Systemic and local antimicrobial strategies to prevent Periprosthetic joint infection

Periprosthetic joint infection (PJI) is a severe complication of total joint arthroplasty and necessitates comprehensive strategies for prevention. One of the key features in infection prevention is the optimal selection of antimicrobial strategies. This review evaluates systemic and local antimicrobial approaches to PJI prevention, including systemic antibiotic prophylaxis, nasal and skin decolonization of Staphylococcus aureus, local antimicrobial delivery into the joint space, and antimicrobial modification of the implant surface. We conducted a literature search of the MEDLINE, Web of Science, Cochrane and ClinicalTrials.gov databases for recent evidence from randomized and observational studies, as well as current orthopedic guidelines concerning these topics. Further reductions in the incidence of PJI through antimicrobial strategies will require: (1) the adoption of alternative trial designs such as registry-nested and adaptive platform trials to study outcomes with low event rates; (2) improved adherence to established best practices, particularly in systemic antibiotic prophylaxis; (3) precision prevention informed by validated risk stratification tools; and (4) novel interventions targeting emerging biological mechanisms such as the gut microbiome.