Recommendations for antibiotics in patients with joint prosthesis are irresponsible and indefensible.

N ew quality and safety agendas have emerged in health care at the beginning of the 21st century. Although the goals of these agendas are lofty and broad, they include providing safe, cost-effective care, eliminating waste and providing treatments that prolong and improve quality of life. Our job, as stewards of antimicrobials, is closely intertwined with these agendas. Antibiotics are life saving and cost effective in a variety of settings, but are often wasted, used for non-infectious diseases or given to patients for an ill-defined benefit without due consideration of risks. Thus, we are keenly interested in guidelines and statements on the use of antibiotics and the clinical evidence on which they are based. The American Academy of Orthopaedic Surgeons (AAOS) recently issued an " information statement " on antibiotic prophylaxis for patients with joint prostheses, which was prepared by its Guidelines and Technology Oversight Committee. 1 Bacteremia-induced prosthetic joint infections are extremely rare events (if they occur at all), and it is, therefore, implausible that any intervention to reduce bacteremia will be shown to be effective (let alone cost effective or safe). In this article, we point out why the AAOS statement is both irresponsible and indefensible, that it was developed in direct contravention of the AAOS's own guiding principles and how it will do little to help the individual patient. Resistance BLOCKINto BLOCKINAntibiotics The health care community is currently experiencing an unprecedented threat from antimicrobial-resistant organisms for which treatment options are limited. In the 1990s, we were introduced to health care-acquired methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant Enterococcus and drug-resistant Pseudomonas aeruginosa in hospitals and a global threat of penicillin-resistant Streptococcus pneumoniae. We are now seeing additional drug-resistant organisms circulating outside health care institutions , such as community-acquired MRSA (a dramatically virulent organism), coliforms producing extended-spectrum ß-lactamases (enzymes that render them resistant to all penicillins and cephalosporins) and a new aggressive strain of Clostridium difficile. In light of this threat coupled with a drying antibiotic pipeline, infectious disease experts have started a new campaign— " bad bugs, no drugs " —in this war against disease-causing antibiotic-resistant bacteria. 2 Resistance develops as an evolutionary response to the presence of antibiotics. Dar-winian principles argue (and epidemiologic evidence has repeatedly shown) that increasing use of antibiotics is associated with the emergence and spread of antimicrobial-resistant organisms in the environment and in patients. The selection pressure of an additional million patients (the annual …