Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence

Abstract

In view of the demographic changes and projected increase of arthroplasty procedures worldwide, the number of prosthetic joint infection cases will naturally grow. Therefore, in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance. In the absence of a “miracle weapon” priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks, the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen. Instead of a “one size fits all” philosophy, it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient- and procedure-related risk factors. A stronger focus on the local application mode via use of high dose dual antibiotic-loaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre. The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.

Keywords: Prosthetic joint infection; Antibiotic-loaded bone cement; Single low dose antibiotic-loaded bone cement; Dual high dose antibiotic-loaded bone cement; Antibiotic prophylaxis; Risk-for-infection patients

Core Tip: The objective of an effective antibiotic prophylaxis in arthroplasty may be best achieved through the combination of a systemic and local application route via antibiotic-loaded bone cement. Based on the observation of strong synergistic effects in antibiotic elution and antimicrobial efficacy of dual antibiotic-loaded bone cements, the hypothesis of a clinically more meaningful prophylaxis has been tested against gentamicin-only containing bone cements. Evidence is provided that this easy-to-apply strategy might be successful, if important comorbidities or procedure-related factors predispose patients to higher infection risks than usual.