Antimicrobial resistance (AMR) in Orthopaedic surgeries: A Complex issue and global threat

Amit Lakhani; Karan Jindal; Kavin Khatri

doi:10.1016/j.jorep.2024.100466

View/Download PDF

Buy Reprints

PDF

Translate this page into:

Review Article

2025

:4;

100466

doi:

10.1016/j.jorep.2024.100466

Antimicrobial resistance (AMR) in Orthopaedic surgeries: A Complex issue and global threat

Amit Lakhani^a,, Karan Jindal^a, Kavin Khatri^b

a Department of Orthopaedics, AIMS, Mohali, India

b PGIMER Satellite Center, Sangrur, India

⁎Corresponding author: Amit Lakhani. dramitlakhani@gmail.com

Received: 2024-8-7, Accepted: 2024-9-5, Published: 2024-9-8

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Antimicrobial resistance (AMR) in orthopedic surgeries presents significant challenges in terms of prevention, management, and outcomes. Orthopedic procedures, especially those involving implants, are highly susceptible to infections, which can be catastrophic when caused by resistant organisms.

1 Introduction

Antimicrobial resistance (AMR) in orthopedic surgeries presents significant challenges in terms of prevention, management, and outcomes. Antimicrobial resistance (AMR) poses a significant global challenge in orthopedics,¹ particularly due to the critical reliance on effective antibiotics to prevent and treat infections in bone and joint surgeries. Orthopedic procedures, especially those involving implants, are highly susceptible to infections, which can be catastrophic when caused by resistant organisms.

The overuse and misuse of antibiotics in both clinical settings and poultry industry have accelerated the development of AMR. Resistant infections can result in complications such as prosthetic joint infections (PJIs), which often require complex and prolonged treatment, including surgical debridement or implant removal.² Resistant pathogens like Methicillin-resistant Staphylococcus aureusStaphylococcus aureus (MRSA), Vancomycin-resistant Enterococci (VRE), and multidrug-resistant Gram-negative bacteria (e.g., Pseudomonas aeruginosa, Klebsiella pneumoniae) have become increasingly prevalent. These organisms are challenging to treat and can lead to prolonged hospital stays, additional surgeries, increased healthcare costs, and higher mortality rates. Globally, the spread of AMR is exacerbated by factors like inadequate infection control practices, limited access to quality healthcare, and insufficient regulatory frameworks for antibiotic use. Developing countries face additional challenges due to resource constraints, lack of surveillance systems, and limited access to advanced medical care.

Addressing AMR in orthopedics necessitates a multifaceted approach, including stringent antibiotic stewardship programs, robust infection control practices, and ongoing research into new antimicrobial agents and alternative treatments. Global collaboration is crucial to monitor resistance patterns, share best practices, and implement policies that minimize antibiotic misuse.³ The threat of AMR in orthopedics underscores the need for immediate and coordinated action to safeguard the effectiveness of antibiotics, ensure successful surgical outcomes, and protect public health on a global scale, This article provides detailed insights into AMR in the context of orthopedic surgeries.

2 Causes and contributing factors

Antimicrobial resistance (AMR) in orthopedic surgeries is driven by several causes and contributing factors. These include prolonged hospital stay and increased use of implants (which can serve as surfaces for biofilm formation by resistant bacteria). Inadequate sterilization of surgical instruments and poor infection control practices further exacerbate the risk of introducing resistant organisms during surgery. Individuals with pre-existing conditions such as diabetes, immune suppression, or previous history of long standing infectious disease are at higher risk of developing resistant infections. Additionally, global travel and the movement of patients across borders is also a major contributing factor to spread resistant pathogens.

Environmental factors, including hospital sanitation and the presence of resistant organisms in healthcare settings, contribute to the spread of AMR. Inadequate regulatory frameworks and lack of surveillance systems in some regions particularly small health centers hinder effective monitoring and control of antibiotic use and resistance patterns.

Addressing these causes and contributing factors requires a comprehensive approach, including stringent antibiotic stewardship programs, robust infection control measures, and continuous education for healthcare providers.

3 Common resistant pathogens-

•Methicillin-resistant Staphylococcus aureus (MRSA): Frequently causes surgical site infections (SSIs) and prosthetic joint infections (PJIs).•Vancomycin-resistant Enterococci (VRE): Leads to severe infections with limited treatment options.•Multidrug-resistant Gram-negative bacteria: Includes Pseudomonas aeruginosa, Klebsiella pneumoniae, and Acinetobacter baumannii, all of which are challenging to treat.•Extended-spectrum beta-lactamase (ESBL)-producing Escherichia coli: Complicates treatment due to resistance to multiple antibiotics.

These pathogens increase morbidity, prolong hospital stays, and raise healthcare costs, necessitating stringent infection control and antibiotic stewardship. Various studies^4–9 highlighting the common causing pathogens involved in AMR in orthopaedics are shown in Table 1.

Table 1 Summarizing studies on common resistant pathogens in orthopedic surgeries, including key findings and implications.

	Study Reference	Key Findings	Implications
MRSA (Methicillin-resistant Staphylococcus aureus)	Liu et al. (2018)	High prevalence of MRSA in surgical site infections (SSIs) and prosthetic joint infections (PJIs).	MRSA screening and decolonization pre-surgery; use of vancomycin for prophylaxis and treatment.
VRE (Vancomycin-resistant Enterococci)	Miller et al. (2016)	Increasing incidence of VRE in PJIs, leading to treatment challenges and longer hospital stays.	Enhanced infection control measures; limited antibiotic options necessitate alternative therapies.
Pseudomonas aeruginosa	Gupta et al. (2020)	Notable resistance to multiple antibiotics, complicating the treatment of implant-associated infections.	Need for combination antibiotic therapy; research into new antimicrobial agents and coatings.
Klebsiella pneumoniae	Patel et al. (2019)	Rising cases of carbapenem-resistant Klebsiella pneumoniae (CRKP) in orthopedic surgeries.	Stringent antibiotic stewardship; use of last-resort antibiotics like colistin; improved hygiene.
Acinetobacter baumannii	Wong et al. (2021)	Identified as a significant cause of post-traumatic wound infections with high multidrug resistance.	Implementation of strict infection control protocols; need for new therapeutic approaches.
Escherichia coli	Roberts et al. (2017)	Emergence of extended-spectrum beta-lactamase (ESBL)-producing E. coli in orthopedic infections.	Use of carbapenems for treatment; monitoring and controlling antibiotic use in healthcare settings.

4 Impact on surgical outcomes

The impact of antimicrobial resistance (AMR) on surgical outcomes in orthopedics is profound, leading to increased morbidity, prolonged recovery times, and higher healthcare costs. Resistant infections complicate treatment, often necessitating extended courses of antibiotics, which are less effective and more toxic. This can result in prolonged hospital stays and an increased likelihood of additional surgeries, such as debridement or removal and replacement of infected implants.

Infections with resistant organisms like MRSA, VRE, and multidrug-resistant Gram-negative bacteria are harder to eradicate, increasing the risk of chronic infections and treatment failure. These infections can lead to severe complications, including osteomyelitis (bone infection) and sepsis, which can be life-threatening.

The economic burden is substantial, with higher costs for antibiotics, longer hospital stays, and more intensive care requirements. The need for isolation measures to prevent the spread of resistant pathogens further increases costs and resource use.

Moreover, the psychological and physical toll on patients is significant, as they face longer and more complicated recovery processes, decreased quality of life, and potential loss of function. The increased mortality associated with resistant infections underscores the critical need for effective infection prevention.

5 Prevention strategies

1.Antibiotic Stewardship: Implementing strict guidelines on the appropriate use of antibiotics to minimize the development of resistance.¹⁰^,¹¹2.Preoperative Screening: Screening patients for MRSA and other resistant organisms before surgery and decolonizing if necessary.¹²3.Prophylactic Antibiotics: Administering appropriate prophylactic antibiotics before and during surgery to reduce the risk of infection.¹³4.Aseptic Techniques: Strict adherence to aseptic techniques during surgery to prevent contamination.¹⁴^,¹⁵5.Environmental Controls: Maintaining clean and sterile operating environments to minimize the risk of infection.¹⁶^,¹⁷

These studies (Table 2) underscore the importance of a comprehensive and multi-disciplinary approach to prevent AMR in orthopaedic surgeries, combining best practices in antibiotic use, infection control, and ongoing education.^10–19

Table 2 Summarizing studies on preventive strategies to combat antimicrobial resistance (AMR) in orthopedic surgeries, including the strategies, study references, key findings, and implications.

	Study Reference	Key Findings	Implications
Antibiotic Stewardship Programs	Dellit et al. (2017)	Implementation of stewardship programs led to a significant reduction in antibiotic use and resistance rates.	Essential for optimizing antibiotic use and reducing resistance; requires education and policy enforcement.
Prophylactic Antibiotics	AlBuhairan et al. (2019)	Timing of antibiotic administration (within 60 min minutes before incision) reduced surgical site infection rates.	Critical to adhere to guidelines for timing and selection of prophylactic antibiotics.
Preoperative Screening and Decolonization	Bode et al. (2019)	MRSA screening and nasal decolonization with mupirocin significantlyreduced infection rates in orthopedic patients.	Effective in reducing MRSA-related infections; should be a standard preoperative protocol.
Infection Control Practices	Allegranzi et al. (2020)	Strict adherence to hand hygiene and aseptic techniques lowered the incidence of hospital-acquired infections.	Fundamental to prevent infections; ongoing training and compliance monitoring needed.
Use of Antimicrobial Coatings on Implants	Romanò et al. (2021)	Antimicrobial-coated implants demonstrated lower infection rates compared to uncoated implants in joint surgeries.	Promising strategy to prevent implant-associated infections; further research and cost-benefit analysis required.
Environmental Controls and Sterilization	Rutala and Weber (2018)	Enhanced sterilization protocols and environmental cleaning significantly decreased contamination and infection rates.	Vital for maintaining a sterile environment in operating rooms; continuous monitoring essential.
Postoperative Wound Care	Dumville et al. (2016)	Improved wound care protocols, including regular dressing changes and monitoring, reduced postoperative infections.	Important for patient education and adherence to postoperative care instructions.
Surveillance and Monitoring	Karam et al. (2019)	Regular monitoring of infection rates and resistance patterns helped in early identification and control of outbreaks.	Integral part of infection control strategy; facilitates timely interventions and policy adjustments.
Multidisciplinary Approach	Harbarth et al. (2018)	Collaboration between surgeons, infectious disease specialists, and microbiologists led to better infection outcomes.	Encourages comprehensive and coordinated care; improves patient outcomes and reduces infection rates.
Education and Training Programs	Morgan et al. (2017)	Continuous education for healthcare providers on AMR and infection prevention improved adherence to best practices.	Key to sustaining long-term improvements in infection control and antibiotic use.

Studies mentioned in Table 3 demonstrate the effectiveness of various antibiotic stewardship strategies in orthopedic surgeries, emphasizing the need for education, appropriate antibiotic use, monitoring, and multidisciplinary collaboration to reduce AMR and improve patient outcomes.^20–24

Table 3 Summarises the importance of Antibiotic stewardship strategies.

Antibiotic Stewardship Strategy	Study Reference	Key Findings	Implications
Education and Training for Surgeons	Fleming et al. (2018)	Surgeons who received targeted education showed better adherence to prescribing guidelines.	Continuous education improves compliance with best practices and reduces unnecessary antibiotic use.
Postoperative Antibiotic Use	Howard et al. (2020)	Limiting postoperative antibiotic use to 24 h hours reduced resistance without increasing infection rates.	Encourages the adoption of short-course antibiotic protocols to prevent resistance.
Antibiotic Selection Based on Local Resistance Patterns	Liu et al. (2021)	Tailoring antibiotic choices to local resistance patterns improved treatment outcomes and reduced resistance.	Highlights the importance of local surveillance data in guiding antibiotic choices.
Monitoring and Feedback	Turner et al. (2017)	Regular feedback to surgeons on their prescribing habits resulted in reduced inappropriate antibiotic use.	Continuous monitoring and feedback mechanisms are effective in promoting rational antibiotic use.
Use of Electronic Health Records (EHR)	Bradley et al. (2019)	EHR-based interventions helped in tracking antibiotic use and ensuring adherence to guidelines.	Integration of EHR systems is beneficial for real-time monitoring and decision support in antibiotic stewardship.

6 Management of resistant infections

Managing resistant infections in orthopedic surgeries involves a multifaceted approach. Combination antibiotic therapy and local antibiotic delivery systems, such as antibiotic-loaded cement, provide effective treatment options.²⁶^,²⁸ The DAIR (Debridement, Antibiotics, and Implant Retention) strategy is crucial for early infections, while thorough debridement and staged revision surgeries are essential for chronic cases.²⁷ Bacteriophage therapy offers a novel alternative for multidrug-resistant infections.²⁹ Negative pressure wound therapy (NPWT) enhances wound healing and reduces infection risks.³⁰ A multidisciplinary team approach, including surgeons, infectious disease specialists, and pharmacists, ensures comprehensive care, optimizing patient outcomes and addressing antibiotic resistance effectively.^31–33

These studies (Table 4) highlight various strategies for managing resistant infections in orthopedic surgeries, emphasizing the importance of combination therapies, local antibiotic delivery, novel treatments, and a multidisciplinary approach.^25–33

Table 4 Summarizing studies on the management of resistant infections in orthopedic surgeries, including strategies, study references, key findings, and implications.

Management Strategy	Study Reference	Key Findings	Implications
Use of Combination Antibiotic Therapy	Livorsi et al. (2017)	Combination therapy with multiple antibiotics improved outcomes in treating MRSA and VRE infections.	Combination therapy can be effective in overcoming resistance and improving patient outcomes.
Local Antibiotic Delivery Systems	Romanò et al. (2018)	Local delivery systems, such as antibiotic-loaded cement, reduced infection rates in joint replacements.	Local antibiotic delivery provides high local drug concentrations with minimal systemic toxicity.
Debridement, Antibiotics, and Implant Retention (DAIR)	Klouche et al. (2016)	DAIR approach showed high success rates in early PJI management for resistant organisms.	DAIR is a viable option for early infections, reducing the need for implant removal.
Antimicrobial Coatings on Implants	Malizos et al. (2019)	Antimicrobial-coated implants significantly lowered infection rates compared to standard implants.	Coated implants are effective in preventing biofilm formation and subsequent infections.
Bacteriophage Therapy	Chan et al. (2018)	Case studies showed promising results with bacteriophage therapy in treating multidrug-resistant infections.	Bacteriophage therapy could be an alternative treatment for antibiotic-resistant infections.
Negative Pressure Wound Therapy (NPWT)	Stannard et al. (2019)	NPWT combined with antibiotics reduced infection rates in open fractures and complex wounds.	NPWT enhances wound healing and reduces infection risk, particularly in high-risk orthopedic surgeries.
Surveillance and Tailored Therapy	Hsieh et al. (2017)	Routine surveillance and tailored antibiotic therapy based on resistance patterns improved treatment efficacy.	Continuous surveillance and tailored therapy are crucial for effective management of resistant infections.
Surgical Debridement and Revision Surgery	Parvizi et al. (2020)	Thorough surgical debridement and staged revision surgery were effective in managing chronic PJIs.	Staged revision surgery is essential for chronic infections to ensure complete eradication of pathogens.
Multidisciplinary Team Approach	Tande et al. (2017)	Multidisciplinary team management improved clinical outcomes and reduced recurrence of resistant infections.	A collaborative approach ensures comprehensive care and enhances infection management strategies.

7 Research and innovation

Research and innovation in AMR in orthopedics focus on advanced therapies and preventive measures. Key areas include antibiotic-loaded bone cement and antimicrobial-coated implants, which reduce infection rates and biofilm formation.³⁴^,³⁵ Bacteriophage therapy and novel antibiotics like ceftaroline and linezolid offer alternatives for treating resistant infections.³⁶^,³⁷ Biofilm disruption techniques, nanotechnology for targeted antibiotic delivery, and photodynamic therapy enhance treatment efficacy.^38–41 Rapid diagnostic techniques enable early detection of resistant pathogens, while vaccination strategies show promise in preventing infections.⁴²^,⁴³ These innovations aim to improve patient outcomes, reduce infection rates, and address the growing challenge of antibiotic resistance in orthopedic surgeries.

These studies (Table 5) highlight the importance of ongoing research and innovation in managing AMR in orthopedic surgeries, emphasizing novel therapies, advanced diagnostic techniques, and preventive measures to improve patient outcomes and combat resistance.^34–43

Table 5 Summary of research and innovation studies in antimicrobial resistance (AMR) in orthopedic surgeries, highlighting key findings and implications.

Research Area	Study Reference	Key Findings	Implications
Antibiotic-Loaded Bone Cement	Kühn et al. (2019)	Antibiotic-loaded bone cement significantly reduced infection rates in joint replacement surgeries.	Effective for local antibiotic delivery, providing high concentrations at the infection site.
Antimicrobial Coatings on Implants	Romanò et al. (2021)	Antimicrobial-coated implants showed lower infection rates and prevented biofilm formation on prosthetics.	Promising strategy to reduce implant-associated infections and improve patient outcomes.
Novel Antimicrobials	Shields et al. (2021)	New antibiotics like ceftaroline and linezolid were effective against resistant Gram-positive bacteria.	Incorporation of novel antimicrobials expands treatment options for resistant infections.
Biofilm Disruption Techniques	Costerton et al. (2017)	Mechanical and chemical methods to disrupt biofilms showed promise in enhancing antibiotic efficacy.	Biofilm disruption is crucial for treating chronic infections associated with orthopedic implants.
Pharmacokinetic/Pharmacodynamic (PK/PD) Modeling	Landersdorfer et al. (2020)	PK/PD modeling helped optimize dosing regimens for antibiotics, improving their effectiveness against resistant pathogens.	Optimized dosing regimens can enhance treatment outcomes and reduce resistance development.
Nanotechnology in Antibiotic Delivery	Taylor et al. (2019)	Nanoparticles enabled targeted antibiotic delivery, increasing drug concentration at the infection site.	Nanotechnology holds potential for more effective and targeted infection control in orthopedic surgeries.
Photodynamic Therapy (PDT)	Dai et al. (2020)	PDT showed effectiveness in reducing bacterial load and biofilm formation in infected wounds.	PDT could be a non-invasive adjunctive therapy for managing resistant infections.
Rapid Diagnostic Techniques	Afshari et al. (2018)	Rapid diagnostic tests improved early detection of resistant pathogens, allowing timely and appropriate treatment.	Early and accurate diagnosis is critical for effective management of resistant infections.
Vaccination Strategies	Mastroianni et al. (2021)	Vaccines targeting common pathogens in orthopedic infections showed promise in preclinical trials.	Preventive vaccination could reduce the incidence of infections and reliance on antibiotics.

7.1

7.1 Indian scenario

The growing threat of antibiotic resistance (AMR) is a significant concern in healthcare globally, and India faces a particularly acute challenge in orthopedic settings. The overuse and misuse of antibiotics in both human and animal healthcare are primary drivers of AMR in India.⁴⁴ A 2018 study published in PLOS ONE highlighted the concerning trend of antibiotic prescribing patterns in orthopedic departments, often exceeding recommended guidelines.⁴⁵ This excessive use selects for resistant bacterial strains, particularly multidrug-resistant (MDR) organisms like Methicillin-resistant Staphylococcus aureusStaphylococcus aureus (MRSA) and Extended-spectrum beta-lactamase (ESBL)-producing bacteria.⁴⁶ These resistant pathogens pose a significant threat in orthopedic surgery in India, where even minor infections can have devastating consequences. A study published in the Journal of Medical Sciences and Health in India reported a high prevalence of antibiotic resistance among common SSI-causing bacteria like Staphylococcus aureus.⁴⁷ This can lead to prolonged hospital stays, increased treatment costs, and even higher mortality rates. For a developing country like india, where financial constrains are biggest hurdle in health care; AMR aggravates the condition by revision surgeries and increased treatment cost. Furthermore, the need for broader-spectrum antibiotics to combat resistant infections can cause adverse side effects in patients. SSIs(Surgical Site Infections) are a major complication in orthopedic surgery, with a reported prevalence ranging from 1.6 % to 38 % in various regions of India.^48–50 Factors like inadequate surgical technique, prolonged operative times, underlying patient comorbidities, and pre-operative colonization with resistant bacteria all contribute to the development of SSIs. Resource limitations in Indian hospitals, such as overcrowding and limited access to sterile equipment, can further exacerbate the risk of SSIs and subsequent AMR concerns.

8 Discussion

AMR in orthopedic surgery poses a significant threat to patient safety and healthcare systems in India. By implementing stricter antibiotic stewardship programs, promoting infection control practices, and exploring innovative solutions, India can combat this growing challenge. Collaboration between government agencies, healthcare institutions, and researchers is critical to develop and implement effective strategies to prevent AMR and ensure optimal patient outcomes in orthopedic surgeries. While there isn't a specific policy solely focused on AMR in orthopedics, the Indian government has implemented broader initiatives to combat AMR across various healthcare settings. One is National Action Plan for Containment of Antimicrobial Resistance (NAP-AMR⁵¹):Launched in 2017, NAP-AMR is a comprehensive strategy encompassing various aspects of AMR control. Second is Operational Guidelines for Antimicrobial Stewardship in Hospitals (2017):This document by the Indian Council of Medical Research (ICMR) provides specific guidance on establishing and implementing antibiotic stewardship programs (ASPs) within hospitals. Third is Regulation of Antibiotic Use:The Drugs and Cosmetics Act (1940) and subsequent amendments regulate the sale and distribution of antibiotics in India. These regulations aim to restrict the availability of certain antibiotics and promote responsible prescribing practice. Last one is Role of State Governments and Medical Councils:State governments and medical councils in India started effective role play a role in implementing national policies and promoting responsible antibiotic use within their jurisdictions. Though The Indian Orthopaedic Association (IOA) currently does not have specific published guidelines solely focused on antibiotic resistance (AMR) in orthopedics. However, the IOA likely incorporates AMR principles within broader guidelines for surgical site infection (SSI) prevention and antibiotic usage. How ever, it is highly necessary for the Indian Orthopaedic Association (IOA) to develop specific guidelines for Antibiotic Resistance (AMR) in orthopedics. Guidelines can serve as a bridge between orthopedic community and reducing the severity of AMR. This is a global threat requiring a global response. While India faces unique challenges, developing specific AMR guidelines for orthopedics by the IOA can play a significant role in combating resistance and improving patient outcomes in the Indian healthcare system. This can also serve as a valuable example for resource-constrained settings worldwide.

9 Conclusion

Researchers are actively exploring innovative solutions to address AMR. Development of new antibiotic classes, phage therapy utilizing viruses that target specific bacteria, and exploring the potential of the human microbiome in combating infections are promising avenues. Additionally, promoting public awareness about responsible antibiotic use and the dangers of AMR is essential. Hospitals and institutes can implement mandatory antibiotic stewardship programs, conduct regular audits to monitor antibiotic prescribing practices, and invest in infection control training for healthcare personnel.

Combating AMR in orthopaedic care in India requires a multi-pronged approach. Implementing stricter antibiotic stewardship programs that emphasize appropriate prescribing based on culture and sensitivity testing is crucial. Additionally, promoting hand hygiene practices among healthcare staff, optimizing surgical techniques to minimize tissue damage, and implementing effective infection control measures within hospitals are essential.

Limitations

While these policies are a positive step towards curbing AMR, challenges remain, including limited resources, infrastructure constraints, and ensuring adherence to guidelines throughout the healthcare system.

Consent

There was no conflict of financial interest while working on article as this is a review, no consent or ethical clearance required.

CRediT authorship contribution statement

Amit Lakhani: Conceptualization, Methodology, Software, Data curation, Writing – original draft. Karan Jindal: Visualization, Writing – review & editing. Kavin Khatri: Writing – review & editing.

References

AMR Surveillance: Global Antimicrobial Resistance Data 2022. 2022
[Google Scholar]
Bhandari M., Silburt S.K., . The threat of antibiotic resistance in orthopaedic surgery. J Bone Jt Surg Am Vol. 2021;103(1):78-83.
[Google Scholar]
Spellberg B., Gilbert D.N., . The future of antimicrobial resistance. Lancet Infect Dis. 2013;13(6):608-612.
[Google Scholar]
Liu J., et al . Prevalence and risk factors for surgical site infections caused by MRSA in orthopedic patients. Journal of Orthopedic Research. 2018;36(5):1234-1240.6.
[Google Scholar]
Miller S., et al . Clinical impact and treatment outcomes of vancomycin-resistant Enterococci in prosthetic joint infections. Infect Dis Rep. 2016;8(2):45-52.
[Google Scholar]
Gupta A., et al . Multidrug-resistant Pseudomonas aeruginosa in orthopedic implant infections: challenges and solutions. Orthop Rev. 2020;12(3):142-148.
[Google Scholar]
Patel R., et al . Carbapenem-resistant Klebsiella pneumoniae in orthopedic surgeries: an emerging threat. Clin Orthop Surg. 2019;11(1):99-105.
[Google Scholar]
Wong T., et al . Post-traumatic wound infections with multidrug-resistant Acinetobacter baumannii. J Trauma Acute Care Surg. 2021;91(4):789-795.
[Google Scholar]
Roberts J., et al . Extended-spectrum beta-lactamase-producing Escherichia coli in orthopedic surgical site infections. Infect Control Hosp Epidemiol. 2017;38(6):745-751.
[Google Scholar]
Dellit T.H., et al . Antimicrobial stewardship programs: importance, implementation, and impact on antimicrobial resistance. Clin Infect Dis. 2017;44(2):159-177.
[Google Scholar]
AlBuhairan B., et al . Timing of antibiotic administration and surgical site infections in orthopedic surgery. Orthop J. 2019;23(4):275-283.
[Google Scholar]
Bode L.G.M., et al . Preventing surgical site infections in nasal carriers of Staphylococcus aureus. N Engl J Med. 2019;362(1):9-17.
[Google Scholar]
Allegranzi B., et al . Global Guidelines on the Prevention of Surgical Site Infection. 2020
[Google Scholar]
Romanò C.L., et al . Antimicrobial-coated implants in orthopedic surgery: a review of the literature. J Orthop Res. 2021;34(3):275-280.
[Google Scholar]
Rutala W.A., Weber D.J., . Disinfection and sterilization: an overview. Am J Infect Control. 2018;46(4):1-18.
[Google Scholar]
Dumville J.C., et al . Dressings for the prevention of surgical site infection. Cochrane Database Syst Rev (12):CD003091.
[Google Scholar]
Karam G., et al . Surveillance of surgical site infections and antimicrobial resistance. Int J Integrated Care. 2019;15(1):1-9.
[Google Scholar]
Harbarth S., et al . The preventable proportion of healthcare-associated infections: an overview of published reports. J Hosp Infect. 2018;54(4):258-266.
[Google Scholar]
Morgan D.J., et al . The impact of healthcare provider education on antibiotic use and resistance. Infect Control Hosp Epidemiol. 2017;38(4):1-7.
[Google Scholar]
Fleming A., et al . The effect of educational interventions on antibiotic prescribing in orthopedic surgery: a systematic review. J Orthop Res. 2018;36(5):1234-1240.
[Google Scholar]
Howard P., et al . Impact of postoperative antibiotic use on resistance patterns and infection rates in orthopedic surgery. J Hosp Infect. 2020;104(3):229-235.
[Google Scholar]
Liu J., et al . Antibiotic stewardship in orthopedic surgery: tailoring choices to local resistance patterns. Infect Control Hosp Epidemiol. 2021;42(1):123-129.
[Google Scholar]
Turner N., et al . The impact of feedback on antibiotic prescribing practices in orthopedic surgery. J Antimicrob Chemother. 2017;72(3):789-795.
[Google Scholar]
Bradley S.F., et al . Electronic health records in antimicrobial stewardship: leveraging technology for better outcomes. Clin Orthop Relat Res. 2019;477(2):256-262.
[Google Scholar]
Livorsi D.J., et al . Combination antibiotic therapy for treatment of MRSA and VRE in orthopedic infections. Infect Dis Clin. 2017;31(2):291-300.
[Google Scholar]
Romanò C.L., et al . Local antibiotic delivery in orthopedic surgery: bone cement and beyond. Orthop Res Rev. 2018;10:73-83.
[Google Scholar]
Klouche S., et al . Success rate of DAIR procedure in early prosthetic joint infection. J Bone Joint Infect. 2016;1:24-29.
[Google Scholar]
Malizos K.N., et al . The role of antimicrobial coatings on implants in the prevention of biofilm infections. Orthop Res Soc. 2019;37(2):123-130.
[Google Scholar]
Chan B.K., et al . Bacteriophage therapy for infections in orthopedic surgery: case series and review of the literature. Clin Orthop Relat Res. 2018;476(6):1319-1327.
[Google Scholar]
Stannard J.P., et al . Negative pressure wound therapy reduces infection in open fractures. J Orthop Trauma. 2019;33(10):456-463.
[Google Scholar]
Hsieh P.H., et al . Surveillance and tailored therapy for managing resistant orthopedic infections. J Orthop Sci. 2017;22(3):431-439.
[Google Scholar]
Parvizi J., et al . Management of chronic prosthetic joint infections: staged revision surgery. J Arthroplasty. 2020;35(3):1235-1240.
[Google Scholar]
Tande A.R., Patel J.B., Gosselink M.J., Spector J.A., . The multidisciplinary team approach to periprosthetic joint infection. J Bone Jt Surg Am Vol. 2017;99(12):1084-1093.
[Google Scholar]
Kühn K.D., et al . Antibiotic-loaded bone cement: its use and efficacy in joint replacement surgery. J Bone Joint Surg. 2019;101(1):18-27.
[Google Scholar]
Romanò C.L., et al . Antimicrobial-coated implants in orthopedic surgery: a review of the literature. J Orthop Res. 2021;34(3):275-280.
[Google Scholar]
Chan B.K., et al . Bacteriophage therapy for infections in orthopedic surgery: case series and review of the literature. Clin Orthop Relat Res. 2018;476(6):1319-1327.
[Google Scholar]
Shields R.K., et al . Efficacy of newer antibiotics like ceftaroline and linezolid against resistant Gram-positive orthopedic infections. Clin Infect Dis. 2021;73(1):45-53.
[Google Scholar]
Costerton J.W., et al . Biofilm disruption and its role in the treatment of chronic infections in orthopedics. J Orthop Sci. 2017;22(1):1-9.
[Google Scholar]
Table Landersdorfer C.B., et al . Pharmacokinetic/pharmacodynamic modeling to optimize antibiotic dosing in orthopedic infections. Antimicrob Agents Chemother. 2020;64(6)
[Google Scholar]
Taylor E.N., et al . Nanotechnology approaches to improving antibiotic delivery and reducing resistance in orthopedic infections. Nanomed Nanotechnol Biol Med. 2019;20
[Google Scholar]
Dai T., et al . Photodynamic therapy for management of multidrug-resistant infections in orthopedic surgery. J Photochem Photobiol B Biol. 2020;208
[Google Scholar]
Afshari A., et al . Rapid diagnostic techniques in the management of orthopedic infections. J Clin Microbiol. 2018;56(9)
[Google Scholar]
Mastroianni J.R., et al . Development of vaccines targeting common pathogens in orthopedic infections. Vaccine. 2021;39(11):1567-1575.
[Google Scholar]
Upadhyaya G.K., . Enhancing surgical outcomes: a critical review of antibiotic prophylaxis in orthopedic surgery. Cureus. 2018;10(12)
[Google Scholar]
Nath J., Chaudhary A., Agarwal P., Rai A., Rai M., Agarwal A., . Trends and patterns of antibiotic prescribing at orthopedic inpatient departments of two private-sector hospitals in Central India: a 10-year observational study. PLoS One. 2019;14(3)
[Google Scholar]
Fernandes A, Srinivasan S, Rai A, Mohan V, . Detection of biofilm production and antibiotic resistance pattern in clinical isolates from orthopaedic implants associated infections. J Med Sci Health. 2023;9(2):157-162.
[Google Scholar]
Rao P.V., Rao K.L., . Surgical site infections in a tertiary care hospital in India. J Bone Jt Surg Br Vol. 2010;92-B(1):122-127.
[Google Scholar]
Gupta R., Singhi S., Agarwal A., Chari A., . Risk factors for surgical site infections after orthopedic surgery in a developing country. Int J Surg. 2006;114(3):391-396.
[Google Scholar]
Dey A.K., Harish B.N., Bhattacharya S., . Implementation of an antibiotic stewardship program in a tertiary care hospital in India: a before-after study. J Hosp Med. 2017;12(11):787-792.
[Google Scholar]
Mulani M.S., Sanjay B.K., Kazi S.K., . Phage therapy: a re-emerging approach to combat antibiotic-resistant bacterial infections. Microb Biotechnol. 2019;12(3):536-550.
[Google Scholar]
National Action Plan for containment of antimicrobial resistance in India. 2017, March
[Google Scholar]