Placement of antibiotic impregnated PMMA can be used as an adjunct to D&I to deliver increased local antibiotic concentrations while minimizing the associated side effects of high systemic loads of these antibiotics. Indications include contamination with open fractures and traumatic amputations, treatment of established osteomyelitis, and dead space management with associated soft tissue defect. Animal models demonstrate a PMMA bead pouch is more effective without NPWT because the antibiotic remains in the wound without collecting in the vacuum canister.13 The PMMA beads are usually prepared on a suture or wire and laid within the wound and covered with a semipermeable membrane, forming a bead pouch. Typically reserved for Role 3 and 4 use, a PMMA bead pouch may be used in conjunction with NPWT. It may be helpful to place the antibiotic beads in the deep portion of the wound and not in direct contact with the reticulated open cell foam to allow stasis of antibiotics concentrations in the wound. The choice of antibiotic should be directed by the local antibiogram. Common antibiotics include heat stable powder formulations of tobramycin, vancomycin, imipenem, and colistin. Recent evidence also supports prefabricating and sterilely packaging PMMA beads for subsequent use, allowing for bead use in a multi-casualty/time constrained setting. The efficacy of this adjunct is supported by several small studies and case series which, in aggregate, suggest this can lead to a 10% or greater absolute decrease in wound infections.14 Further research is needed on its use in combat trauma patients. Recent epidemiologic studies by the Trauma Infectious Disease Outcomes Study Group showed an increased rate of osteomyelitis when PMMA antibiotic beads were used.15-17 These results should be viewed cautiously as they did not control for confounding factors (such as selection bias that the beads were used or patients at a higher baseline risk of developing osteomyelitis).