For decades, prolonged courses of systemic antibiotics have been standard practice after surgery for orthopaedic infections—osteomyelitis, prosthetic joint infection, fracture-related infection, and yes, even diabetic foot infections. The reasoning was simple: biofilm is hard to reach, and more antibiotics must be better than less.
But what if, with the right local antibiotic strategy, less really is more?
The Study
The Short or Long Antibiotic Regimes in Orthopaedics (SOLARIO) trial—led by Maria Dudareva, Martin McNally, Matthew Scarborough, and colleagues at Oxford’s Nuffield Orthopaedic Centre—set out to answer that question.
This multicentre, open-label, non-inferiority RCT randomized 500 adults with orthopaedic infections to one of two arms:
- Short-course: ≤ 7 days of systemic antibiotics
- Long-course: ≥ 4 weeks of systemic antibiotics
All participants received local antibiotic therapy via a bioabsorbable carrier placed at the time of surgery.
The primary endpoint was definite treatment failure within 12 months, adjudicated by an independent blinded committee. A 10 % non-inferiority margin was used—tight, but clinically meaningful.
The Findings
The SOLARIO team announced last year that the short-course arm was non-inferior to the standard 4-week course, provided that local antibiotic therapy was used.
In other words, patients who stopped systemic antibiotics after a week did just as well as those who continued for a month or more—and they experienced fewer adverse events.
Press releases from BONESUPPORT (the manufacturer of CERAMENT G/V, one of the local carriers used in the trial) summarized the key findings:
- Median systemic antibiotic duration: 5 days vs 37 days
- Infection recurrence: No significant difference
- Adverse events: 82.8 % of short-course patients were event-free at 6 weeks (vs 54.1 % in the standard-course arm); severe AEs were markedly lower in the short group
The full dataset and peer-reviewed publication are expected soon.
Why the Type of Cement Matters
As Dr. Meghan Brennan, Associate Professor of Infectious Diseases at the University of Wisconsin and this year’s ALPS Travelling Fellow, has emphasized, the type of carrier cement matters.
The thermal characteristics of the material and its antibiotic-release profile can profoundly influence clinical outcomes. In particular:
- Exothermic polymerizing cements (like PMMA) may partially inactivate heat-sensitive antibiotics during curing.
- Bioabsorbable ceramic composites (such as calcium sulfate/hydroxyapatite systems) avoid this problem and can sustain therapeutic antibiotic concentrations for over a week.
Choosing a carrier that releases antibiotics predictably and for a clinically relevant duration is therefore critical—an essential nuance when translating SOLARIO’s findings into practice.
Enthusiasm on the Ground
Dr. Brennan recently visited Oxford and reported palpable enthusiasm among the clinicians involved in SOLARIO.
She described the atmosphere as one of quiet confidence—that this trial could mark a major shift in how we approach the balance between local and systemic therapy. For infectious disease specialists, surgeons, and wound physicians alike, it represents a convergence of antimicrobial stewardship, precision surgery, and patient-centered care.
Looking Ahead
SOLARIO underscores a broader truth: innovation in infection management often lies not in new drugs, but in how we combine surgical technique with pharmacology.
The Oxford team deserves enormous credit for conducting a rigorous, pragmatic trial that challenges dogma and aligns with modern stewardship principles.
As the full results emerge, SOLARIO may well help redefine standards of care—not only in orthopaedic infection, but across the entire spectrum of limb preservation.
Citation:
Dudareva M, Kümin M, Vach W, Kaier K, Ferguson J, McNally M, Scarborough M.
“Short or Long Antibiotic Regimes in Orthopaedics (SOLARIO): a randomised controlled open-label non-inferiority trial of duration of systemic antibiotics in adults with orthopaedic infection treated operatively with local antibiotic therapy.”
Trials. 2019; 20:693. DOI: 10.1186/s13063-019-3832-3
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