We set out to evaluate the clinical efficacy of individual
antibiotic agents for bone and joint
infections in adults. Published and unpublished controlled trials reported between 1966 and 2000 were reviewed to determine if they involved random or quasi-random allocation to systemically administered antimicrobials or local
antibiotic therapy for
osteomyelitis and
septic arthritis. Quiescence of
infection after 1 year of follow-up was defined as the primary outcome measure. 22 trials containing 927 patients were eligible for final analysis. Varying proportions of the entire study population could be evaluated with respect to primary and secondary endpoints. Methodological quality was poor among most studies, and interpretability of results was further limited by small sample sizes, missing descriptions of patient populations and disease characteristics, and the frequent application of concomitant
antibiotics. A trend towards improved, long-lasting infection control was observed in favour of a
rifampicin-
ciprofloxacin combination versus
ciprofloxacin monotherapy for the treatment of
staphylococcal infections related to orthopaedic devices (absolute risk difference [ARD] 28-9%; 95% CI -0.7 to 54.4%). Obviously unbalanced comparative studies showed some benefit of
ticarcillin for bone
infections caused by Pseudomonas species. No significant differences in therapeutic efficacy were found among trials comparing oral
fluoroquinolones with intravenous
beta-lactam drugs for both end-of-treatment (OR 0.8; 0.5 to 1.4) and long-term results (OR 1.3; 0.8 to 2.1). A variety of drugs was used as controls, thereby leading to inconsistent findings of
drug-related side effects. Only one randomised trial was suitable to investigate the impact of
polymethylmethacrylate gentamicin bead chains compared with parenteral
antibiotics for skeletal
infections, although this study was biased by patients receiving both combined local and systemic
antibiotic therapy. Whereas intention-to-treat evaluation suggested a therapeutic advantage of systemic over local
therapy, this trend diminished in the per-protocol analysis (1-year follow-up ARD -2.3;-17.5 to 10.8%). There exists little high-quality evidence on
antibiotic therapy for
osteomyelitis and
septic arthritis. The observed heterogeneity among patient populations and medical and surgical treatment concepts preclude reliable inferences from the available data.