Drug treatments for prosthetic joint infections in the era of multidrug resistance

ABSTRACT

Introduction: Despite many advances, the management of prosthetic joint infection is still a complex issue. Moreover, in recent years the problem of antimicrobial resistance has emerged as an important challenge.

Areas covered: We analysed recent advances in different aspects of prosthetic joint infections. The importance of biofilms needs to be considered for antibiotic selection because, when embedded in these structures, bacteria acquire resistant behaviour. Moreover, the presence of resistance mechanisms in some species of organisms increases the difficulty of management. In this sense, the growing importance of methicillin-resistant staphylococci, multidrug-resistant Enterobacteriaceae or Pseudomonas aeruginosa is of increasing concern. Together with these organisms, others with constitutive resistance against most antibiotics (like Enterococcus sp., mycobacteria or fungi) represent a similar problem for selection of therapy. Research into new materials that can be used as drug carriers opens a new field for management of these infections and will likely come to the front line in the coming years.

Expert opinion: Individualised therapies should carefully consider the aetiology, pathogenesis and antimicrobial susceptibility. Satisfactory clinical outcome could be further fostered by enhancing the multidisciplinary approach, with better collaboration in the antibiotic selection and the surgical management.

KEYWORDS:

• Prosthetic joint infection
• treatment
• resistance
• multidrug-resistance
• biomaterial
• methicillin-resistant
• carbapenemase

Article highlights

• The management of prosthetic joint infections is a complex process that must involve many different specialists, especially if a multidrug-resistant organism appears as the cause of the infection.

• The importance of the etiological diagnosis of the infection is increasing because the frequent isolation of microorganisms’ resistant to different antibiotics.

• The selection of proper antimicrobial therapy must take into consideration several issues (bone concentration, phenotypic resistance of the microorganism, bioavailability, experimental models, clinical experience, and many others).

• Surgery has a key role in the management of these patients and has important implications in antibiotic selection.

• The presence of a biofilm is the pivotal process in the pathogenesis of the infection, and is also of extreme importance regarding the selection of the optimal treatment of the patients.

• Future research is aimed mainly to the development of antibiofilm agents, new biomaterials or modifications of those currently used, and better antibiotic management for each patient and organism.

This box summarizes key points contained in the article.

Acknowledgments

The authors would like to acknowledge Mr. Oliver Shaw for his help with the English language.

Declaration of interest

This work and some of the cited research have been funded by a grant from the Spanish MINECO [MAT2013-48224-C2-2-R]. J Esteban has received travel grants from Pfizer, Novartis, bioMérieux, and LETI, he has been also a member of an advisory panel for Pfizer. C Perez-Jorge, has received travel grants from Pfizer, Novartis and bioMérieux. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.