1. Cure in the first attempt is essential for B&J infections. Each episode of treatment failure leads to significant tissue damage and loss of functional integrity.
2. The cure is defined as long-term, pain free functional joint/limb with complete eradication of infection. This requires a combination of an appropriate surgical procedure and long-term directed antimicrobials. (Although this is an antimicrobial guideline, we have included and emphasized on appropriate surgical debridement with removal of implants if possible, as this is an integral part of the successful management of B&J infections).
3. The most important consideration in the management of bone & joint infections is the presence of biofilm associated with implants and prosthesis. The implications of biofilm formation are:
   • Antibiotic penetration into biofilm is poor
   • Antibiotics that penetrate may not act on biofilm organisms (non-replicating, stationary phase)
   • Biofilm organisms are protected from immune processes like phagocytosis
   • Biofilm organisms can acquire resistance patterns from one another

Hence, the antimicrobial regimen used to treat B&J infections should have the following properties:

• Bactericidal drugs are preferred for deep seated infections e.g. osteomyelitis
• Agents with good bone penetration
• Drugs with biofilm activity (penetration into biofilm, action against biofilm organisms)
• Least toxic and most affordable regimen should be used in view of prolonged duration of treatment

The use of local antibiotic cement spacer/antibiotic impregnated beads is a useful adjunctive treatment option along with systemic antibiotics, especially in drug resistant, difficult to treat B&J infections. It provides high concentrations of the drug locally which elute over a period of days-weeks, without increasing systemic toxicity.