Patients at a high risk of PJI: Can we reduce the incidence of infection using dual antibiotic-loaded bone cement?

Abstract

Prosthetic joint infection (PJI) is one of the most devastating complications of orthopedic surgery. However, not all patients are equally at the risk of severe infection. The incidences of PJI vary with the host and surgery-related risk factors. It is now generally accepted that some important medical comorbidities may predispose the patients to a high risk of PJI. Time-consuming and invasive surgical procedures, such as revision arthroplasties, are also associated with a high incidence of PJI, presumably due to the increased risk of surgical site contamination. Effective infection-preventing strategies should begin with identifying and optimizing the patients at a high risk of infection prior to surgery. Optimizing the operating room environment and antibiotic prophylaxis are also essential strategies that help minimize the overall incidence of infection in orthopedic surgery. The ideal antibiotic prophylaxis is still under debate, and discussions have emerged about whether variations or adjustments to the standard protocol are justified in patients at a high risk of infection. This also includes evaluating the possible benefits and risks of using high-dose dual antibiotic-loaded bone cement instead of low-dose single antibiotic-loaded bone cement in arthroplasty. This review summarizes the evidence showing that the combination of two local antibiotics in bone cement exerts a strong and longer-lasting antimicrobial effect against PJI-associated pathogens. This conclusion is consistent with the preliminary clinical studies showing a low incidence of PJI in high-risk patients undergoing cemented hemiarthroplasty, cemented revision, and primary arthroplasty if dual ALBC is used. These results may encourage clinicians to consolidate this hypothesis in a wider clinical range.

Novel reconstruction method by mega-prosthesis wrapped with vancomycin-containing cement after resection of malignancies

“…Third, recent studies are controversial on whether antimicrobial-containing cement is effective in preventing PJI. [34,35] However, this method may prevent PJI long-term by reducing dead space. Despite these limitations, this method could be useful as an infection control measure.…”

Editorial: Management of PJI/SSI after joint arthroplasty

“…They highlighted the need for careful patient selection and appropriate antibiotic choice to maximize benefits and minimize risks. Berberich et al [ 18 ] reviewed the potential of dual antibiotic-loaded bone cement (ALBC) in the prevention of PJI in high-risk patients. Studies indicated that the local delivery of antibiotics via bone cement could provide enhanced and sustained antimicrobial effects, thereby lowering the incidence of PJI.…”

The rate and management of prosthetic joint infection in the low-income setting: a cross-sectional study

“…Nowadays, after the evidence that antibiotic-loaded cement lowers infection rates and does not contribute to the exacerbation of antibiotic resistance 18 , it has become widely used as a prophylactic measure. There are even proposals for using dual antibiotic-loaded bone cement, which can be synergistically efficacious 19 .…”