Antimicrobials in polymethylmethacrylate: from prevention to prosthetic joint infection treatment: basic principles and risk of resistance

Abstract

Background Excellent revisions about antibiotic-loaded bone cement (ALBC) have been recently published. In the present article, we review the principles and limitations of local antibiotic delivery in the context of recent advances in the pathogenesis of prosthetic joint infections (PJI), with particular attention paid to the potential association between ALBC and antimicrobial resistance. Main body Recalcitrance of PJI is related to the ability of pathogens to adapt to particular environments present in bone tissue and protect themselves from host immunity in different ways. Accordingly, delivery of high local antimicrobial concentrations using ALBC is needed. Most relevant clinical data showing the efficacy of ALBC for PJI prophylaxis and treatment are reviewed, and we dissected the limitations on the basis of the recent findings from animal models and suggested that aminoglycosides, in particular, could not be the best option. One of the major concerns associated with ALBC is the emergence of resistance because of theoretical prolonged exposure to low antibiotic concentrations. We summarize the mechanisms for the selection of resistant microorganisms, and we critically reviewed the evidence from animal models and clinical data from observational and registry studies and concluded that there is no evidence to support this association. Conclusion While waiting for better evidence from well-designed clinical trials, ALBC shows a beneficial effect as a prophylaxis in arthroplasty, and to avoid the colonization of spacers used for two-stage revision in patients with PJI. Experimental models and clinical evidence suggest the need to achieve high local antimicrobial concentrations to obtain the highest prophylactic and therapeutic effect. The current evidence does not support the risk of increasing resistance with use of ALBC. In the future, it is necessary to evaluate new carriers and different antimicrobials to improve clinical outcomes.

Systematic Review on the Current Situation and Development of Local Antimicrobial Agents in Revision Arthroplasty for Periprosthetic Joint Infection (PJI)

“…As they are very effective against bacteria on the downside to their safety there is a significant challenge of developing antibiotic resistance. The longer use of antibiotics may lead to the development of resistant strains which brings to careful consideration regarding the use antibiotic and the amount of time to be used (Sabater-Martos et al, 2023).…”

<i>In vivo</i> effectiveness of polymer hydrogels impregnated with an antibacterial drug in chronic osteomyelitis

“…До операции только 29 % бактерий имели резистентность к гентамицину, а после лечения костным цементом доля их возросла до 41 % [14]. George et al, сравнивая результаты пациентов до имплантации ПММА, насыщенным ванкомицином, и после, отмечают повышение МПК в 36 % случаев [15]. Другой in vivo эксперимент на крысах показал высокий процент (78 %) антибиотикорезистентных S. epidermidis в группе, где костный цемент, содержащий гентамицин, применялся в качестве профилактического средства [16].…”

Editorial: Management of PJI/SSI after joint arthroplasty

“…Antibiotic-loaded bone cement (ALBC) has been recognized as an important tool in the prevention and treatment of PJI. Soriano et al [ 17 ] examined the use of ALBC and discussed its pharmacokinetics, efficacy in infection prevention, prophylactic and therapeutic effects, and potential risks of antimicrobial resistance. They highlighted the need for careful patient selection and appropriate antibiotic choice to maximize benefits and minimize risks.…”