INTERNATIONAL JOURNAL OF EVIDENCE-BASED MEDICINE
Review Article
Jun 29, 2026 169 78

Systematic Review of Antimicrobial Biomaterials for Medical Implants: Clinical Strategies for Reducing Device-Associated Infections

Adepeju Kafayat Olowookere 1 * ,
Bolawa Fredrick Babatunde 2,
Ebenezer Oluwadamilare Oyekanmi 3,
Adeyemo Rashidat Abolore 4
1 Department of Nanoscience, University of North Carolina at Greensboro, Greensboro, NC, USA2 Department of Plant Science and Biotechnology, Adekunle Ajasin University, Akungba Akoko, Ondo State, Nigeria 3 Department of Medical Laboratory Science, Ladoke Akinola University of Technology, Ogbomosho, Oyo State, Nigeria4 Department of Medical Laboratory science, Fountain University, Osogbo, Osun State, Nigeria* Corresponding Author
International Journal of Evidence-Based Medicine, 1(2), 2026, jebm006, https://doi.org/10.63946/jebm/18874
Publication date: Jun 29, 2026
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ABSTRACT

Background: Device-associated infections remain major complications of medical implants, contributing to prolonged hospitalisation, revision surgery, morbidity, and increased healthcare burden. Biofilm formation provides the biological rationale for antimicrobial implant strategies, although clinical studies often assess downstream infection outcomes rather than direct biofilm measures.
Objectives: This systematic review evaluated the clinical effectiveness, safety, and certainty of evidence for antimicrobial biomaterials and implant surface modification strategies in reducing device-associated infections, reinfection, microbial colonisation, and related complications among human implant recipients.
Methodology: A systematic search of PubMed, ScienceDirect, and Dimensions was conducted for original human studies published between 2015 and 2025. Eligible studies included randomised trials and observational cohorts evaluating antimicrobial biomaterials against conventional, uncoated, or standard-care comparators. Data extraction covered implant type, antimicrobial coating, comparator, infection-related outcomes, adverse events, and follow-up duration. Quality appraisal was performed using RoB 2 and ROBINS-I, while certainty of evidence was assessed narratively. A structured narrative synthesis was conducted because of heterogeneity in implant types, interventions, indications, comparators, and outcome definitions.
Findings: Twenty studies were included. DAC hydrogel coatings showed the most consistent association with reduced surgical site infection, periprosthetic joint infection, reinfection, and complications in selected orthopaedic settings. Silver- and iodine-coated implants showed promise in high-risk oncological reconstruction, while gentamicin-coated nails and calcium sulphate-based strategies appeared useful in trauma fixation and second-stage reimplantation. However, most studies were retrospective or non-randomised, several had serious risk of bias, and none directly quantified biofilm formation.
Conclusion: Antimicrobial biomaterials may reduce infection risk in selected implant settings, especially orthopaedic applications, but broader conclusions require cautious interpretation and stronger prospective evidence.

KEYWORDS

Antimicrobial Biomaterials Medical Implants Device-Associated Infection Surgical Site Infection Periprosthetic Joint Infection Clinical Outcomes

CITATION (Vancouver)

Olowookere AK, Babatunde BF, Oyekanmi EO, Abolore AR. Systematic Review of Antimicrobial Biomaterials for Medical Implants: Clinical Strategies for Reducing Device-Associated Infections. International Journal of Evidence-Based Medicine. 2026;1(2):jebm006. https://doi.org/10.63946/jebm/18874
APA
Olowookere, A. K., Babatunde, B. F., Oyekanmi, E. O., & Abolore, A. R. (2026). Systematic Review of Antimicrobial Biomaterials for Medical Implants: Clinical Strategies for Reducing Device-Associated Infections. International Journal of Evidence-Based Medicine, 1(2), jebm006. https://doi.org/10.63946/jebm/18874
Harvard
Olowookere, A. K., Babatunde, B. F., Oyekanmi, E. O., and Abolore, A. R. (2026). Systematic Review of Antimicrobial Biomaterials for Medical Implants: Clinical Strategies for Reducing Device-Associated Infections. International Journal of Evidence-Based Medicine, 1(2), jebm006. https://doi.org/10.63946/jebm/18874
AMA
Olowookere AK, Babatunde BF, Oyekanmi EO, Abolore AR. Systematic Review of Antimicrobial Biomaterials for Medical Implants: Clinical Strategies for Reducing Device-Associated Infections. International Journal of Evidence-Based Medicine. 2026;1(2), jebm006. https://doi.org/10.63946/jebm/18874
Chicago
Olowookere, Adepeju Kafayat, Bolawa Fredrick Babatunde, Ebenezer Oluwadamilare Oyekanmi, and Adeyemo Rashidat Abolore. "Systematic Review of Antimicrobial Biomaterials for Medical Implants: Clinical Strategies for Reducing Device-Associated Infections". International Journal of Evidence-Based Medicine 2026 1 no. 2 (2026): jebm006. https://doi.org/10.63946/jebm/18874
MLA
Olowookere, Adepeju Kafayat et al. "Systematic Review of Antimicrobial Biomaterials for Medical Implants: Clinical Strategies for Reducing Device-Associated Infections". International Journal of Evidence-Based Medicine, vol. 1, no. 2, 2026, jebm006. https://doi.org/10.63946/jebm/18874

REFERENCES

  1. Scialla S, Martuscelli G, Nappi F, Singh SSA, Iervolino A, Larobina D, et al. Trends in Managing Cardiac and Orthopaedic Device-Associated Infections by Using Therapeutic Biomaterials. Polymers (Basel). 2021 May 12;13(10):1556. doi:10.3390/polym13101556
  2. Kadirvelu L, Sivaramalingam SS, Jothivel D, Chithiraiselvan DD, Karaiyagowder Govindarajan D, Kandaswamy K. A review on antimicrobial strategies in mitigating biofilm-associated infections on medical implants. Current Research in Microbial Sciences. 2024 Jan 1;6:100231. doi:10.1016/j.crmicr.2024.100231
  3. Negut I, Albu C, Bita B. Advances in Antimicrobial Coatings for Preventing Infections of Head-Related Implantable Medical Devices. Coatings. 2024 Feb 20;14(3). doi:10.3390/coatings14030256
  4. Shahid A, Aslam B, Muzammil S, Aslam N, Shahid M, Almatroudi A, et al. The prospects of antimicrobial coated medical implants. Journal of Applied Biomaterials and Functional Materials. 2021;19. doi:10.1177/22808000211040304
  5. Bouloussa H, Mirza M, Ansley B, Jilakara B, Yue JJ. Implant Surface Technologies to Prevent Surgical Site Infections in Spine Surgery. Int J Spine Surg. 2023 Dec 27;17(S3):S75–85. doi:10.14444/8563
  6. Mishra A, Aggarwal A, Khan F. Medical Device-Associated Infections Caused by Biofilm-Forming Microbial Pathogens and Controlling Strategies. Antibiotics. 2024 Jul 3;13(7). doi:10.3390/antibiotics13070623
  7. Sharma S, Mohler J, Mahajan SD, Schwartz SA, Bruggemann L, Aalinkeel R. Microbial Biofilm: A Review on Formation, Infection, Antibiotic Resistance, Control Measures, and Innovative Treatment. Microorganisms. 2023 Jun 18;11(6). doi:10.3390/microorganisms11061614
  8. Grooters KE, Ku JC, Richter DM, Krinock MJ, Minor A, Li P, et al. Strategies for combating antibiotic resistance in bacterial biofilms. Front Cell Infect Microbiol. 2024 Jan 19;14. doi:10.3389/fcimb.2024.1352273
  9. Akay S, Yaghmur A. Recent Advances in Antibacterial Coatings to Combat Orthopedic Implant-Associated Infections. Molecules. 2024 Mar 5;29(5). doi:10.3390/molecules29051172
  10. Teixeira-Santos R, Lima M, Gomes LC, Mergulhão FJ. Antimicrobial coatings based on chitosan to prevent implant-associated infections: A systematic review. iScience. 2021 Dec 17;24(12):103480. doi:10.1016/j.isci.2021.103480
  11. van Dun SCJ, Verheul M, Pijls BGCW, van Prehn J, Scheper H, Galli F, et al. Influence of surface characteristics of implant materials on MRSA biofilm formation and effects of antimicrobial treatment. Front Microbiol. 2023 Apr 20;14. doi:10.3389/fmicb.2023.1145210
  12. Braem A, Kamarudin NHN, Bhaskar N, Hadzhieva Z, Mele A, Soulié J, et al. Biomaterial strategies to combat implant infections: new perspectives to old challenges. International Materials Reviews. 2023 Nov 1;68(8):1011–49. doi:10.1080/09506608.2023.2193784
  13. Yu YM, Lu YP, Zhang T, Zheng YF, Liu YS, Xia DD. Biomaterials science and surface engineering strategies for dental peri-implantitis management. zggx. 2025 Dec 13;12(3):354–92. doi:10.1186/s40779-024-00532-9
  14. Khan SA, Shakoor A. Recent Strategies and Future Recommendations for the Fabrication of Antimicrobial, Antibiofilm, and Antibiofouling Biomaterials. IJN. 2023 Jun 21;18:3377–405. doi:10.2147/IJN.S406078
  15. Ul Haq I, Krukiewicz K. Antimicrobial approaches for medical implants coating to prevent implants associated infections: Insights to develop durable antimicrobial implants. Applied Surface Science Advances. 2023 Dec 1;18:100532. doi:10.1016/j.apsadv.2023.100532
  16. Wang M, Zheng Y, Yin C, Dai S, Fan X, Jiang Y, et al. Recent Progress in antibacterial hydrogel coatings for targeting biofilm to prevent orthopedic implant-associated infections. Front Microbiol. 2023 Dec 22;14. doi:10.3389/fmicb.2023.1343202
  17. Sahoo J, Sarkhel S, Mukherjee N, Jaiswal A. Nanomaterial-Based Antimicrobial Coating for Biomedical Implants: New Age Solution for Biofilm-Associated Infections. ACS Omega. 2022 Dec 10;7(50):45962–80. doi:10.1021/acsomega.2c06211
  18. Su Q, Xue Y, Wang C, Zhou Q, Zhao Y, Su J, et al. Strategies and applications of antibacterial surface-modified biomaterials. Bioactive Materials. 2025 Nov 1;53:114–40. doi:10.1016/j.bioactmat.2025.07.009
  19. Cometta S, Hutmacher DW, Chai L. In vitro models for studying implant-associated biofilms - A review from the perspective of bioengineering 3D microenvironments. Biomaterials. 2024 Sep 1;309:122578. doi:10.1016/j.biomaterials.2024.122578
  20. Schardt C, Adams MB, Owens T, Keitz S, Fontelo P. Utilization of the PICO framework to improve searching PubMed for clinical questions. BMC Med Inform Decis Mak. 2007 Jun 15;7(1):16. doi:10.1186/1472-6947-7-16
  21. Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al. The PRISMA 2020 statement: an updated guideline for reporting systematic reviews. BMJ. 2021 Mar 29;372:n71. doi:10.1136/bmj.n71
  22. Sterne JAC, Savović J, Page MJ, Elbers RG, Blencowe NS, Boutron I, et al. RoB 2: a revised tool for assessing risk of bias in randomised trials. BMJ. 2019 Aug 28;366:l4898. doi:10.1136/bmj.l4898
  23. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ. 2016 Oct 12;355:i4919. doi:10.1136/bmj.i4919
  24. Campbell M, McKenzie JE, Sowden A, Katikireddi SV, Brennan SE, Ellis S, et al. Synthesis without meta-analysis (SWiM) in systematic reviews: reporting guideline. BMJ. 2020 Jan 16;368:l6890. doi:10.1136/bmj.l6890
  25. Wafa H, Grimer RJ, Reddy K, Jeys L, Abudu A, Carter SR, et al. Retrospective evaluation of the incidence of early periprosthetic infection with silver-treated endoprostheses in high-risk patients: case-control study. Bone Joint J. 2015 Feb;97-B(2):252–7. doi:10.1302/0301-620X.97B2.34554
  26. Shirai T, Tsuchiya H, Terauchi R, Tsuchida S, Mizoshiri N, Igarashi K, et al. The outcomes of reconstruction using frozen autograft combined with iodine-coated implants for malignant bone tumors: compared with non-coated implants. Jpn J Clin Oncol. 2016 Aug;46(8):735–40. doi:10.1093/jjco/hyw065
  27. Donati F, Di Giacomo G, D'Adamio S, Ziranu A, Careri S, Rosa M, et al. Silver-Coated Hip Megaprosthesis in Oncological Limb Savage Surgery. Biomed Res Int. 2016;2016:9079041. doi:10.1155/2016/9079041
  28. Romanò CL, Malizos K, Capuano N, Mezzoprete R, D'Arienzo M, Van Der Straeten C, et al. Does an Antibiotic-Loaded Hydrogel Coating Reduce Early Post-Surgical Infection After Joint Arthroplasty? J Bone Jt Infect. 2016;1:34–41. doi:10.7150/jbji.15986
  29. Malizos K, Blauth M, Danita A, Capuano N, Mezzoprete R, Logoluso N, et al. Fast-resorbable antibiotic-loaded hydrogel coating to reduce post-surgical infection after internal osteosynthesis: a multicenter randomized controlled trial. J Orthop Traumatol. 2017 Jun;18(2):159–69. doi:10.1007/s10195-017-0442-2
  30. Hardes J, Henrichs MP, Hauschild G, Nottrott M, Guder W, Streitbuerger A. Silver-Coated Megaprosthesis of the Proximal Tibia in Patients With Sarcoma. J Arthroplasty. 2017 Jul;32(7):2208–13. doi:10.1016/j.arth.2017.02.054
  31. Zajonz D, Birke U, Ghanem M, Prietzel T, Josten C, Roth A, et al. Silver-coated modular Megaendoprostheses in salvage revision arthroplasty after periimplant infection with extensive bone loss - a pilot study of 34 patients. BMC Musculoskelet Disord. 2017 Sep 2;18(1):383. doi:10.1186/s12891-017-1742-7
  32. Capuano N, Logoluso N, Gallazzi E, Drago L, Romanò CL. One-stage exchange with antibacterial hydrogel coated implants provides similar results to two-stage revision, without the coating, for the treatment of peri-prosthetic infection. Knee Surg Sports Traumatol Arthrosc. 2018 Nov;26(11):3362–7. doi:10.1007/s00167-018-4896-4
  33. Parry MC, Laitinen MK, Albergo JI, Gaston CL, Stevenson JD, Grimer RJ, et al. Silver-coated (Agluna®) tumour prostheses can be a protective factor against infection in high risk failure patients. Eur J Surg Oncol. 2019 Apr;45(4):704–10. doi:10.1016/j.ejso.2018.12.009
  34. Pinto D, Manjunatha K, Savur AD, Ahmed NR, Mallya S, Ramya V. Comparative study of the efficacy of gentamicin-coated intramedullary interlocking nail versus regular intramedullary interlocking nail in Gustilo type I and II open tibia fractures. Chin J Traumatol. 2019 Oct;22(5):270–3. doi:10.1016/j.cjtee.2019.03.006
  35. Zagra L, Gallazzi E, Romanò D, Scarponi S, Romanò C. Two-stage cementless hip revision for peri-prosthetic infection with an antibacterial hydrogel coating: results of a comparative series. Int Orthop. 2019 Jan;43(1):111–5. doi:10.1007/s00264-018-4206-2
  36. Streitbuerger A, Henrichs MP, Hauschild G, Nottrott M, Guder W, Hardes J. Silver-coated megaprostheses in the proximal femur in patients with sarcoma. Eur J Orthop Surg Traumatol. 2019 Jan;29(1):79–85. doi:10.1007/s00590-018-2270-3
  37. De Meo D, Calogero V, Are L, Cavallo AU, Persiani P, Villani C. Antibiotic-Loaded Hydrogel Coating to Reduce Early Postsurgical Infections in Aseptic Hip Revision Surgery: A Retrospective, Matched Case-Control Study. Microorganisms. 2020 Apr 15;8(4):571. doi:10.3390/microorganisms8040571
  38. Sambri A, Zucchini R, Giannini C, Zamparini E, Viale P, Donati DM, et al. Silver-coated (PorAg®) endoprosthesis can be protective against reinfection in the treatment of tumor prostheses infection. Eur J Orthop Surg Traumatol. 2020 Dec;30(8):1345–53. doi:10.1007/s00590-020-02705-3
  39. Greco T, Cianni L, Polichetti C, Inverso M, Maccauro G, Perisano C. Uncoated vs. Antibiotic-Coated Tibia Nail in Open Diaphyseal Tibial Fracture (42 according to AO Classification): A Single Center Experience. Biomed Res Int. 2021;2021:7421582. doi:10.1155/2021/7421582
  40. Zoccali C, Scoccianti G, Biagini R, Daolio PA, Giardina FL, Campanacci DA. Antibacterial hydrogel coating in joint mega-prosthesis: results of a comparative series. Eur J Orthop Surg Traumatol. 2021 Dec;31(8):1647–55. doi:10.1007/s00590-021-02884-7
  41. Sacchetti F, Kilian R, Muratori F, Cherix S, Foschi L, Morganti R, et al. The Performances of Conventional Titanium and Silver-Coated Megaprostheses in Non-oncological and Post-oncological Patients: An Analysis of Infection Failures in 142 Patients. Arch Bone Jt Surg. 2022 May;10(5):439–46. doi:10.22038/ABJS.2021.58351.2889
  42. De Meo D, Martini P, Pennarola MF, Guarascio G, Rivano Capparuccia M, Iaiani G, et al. Hydrogel Coating versus Calcium Sulphate Beads as a Local Antibiotic Carrier for Debridement Procedures in Acute Periprosthetic Joint Infection: A Preliminary Study. Gels. 2023 Sep 18;9(9):758. doi:10.3390/gels9090758
  43. McPherson EJ, Crawford BM, Kenny SG, Dipane MV, Salarkia S, Stavrakis AI, et al. Point-of-Care Coating of Revision Femoral Stems With Antibiotic-Loaded Calcium Sulfate: Reduction in Infection After 2nd Stage Reimplantation but Not With Aseptic Revisions. Arthroplast Today. 2024 Feb;25:101302. doi:10.1016/j.artd.2023.101302
  44. Ding BTK, D'Apolito R, Sciamanna L, Zagra L. Antibacterial hydrogel coating is associated with lower complication risks after complex high-risk primary and cementless hip revision arthroplasty: a retrospective matched cohort study. Bone Jt Open. 2025 Jun 1;6(6 Supple B):15–23. doi:10.1302/2633-1462.66.BJO-2025-0004.R1
  45. Fiore M, Sambri A, Zucchini R, Giannini C, Donati DM, De Paolis M. Silver-coated megaprosthesis in prevention and treatment of peri-prosthetic infections: a systematic review and meta-analysis about efficacy and toxicity in primary and revision surgery. Eur J Orthop Surg Traumatol. 2021 Feb;31(2):201–20. doi:10.1007/s00590-020-02779-z
  46. Bulut HI, Okay E, Kanay E, Batibay SG, Ozkan K. Comparative effectiveness of silver-coated implants in periprosthetic infection prevention: A systematic review and meta-analysis. Journal of Orthopaedics. 2025 Mar 1;61:133–9. doi:10.1016/j.jor.2024.10.009
  47. Kaspiris A, Vasiliadis E, Pantazaka E, Lianou I, Melissaridou D, Savvidis M, et al. Current Progress and Future Perspectives in Contact and Releasing-Type Antimicrobial Coatings of Orthopaedic Implants: A Systematic Review Analysis Emanated from In Vitro and In Vivo Models. Infectious Disease Reports. 2024 Mar 25;16(2):298–316. doi:10.3390/idr16020025
  48. Li H, Wang D, Zhang W, Xu G, Xu C, Liu W, et al. Potential side effects of antibacterial coatings in orthopaedic implants: A systematic review of clinical studies. Front Bioeng Biotechnol. 2023 Feb 9;11. doi:10.3389/fbioe.2023.1111386
  49. Teulé-Trull M, Altuna P, Arregui M, Rodriguez-Ciurana X, Aparicio C. Antibacterial coatings for dental implants: A systematic review. Dent Mater. 2025 Mar;41(3):229–47. doi:10.1016/j.dental.2024.12.001

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