Louis Kwong, MD, in his latest article, shared the importance of practicing good stewardship with antibiotics, which may reduce resistance cement weakening. Below are the key takeaways from the original article” Mixed data prompt questions on antibiotic bone cement” on healio.com, in which Louis M. Kwong shared his thoughts along with other distinguished experts.
The International Consensus Meeting on Musculoskeletal Infection, held in Philadelphia on July 25–27, 2018, brought together 98 countries’ worth of experts in musculoskeletal infections and infection management to explore ways to enhance the diagnosis, management, and prevention of musculoskeletal infections. The use of antibiotic-loaded bone cement in primary total joint arthroplasty to prevent periprosthetic joint infection was the subject of intense debate among the delegates among the topics discussed.
While antibiotic-loaded bone cement has been around since the 1970s, some sources that Orthopedics Today spoke with for this cover story stated that there are differences in global registry data regarding the reporting of results and revision rates for primary total joint arthroplasty (TJA) using antibiotic-loaded cement.
Louis Kwong, MD, FACS, said “Prior to using antibiotic-loaded cement in primary joint arthroplasty, orthopedic surgeons should assess patients for renal function, allergy to antibiotics, and risk of PJI.”
Orthopedic surgeons hold differing opinions about when to use antibiotic-loaded bone cement in total joint arthroplasty (TJA). This could be because of the inconsistent outcomes and paucity of data observed across registries.
According to sources consulted, antibiotic-loaded bone cement ought to be reserved for primary TJA patients who are more likely to experience pressure injuries. Patients with diabetes, anemia, sickle cell anemia, autoimmune diseases, weakened immune systems, or a history of infection are included in this.
According to Louis M. Kwong, MD, FACS, randomized, controlled trials may address concerns regarding antibiotic efficacy, antibiotic resistance, and the duration required for antibiotics to elute from cement. However, regarding infection control, he stated that the kinds of research required to address important issues such as these are challenging to carry out and might never be completed.
“We are likely going to be dependent for some time on large databases, like national registries or consensus opinions, because of the challenges associated with obtaining level-1 data looking at the impact of the different strategies, like the use of antibiotics in cement for primary total joint,” Kwong, renowned Orthopaedic Surgeon said during the interview.
Whether deciding to use antibiotic-loaded bone cement routinely or only in patients at high risk for PJI after primary TJA, it is important to assess patients on an individual basis and identify for them whether the benefits outweigh the risks, Louis Kwong, MD emphasizes.
Surgeons should be aware of the patient’s allergy history so they do not use an antibiotic to which the patient may be allergic. Although it is uncommon, certain antibiotics, such as gentamicin, have been associated with an increase in acute renal failure, he said.
“Look at the renal function of the patient because there can be measurable levels of antibiotics, like aminoglycosides, in the systemic circulation. This can have a potentially serious adverse effect on kidney function for patients who have chronic renal failure or pre-existing renal disease,” Louis Kwong, MD added.
The cost of antibiotic-loaded bone cement indeed raises questions, but its benefits may speak for themselves prices, shared Louis Kwong.
“We have little in the way of new antibiotics that are being developed due to the cost. Antibiotics like vancomycin represent one of our most valuable tools against infection,” Louis M. Kwong, MD said. “The concerns always are if we begin routinely using this in cement, might this, in the long run, be a detriment by fostering increasing antibiotic resistance to one of the few tools that we have?”
Other examples, according to Kwong, include shortening the surgery’s duration and minimizing traffic in and out of the operating room, both of which can lower the risk of infection.
“We use prophylactic antibiotics that are administered IV, make sure we administer it at the appropriate time and in the appropriate dose, which is fairly universally well-practiced by orthopedic surgeons throughout the country,” Louis Kwong, MD said.
Lower-level scientific evidence notwithstanding, Louis Kwong, MD, stated that diluted betadine solution seems to be beneficial in lowering the risk of infection.
“There are many tools that we have in our armamentarium that can be used use in addition to antibiotics in higher-risk individuals so that we can have a positive impact on reducing infection risk and likely reserve the use of antibiotic-loaded cement to selected individuals,” Louis Kwong, MD concludes.
