Recommendations for Systemic Antimicrobial Therapy in Fracture-Related Infection: A Consensus From an International Expert Group

Antibiotic Summary:

The main points of the article are as follows:

1. Biofilm development on implant surfaces is a major obstacle to eradicating infections. Biofilms make bacteria more resistant to antibiotics, and the effectiveness of antibiotics decreases with the age of the biofilm.
2. Surgical debridement to reduce bacterial load and the use of local antimicrobials are important in the treatment of FRI.
3. Two main surgical treatment concepts are used: Debridement, Antimicrobial therapy, and Implant Retention (DAIR), and debridement with implant removal or exchange.
4. The duration of antimicrobial treatment depends on the specific treatment strategy. In cases where the implant is removed after fracture consolidation, 4-6 weeks of intravenous (IV) antibiotics followed by oral antibiotics for a total of 6 weeks is recommended.
5. In cases where the implant is retained, a 12-week treatment duration with biofilm-active antibiotics is recommended if possible. If biofilm-active antibiotics cannot be used, suppressive therapy may be necessary until the fracture is consolidated enough to remove the implant.

6. If a two-stage exchange is performed, an initial duration of 6weeks of biofilm-active therapy is recommended. The optimal continuation therapy after the first 6 weeks is unclear, with two approaches being immediate reimplantation followed by further biofilm-active treatment or a 2-week antibiotic-free interval before reimplantation. If no there are no clinical signs of infection at time of reimplantation and tissue cultures from reimplantation stay negative, the antibiotics that were restarted

   after implantation can be stopped

7. Empirical antibiotic therapy should not be started until initial surgical debridement, unless the patient is septic. Empiric therapy should be broad-spectrum initially and adjusted based on culture results.
8. For Staphylococcus species, a combination of rifampicin and another active antibiotic is recommended after the initial IV period. Rifampicin is effective against growing and nongrowing staphylococci in biofilms, but monotherapy should be avoided to prevent resistance.

These recommendations are based on expert consensus and the available literature since controlled trials specifically for FRI management are limited. Individualized treatment plans and further research are encouraged to improve the understanding and treatment of FRI.