Clinical practice guidelines for antimicrobial-loaded cements and beads in orthopedic trauma and arthroplasty

Implants in orthopedic trauma and arthroplasty surgery establish a milieu conducive to biofilm formation. Antimicrobial-loaded cements (ABCs) and beads have become popular in treating acute and chronic orthopedic surgery-related infections. The growing incidence of antimicrobial resistance has necessitated the exploration of alternative antibiotic medications. This review aims to demonstrate meaningful clinical decision-making guidance for orthopedic surgeons in approaching the management of these complex infections.

This study protocol was conducted following the PRISMA checklist and guidelines of the Cochrane Handbook for Systematic Reviews of Interventions. PubMed, Ovid MEDLINE, Web of Science, and other databases were queried using applicable search terms. Relevant dosing, efficacy, and elution profiles were reviewed and compiled from 74 articles published between 1976 and 2019. First-line and targeted therapies were identified against rare and resistant bacteria. Drug therapies not recommended due to excessive cytotoxicity or poor delivery kinetics were also elucidated.

This compilation describes thirty-two antibiotics and three antifungals that have successfully managed orthopedic surgery-related infections, including infections with numerous recalcitrant and multidrug-resistant species. Optimized ratios of carrier to antimicrobial are provided for each delivery method. The elution and efficacy profiles of the various antibiotics are described when available.

These recommendations offer the most up-to-date and comprehensive practice guidelines for using antimicrobials in cements and beads for treating orthopedic hardware-related infections. With the ever-evolving propensity of bacteria to develop antibiotic resistance, these recommendations are dynamic. Collaboration with medicine, infectious disease, and/or pharmacology teams is recommended to create institutional protocols for antibiotic-eluting implants and close comanagement to ensure efficacy and patient safety.