Risk assessment of antibiotic resistance development by antibiotic-loaded bone cements: is it a clinical concern?

Because of the risk of bacterial biofilm infections, prophylactic use of antibiotics in orthopaedic procedures involving the implantation of large prosthesis systems is considered mandatory.

A strategy based on the rationale that local antibiotics released from bone cement or other carriers establish a second antibacterial frontline in and around the prosthesis is considered complementary to the administration of systemic antibiotics.

Although less common as a consequence of the initially very high drug concentrations of local antibiotics in the tissues, a selection process of previous high resistance bacteria may occur, leading to antibiotic resistance.

The use of antibiotic combinations in bone cement is generally accepted to improve antibiotic efficacy and minimizes the treatment failure risk due to antibiotic resistance. This is important in septic revisions and/or in patients at particularly high risk of infection.

On an individual basis, the benefit of a lower infection probability with combined systemic and local antibiotic application should outweigh the risk of the selection of more resistant bacteria. Each prevented infection means that a complex and extended antibiotic therapy with risk of resistance development over time has been avoided.

On an epidemiological level there is no clinical evidence that the routine use of bone cement impregnated with appropriate bactericidal antibiotics promotes the widespread development of antibiotic resistance and thereby puts the successful treatment of a prosthetic joint infection at higher risk.