also found to have evidence of infection in the operating room by the surgeon. Early onset of SHI represented SHI presenting within 30 days of hardware placement. Late onset SHI was defined as infections occurring after 30 days of hardware placement. SAT was defined as any oral antibiotic treatment for an extended duration of time of at least 3 months, after an initial intravenous or oral antibiotic course of at least 2–4 weeks. Multimorbidity was 2 or more comorbidities of any cardiovascular disease, hypertension, diabetes, cancer, renal failure, chronic obstructive pulmonary disease, Asthma, immunosuppression or other chronic medical conditions. The primary outcomes evaluated were rates of SHI recurrence with recurrence representing patients that were readmitted with SHI at the same site after previous surgical treatment, not limited to debridement, hardware revision or explant, and/or medical treatment with antimicrobials for SHI. Hardware status was evaluated as all hardware removed (no hardware present) vs partial revision (some or all hardware replaced) vs all original hardware retained. Secondary outcomes included: 1. rate of documented ADR from SAT which included any side effects or negative outcome to the antibiotic, not limited to allergic reaction or unpleasant response, that is unintended ( 13 ); 2. the development of antibiotic resistance to SAT which was determined when a recurrent SHI occurred and new culture results from the same site grew the same organism with resistance to more antibiotics or a new multidrug resistant organism (MDRO), not previously isolated. A MDRO is defined as an organism that is resistant to one or more classes of antimicrobial agents isolated in the setting of recurrent SHI, while undergoing SAT Data Analyses : Descriptive analyses were performed for all data collected using Microsoft Excel software (Redmond, WA, USA), and Stata software (Stata Corp, Texas). To determine the appropriate duration of treatment with SAT, SAT duration and other categorical variables selected a priori were each classified according to the frequency of recurrent infection and analyzed using Person’s chi square and univariate logistic regression for any association of these variables with recurrent infection. Multivariate logistic regression was performed to examine the association of recurrent infection and age, SAT duration, hardware revision status (all hardware retained versus full or partial hardware revision), organism type ( Staphylococcus aureus versus non- Staphylococcus aureus ), body mass index (BMI), Multimorbidity and albumin level. Results Table 1 shows the demographics and characteristics of the cohort. A total of 82 patients met the eligibility criteria for spinal hardware infection (SHI). The median age was 61 years (range 53.2–72.5), 54.9% of the patients were female and 44 (53.7%) had early infection. Common comorbidities included cardiovascular disease (31.7%), diabetes (36.6%) and chronic kidney disease (26.8%), multimorbidity (59.8%), and 22% were smokers. The most common orthopedic indications for spinal instrumentation were fracture (22.0%), followed by lumbar stenosis (14.6%). 22.0% of the diagnoses were classified as “other”, including post-laminectomy syndrome, pseudoarthrosis, kyphosis, and scoliosis. The lumbar spine was the most frequently infected region (36.6%), followed by thoraco-lumbar (18.3%) and thoracic (15.9%). Table 1 Baseline Characteristics of Patients (N = 82) Demographics Median (range) Age 61 (53.2–72.5) BMI 28.9 (25.3–35.9) Female (%) 45 (54.9) Comorbidities N (%) Cardiovascular disease 26 (31.7) Diabetes mellitus 30 (36.6) Kidney disease 22 (26.8) Cancer history 16 (19.5) Tobacco N (%) Never smoked 41 (50.0) Former smoker 23 (28.0) Current smoker 18 (22.0) Primary diagnosis (orthopedics) N (%) Fracture 18 (22.0) Others 18 (22.0) Lumbar stenosis 12 (14.6) Myeloradiculopathy 11 (13.4) Spondylolisthesis 8 (9.8) Flat back syndrome 7 (8.5) Infection 5 (6.1) Spinal tumor 3 (3.7) Infection Location N (%) Lumbar 30 (36.6) Thoraco-lumbar 15 (18.3) Thoracic 13 (15.9) Cervical 11 (13.4) Lumbosacral 10 (12.2) Cervical-thoracic 3 (3.7) Pathogens N (%) MSSA 19 (23.2) Culture Negative 13 (15.9) Polymicrobial 13 (15.9) MRSA 12 (14.6) Other gram negatives 12 (14.6) CoNS 6 (7.3) E.coli 4 (4.9) Anaerobes 2 (2.4) Streptococcus group G 1 (1.2) Bacteremia N = 29 (%) MSSA 11(37.9) MRSA 7 (24.1) Other gram negatives* 6 (20.7) Other gram positives ** 2 (6.9) E.coli 3 (10.3) * Eikenella spp, Proteus mirabilis , 2 Pseudomonas spp , 2 Enterobacter cloacae complex ** Enterococcus fecalis and Streptococcus pneumoniae Staphylococcus aureus comprised 37.8% of cultured organisms, with MSSA (23.2%) and MRSA (14.6%). Polymicrobial infections and culture-negative infections each accounted for 15.9% of cases. There were an additional 3 MRSA and 3 MSSA in the polymicrobial infections and Enterococcus fecalis was present in 5 of the polymicrobial cultures. Coagulase-negative Staphylococci comprised 7.3% and Streptococcus spp grew in only one culture. E. coli was the most frequently isolated gram negative (4.9%) while other gram-negative organisms, including Pseudomonas, Enterobacter, Klebsiella and Morganella spp comprised 14.6%. Candida spp was identified in 3 polymicrobial cultures but not in pure culture. 29 (35.4%) had bacteremia, mostly gram positives (68.9%): MSSA (37.9%), MRSA (24.1%), E.fecalis and S.pneumoniae (6.9%). Gram negative organisms were responsible for 31% of bacteremia: E. coli (10.3%) and other gram negatives (20.7%) A total of 54 patients (65.8%) were treated with suppressive antibiotic therapy (SAT), Table 2 . Doxycycline, 23 (42.6%) was the most frequently used SAT followed by levofloxacin, 11 (20.4%) and cephalexin, 9 (16.7%). The median SAT duration was 52 weeks (range12 to 191 weeks). A total of 12 patients (14.6%) experienced recurrence, while 8 (9.7%) experienced recurrence while on SAT. Recurrence was not significantly associated with SAT or SAT duration in univariate or adjusted models. SAT was not included in the multivariate model due to its collinearity with SAT duration. There was a higher recurrence rate with hardware retention: partial hardware revision, 7.3% (OR 6.30 [0.70–57.07]) and full retention, 6.1% (OR 3.62 [0.39–33.30]) compared to complete hardware removal, N = 1 (1.2%) but these associations were not statistically significant in unadjusted or adjusted models. Other variables including age, onset, infection location, BMI, smoking status, albumin, multimorbidity, and organism type ( S. aureus vs non– S. aureus ) were not significantly associated with recurrence in either univariate or multivariate models. Furthermore, SAT and SAT duration did not have any significant association with recurrent infection in the subset of patients with early onset infection who underwent debridement and implant retention (Table 3 ) or those with late onset infection, Supplementary (S) Table 1 . The median time to recurrent infection while on SAT did not differ significantly among patients who received SAT for 52 weeks (S Table 2 ). There was a trend to higher SAT utilization where all hardware was retained (30.5%), compared to partial revision (23.2%), or where all hardware was removed (12.2%), but this did not reach statistical significance (χ 2 5.57, P = .06) and SAT duration did not vary by hardware status (Table 4 ). SAT was utilized more in early onset infections: 31 (70.5%) N = 44, compared to late onset infections: 23 (60.5%) N = 38 but this did not reach statistical significance (95% CI 0.30–1.37; P = .12). Conversely, a longer SAT duration > 12 weeks was used in 17 (77.3%), N = 22 of late onset infections compared to 19 (61.3%), N = 31 of early onset infections, but not statistically significant (95% CI 0.77–6.78: P = 0.07) Table 2 Univariate and Multivariate Logistic Regression Analyses showing Association of Patient Characteristics with Recurrence of Infection. Variable Total N (%) No Recurrence N = 70 (85.4%) Recurrence N = 12 (14.6%) OR (CI) Univariate OR (CI) Multivariate Age years 70 22 (26.8) 20 (24.4) 2 (2.4) 1.2 (.09-14.7) .45 (.17-11.8) SAT No 28 (34.2) 24 (29.3) 4 (4.9) Yes 54 (65.8) 46 (56.1) 8 (9.7) 1.04 (.29-3.82) SAT Duration. N = 53 (1 missing) > 52weeks 21 (39.6) 18 (34.0) 3 (5.7) 24–52 weeks 13 (24.53) 11 (20.8) 2 (3.8) 1.09 (.16-7.59) 1.46 (.15-14.1) < 24 weeks 19 (35.9) 16 (30.2) 3 (5.7) 1.13 (.20-6.39) .91 (.09-8.46) Onset of SHI Early 44 (53.7) 36 (43.9) 8 (9.8) Late 38 (46.3) 34 (41.5) 4 (4.9) .53(.14-1.92) Hardware Status All removed 22 (26.8) 21 (25.6) 1 (1.2) Partial revision 26 (31.7) 20 (24.4) 6 (7.3) 6.30 (.70-57.07) All retained 34 (41.5) 29 (35.4) 5 (6.1) 3.62 (.39-33.30) ^ 1.01 (.15-6.86) Organism Non- S. aureus 45 (54.9) 38 (46.3) 7 (8.5) S. aureus * 37 (45.1) 32 (39.0) 5 (6.1) .85 (.24-2.93) .94 (.16-5.67) Bacteremia No 53 (64.6) 44 (53.7) 9 (11.0) Yes 29 (35.4) 26 (31.7) 3 (3.6) .56 (.14-2.27) Infection location** Cervical 14 (17.0) 13 (15.9) 1 (1.2) Thoracic 28 (34.2) 23 (28.1) 5 (6.1) 2.83 (.30-26.9) Lumbar 40 (48.8) 34 (41.5) 6 (7.3) 2.29 (.25-20.9) Smoking history Never smoked 41 (50.0) 37 (45.1) 4 (4.9) Prior smoker 23 (28.1) 19 (23.2) 4 (4.9) 1.95 (.44-8.66) Current smoker 18 (21.9) 14 (17.1) 4 (4.9) 2.64 (.58-12.04) BMI 18.5 - <25 20 (24.4) 17 (20.7) 3 (3.7) 25 - 30 39 (47.6) 34 (41.5) 5 (6.1) .83 (.18 − 3.90) .55 (.07-4.40) Multimorbidity No 33 (40.2) 29 (35.4) 4 (4.9) Yes 49 (59.8) 41 (50.0) 8 (9.8) 1.42 (.39-5.14) 1.70(.29-10.07) Albumin g/dl >=3.5 21 (28.4) 16 (21.6) 5 (6.8) < 3.5 53 (71.6) 46 (62.2) 7 (9.5) .49 (.14-1.75) .51 (.08-3.49) * S. aureus as a single isolate or in polymicrobial culture ** Infection location that spans two levels is labeled according to the proximal location. For example, cervical thoracic is labeled cervical, thoraco-lumbar is labeled thoracic and lumbosacral is labeled lumbar. ^ Ran as a binary variable. All hardware removed or partial revision versus all original hardware retained. Table 3 Univariate Analysis showing the Association of SAT and Organism Type with Recurrence of Infection among Patients with Early Onset Infection who Underwent Debridement with Implant Retention Variable Total N = 31 (%) No Recurrence N = 26 (83.9%) Recurrence N = 5 (16.1%) OR (CI) Univariate P value SAT No 9 (29.0) 8 (25.8) 1 (3.2) Yes 22(71.0) 18 (58.1) 4 (12.9) 1.77 (.17-18.53) .63 SAT duration N = 22. N = 18 (81.2). N = 4 (18.2) > 52weeks 7 (31.8) 6 (27.3) 1 (4.6) 24–52 weeks 6 (27.3) 5 (22.7) 1 (4.6) 1.2 (.05-24.47) .91 < 24 weeks 9 (40.9) 7 (81.8) 2 (9.0) 1.7 (.12-23.93) .69 SAT duration 2 12 weeks 14 (63.6) 12(54.6) 2 (8.1) .5 (.05-4.47) .54 Organism Non S.aureus 14 (45.2) 12 (38.7) 2 (6.5) S.aureus 17 (54.8) 14 (45.2) 3 (9.7) 1.28 (.18-9.02) .80 Table 4 SAT Utilization by Hardware Status and by Onset Hardware Status N = 82 (%) All hardware removed Partial Revision All original hardware retained χ 2 SAT No 12 (14.6) 7 (8.5) 9 (11.0) 5.57 (P = 0.06) * Yes 10 (12.2) 19 (23.2) 25 (30.5) SAT duration. N = 53 (%) missing 1 > 52weeks 4 (7.6) 8 (15.1) 9 (17.0) 2.49 (P = .65) 24–52 weeks 4 (7.6) 3 (5.7) 6 (11.3) < 24 weeks 2 (3.8) 7 (13.2) 10 (18.9) SAT duration 2. N = 53 (%) missing 1 12 weeks 8 (15.1) 12 (22.6) 16 (30.2) Early Onset Infections. N = 44 (%) SAT No 1 (2.3) 3 (6.8) 9 (20.5) 0.43 (P = 0.81) Yes 1 (2.3) 8 (18.2) 22 (50) SAT duration. N = 31 (%) Missing 1 > 52 weeks 1 (3.2) 1 (3.2) 7 (22.6) 3.90 (P = 0.42) 24–52 weeks 0 (0.0) 2 (6.5) 6 (19.4) < 24 weeks 0 (0) 5 (16.1) 9 (29.0) SAT duration 2. N = 31(%) Missing 1 12 weeks 1 (3.2) 4 (12.9) 14 (45.2) 1.11 (P = 0.57) Late Onset Infections N = 38 (%) SAT No 11 (29.0) 4 (10.5) 0 (0.0) 5.00 (P = 0.08) Yes 9 (23.7) 11 (29.0) 3 (7.9) SAT duration. N = 22 (%) missing 1 > 52 weeks 3 (13.6) 7(31.8) 2 (9.1) 4.71 (P = 0.32) 24–52 weeks 4 (18.2) 1 (4.6) 0 (0.0) < 24 weeks 2 (9.1) 2 (9.1) 1 (4.6) SAT duration 2. N = 22 (%) missing 1 12 weeks 7 (31.8) 8 (36.4) 2 (9.1) *Univariate analysis of SAT utilization for all hardware removed as reference versus partial revision or all hardware retained: OR 3.3 (95% CI 1.21–8.98; P = 0.04) Adverse drug reactions were documented in 6 of 54 SAT patients (11.1%), including rash, photosensitivity, nausea/vomiting, and fatigue (Table 5 ). One patient who was on fluconazole and doxycycline for a polymicrobial SHI developed Clostridium difficile infection ( C. diff ), while one patient discontinued SAT due to tendonitis. In contrast, 11 of 81 patients (13.6%) had ADRs related to IV antibiotics, including C. diff in two patients on ertapenem, neutropenia, liver toxicity, and a case of Stevens-Johnson syndrome. There was no significant difference in ADR rates between SAT and IV antibiotic therapy (mid-p exact 95% CI [0.32–1.80], P = 0.82). Table 5 Antibiotics used for SAT showing ADR and Side effects Suppressive antibiotic used N = 54 Number of patients on antibiotic (%) Number of patients on antibiotic side effect Side effects Doxycycline 23 (42.6) 1 Photosensitivity Levofloxacin 11 (20.4) 1 Tendonitis Cephalexin 9 (16.7) 1 Fatigue Trimethoprim-sulfamethoxazole 7 (13.0) 1 Nausea and vomiting Metronidazole 6 (11.1) Fluconazole 5 (9.3) Amoxicillin-clavulanate 4 (7.4) Minocycline 3 (5.6) 1 Rash Ciprofloxacin 2 (3.7) Omnicef 2 (3.7) Cefadroxil 2 (3.7) Doxycycline plus fluconazole 1 (1.9) C. diff All but one patient received intravenous (IV) antibiotics as the initial antibiotic therapy, with a median duration of 6 weeks. One patient received levofloxacin as initial therapy. Only one patient developed antibiotic resistance: vancomycin resistant Enterococcus faecium (resistant to ampicillin, doxycycline, with synergy not likely with high level gentamicin or streptomycin) was cultured in recurrent SHI while on minocycline for SAT in a patient who previously had culture negative SHI. Discussion In our study, neither the use of suppressive oral antibiotic therapy (SAT) nor the duration of antibiotic suppression affected the rate of recurrent spinal hardware infection (SHI) in either early infection or late onset cohorts. The rate of recurrence in our study was 14.6%, with no difference between early or late onset infection, regardless of SAT or hardware status. This rate is comparable to other studies in SHI where patients underwent surgery, which showed similar treatment failure rates of ~17%, N=81-129 (7, 14, 15). Furthermore, there was no difference in the median time to SHI recurrence among patients treated with SAT for a duration of less than 24 weeks, 24-52 or more than 52 weeks. Consequently, we were unable to determine SAT efficacy or the appropriate duration of SAT for SHI. Hence, the optimal duration of SAT for SHI continues to be poorly defined as it is for other biofilm-driven infections such as vascular graft infections and prosthetic joint infections (PJI). In SHI, SAT is mostly employed where it is not feasible to remove hardware due to spine instability, which usually occurs with early SHI. Other studies have shown conflicting results in early onset SHI with SAT. Some showed 1–2-year cure rates of 80-88% with 10 –12 weeks of antimicrobial treatment, and another showed treatment success with 3 months of SAT but not with >6 months of SAT in patients with early infection following debridement and implant retention or single stage revision (14-16). However, in another study of early onset SHI treated with debridement and implant retention, SAT was associated with 2-year cure rate of 80% compared to 33% in patients who did not receive SAT (7). Overall, these studies seem to indicate that patients with early onset SHI who undergo debridement with implant retention do not need a prolonged duration of SAT, but a randomized controlled trial is needed to clarify the optimal SAT duration for early SHI. This is especially the case because the utilization of SAT is not standardized and there is variation based on clinician preferences with respect to SAT and hardware status, as seen in our study (Table 4). This variation supports that there is a paucity of evidence available to create guidelines to decide on how to treat these patients with SAT and thus a randomized control trial is urgently needed. On the other hand, patients with late onset SHI where hardware is retained either post revision or without revision may need a prolonged duration of SAT. This might be needed given the establishment of biofilm in the bone and on spinal hardware that will present a challenge for antibiotic penetration despite a prolonged course of treatment beyond 3 months. Yet as seen in our study, the optimal duration of SAT for late onset SHI is also poorly defined and patients had recurrence with a long or shorter duration of SAT. As a result, recurrence may be more directly correlated with adequacy of surgical procedures in achieving source control with debridement of all biofilms. However, determining in vivo biofilm persistence and the need for further debridement is difficult and no standardized procedures have been devised. SHI recurrence or treatment failure may be due to certain patient-specific or microbial factors as has been identified in other studies such as systemic malignancy, radiation therapy, infection from S. aureus or polymicrobial infection (7, 14, 15). In our study, we did not identify any significant factors associated with SHI recurrence. The microbiology of SHI in our study is similar to that seen in other studies with S. aureus predominating in up to 40% of cases (7, 14, 15). An interesting fact is that we identified Streptococci species in only one patient, unlike other studies where Streptococci was the identified etiology in 10-30% of cases (7, 15). Culture negative and polymicrobial cases (16% for each category) were the next predominant etiology after S. aureus in our study, and these cases typically pose a challenge for SAT due to the uncertainty of antibiotic choice and efficacy, as well as the tendency to use multiple antibiotics in this situation, thereby exposing the patient potentially to more risk of ADR. In our study, ADR occurred in 6 of the 54 patients that received SAT (11.1%.), including one case of C. diff, which occurred in a patient with polymicrobial infection being treated with doxycycline and fluconazole, which may indicate a greater risk of ADR in patients with polymicrobial infection requiring multiple antibiotics. The ADR rate to SAT in our study was comparable and non-significant to the rate of ADR with the use of IV antibiotics (13.6%), though there were two cases of C. diff in patients being treated with ertapenem and the ADR to IV antibiotics appeared to be of greater severity such as Stevens Johnson’s syndrome and liver toxicity. Data on the rate of ADR to SAT in SHI is sparse, with rates ranging from 0-15%, with no cases of C. diff reported after at least 6 months of treatment (7, 15). However, the rate of ADR to SAT on a larger scope involving PJI and vascular graft infections is as high as 25-40%, predominantly gastrointestinal (35%), followed by dermatologic changes such as rash (25%) (17-19). Our study did not show any specific patterns of ADR to SAT, with each of the 6 cases manifesting different symptoms as shown in Table 5. Nonetheless, more studies will be needed to show if the rate of ADR for SHI is lower than that seen in other hardware-associated infections. Of note, the initial antibiotic therapy and route in our study was intravenous (IV), with a median duration of 6 weeks in all but one patient who received levofloxacin as initial therapy. There is a shift from a 6-week duration of IV antibiotics to as low as a 2-week lead-in with IV, followed by oral antibiotics or no IV antibiotics at all, and more studies have shown non-inferiority of oral compared to IV antibiotics in orthopedic infections (20-22). The implication of how this affects SAT remains to be seen but may imply prolonged use of oral antibiotics than is typically used. However, this may not be negatively impactful given the avoidance of PICC lines and other extrinsic risks associated with IV therapy such as catheter related complications. Nonetheless, it remains to be seen if oral antibiotics are associated with less ADR than intravenous antibiotics. As shown in our study, the rate of ADR may be similar with oral or IV therapy, but studies show additional risk of IV antibiotics when catheter related factors are considered (21, 23). The development of antimicrobial resistance is a recognized risk of prolonged antimicrobial therapy, with rates ranging from 7-40% reported with SAT in prosthetic joint infections, especially with regards to the development of resistance to rifampin (18, 24, 25). There is very sparse data on the risk of antimicrobial resistance development on SAT for SHI. Although the median duration of SAT in our study was 52 weeks (range 12-191), we identified only one case of a MDRO with SAT (1.9%), which was a Vancomycin resistant Enterococcus faecium from a previously culture negative SHI. The low rate of antibiotic resistance identified in our study may be due to our definition of resistance, which was limited to cases of recurrent infection because we did not evaluate if they developed MDROs at other sites. In addition, we did not utilize rifampin for SAT in our study as this antibiotic was employed only as initial antibiotic regimen in combination with IV therapy. This suggests that in the absence of rifampin, the risk of MDRO development with SAT for SHI may be low. Our study has several strengths including a sample size comparable to that used in similar studies, a real-world observational approach using data that was available in everyday clinical practice, and the assessment for the development of adverse drug reaction and drug resistance on SAT, which to our knowledge, are very sparse in SHI literature. Nonetheless, there are several limitations to this study, such as the retrospective nature, which revealed that SAT utilization was not standardized in our cohort, as not all the patients with retained hardware received SAT and some patients who had all hardware removed received SAT. Hence, it is possible that the determination of SAT efficacy and optimal duration may have been diminished. However, this is the actual experience in practice, which doesn’t negate a treating clinician’s clinical judgement in managing a patient. As stated earlier, MDRO definition was limited to the site of original infection so we may have missed MDRO development at other sites. Our study did not include SHI patients who did not undergo surgery; hence, we were unable to determine the role of SAT in this category of patients. In conclusion, SAT continues to be employed in the treatment of SHI, especially where hardware is retained. The efficacy and optimal duration of SAT remains an enigma reflected by the variation in practice across clinicians. Our study showed that in patients with SHI who underwent surgery, neither the use of SAT nor SAT duration had any impact on recurrence of SHI regardless of onset or hardware status, including patients with early onset SHI who underwent debridement and implant retention. The rate of ADR with SAT was comparable to ADR with intravenous antibiotics and the rate of antimicrobial resistance development was low. Consequently, a randomized control trial is urgently needed to determine the role of SAT and its optimal application in the treatment of SHI. Abbreviations SHI: Spinal hardware infection SAT: Suppressive antibiotic therapy ADR: Adverse drug reaction MDRO: Multi drug resistant organism S: Supplementary C. diff: Clostridium difficile S. aureus: Staphylococcal aureus E. coli: Escherichia coli BMI: Body mass index MSSA: Methicillin resistant Staphylococcus aureus MRSA: Methicillin resistant Staphylococcus aureus . CoNS: Coagulase negative Staphylococci PJI: Prosthetic Joint Infection Declarations Ethics Approval and consent to participate: The study was approved by the Institutional Review Board of the University of Maryland School of Medicine. (HP-00101883). The study was conducted in accordance with the principles of the Declaration of Helsinki. Informed consent to participate was deemed unnecessary according to the University of Maryland, Baltimore (UMB) Institutional Review Board (IRB) and national regulations, 45 CFR 46.104(d). The UMB IRB reviewed the research protocol (HP-00101883) and determined it to be exempt under 45 CFR 46.104(d) based on the following category: Secondary research for which consent is not required: Secondary research uses of identifiable private information or identifiable biospecimens, if at least one of the following criteria is met: information, which may include information about biospecimens, is recorded by the investigator in such a manner that the identity of the human subjects cannot readily be ascertained directly or through identifiers linked to the subjects, the investigator does not contact the subjects, and the investigator will not re-identify subjects. Clinical trial number: Not applicable. Consent for publication: Not applicable. Availability of data and Materials: The data set used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests: The authors declare that they have no competing interests. Funding: This study was not funded. Author’s contributions: A.C worked on data collection, analysis and writing the results section. J.D conceived the project, reviewed, and edited the manuscript, and supervised the project. U. E worked on data collection, analysis, writing and editing the manuscript, and supervision of the project. All authors reviewed the text and agreed on the final version of the manuscript Acknowledgements: Not applicable. References Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int. 2013;4(Suppl 5):S392–403. Deyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery - the case for restraint. N Engl J Med. 2004;350(7):722–6. Growth in Discharges with Procedures on the Musculoskeletal System, 1993–2005 [Internet]. 2005. Available from: https://hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_3_6B.jsp Most Frequent Operating Room Procedures Performed in U.S, Hospitals. 2003–2012 [Internet]. 2014. Available from: https://hcup-us.ahrq.gov/reports/statbriefs/sb186-Operating-Room-Procedures-United-States-2012.pdf Dowdell J, Brochin R, Kim J, Overley S, Oren J, Freedman B, et al. Postoperative Spine Infection: Diagnosis and Management. Global Spine J. 2018;8(4 Suppl):s37–43. Bürger J, Palmowski Y, Pumberger M. Comprehensive treatment algorithm of postoperative spinal implant infection. J Spine Surg. 2020;6(4):793–9. Kowalski TJ, Berbari EF, Huddleston PM, Steckelberg JM, Mandrekar JN, Osmon DR. The management and outcome of spinal implant infections: contemporary retrospective cohort study. Clin Infect Dis. 2007;44(7):913–20. Bose B. Delayed infection after instrumented spine surgery: case reports and review of the literature. Spine J. 2003;3(5):394–9. Viola RW, King HA, Adler SM, Wilson CB. Delayed infection after elective spinal instrumentation and fusion. A retrospective analysis of eight cases. Spine (Phila Pa 1976). 1997;22(20):2444–50. discussion 50 – 1. Kalfas F, Severi P, Scudieri C. Infection with Spinal Instrumentation: A 20-Year, Single-Institution Experience with Review of Pathogenesis, Diagnosis, Prevention, and Management. Asian J Neurosurg. 2019;14(4):1181–9. Palmowski Y, Bürger J, Kienzle A, Trampuz A. Antibiotic treatment of postoperative spinal implant infections. J Spine Surg. 2020;6(4):785–92. Ruiz-Sancho A, Núñez-Núñez M, Castelo-Corral L, Martínez-Marcos FJ, Lois-Martínez N, Abdul-Aziz MH, et al. Dalbavancin as suppressive antibiotic therapy in patients with prosthetic infections: efficacy and safety. Front Pharmacol. 2023;14:1185602. Prevention CfDCa. Medication Safety and Your Health. 2024. Wille H, Dauchy FA, Desclaux A, Dutronc H, Vareil MO, Dubois V, et al. Efficacy of debridement, antibiotic therapy and implant retention within three months during postoperative instrumented spine infections. Infect Dis (Lond). 2017;49(4):261–7. Keller SC, Cosgrove SE, Higgins Y, Piggott DA, Osgood G, Auwaerter PG. Role of Suppressive Oral Antibiotics in Orthopedic Hardware Infections for Those Not Undergoing Two-Stage Replacement Surgery. Open Forum Infect Dis. 2016;3(4):ofw176. Dubée V, Lenoir T, Leflon-Guibout V, Briere-Bellier C, Guigui P, Fantin B. Three-month antibiotic therapy for early-onset postoperative spinal implant infections. Clin Infect Dis. 2012;55(11):1481–7. Nowak MA, Winner JS, Beilke MA. Prolonged oral antibiotic suppression in osteomyelitis and associated outcomes in a Veterans population. Am J Health Syst Pharm. 2015;72(23 Suppl 3):S150–5. Horne M, Woolley I, Lau JSY. The Use of Long-term Antibiotics for Suppression of Bacterial Infections. Clin Infect Dis. 2024;79(4):848–54. Reinecke P, Morovic P, Niemann M, Renz N, Perka C, Trampuz A et al. Adverse Events Associated with Prolonged Antibiotic Therapy for Periprosthetic Joint Infections-A Prospective Study with a Special Focus on Rifampin. Antibiot (Basel). 2023;12(11). Conterno LO, Turchi MD. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst Rev. 2013;2013(9):Cd004439. Li HK, Rombach I, Zambellas R, Walker AS, McNally MA, Atkins BL, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. N Engl J Med. 2019;380(5):425–36. Obremskey WT, O'Toole RV, Morshed S, Tornetta P 3rd, Murray CK, Jones CB, et al. Oral vs Intravenous Antibiotics for Fracture-Related Infections: The POvIV Randomized Clinical Trial. JAMA Surg. 2025;160(3):276–84. Spellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis. 2012;54(3):393–407. 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. Pradier M, Nguyen S, Robineau O, Titecat M, Blondiaux N, Valette M, et al. Suppressive antibiotic therapy with oral doxycycline for Staphylococcus aureus prosthetic joint infection: a retrospective study of 39 patients. Int J Antimicrob Agents. 2017;50(3):447–52. Additional Declarations No competing interests reported. Supplementary Files SuppressiveAntibioticTherapyforSHISupplementarymaterial.docx Cite Share Download PDF Status: Published Journal Publication published 11 Mar, 2026 Read the published version in BMC Infectious Diseases → Version 1 posted Editorial decision: Revision requested 02 Nov, 2025 Reviews received at journal 07 Sep, 2025 Reviewers agreed at journal 23 Aug, 2025 Reviews received at journal 10 Aug, 2025 Reviewers agreed at journal 08 Aug, 2025 Reviewers invited by journal 08 Aug, 2025 Editor assigned by journal 06 Aug, 2025 Editor invited by journal 18 Jul, 2025 Submission checks completed at journal 17 Jul, 2025 First submitted to journal 17 Jul, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7120988","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":498789162,"identity":"ae2689d6-20a1-4583-bf4d-9901821e2777","order_by":0,"name":"Adil Choudhry","email":"","orcid":"","institution":"University of Maryland Medical School","correspondingAuthor":false,"prefix":"","firstName":"Adil","middleName":"","lastName":"Choudhry","suffix":""},{"id":498789163,"identity":"475213da-1241-4b9c-aefe-891ebee1d0a5","order_by":1,"name":"James B Doub","email":"","orcid":"","institution":"University of Maryland School of Medicine","correspondingAuthor":false,"prefix":"","firstName":"James","middleName":"B","lastName":"Doub","suffix":""},{"id":498789164,"identity":"b3093396-21cc-4166-8c21-a6a1fef60fea","order_by":2,"name":"Uzoamaka A Eke","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA8UlEQVRIiWNgGAWjYBACg/vHGBg+GByA8S2AOIGBgQeflhtsDIwzEFokiNPCzMNAopbExzYFdxIbJLITP1e2ScibsycwPnjbhs8vbYeNcwyeAbXkbpY82yZhuLPnAbPhXHxabrC3SecYHDZmkMjdINnYJsG44UYCmzQvfi3tvy0gWjb/BGqxB2ph/41fC9sxZgaDw3JALdtAtiSCbGHGp0VyBluyZA9QCxvP222WDeckkjecedgsOeccbi388scMP/z4c5iHnz13882GMhvbDceTD354U4ZbCxywgQhGCNlAhHo4+EOK4lEwCkbBKBgpAADMmVUlrn2D4wAAAABJRU5ErkJggg==","orcid":"","institution":"University of Maryland School of Medicine","correspondingAuthor":true,"prefix":"","firstName":"Uzoamaka","middleName":"A","lastName":"Eke","suffix":""}],"badges":[],"createdAt":"2025-07-14 12:08:20","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7120988/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7120988/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12879-026-12901-x","type":"published","date":"2026-03-11T15:58:11+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":104739443,"identity":"4384cb77-d400-45dd-9552-00cc0b8e964d","added_by":"auto","created_at":"2026-03-16 16:06:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1024303,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7120988/v1/5ba31523-f2df-4970-a14a-61cb8de50bba.pdf"},{"id":89018129,"identity":"ab05ce0d-20d5-4a58-b3b8-6825a18510dc","added_by":"auto","created_at":"2025-08-13 19:17:44","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":17577,"visible":true,"origin":"","legend":"","description":"","filename":"SuppressiveAntibioticTherapyforSHISupplementarymaterial.docx","url":"https://assets-eu.researchsquare.com/files/rs-7120988/v1/1bdc1edffcbcea302e693ae5.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Suppressive Antibiotic Therapy for Spinal Hardware Infection: A Retrospective Cohort Study","fulltext":[{"header":"Background","content":"\u003cp\u003eSpinal hardware infection (SHI) is one of the most devastating complications of spine surgery due to the costs and morbidity associated with conventional treatments. SHI has a reported incidence of 3\u0026ndash;20% (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e). However, as the number of spinal fusion surgeries performed in the US more than doubled in the last two decades, SHI is expected to become even more of a substantial problem (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). SHI can be broadly classified as early (presenting within 30 days of surgery) or delayed (appearing months to years after surgery) (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe clinical presentation, mechanism of infection, microbiology and treatment modality typically varies in early compared to delayed SHI (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). The proposed pathogenesis of SHI includes intraoperative seeding, contiguous microbial spread from wounds, metal fretting nd hematogenous seeding (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). In delayed SHI, metal wear and corrosion damage can lead to inflammation, allowing for indolent bacteria, such as coagulase negative Staphylococci and Propionibacterium acnes that are present to flourish, leading to symptoms. On the other hand, in early SHI, more virulent pathogens such as \u003cem\u003eStaphylococcus aureus (S. aureus)\u003c/em\u003e, aerobic \u003cem\u003eStreptococci\u003c/em\u003e and enteric gram negatives are implicated, causing symptoms to occur much sooner (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003cp\u003eTreatment of SHI is complicated due to the presence of hardware and subsequently the presence of microbial biofilm that conventional antibiotics have poor ability to eradicate (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Ideally, treatment involves implant removal and debridement, followed by antibiotic therapy, usually for a minimum of 6 weeks. However, implant removal is not always feasible, especially in early SHI due to spinal instability. Hence, in early SHI, the most employed treatment modality is debridement, implant retention and then an initial long course of antibiotics for 6 weeks followed by suppressive antibiotic therapy (SAT). The goal of SAT in this setting is to prevent relapse or recurrence of infection due to the retained hardware and incomplete source control. SAT has been shown to achieve 2-year cure rates similar to implant removal plus antibiotic therapy (80%), versus cure rate of 33% without SAT (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). On the other hand, SAT has not been shown to be as successful in delayed SHI, where implant removal is almost always needed to effect cure, with treatment failures as high as 50\u0026ndash;60% when the implant is retained (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). SAT has traditionally involved the use of an oral antibiotic that is active against the isolated pathogen/s, deemed tolerable to the patient with potentially minimal side effects, although new long-acting intravenous infusions, such as dalbavancin have begun to have a role in treating these types of infections as well (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eHowever, the optimal duration of SAT for SHI is poorly defined. In addition, there is a paucity of data on SAT outcome with regards to adverse drug reactions (ADR), tolerability and SAT antibiotic resistance development. Consequently, in this study, our aim was to determine the appropriate duration of SAT for SHI based on recurrent infection rate on SAT, rate of ADR, and rate of development of antibiotic resistance to SAT in patients with SHI.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cp\u003e\u003cem\u003eStudy Design and setting\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eThis was a retrospective cohort study of patients 18 years of age or older, who underwent surgical intervention for the treatment of SHI at the University of Maryland Medical Center (UMMC) in Baltimore between January 1st, 2015, to January 1st, 2020. The study was approved by the Institutional Review Board of the University of Maryland School of Medicine. (HP-00101883). Informed consent to participate was deemed unnecessary according to the University of Maryland, Baltimore (UMB) Institutional Review Board (IRB) and national regulations, 45 CFR 46.104(d). The UMB IRB reviewed the research protocol (HP-00101883) and determined it to be exempt under 45 CFR 46.104(d).\u003c/p\u003e\u003cp\u003ePatients were identified using the EPIC electronic medical record database based on International Statistical Classification of Diseases and Related Health Problems (ICD-10) and Current Procedural Terminology (CPT) codes. Data pulled electronically was manually reviewed for accuracy of study entry based on the definition of spinal hardware infection. Manual review of individual charts was conducted and recorded based on patient comorbidities, demographic factors, onset of SHI, utilization of SAT, duration of SAT, microbiology, antimicrobials utilized, hardware revision status (all hardware removed with no hardware present, partial revision where some or all original hardware is replaced, or full hardware retention, where all original hardware is retained), recurrent infection, adverse reaction to antimicrobials and development of antibiotic resistance.\u003c/p\u003e\u003cp\u003e\u003cem\u003eDefinitions of variables and primary outcomes\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eSHI was defined as any patient with spinal hardware who presented with any local wound changes around hardware not limited to pain, swelling, redness, drainage, or hardware exposure, that was also found to have evidence of infection in the operating room by the surgeon. Early onset of SHI represented SHI presenting within 30 days of hardware placement. Late onset SHI was defined as infections occurring after 30 days of hardware placement. SAT was defined as any oral antibiotic treatment for an extended duration of time of at least 3 months, after an initial intravenous or oral antibiotic course of at least 2\u0026ndash;4 weeks. Multimorbidity was 2 or more comorbidities of any cardiovascular disease, hypertension, diabetes, cancer, renal failure, chronic obstructive pulmonary disease, Asthma, immunosuppression or other chronic medical conditions.\u003c/p\u003e\u003cp\u003eThe primary outcomes evaluated were rates of SHI recurrence with recurrence representing patients that were readmitted with SHI at the same site after previous surgical treatment, not limited to debridement, hardware revision or explant, and/or medical treatment with antimicrobials for SHI. Hardware status was evaluated as all hardware removed (no hardware present) vs partial revision (some or all hardware replaced) vs all original hardware retained. Secondary outcomes included: 1. rate of documented ADR from SAT which included any side effects or negative outcome to the antibiotic, not limited to allergic reaction or unpleasant response, that is unintended (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e); 2. the development of antibiotic resistance to SAT which was determined when a recurrent SHI occurred and new culture results from the same site grew the same organism with resistance to more antibiotics or a new multidrug resistant organism (MDRO), not previously isolated. A MDRO is defined as an organism that is resistant to one or more classes of antimicrobial agents isolated in the setting of recurrent SHI, while undergoing SAT\u003c/p\u003e\u003cp\u003e\u003cem\u003eData Analyses\u003c/em\u003e:\u003c/p\u003e\u003cp\u003eDescriptive analyses were performed for all data collected using Microsoft Excel software (Redmond, WA, USA), and Stata software (Stata Corp, Texas). To determine the appropriate duration of treatment with SAT, SAT duration and other categorical variables selected a priori were each classified according to the frequency of recurrent infection and analyzed using Person\u0026rsquo;s chi square and univariate logistic regression for any association of these variables with recurrent infection. Multivariate logistic regression was performed to examine the association of recurrent infection and age, SAT duration, hardware revision status (all hardware retained versus full or partial hardware revision), organism type (\u003cem\u003eStaphylococcus aureus\u003c/em\u003e versus non-\u003cem\u003eStaphylococcus aureus\u003c/em\u003e), body mass index (BMI), Multimorbidity and albumin level.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eTable\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e shows the demographics and characteristics of the cohort. A total of 82 patients met the eligibility criteria for spinal hardware infection (SHI). The median age was 61 years (range 53.2\u0026ndash;72.5), 54.9% of the patients were female and 44 (53.7%) had early infection. Common comorbidities included cardiovascular disease (31.7%), diabetes (36.6%) and chronic kidney disease (26.8%), multimorbidity (59.8%), and 22% were smokers.\u003c/p\u003e\n\u003cp\u003eThe most common orthopedic indications for spinal instrumentation were fracture (22.0%), followed by lumbar stenosis (14.6%). 22.0% of the diagnoses were classified as \u0026ldquo;other\u0026rdquo;, including post-laminectomy syndrome, pseudoarthrosis, kyphosis, and scoliosis. The lumbar spine was the most frequently infected region (36.6%), followed by thoraco-lumbar (18.3%) and thoracic (15.9%).\u003c/p\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab5\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eBaseline Characteristics of Patients\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;82)\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDemographics\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMedian (range)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAge\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e61 (53.2\u0026ndash;72.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28.9 (25.3\u0026ndash;35.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFemale (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (54.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eComorbidities\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCardiovascular disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 (31.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eDiabetes mellitus\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (36.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eKidney disease\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (26.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCancer history\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (19.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eTobacco\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNever smoked\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFormer smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (28.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCurrent smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (22.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrimary diagnosis (orthopedics)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFracture\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (22.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOthers\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (22.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLumbar stenosis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (14.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMyeloradiculopathy\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (13.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpondylolisthesis\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eFlat back syndrome\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (8.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInfection\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (6.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSpinal tumor\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eInfection Location\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLumbar\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e30 (36.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThoraco-lumbar\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e15 (18.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThoracic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (15.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCervical\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (13.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLumbosacral\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (12.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCervical-thoracic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePathogens\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMSSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (23.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCulture Negative\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (15.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePolymicrobial\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (15.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMRSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (14.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther gram negatives\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (14.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCoNS\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (7.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAnaerobes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eStreptococcus group G\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eBacteremia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;29 (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMSSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11(37.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eMRSA\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (24.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther gram negatives*\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (20.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eOther gram positives **\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (6.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eE.coli\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (10.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003e* \u003cem\u003eEikenella spp, Proteus mirabilis\u003c/em\u003e, 2 \u003cem\u003ePseudomonas spp\u003c/em\u003e, 2 \u003cem\u003eEnterobacter cloacae complex\u003c/em\u003e\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"2\"\u003e** \u003cem\u003eEnterococcus fecalis\u003c/em\u003e and \u003cem\u003eStreptococcus pneumoniae\u003c/em\u003e\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cem\u003eStaphylococcus aureus\u003c/em\u003e comprised 37.8% of cultured organisms, with MSSA (23.2%) and MRSA (14.6%). Polymicrobial infections and culture-negative infections each accounted for 15.9% of cases. There were an additional 3 MRSA and 3 MSSA in the polymicrobial infections and \u003cem\u003eEnterococcus fecalis\u003c/em\u003e was present in 5 of the polymicrobial cultures. \u003cem\u003eCoagulase-negative Staphylococci\u003c/em\u003e comprised 7.3% and \u003cem\u003eStreptococcus spp\u003c/em\u003e grew in only one culture. \u003cem\u003eE. coli\u003c/em\u003e was the most frequently isolated gram negative (4.9%) while other gram-negative organisms, including \u003cem\u003ePseudomonas, Enterobacter, Klebsiella and Morganella spp\u003c/em\u003e comprised 14.6%. \u003cem\u003eCandida spp\u003c/em\u003e was identified in 3 polymicrobial cultures but not in pure culture. 29 (35.4%) had bacteremia, mostly gram positives (68.9%): MSSA (37.9%), MRSA (24.1%), \u003cem\u003eE.fecalis and S.pneumoniae\u003c/em\u003e (6.9%). Gram negative organisms were responsible for 31% of bacteremia: \u003cem\u003eE. coli\u003c/em\u003e (10.3%) and other gram negatives (20.7%)\u003c/p\u003e\n\u003cp\u003eA total of 54 patients (65.8%) were treated with suppressive antibiotic therapy (SAT), Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e. Doxycycline, 23 (42.6%) was the most frequently used SAT followed by levofloxacin, 11 (20.4%) and cephalexin, 9 (16.7%). The median SAT duration was 52 weeks (range12 to 191 weeks). A total of 12 patients (14.6%) experienced recurrence, while 8 (9.7%) experienced recurrence while on SAT. Recurrence was not significantly associated with SAT or SAT duration in univariate or adjusted models. SAT was not included in the multivariate model due to its collinearity with SAT duration. There was a higher recurrence rate with hardware retention: partial hardware revision, 7.3% (OR 6.30 [0.70\u0026ndash;57.07]) and full retention, 6.1% (OR 3.62 [0.39\u0026ndash;33.30]) compared to complete hardware removal, N\u0026thinsp;=\u0026thinsp;1 (1.2%) but these associations were not statistically significant in unadjusted or adjusted models. Other variables including age, onset, infection location, BMI, smoking status, albumin, multimorbidity, and organism type (\u003cem\u003eS. aureus\u003c/em\u003e vs non\u0026ndash;\u003cem\u003eS. aureus\u003c/em\u003e) were not significantly associated with recurrence in either univariate or multivariate models. Furthermore, SAT and SAT duration did not have any significant association with recurrent infection in the subset of patients with early onset infection who underwent debridement and implant retention (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e3\u003c/span\u003e) or those with late onset infection, Supplementary (S) Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e1\u003c/span\u003e. The median time to recurrent infection while on SAT did not differ significantly among patients who received SAT for \u0026lt;\u0026thinsp;24 weeks, 24\u0026ndash;52 weeks or \u0026gt;\u0026thinsp;52 weeks (S Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e2\u003c/span\u003e). There was a trend to higher SAT utilization where all hardware was retained (30.5%), compared to partial revision (23.2%), or where all hardware was removed (12.2%), but this did not reach statistical significance (\u0026chi;\u003csup\u003e2\u003c/sup\u003e 5.57, P\u0026thinsp;=\u0026thinsp;.06) and SAT duration did not vary by hardware status (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e4\u003c/span\u003e). SAT was utilized more in early onset infections: 31 (70.5%) N\u0026thinsp;=\u0026thinsp;44, compared to late onset infections: 23 (60.5%) N\u0026thinsp;=\u0026thinsp;38 but this did not reach statistical significance (95% CI 0.30\u0026ndash;1.37; P\u0026thinsp;=\u0026thinsp;.12). Conversely, a longer SAT duration\u0026thinsp;\u0026gt;\u0026thinsp;12 weeks was used in 17 (77.3%), N\u0026thinsp;=\u0026thinsp;22 of late onset infections compared to 19 (61.3%), N\u0026thinsp;=\u0026thinsp;31 of early onset infections, but not statistically significant (95% CI 0.77\u0026ndash;6.78: P\u0026thinsp;=\u0026thinsp;0.07)\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab1\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eUnivariate and Multivariate Logistic Regression Analyses showing Association of Patient Characteristics with Recurrence of Infection.\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal N (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo Recurrence\u003c/p\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;70 (85.4%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRecurrence N\u0026thinsp;=\u0026thinsp;12 (14.6%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR (CI)\u003c/p\u003e\n\u003cp\u003eUnivariate\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR (CI)\u003c/p\u003e\n\u003cp\u003eMultivariate\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eAge years\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;50\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (15.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (14.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e50\u0026ndash;70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e47 (57.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (46.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (11.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.84(.32-24.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.29 (.18-29.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;70\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (26.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (24.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (2.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.2 (.09-14.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.45 (.17-11.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28 (34.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24 (29.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e54 (65.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46 (56.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (9.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.04 (.29-3.82)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT Duration.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; N\u0026thinsp;=\u0026thinsp;53 (1 missing)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;52weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (39.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (34.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (5.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u0026ndash;52 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (24.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (20.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (3.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.09 (.16-7.59)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.46 (.15-14.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;24 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (35.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (30.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (5.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.13 (.20-6.39)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.91 (.09-8.46)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eOnset of SHI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eEarly\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44 (53.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e36 (43.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (46.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34 (41.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.53(.14-1.92)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eHardware Status\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAll removed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (26.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (25.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePartial revision\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 (31.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (24.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (7.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6.30 (.70-57.07)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAll retained\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34 (41.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 (35.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (6.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.62 (.39-33.30)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003csup\u003e^\u003c/sup\u003e1.01 (.15-6.86)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eOrganism\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon-\u003cem\u003eS. aureus\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e45 (54.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e38 (46.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (8.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eS. aureus\u003c/em\u003e *\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 (45.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e32 (39.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (6.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.85 (.24-2.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.94 (.16-5.67)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eBacteremia\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53 (64.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e44 (53.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (11.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 (35.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e26 (31.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (3.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.56 (.14-2.27)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eInfection location**\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCervical\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (17.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e13 (15.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (1.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eThoracic\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e28 (34.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (28.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (6.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.83 (.30-26.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eLumbar\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e40 (48.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34 (41.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (7.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.29 (.25-20.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eSmoking history\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNever smoked\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e37 (45.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePrior smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (28.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (23.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.95 (.44-8.66)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eCurrent smoker\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (21.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (17.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.64 (.58-12.04)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eBMI\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18.5 - \u0026lt;25\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e20 (24.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e17 (20.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25 - \u0026lt;30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e23 (28.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (23.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.19 (.23-6.11)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.20 (.14-2.81)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;30\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e39 (47.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e34 (41.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (6.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.83 (.18\u0026thinsp;\u0026minus;\u0026thinsp;3.90)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.55 (.07-4.40)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eMultimorbidity\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e33 (40.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e29 (35.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (4.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e49 (59.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e41 (50.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (9.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.42 (.39-5.14)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.70(.29-10.07)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\" align=\"left\"\u003e\n\u003cp\u003eAlbumin g/dl\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;=3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e21 (28.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (21.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (6.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;3.5\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e53 (71.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e46 (62.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (9.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.49 (.14-1.75)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.51 (.08-3.49)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003e*\u003cem\u003eS. aureus\u003c/em\u003e as a single isolate or in polymicrobial culture\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003e** Infection location that spans two levels is labeled according to the proximal location. For example, cervical thoracic is labeled cervical, thoraco-lumbar is labeled thoracic and lumbosacral is labeled lumbar.\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"6\"\u003e^ Ran as a binary variable. All hardware removed or partial revision versus all original hardware retained.\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"char\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003ctable id=\"Tab2\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eUnivariate Analysis showing the Association of SAT and Organism Type with Recurrence of Infection among Patients with Early Onset Infection who Underwent Debridement with Implant Retention\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eVariable\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eTotal N\u0026thinsp;=\u0026thinsp;31 (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eNo Recurrence\u003c/p\u003e\n\u003cp\u003eN\u0026thinsp;=\u0026thinsp;26 (83.9%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eRecurrence N\u0026thinsp;=\u0026thinsp;5 (16.1%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eOR (CI)\u003c/p\u003e\n\u003cp\u003eUnivariate\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\n\u003cp\u003eP value\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9 (29.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (25.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (3.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e22(71.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e18 (58.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (12.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.77 (.17-18.53)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.63\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT duration\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp; N\u0026thinsp;=\u0026thinsp;22.\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;\u0026nbsp;N\u0026thinsp;=\u0026thinsp;18 (81.2).\u0026nbsp;\u0026nbsp;\u0026nbsp;N\u0026thinsp;=\u0026thinsp;4 (18.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;52weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e7 (31.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u0026ndash;52 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e6 (27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (22.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.2 (.05-24.47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.91\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;24 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e9 (40.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (81.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.7 (.12-23.93)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.69\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT duration 2\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;=12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e8 (36.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (27.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14 (63.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12(54.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (8.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.5 (.05-4.47)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.54\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eOrganism\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNon \u003cem\u003eS.aureus\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e14 (45.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (38.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (6.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u003cem\u003eS.aureus\u003c/em\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"char\" char=\".\"\u003e\n\u003cp\u003e17 (54.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (45.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (9.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.28 (.18-9.02)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e.80\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e\n\u003ctable id=\"Tab3\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eSAT Utilization by Hardware Status and by Onset\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003cth colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eHardware Status N\u0026thinsp;=\u0026thinsp;82 (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth align=\"left\"\u003e\u0026nbsp;\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAll hardware removed\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003ePartial Revision\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eAll original hardware retained\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026chi;\u003csup\u003e2\u003c/sup\u003e\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (14.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (8.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (11.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.57 (P\u0026thinsp;=\u0026thinsp;0.06) *\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (12.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e19 (23.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e25 (30.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT duration. N\u0026thinsp;=\u0026thinsp;53 (%) missing 1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;52weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (7.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (15.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (17.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2.49 (P\u0026thinsp;=\u0026thinsp;.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u0026ndash;52 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (7.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (5.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (11.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;24 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (3.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (13.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e10 (18.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT duration 2. N\u0026thinsp;=\u0026thinsp;53 (%) missing 1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;=12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (3.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (11.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (17.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.86 (P\u0026thinsp;=\u0026thinsp;0.65)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (15.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e12 (22.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e16 (30.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eEarly Onset Infections. N\u0026thinsp;=\u0026thinsp;44 (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSAT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (2.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (6.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (20.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.43 (P\u0026thinsp;=\u0026thinsp;0.81)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (2.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (18.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e22 (50)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT duration. N\u0026thinsp;=\u0026thinsp;31 (%) Missing 1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;52 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (3.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (3.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (22.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3.90 (P\u0026thinsp;=\u0026thinsp;0.42)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u0026ndash;52 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (6.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e6 (19.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;24 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5 (16.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (29.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\" align=\"left\"\u003e\n\u003cp\u003eSAT duration 2. N\u0026thinsp;=\u0026thinsp;31(%) Missing 1\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;=12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (12.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (25.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (3.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (12.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e14 (45.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1.11 (P\u0026thinsp;=\u0026thinsp;0.57)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd colspan=\"3\" align=\"left\"\u003e\n\u003cp\u003eLate Onset Infections N\u0026thinsp;=\u0026thinsp;38\u0026nbsp; (%)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eSAT\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eNo\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (29.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (10.5)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e5.00 (P\u0026thinsp;=\u0026thinsp;0.08)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003eYes\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e9 (23.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e11 (29.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (7.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eSAT duration. N\u0026thinsp;=\u0026thinsp;22 (%) missing 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;52 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e3 (13.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7(31.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4.71 (P\u0026thinsp;=\u0026thinsp;0.32)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e24\u0026ndash;52 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e4 (18.2)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0 (0.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;\u0026thinsp;24 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"4\" align=\"left\"\u003e\n\u003cp\u003eSAT duration 2. N\u0026thinsp;=\u0026thinsp;22 (%) missing 1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026lt;=12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e1 (4.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e0.24 (P\u0026thinsp;=\u0026thinsp;0.89)\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e\u0026gt;\u0026thinsp;12 weeks\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e7 (31.8)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e8 (36.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\n\u003cp\u003e2 (9.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003ctfoot\u003e\n\u003ctr\u003e\n\u003ctd colspan=\"5\"\u003e*Univariate analysis of SAT utilization for all hardware removed as reference versus partial revision or all hardware retained: OR 3.3 (95% CI 1.21\u0026ndash;8.98; P\u0026thinsp;=\u0026thinsp;0.04)\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tfoot\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAdverse drug reactions were documented in 6 of 54 SAT patients (11.1%), including rash, photosensitivity, nausea/vomiting, and fatigue (Table\u0026nbsp;\u003cspan class=\"InternalRef\"\u003e5\u003c/span\u003e). One patient who was on fluconazole and doxycycline for a polymicrobial SHI developed \u003cem\u003eClostridium difficile\u003c/em\u003e infection (\u003cem\u003eC. diff\u003c/em\u003e), while one patient discontinued SAT due to tendonitis. In contrast, 11 of 81 patients (13.6%) had ADRs related to IV antibiotics, including \u003cem\u003eC. diff\u003c/em\u003e in two patients on ertapenem, neutropenia, liver toxicity, and a case of Stevens-Johnson syndrome. There was no significant difference in ADR rates between SAT and IV antibiotic therapy (mid-p exact 95% CI [0.32\u0026ndash;1.80], P\u0026thinsp;=\u0026thinsp;0.82).\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003ctable id=\"Tab4\" style=\"width: 850px;\" border=\"1\"\u003e\u003ccaption\u003e\n\u003cdiv class=\"CaptionNumber\"\u003eTable 5\u003c/div\u003e\n\u003cdiv class=\"CaptionContent\"\u003e\n\u003cp\u003eAntibiotics used for SAT showing ADR and Side effects\u003c/p\u003e\n\u003c/div\u003e\n\u003c/caption\u003e\n\u003cthead\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003cth style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eSuppressive antibiotic used N\u0026thinsp;=\u0026thinsp;54\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 229.167px;\" align=\"left\"\u003e\n\u003cp\u003eNumber of patients on antibiotic (%)\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\n\u003cp\u003eNumber of patients on antibiotic side effect\u003c/p\u003e\n\u003c/th\u003e\n\u003cth style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\n\u003cp\u003eSide effects\u003c/p\u003e\n\u003c/th\u003e\n\u003c/tr\u003e\n\u003c/thead\u003e\n\u003ctbody\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eDoxycycline\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e23 (42.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\n\u003cp\u003ePhotosensitivity\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eLevofloxacin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e11 (20.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\n\u003cp\u003eTendonitis\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eCephalexin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e9 (16.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\n\u003cp\u003eFatigue\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eTrimethoprim-sulfamethoxazole\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e7 (13.0)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\n\u003cp\u003eNausea and vomiting\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eMetronidazole\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e6 (11.1)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eFluconazole\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e5 (9.3)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eAmoxicillin-clavulanate\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e4 (7.4)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eMinocycline\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e3 (5.6)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\n\u003cp\u003eRash\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eCiprofloxacin\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eOmnicef\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eCefadroxil\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e2 (3.7)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003c/tr\u003e\n\u003ctr style=\"height: 35px;\"\u003e\n\u003ctd style=\"height: 35px; width: 212.833px;\" align=\"left\"\u003e\n\u003cp\u003eDoxycycline plus fluconazole\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 229.167px;\" align=\"char\" char=\".\"\u003e\n\u003cp\u003e1 (1.9)\u003c/p\u003e\n\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 268px;\" align=\"left\"\u003e\u0026nbsp;\u003c/td\u003e\n\u003ctd style=\"height: 35px; width: 116px;\" align=\"left\"\u003e\n\u003cp\u003eC. diff\u003c/p\u003e\n\u003c/td\u003e\n\u003c/tr\u003e\n\u003c/tbody\u003e\n\u003c/table\u003e\n\u003c/div\u003e\n\u003cp\u003eAll but one patient received intravenous (IV) antibiotics as the initial antibiotic therapy, with a median duration of 6 weeks. One patient received levofloxacin as initial therapy. Only one patient developed antibiotic resistance: vancomycin resistant \u003cem\u003eEnterococcus faecium\u003c/em\u003e (resistant to ampicillin, doxycycline, with synergy not likely with high level gentamicin or streptomycin) was cultured in recurrent SHI while on minocycline for SAT in a patient who previously had culture negative SHI.\u003c/p\u003e\n\u003cdiv class=\"gridtable\"\u003e\n\u003cdiv class=\"colspec\" align=\"left\"\u003e\u0026nbsp;\u003c/div\u003e\n\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn our study, neither the use of suppressive oral antibiotic therapy (SAT) nor the duration of antibiotic suppression affected the rate of recurrent spinal hardware infection (SHI) in either early infection or late onset cohorts. The rate of recurrence in our study was 14.6%, with no difference between early or late onset infection, regardless of SAT or hardware status. This rate is comparable to other studies in SHI where patients underwent surgery, which showed similar treatment failure rates of ~17%, N=81-129 \u0026nbsp;(7, 14, 15). Furthermore, there was no difference in the median time to SHI recurrence among patients treated with SAT for a duration of less than 24 weeks, 24-52 or more than 52 weeks. Consequently, we were unable to determine SAT efficacy or the appropriate duration of SAT for SHI.\u003c/p\u003e\n\u003cp\u003eHence, the optimal duration of SAT for SHI continues to be poorly defined as it is for other biofilm-driven infections such as vascular graft infections and prosthetic joint infections (PJI). In SHI, SAT is mostly employed where it is not feasible to remove hardware due to spine instability, which usually occurs with early SHI. Other studies have shown conflicting results in early onset SHI with SAT. \u0026nbsp;Some showed 1–2-year cure rates of 80-88% with 10 –12 weeks of antimicrobial treatment, and another showed treatment success with 3 months of SAT but not with \u0026gt;6 months of SAT in patients with early infection following debridement and implant retention or single stage revision (14-16). However, in another study of early onset SHI treated with debridement and implant retention, SAT was associated with 2-year cure rate of 80% compared to 33% in patients who did not receive SAT (7). \u0026nbsp;Overall, these studies seem to indicate that patients with early onset SHI who undergo debridement with implant retention do not need a prolonged duration of SAT, but a randomized controlled trial is needed to clarify the optimal SAT duration for early SHI. This is especially the case because the utilization of SAT is not standardized and there is variation based on clinician preferences with respect to SAT and hardware status, as seen in our study (Table 4). This variation supports that there is a paucity of evidence available to create guidelines to decide on how to treat these patients with SAT and thus a randomized control trial is urgently needed.\u003c/p\u003e\n\u003cp\u003eOn the other hand, patients with late onset SHI where hardware is retained either post revision or without revision may need a prolonged duration of SAT. \u0026nbsp;This might be needed given the establishment of biofilm in the bone and on spinal hardware that will present a challenge for antibiotic penetration despite a prolonged course of treatment beyond 3 months. Yet as seen in our study, the optimal duration of SAT for late onset SHI is also poorly defined and patients had recurrence with a long or shorter duration of SAT. \u0026nbsp;As a result, recurrence may be more directly correlated with adequacy of surgical procedures in achieving source control with debridement of all biofilms. \u0026nbsp;However, determining in vivo biofilm persistence and the need for further debridement is difficult and no standardized procedures have been devised. \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSHI recurrence or treatment failure may be due to certain patient-specific or microbial factors as has been identified in other studies such as systemic malignancy, radiation therapy, infection from \u003cem\u003eS. aureus\u003c/em\u003e or polymicrobial infection (7, 14, 15). \u0026nbsp;In our study, we did not identify any significant factors associated with SHI recurrence. \u0026nbsp;The microbiology of SHI in our study is similar to that seen in other studies with \u003cem\u003eS. aureus\u003c/em\u003e predominating in up to 40% of cases (7, 14, 15). An interesting fact is that we identified \u003cem\u003eStreptococci\u003c/em\u003e species in only one patient, unlike other studies where \u003cem\u003eStreptococci\u003c/em\u003e was the identified etiology in 10-30% of cases (7, 15). Culture negative and polymicrobial cases (16% for each category) were the next predominant etiology after \u003cem\u003eS. aureus\u003c/em\u003e in our study, and these cases typically pose a challenge for SAT due to the uncertainty of antibiotic choice and efficacy, as well as the tendency to use multiple antibiotics in this situation, thereby exposing the patient potentially to more risk of ADR.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp;In our study, ADR occurred in 6 of the 54 patients that received SAT (11.1%.), including one case of \u003cem\u003eC. diff,\u003c/em\u003e which occurred in a patient with polymicrobial infection being treated with doxycycline and fluconazole, which may indicate a greater risk of ADR in patients with polymicrobial infection requiring multiple antibiotics. The ADR rate to SAT in our study was comparable and non-significant to the rate of ADR with the use of IV antibiotics (13.6%), though there were two cases of \u003cem\u003eC. diff\u003c/em\u003e in patients being treated with ertapenem and the ADR to IV antibiotics appeared to be of greater severity such as Stevens Johnson’s syndrome and liver toxicity. \u0026nbsp; Data on the rate of ADR to SAT in SHI is sparse, with rates ranging from 0-15%, with no cases of \u003cem\u003eC. diff\u003c/em\u003e reported after at least 6 months of treatment (7, 15). However, the rate of ADR to SAT on a larger scope involving PJI and vascular graft infections is as high as 25-40%, predominantly gastrointestinal (35%), followed by dermatologic changes such as rash (25%) (17-19). Our study did not show any specific patterns of ADR to SAT, with each of the 6 cases manifesting different symptoms as shown in Table 5. Nonetheless, more studies will be needed to show if the rate of ADR for SHI is lower than that seen in other hardware-associated infections.\u003c/p\u003e\n\u003cp\u003eOf note, the initial antibiotic therapy and route in our study was intravenous (IV), with a median duration of 6 weeks in all but one patient who received levofloxacin as initial therapy. There is a shift from a 6-week duration of IV antibiotics to as low as a 2-week lead-in with IV, followed by oral antibiotics or no IV antibiotics at all, and more studies have shown non-inferiority of oral compared to IV antibiotics in orthopedic infections (20-22). The implication of how this affects SAT remains to be seen but may imply prolonged use of oral antibiotics than is typically used. However, this may not be negatively impactful given the avoidance of PICC lines and other extrinsic risks associated with IV therapy such as catheter related complications. Nonetheless, it remains to be seen if oral antibiotics are associated with less ADR than intravenous antibiotics. As shown in our study, the rate of ADR may be similar with oral or IV therapy, but studies show additional risk of IV antibiotics when catheter related factors are considered (21, 23).\u003c/p\u003e\n\u003cp\u003eThe development of antimicrobial resistance is a recognized risk of prolonged antimicrobial therapy, with rates ranging from 7-40% reported with SAT in prosthetic joint infections, especially with regards to the development of resistance to rifampin (18, 24, 25). There is very sparse data on the risk of antimicrobial resistance development on SAT for SHI. Although the median duration of SAT in our study was 52 weeks (range 12-191), we identified only one case of a MDRO with SAT (1.9%), which was a Vancomycin resistant \u003cem\u003eEnterococcus faecium\u003c/em\u003e from a previously culture negative SHI. The low rate of antibiotic resistance identified in our study may be due to our definition of resistance, which was limited to cases of recurrent infection because we did not evaluate if they developed MDROs at other sites. \u0026nbsp;In addition, we did not utilize rifampin for SAT in our study as this antibiotic was employed only as initial antibiotic regimen in combination with IV therapy. This suggests that in the absence of rifampin, the risk of MDRO development with SAT for SHI may be low.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eOur study has several strengths including a sample size comparable to that used in similar studies, a real-world observational approach using data that was available in everyday clinical practice, and the assessment for the development of adverse drug reaction and drug resistance on SAT, which to our knowledge, are very sparse in SHI literature.\u003c/p\u003e\n\u003cp\u003eNonetheless, there are several limitations to this study, such as the retrospective nature, which revealed that SAT utilization was not standardized in our cohort, as not all the patients with retained hardware received SAT and some patients who had all hardware removed received SAT. Hence, it is possible that the determination of SAT efficacy and optimal duration may have been diminished. However, this is the actual experience in practice, which doesn’t negate a treating clinician’s clinical judgement in managing a patient. As stated earlier, MDRO definition was limited to the site of original infection so we may have missed MDRO development at other sites. Our study did not include SHI patients who did not undergo surgery; hence, we were unable to determine the role of SAT in this category of patients.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; \u0026nbsp; In conclusion, SAT continues to be employed in the treatment of SHI, especially where hardware is retained. The efficacy and optimal duration of SAT remains an enigma reflected by the variation in practice across clinicians. Our study showed that in patients with SHI who underwent surgery, neither the use of SAT nor SAT duration had any impact on recurrence of SHI regardless of onset or hardware status, including patients with early onset SHI who underwent debridement and implant retention. The rate of ADR with SAT was comparable to ADR with intravenous antibiotics and the rate of antimicrobial resistance development was low. Consequently, a randomized control trial is urgently needed to determine the role of SAT and its optimal application in the treatment of SHI. \u0026nbsp;\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eSHI: Spinal hardware infection\u003c/p\u003e\n\u003cp\u003eSAT: Suppressive antibiotic therapy\u003c/p\u003e\n\u003cp\u003eADR: Adverse drug reaction\u003c/p\u003e\n\u003cp\u003eMDRO: Multi drug resistant organism\u003c/p\u003e\n\u003cp\u003eS: Supplementary\u003c/p\u003e\n\u003cp\u003eC. diff: \u003cem\u003eClostridium difficile\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eS. aureus: Staphylococcal aureus\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eE. coli: Escherichia coli\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eBMI: Body mass index\u003c/p\u003e\n\u003cp\u003eMSSA: Methicillin resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eMRSA: \u0026nbsp;Methicillin resistant \u003cem\u003eStaphylococcus aureus\u003c/em\u003e.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;CoNS: Coagulase negative \u003cem\u003eStaphylococci\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003ePJI: Prosthetic Joint Infection\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics Approval and consent to participate:\u0026nbsp;\u003c/strong\u003eThe study was approved by the Institutional Review Board of the University of Maryland School of Medicine. (HP-00101883).\u0026nbsp;The study was conducted in accordance with the principles of the Declaration of Helsinki.\u003c/p\u003e\n\u003cp\u003eInformed consent to participate was deemed unnecessary according to the University of Maryland, Baltimore (UMB) Institutional Review Board (IRB) and national regulations, 45 CFR 46.104(d). The UMB IRB reviewed the research protocol (HP-00101883) and determined it to be exempt under 45 CFR 46.104(d) based on the following category:\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eSecondary research for which consent is not required: Secondary research uses of identifiable private information or identifiable biospecimens, if at least one of the following criteria is met: information, which may include information about biospecimens, is recorded by the investigator in such a manner that the identity of the human subjects cannot readily be ascertained directly or through identifiers linked to the subjects, the investigator does not contact the subjects, and the investigator will not re-identify subjects.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and Materials:\u0026nbsp;\u003c/strong\u003eThe data set used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests:\u0026nbsp;\u003c/strong\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u0026nbsp;\u003c/strong\u003eThis study was not funded.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor’s contributions:\u0026nbsp;\u003c/strong\u003eA.C worked on data collection, analysis and writing the results section. J.D conceived the project, reviewed, and edited the manuscript, and supervised the project. U. E worked on data collection, analysis, writing and editing the manuscript, and supervision of the project. All authors reviewed the text and agreed on the final version of the manuscript\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements:\u003c/strong\u003e Not applicable.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eKasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int. 2013;4(Suppl 5):S392\u0026ndash;403.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDeyo RA, Nachemson A, Mirza SK. Spinal-fusion surgery - the case for restraint. N Engl J Med. 2004;350(7):722\u0026ndash;6.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eGrowth in Discharges with Procedures on the Musculoskeletal System, 1993\u0026ndash;2005 [Internet]. 2005. Available from: \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_3_6B.jsp\u003c/span\u003e\u003cspan address=\"https://hcup-us.ahrq.gov/reports/factsandfigures/figures/2005/2005_3_6B.jsp\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMost Frequent Operating Room Procedures Performed in U.S, Hospitals. 2003\u0026ndash;2012 [Internet]. 2014. 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Infection with Spinal Instrumentation: A 20-Year, Single-Institution Experience with Review of Pathogenesis, Diagnosis, Prevention, and Management. Asian J Neurosurg. 2019;14(4):1181\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePalmowski Y, B\u0026uuml;rger J, Kienzle A, Trampuz A. Antibiotic treatment of postoperative spinal implant infections. J Spine Surg. 2020;6(4):785\u0026ndash;92.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRuiz-Sancho A, N\u0026uacute;\u0026ntilde;ez-N\u0026uacute;\u0026ntilde;ez M, Castelo-Corral L, Mart\u0026iacute;nez-Marcos FJ, Lois-Mart\u0026iacute;nez N, Abdul-Aziz MH, et al. Dalbavancin as suppressive antibiotic therapy in patients with prosthetic infections: efficacy and safety. Front Pharmacol. 2023;14:1185602.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrevention CfDCa. Medication Safety and Your Health. 2024.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWille H, Dauchy FA, Desclaux A, Dutronc H, Vareil MO, Dubois V, et al. Efficacy of debridement, antibiotic therapy and implant retention within three months during postoperative instrumented spine infections. Infect Dis (Lond). 2017;49(4):261\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eKeller SC, Cosgrove SE, Higgins Y, Piggott DA, Osgood G, Auwaerter PG. Role of Suppressive Oral Antibiotics in Orthopedic Hardware Infections for Those Not Undergoing Two-Stage Replacement Surgery. Open Forum Infect Dis. 2016;3(4):ofw176.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDub\u0026eacute;e V, Lenoir T, Leflon-Guibout V, Briere-Bellier C, Guigui P, Fantin B. Three-month antibiotic therapy for early-onset postoperative spinal implant infections. Clin Infect Dis. 2012;55(11):1481\u0026ndash;7.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eNowak MA, Winner JS, Beilke MA. Prolonged oral antibiotic suppression in osteomyelitis and associated outcomes in a Veterans population. Am J Health Syst Pharm. 2015;72(23 Suppl 3):S150\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHorne M, Woolley I, Lau JSY. The Use of Long-term Antibiotics for Suppression of Bacterial Infections. Clin Infect Dis. 2024;79(4):848\u0026ndash;54.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eReinecke P, Morovic P, Niemann M, Renz N, Perka C, Trampuz A et al. Adverse Events Associated with Prolonged Antibiotic Therapy for Periprosthetic Joint Infections-A Prospective Study with a Special Focus on Rifampin. Antibiot (Basel). 2023;12(11).\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eConterno LO, Turchi MD. Antibiotics for treating chronic osteomyelitis in adults. Cochrane Database Syst Rev. 2013;2013(9):Cd004439.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eLi HK, Rombach I, Zambellas R, Walker AS, McNally MA, Atkins BL, et al. Oral versus Intravenous Antibiotics for Bone and Joint Infection. N Engl J Med. 2019;380(5):425\u0026ndash;36.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eObremskey WT, O'Toole RV, Morshed S, Tornetta P 3rd, Murray CK, Jones CB, et al. Oral vs Intravenous Antibiotics for Fracture-Related Infections: The POvIV Randomized Clinical Trial. JAMA Surg. 2025;160(3):276\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eSpellberg B, Lipsky BA. Systemic antibiotic therapy for chronic osteomyelitis in adults. Clin Infect Dis. 2012;54(3):393\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePeel 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\u0026ndash;5.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePradier M, Nguyen S, Robineau O, Titecat M, Blondiaux N, Valette M, et al. Suppressive antibiotic therapy with oral doxycycline for Staphylococcus aureus prosthetic joint infection: a retrospective study of 39 patients. Int J Antimicrob Agents. 2017;50(3):447\u0026ndash;52.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Suppressive antibiotic therapy, Spinal hardware infection, Surgical site infection, Antimicrobial resistance, Adverse drug reaction, Antibiotic treatment duration","lastPublishedDoi":"10.21203/rs.3.rs-7120988/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7120988/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground: \u003c/strong\u003eSpinal hardware infection (SHI) is one of the most devastating complications of spine surgery with challenging and undefined antibiotic treatment modalities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eRetrospective cohort study of patients ≥18 years of age who underwent surgery for the treatment of SHI at a university center between 1\u003csup\u003est \u003c/sup\u003eJanuary2015, to 1\u003csup\u003est\u003c/sup\u003e January 2020. The aim was to determine the appropriate duration of suppressive antibiotic therapy (SAT) for SHI based on recurrent infection rate on SAT, rate of adverse drug reaction (ADR) from SAT, and rate of antibiotic resistance to SAT in patients with SHI.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe median age of the 82 patients who met eligibility criteria for the study was 61 years (53.2–72.5), 55% were female, 59.8% had multimorbidity and 53.7% had early infection\u003cem\u003e. Staphylococcus aureus\u003c/em\u003e was the most common cultured organism (37.8%) and 29 (35.4%) of patients had bacteremia. 54 (65.8%) received SAT with a median duration of 52 weeks (12 to 191 weeks). 12 (14.5%) had recurrence, while 8 (9.7%) developed recurrence on SAT. Neither SAT nor SAT duration (\u0026lt;24 weeks, 24-52 or \u0026gt;52 weeks) was associated with recurrence in early or late infection, regardless of hardware status. There was a non-significant higher recurrence rate with partial hardware revision, 7.3% (OR 6.30 [0.70–57.07]) and full hardware retention, 6.1% (OR 3.62 [0.39–33.30]) compared to complete hardware removal, (1.2%). ADR occurred in 6 (11.1%) of patients on SAT and in 11 (13.6%) of patents while on intravenous therapy, with no significant difference (mid-p exact 95% CI [0.32–1.80], p = 0.82).\u0026nbsp;Only one case of drug resistance occurred with SAT.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion:\u003c/strong\u003e In patients who underwent surgery for SHI, neither the use of SAT nor SAT duration had any impact on recurrence of SHI regardless of SHI onset or hardware status. The rate of ADR with SAT was comparable to ADR with intravenous antibiotics and the rate of development of drug resistance was low. A randomized control trial is urgently needed to determine the role of SAT and its optimal application in the treatment of SHI.\u0026nbsp;\u003c/p\u003e","manuscriptTitle":"Suppressive Antibiotic Therapy for Spinal Hardware Infection: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-08-13 19:17:39","doi":"10.21203/rs.3.rs-7120988/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-03T04:40:30+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-07T16:06:44+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"294558357019250639915793172660872219707","date":"2025-08-23T20:05:16+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-08-10T14:41:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"242314358665626836663309814525037344733","date":"2025-08-08T10:42:16+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-08-08T06:53:24+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-08-06T17:57:13+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-07-18T06:12:18+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-07-17T19:31:11+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Infectious Diseases","date":"2025-07-17T12:36:33+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-infectious-diseases","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"infd","sideBox":"Learn more about [BMC Infectious Diseases](http://bmcinfectdis.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/infd","title":"BMC Infectious Diseases","twitterHandle":"#bmcinfectdis","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"7f782c9e-96d1-4622-a9a5-5e64c1f9b9c7","owner":[],"postedDate":"August 13th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-16T16:03:21+00:00","versionOfRecord":{"articleIdentity":"rs-7120988","link":"https://doi.org/10.1186/s12879-026-12901-x","journal":{"identity":"bmc-infectious-diseases","isVorOnly":false,"title":"BMC Infectious Diseases"},"publishedOn":"2026-03-11 15:58:11","publishedOnDateReadable":"March 11th, 2026"},"versionCreatedAt":"2025-08-13 19:17:39","video":"","vorDoi":"10.1186/s12879-026-12901-x","vorDoiUrl":"https://doi.org/10.1186/s12879-026-12901-x","workflowStages":[]},"version":"v1","identity":"rs-7120988","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7120988","identity":"rs-7120988","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}