Principles of systemic antimicrobial therapy in foreign material associated infection in bone tissue, with special focus on periprosthetic infection.

Foreign material associated infection in bone tissue is mostly characterized by the features of sessile pathogens acting from the foreign material surface. These bacteria protected by biofilm attached to the surface are highly resistant for antimicrobial agents and host's own defense as well. Therapy is based on surgical revision, with removal of the foreign material and supplementary antimicrobial therapy. Empirical antimicrobial therapy cannot be recommended unless life threatening septicemia occurs. Infected bone tissue is lower compartment with respect to antimicrobial chemotherapy. Therefore, antibiotics must be administered in high dosage for an extended period of time. It is almost impossible to eradicate these pathogens by antibiotics alone even though the clinical symptoms may be influenced. The options of antimicrobial therapy are: 1. Antibiotics alone: Only suppression of clinical symptoms. 2. Amputation or resection arthroplasty in combination with antibiotics: The results are fair but poor in function. 3. Surgical revision with retention of the foreign material and long-term antibiotic therapy including rifampicin: This procedure is possible in early, not yet established foreign material infections. 4. Treatment of the periprosthetic infection: Surgical revision with exchange of the prosthesis combined with systemic (and optional local) therapy, regardless whether the revision is performed in 1 - or multiple-stages. Treatment of these infections should be carried out in specialized centers in cooperation with an experienced infectious disease specialist. Since most available data are empirical, further prospective studies are needed for evaluation of these therapeutic concepts.