Efficacy of Antibiotic-Loaded Stimulan Beads Against Biofilms on Clinically Relevant Orthopedic Implant Surfaces

Background: Bacterial biofilms play a key role in causing periprosthetic joint infection (PJI). Current PJI management strategies commonly combine systemic antibiotic therapy with localized delivery such as antibiotic-loaded cement or beads to achieve effective tissue penetration and high antimicrobial concentrations at the implant site. We hypothesized that antibiotic-loaded calcium sulfate beads would effectively eradicate early Staphylococcus aureus biofilms but exhibit reduced efficacy against mature biofilms formed in synovial fluid (SF). This study evaluated the efficacy of vancomycin combined with gentamicin (V+G) or tobramycin (V+T) against GFP-expressing S. aureus biofilms grown in the presence of SF. Methods: Biofilms were established on clinically relevant orthopedic implant materials such as titanium (Ti), stainless steel (316L), and polyethylene (PE). Early (1-day) and mature (3-day) biofilms were treated with calcium sulfate beads loaded with V+G or V+T. Antimicrobial efficacy was quantified by colony-forming unit (CFU) enumeration. Minimum inhibitory concentration (MIC) testing was performed on surviving populations to assess potential development of antibiotic resistance. Results: Both antibiotic combinations resulted in no detectable viable bacteria in the 1-day biofilm across all tested materials following treatment, demonstrating strong reduction in early biofilm burden below the detection limit. Treatment of mature biofilms resulted in a 4–5 log reduction. MIC analysis of representative bacteria surviving post-treatment indicated no substantial increase in resistance. Conclusions: These findings show that while locally delivered antibiotic combinations eliminate early biofilms, mature biofilms demonstrate significant tolerance. MIC analysis showed little or no change in vancomycin, gentamicin, and tobramycin susceptibility after treatment, indicating no evident increase in planktonic antibiotic resistance among the surviving isolates. Together, these results highlight the importance of early intervention and the need for strategies that disrupt biofilm structure or improve antibiotic penetration to enhance PJI treatment outcomes.