Antimicrobial Regimens in Cement Spacers for Periprosthetic Joint Infections: A Critical Review
Abstract
:1. Introduction
2. Basic Principles and Types of Spacers
2.1. The Role of Antibiotic-Loaded Cement Spacers in PJIs
2.2. The Types of Spacers in PJIs
3. Spacer Pharmacokinetics
4. Antimicrobial Agents in Spacers
4.1. Characteristics of Antibiotics for Use in Cement Spacers
4.2. Dosage of Antibiotics in Cement Spacers
4.3. Types of Antibiotics in Cement Spacers
4.4. Antifungal-Loaded Bone Cement
5. Mechanical Properties of Antimicrobial Cement
6. The Role of Antimicrobial Cement in Two-Stage Exchange Arthroplasty and Double DAIR Procedure
6.1. Impact of Spacer Exchange on the Success of Two-Stage Revision
6.2. The Double-DAIR Procedure
7. Complications and Toxicity
8. Future Perspectives
9. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Types of Articulating Spacers | Characteristics | |
---|---|---|
Advantages | Disadvantages | |
Hand-made spacers [24] | Lower cost, custom-made to suit specific anatomical configurations, can be loaded with antibiotics that are more sensitive to pathogens | Time-consuming, heightened risk of fracture, potential mismatch with articulating surfaces |
Spacers fashioned from moulds [24] | More consistent geometry, and various sizes, allowing intraoperative selection, can be loaded with antibiotics that are more sensitive to pathogens | Increased procedure costs, higher incidence of mechanical complications |
Commercial preformed spacers [24] | Straightforward intraoperative application, time-saving | Lower antibiotic doses and limitations on the types of antibiotics used |
Spacers with additional metal or polyethylene articulating elements [24] | Semi-constrained to minimise dislocation risk, advocated for complex cases | Limited availability |
New or autoclaved prosthesis [24] | Significant flexibility in two-stage exchange procedures, allowing partial prosthesis removal or combination with other strategies to manage complications | It contradicts recommendations from regulatory bodies like the Food and Drug Administration (FDA) in the USA and the Medicines and Healthcare Products Regulatory Agency (MHRA) in the UK |
Custom-made articulating spacers (CUMARS) [24] | Better joint function, enabling full weight-bearing of the lower extremity, improved inter-stage functionality, easier removal, and effective infection control | High cost |
3D printing-assisted articulating spacers [24] | High geometric consistency, different-sized models while preserving geometry, minimal mechanical complications | Lack of relevant medical regulations and consensus |
Increasing Antibiotic Release | Decreasing Antibiotic Release |
---|---|
Greater the surface area [5] | Increased distance between the cement and surrounding tissues |
Cancellous bone/dead space | Cortical bone |
Porosity/ Intact crystals left from the mixing process | |
Partially mixed cements | |
Joint motion | |
Tissue absorption capacity | |
Increased concentration of the antibiotic |
Cement | Antimicrobial Agents | Coverage Spectrum |
---|---|---|
Palacos | Gentamicin | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli), Gram-positive Staphylococcus, aerobic bacteria |
CMW/Simplex/Palacos | Gentamicin | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli), Gram-positive Staphylococcus, aerobic bacteria |
Palacos | Gentamicin/erythromycin/penicillin | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli, Mycoplasma, Chlamydia trachomatis, Rickettsia), Gram-positive cocci, aerobic bacteria, aerobic bacilli |
Simplex | Penicillin/methicillin/erythromycin/lincomycin/nafcillin/ | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli, Mycoplasma, Chlamydia trachomatis, Rickettsia, Treponema), Gram-positive cocci, aerobic bacteria, aerobic bacilli |
polymyxin/colistimethate | Gram-negative (jnc. Pseudomonas) | |
Simplex/Palacos | Gentamicin/oxacillin/cephazolin | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli), Gram-positive cocci, aerobic bacteria |
Palacos/Simplex/CMW | Sodium fusidate/gentamicin | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli), Gram-positive cocci, aerobic bacteria |
Simplex | Fucidin/clindamycin/gentamicin | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli, Mycoplasma, Chlamydia trachomatis, Rickettsia), Gram-positive cocci, aerobic and anaerobic bacteria and bacilli |
Palacos/Simplex | Penicillin/gentamicin | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli, Mycoplasma, Chlamydia trachomatis, Rickettsia, Treponema), Gram-positive cocci, aerobic bacteria, aerobic bacilli |
Palacos/CMW | Gentamicin sulphate/sodium fusidate/diethanolamine | Gram-negative (Pseudomonas, Proteus, Klebsiella, E. coli) |
Palacos/CMW | Ceftriaxone/coumermycin/sulfampicionmethoxozaole/ | Gram-positive bacteria, Gram-negative bacteria (Klebsiella, E. coli, Proteus, not including Pseudomonas) |
Trimethoprim/cephalothin/vancomycin/fusidic acid/ | Gram-positive bacteria (including methicillin-resistant organisms), Gram-negative bacteria (esp. Pseudomonas) | |
Gentamicin/rifampicin/vancomycin | Gram-positive bacteria (including methicillin-resistant organisms), Gram-negative bacteria (esp. Pseudomonas), Mycobacterium | |
Palacos/Simplex/Zimmer | Vancomycin/amikacin/daptomycin | Gram-positive bacteria (including methicillin-resistant organisms), Gram-negative bacteria (esp. Pseudomonas) |
low viscosity and dough type | ||
Palacos/Simplex | Tobramycin/vancomycin | Gram-positive bacteria, (including methicillin-resistant organisms), Gram-negative bacteria (especially Pseudomonas) |
Palacos | Vancomycin/tobramycin | Gram-positive bacteria, (including methicillin-resistant organisms), Gram-negative bacteria (especially Pseudomonas) |
Cerafix | Vancomycin | Gram-positive bacteria (including methicillin-resistant organisms) |
Antibiotics | Dose per 40 g Cement |
---|---|
Tobramycin | 1 to 4.8 g |
Gentamicin | 0.25 to 4.8 g |
Cefazolin | 1 to 2 g |
Cefuroxime | 1.5 to 2 g |
Ceftazidime | 2 g |
Cefotaxime | 2 g |
Ceftaroline | 2 to 4 g |
Ciprofloxacin | 0.2 to 3 g |
Vancomycin | 0.5 to 4 g |
Clindamycin | 1 to 2 g |
Erythromycin | 0.5 to 1 g |
Colistin | 0.24 g |
Piperacillin—not available Piperacillin-tazobactam | 4 to 8 g |
Aztreonam | 4 g |
Tazobactam | 0.5 g |
Linezolid | 1.2 g |
Meropenem | 0.5 to 4 g |
Daptomycin | 2 g |
Amphotericin | 200 mg |
Voriconazole | 300–600 mg |
Itraconazole | 250 mg |
Fluconazole | 200 mg |
Beads or Bead Chains | Spacers | ||
---|---|---|---|
Pros | Cons | Pros | Cons |
Increased antibiotic concentrations | Disruption of local anatomy | Preservation of local anatomy | Lower antibiotic concentrations and shorter duration |
Cost-effective | Extensive scar tissue formation | Pre-fabricated spacers are costly | Spacer dislocation/ migration |
Low complication rates | Possible joint mobility and weight-bearing | Spacer fractures | |
Simple to use, implant, and remove | |||
Longer period at minimum inhibitory concentration (MIC) |
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Naoum, S.; Koutserimpas, C.; Pantekidis, I.; Giovanoulis, V.; Veizi, E.; Piagkou, M.; Ioannou, P.; Samonis, G.; Domouchtsidou, A.; Tsantes, A.G.; et al. Antimicrobial Regimens in Cement Spacers for Periprosthetic Joint Infections: A Critical Review. Antibiotics 2024, 13, 772. https://doi.org/10.3390/antibiotics13080772
Naoum S, Koutserimpas C, Pantekidis I, Giovanoulis V, Veizi E, Piagkou M, Ioannou P, Samonis G, Domouchtsidou A, Tsantes AG, et al. Antimicrobial Regimens in Cement Spacers for Periprosthetic Joint Infections: A Critical Review. Antibiotics. 2024; 13(8):772. https://doi.org/10.3390/antibiotics13080772
Chicago/Turabian StyleNaoum, Symeon, Christos Koutserimpas, Ioannis Pantekidis, Vasileios Giovanoulis, Enejd Veizi, Maria Piagkou, Petros Ioannou, George Samonis, Aglaia Domouchtsidou, Andreas G. Tsantes, and et al. 2024. "Antimicrobial Regimens in Cement Spacers for Periprosthetic Joint Infections: A Critical Review" Antibiotics 13, no. 8: 772. https://doi.org/10.3390/antibiotics13080772