Staphylococcal Osteomyelitis: Disease Progression, Treatment Challenges, and Future Directions

Photosensitive and Conductive Hydrogel Induced Innerved Bone Regeneration for Infected Bone Defect Repair

Repairing infected bone defects is a challenge in the field of orthopedics because of the limited self-healing capacity of bone tissue and the susceptibility of refractory materials to bacterial activity. Innervation is the initiating factor for bone regeneration and plays a key regulatory role in subsequent vascularization, ossification, and mineralization processes. Infection leads to necrosis of local nerve fibers, impeding the repair of infected bone defects. Herein, a biomaterial that can induce skeletal-associated neural network reconstruction and bone regeneration with high antibacterial activity is proposed for the treatment of infected bone defects. A photosensitive conductive hydrogel is prepared by incorporating magnesium-modified black phosphorus (BP@Mg) into gelatin methacrylate (GelMA). The near-infrared irradiation-based photothermal and photodynamic treatment of black phosphorus endows it with strong antibacterial activity, improving the inflammatory microenvironment and reducing bacteria-induced bone tissue damage. The conductive nanosheets and bioactive ions released from BP@Mg synergistically improve the migration and secretion of Schwann cells, promote neurite outgrowth, and facilitate innerved bone regeneration. In an infected skull defect model, the GelMA-BP@Mg hydrogel shows efficient antibacterial activity and promotes bone and CGRP⁺ nerve fiber regeneration. The phototherapy conductive hydrogel provides a novel strategy based on skeletal-associated innervation for infected bone defect repair.

Hexapeptide decorated β-cyclodextrin delivery system for targeted therapy of bone infection

Successfully treating bone infections is a major orthopedic challenge. Clinically, oral, intravenous, or intramuscular injections of drugs are usually used for direct or complementary treatment. However, once the drug enters the system, it circulates throughout the body, leading to an insufficient local dose and limiting the therapeutic effect because of the lack of targeting in the drug system. In this study, β-cyclodextrin, modified with poly (ethylene glycol) [PEG] and aspartic acid hexapeptide (Asp6-β-CD), was used to specifically target the hydroxyapatite (HA) component of the bone. It was then loaded with norfloxacin (NFX) to treat bone infections. The antibacterial ability of NFX was enhanced by loading it into Asp6-β-CD, because the solubility of Asp6-β-CD@NFX increased significantly. Moreover, Asp6-β-CD could target bone tissue in nude mice and showed significantly enhanced accumulation (10 times) than the unmodified β-CD. In addition, in a rat model of osteomyelitis, Asp6-β-CD@NFX targeted HA well and exerted its antibacterial activity, which reduced inflammation and promoted bone tissue repair. This study indicates that the Asp6-β-CD based drug delivery system can efficiently target bone tissue to enable potential applications for treating bone-related diseases.

Interfacial Mo, W-Conjugated Polarization, and Oxygen Vacancies of MoO2/WO3 in Enhanced Microwave Therapy for MRSA-Induced Osteomyelitis

Deep tissue infection, such as osteomyelitis, caused by methicillin-resistant Staphylococcus aureus (MRSA) infection, poses a serious threat to public health and cannot be effectively treated by antibiotics. In this study, we report a microwave (MW)-responsive MoO₂/WO₃ heterojunction that can be utilized to effectively treat MRSA-infected osteomyelitis under MW irradiation because of the enhanced MW thermal effect and MW catalysis of the composite. The underlying mechanism is as follows: A myriad of oxygen vacancies forms on the surface of MoO₂ and WO₃ by deoxidization effect with hydrogen from the decomposition of sodium borohydride, which induces a mass of free electrons on the surface of the composite and consequently promotes a localized surface plasmon resonance effect (LSPR) under MW irradiation. Furthermore, the conjugation of Mo and W at the interface enhances the LSPR effect. Thus, the LSPR effect not only induces the formation of radical oxygen species, thereby enhancing MW catalysis, but also results in the formation of an interfacial electrical field, which strengthens dipole polarization through synergistic action with oxygen vacancies and contributes to better MW thermal effects. The characteristics of MoO₂/WO₃ prove to be promising for the treatment of deep-tissue infections under MW irradiation.

Microbiology of fracture related infections

Fracture related infection remains a challenging complication that creates a heavy burden for orthopaedic trauma patients, their families, treating physicians and healthcare systems. Even current curative approaches (radical debridement, revision surgery and long-term antibiotics) often result in significant socioeconomic costs and the risk of life-long functional impairment to the patient. The prevalence of osteomyelitis due to trauma and surgical complications does not seem to be diminishing in our society and the emergence of antimicrobial resistance is a major health related concern with global relevance. Despite multi-drug resistant bacteria being on the rise universally, perioperative antibiotic prophylaxis in orthopaedic trauma care has only slightly changed in the last 25 years. Staphylococcus infections remain an increasing global concern, partially due to the resistance mechanisms developed by staphylococci to evade the host immune system and antibiotic treatment, and as such antibiotics are becoming increasingly ineffective. This paper will address fracture related infections in trauma patients, looking at the bacteriology of these infections, its clinical implications and evolving nature.

In Silico Genome-Scale Analysis of Molecular Mechanisms Contributing to the Development of a Persistent Infection with Methicillin-Resistant Staphylococcus aureus (MRSA) ST239

The increasing frequency of isolation of methicillin-resistant Staphylococcus aureus (MRSA) limits the chances for the effective antibacterial therapy of staphylococcal diseases and results in the development of persistent infection such as bacteremia and osteomyelitis. The aim of this study was to identify features of the MRSA_ST239 0943-1505-2016 (SA943) genome that contribute to the formation of both acute and chronic musculoskeletal infections. The analysis was performed using comparative genomics data of the dominant epidemic S. aureus lineages, namely ST1, ST8, ST30, ST36, and ST239. The SA943 genome encodes proteins that provide resistance to the host's immune system, suppress immunological memory, and form biofilms. The molecular mechanisms of adaptation responsible for the development of persistent infection were as follows: amino acid substitution in PBP2 and PBP2a, providing resistance to ceftaroline; loss of a large part of prophage DNA and restoration of the nucleotide sequence of beta-hemolysin, that greatly facilitates the escape of phagocytosed bacteria from the phagosome and formation of biofilms; dysfunction of the AgrA system due to the presence of psm-mec and several amino acid substitutions in the AgrC; partial deletion of the nucleotide sequence in genomic island vSAβ resulting in the loss of two proteases of Spl-operon; and deletion of SD repeats in the SdrE amino acid sequence.

Surveillance of osteoarticular infections caused by Staphylococcus aureus in a paediatric hospital in Mexico City

Staphylococcus aureus is the main aetiologic agent of osteoarticular infections (OAIs) in paediatric patients. The aim of this prospective unicenter study was to describe the phenotypic and genotypic characteristics of S. aureus isolates obtained from OAIs in paediatric patients admitted to tertiary care hospital. Through a surveillance program called OsteoCode, a multidisciplinary team was created and we identified 27 patients with OAIs caused by S. aureus from 2019 to 2021. The susceptibility profile, virulence factors, biofilm formation, pulsed-field gel electrophoresis (PFGE), clonal complex (CC) and sequence type (ST) were determined. In addition, the clinical characteristics and evolution of the patients presented six months after the diagnosis of OAIs were described. Ninety-two percent of the isolates were methicillin-sensitive S. aureus (MSSA). In methicillin-resistant S. aureus (MRSA), SCCmec-II and SCCmec-V were detected. The pvl gene was only observed in MSSA (18.5%) and was associated with highest fever (p=0.015), multiple localization (p=0.017), and soft tissue sites of infection beyond the bone (pyomyositis, pulmonary abscess) (p=0.017). Biofilm formation was detected in 55.6% of isolates. The most common CC were CC5 and CC30 which represent the most common linages for bone and joint infections worldwide. The isolates were distributed in different STs, and ST672 was predominant. MRSA were associated with a longer duration of intravenous treatment and a prolonged hospital stay (p=0.023). Recurrent infection occurred in five children and orthopaedic complications in 33.3% of patients. This is the first study that reflects the epidemiology of S. aureus in OAIs in paediatric patients in Mexico; a clear predominance of MSSA distributed in different STs was observed. Our findings highlight that a multidisciplinary team is required for the diagnosis and treatment of OAIs.

Guanidinium-Decorated Nanostructure for Precision Sonodynamic-Catalytic Therapy of MRSA-Infected Osteomyelitis

Osteomyelitis caused by methicillin-resistant Staphylococcus aureus (MRSA) biofilm infection is difficult to eradicate and can even be life-threatening. Given that the infection is persistent and deep-seated in the bone tissue, controlled and efficient treatment of osteomyelitis remains challenging. Herein, an activatable nanostructure (Au/TNT@PG) is presented for synergistic sonodynamic-catalytic therapy of MRSA-infected osteomyelitis. The Au/TNT@PG backbone is obtained by conjugating a guanidinium-rich polymer (PG), a component that penetrates the biofilm matrix, onto ultrasound (US)-absorbing gold-doped titanate nanotubes (Au/TNTs). Under deep-penetrating US irradiation, the nanocomposite generates ¹ O₂ for sonodynamic therapy and catalyzes the decomposition of endogenous H₂ O₂ into toxic •OH in the acidic infection microenvironment for catalytic therapy, leading to bacterial cell death. Its robust antibacterial effectiveness is attributable to its bacteria-capturing ability, the biofilm penetrability of positively charged guanidinium, and the subsequent synergistic effect of sonodynamic-catalytic action of Au/TNT. Such a remotely controlled approach potentiates the polarization of macrophages to M2-type while suppressing the M1-type, leading to topical inflammation resolution and enhanced osteoblast proliferation and differentiation to inhibit bone loss. Therefore, this study provides a generic nanotherapeutic approach for efficient sonodynamic-catalytic therapy with respect to osteomyelitis.

Microbiological aspects of osteomyelitis in veterinary medicine: drawing parallels to the infection in human medicine

Osteomyelitis is a challenging infectious disease affecting humans and animals. It is difficult to diagnose because, in many cases, symptoms are non-specific and, for example in implant-related cases, can appear long time after surgery. In addition to this, it is also difficult to treat due to the need to find the appropriate antibiotic regime and delivery system to reach the site of infection and to avoid development of bacterial resistance. The central purpose of this review is to compare the microbiological aspects of osteomyelitis in human and veterinary medicine, with the aim of improving the microbiological diagnosis and treatment of this infection in animals. Furthermore, the study of osteomyelitis in animals may help to improve the development of animal models for testing new treatments in humans. Host factors and underlying conditions have been studied mainly in humans, although aspects as immunodeficiency have been described in some veterinary cases. Even when Staphylococcus aureus is still considered the most prevalent causing microorganism, this prevalence should be reviewed using molecular diagnostic techniques, and this could affect treatment options. New approaches to treatment include local delivery of antibiotics using different biomaterials, antimicrobial photodynamic therapy, and new antimicrobial compounds. We would like to remark the need of large, high-quality clinical trials and of the development of guides for the diagnosis and treatment of osteomyelitis in different animal species.

Pyroptosis in inflammatory bone diseases: Molecular insights and targeting strategies

Inflammatory bone diseases include osteoarthritis (OA) and rheumatoid arthritis (RA), which can cause severe bone damage in a chronic inflammation state, putting tremendous pressure on the patients' families and government agencies regarding medical costs. In addition, the complexity of osteoimmunology makes research on these diseases difficult. Hence, it is urgent to determine the potential mechanisms and find effective drugs to target inflammatory bone diseases to reduce the negative effects of these diseases. Recently, pyroptosis, a gasdermin-induced necrotic cell death featuring secretion of pro-inflammatory cytokines and lysis, has become widely known. Based on the effect of pyroptosis on immunity, this process has gradually emerged as a vital component in the etiopathogenesis of inflammatory bone diseases. Herein, we review the characteristics and mechanisms of pyroptosis and then focus on its clinical significance in inflammatory bone diseases. In addition, we summarize the current research progress of drugs targeting pyroptosis to enhance the therapeutic efficacy of inflammatory bone diseases and provide new insights for future directions.

A 13-Year-Old Male With Left Eye Swelling

A 13-year-old male presented with a 10-day history of left eye swelling and pain. These symptoms prompted presentation to the emergency department. He had no significant past medical history and no preceding fevers or chills. He was found on examination of the eyes and the orbit to have left supraorbital erythema, edema, and pain with upward and medial gaze. Examination of the globe, fundus, and visual fields were normal. His white blood cell count was 6.2 (x1000/mm3) with an erythrocyte sedimentation rate of 4 (mm/hr). Diagnostic endoscopic biopsy was performed. Here we present this case alongside clinical reasoning and diagnostic evaluation with relevant input from respective experts. This case discussion reviews the final diagnosis, as well as the corresponding evaluation and management. Diagnostic algorithms based on literature review and clinical experience are also included.

In vitro and in vivo assessment of caprine origin Staphylococcus aureus ST398 strain UTCVM1 as an osteomyelitis pathogen

Staphylococcus aureus (SA) is a significant and well-recognized causative organism of bacterial osteomyelitis. Osteomyelitis is an inflammatory bone disease characterized by progressive bone destruction and loss. This disease causes significant morbidity and mortality to the patient and poses therapeutic challenges for clinicians. To improve the efficacy of therapeutic strategies to combat bacterial osteomyelitis, there is a need to define the molecular epidemiology of bacterial organisms more clearly and further the understanding of the pathogenesis of SA osteomyelitis. We conducted in vitro characterization of the pathogenic capabilities of an isolate of SA ST398 derived from a clinical case of osteomyelitis in a goat. We also report a rodent mandibular defect model to determine the ability of ST398 to cause reproducible osteomyelitis. Our results indicate that ST398 can invade and distort pre-osteoblastic cells in culture, induce significant inflammation and alter expression of osteoregulatory cytokines. We also demonstrate the ability of ST398 to induce osteomyelitis in a rat mandibular model. When compiled, these data support ST398 as a competent osteomyelitis pathogen.

Context-Dependent Roles for Toll-Like Receptors 2 and 9 in the Pathogenesis of Staphylococcus aureus Osteomyelitis

Staphylococcus aureus is the major causative agent of bacterial osteomyelitis, an invasive infection of bone. Inflammation generated by the immune response to S. aureus contributes to bone damage by altering bone homeostasis. Increases in the differentiation of monocyte lineage cells into bone-resorbing osteoclasts (osteoclastogenesis) promote bone loss in the setting of osteomyelitis. In this study, we sought to define the role of Toll-like receptor (TLR) signaling in the pathogenesis of S. aureus osteomyelitis. We hypothesized that S. aureus-sensing TLRs 2 and 9, both of which are known to alter osteoclastogenesis in vitro, promote pathological changes to bone, including increased osteoclast abundance, bone loss, and altered callus formation during osteomyelitis. Stimulation of osteoclast precursors with S. aureus supernatant increased osteoclastogenesis in a TLR2-dependent, but not a TLR9-dependent, manner. However, in vivo studies using a posttraumatic murine model of osteomyelitis revealed that TLR2-null mice experienced similar bone damage and increased osteoclastogenesis compared to wild type (WT) mice. Therefore, we tested the hypothesis that compensation between TLR2 and TLR9 contributes to osteomyelitis pathogenesis. We found that mice deficient in both TLR2 and TLR9 (Tlr2/9^-/-) have decreased trabecular bone loss in response to infection compared to WT mice. However, osteoclastogenesis is comparable between WT and Tlr2/9^-/- mice, suggesting that alternative mechanisms enhance osteoclastogenesis in vivo during osteomyelitis. Indeed, we discovered that osteoclast precursors intracellularly infected with S. aureus undergo significantly increased osteoclast formation, even in the absence of TLR2 and TLR9. These results suggest that TLR2 and TLR9 have context-dependent roles in the alteration of bone homeostasis during osteomyelitis.

Facile post modification synthesis of copper-doped mesoporous bioactive glass with high antibacterial performance to fight bone infection

Successful treatment of infected bone defects caused by multi-drug resistant bacteria (MDR) has become a major clinical challenge, stressing the urgent need for effective antibacterial bone graft substitutes. Mesoporous bioactive glass nanoparticles (MBGNs), a rapidly emerging class of nanoscale biomaterials, offer specific advantages for the development of biomaterials to treat bone infection due to endowed antibacterial features. Herein, we propose a facile post-modification sol-gel strategy to synthesize effective antibacterial MBGNs doped with copper ions (Cu-PMMBGNs). In this strategy, amine functional groups as chelating agents were introduced to premade mesoporous silica nanoparticles (MSNs) which further facilitate the incorporation of high content of calcium (∼17 mol%) and copper ions (∼8 mol%) without compromising nanoparticle shape, mesoporosity, and homogeneity. The resulting nanoparticles were degradable and showed rapidly induce abundant deposition of apatite crystals on their surface upon soaking in simulated body fluids (SBF) after 3 days. Cu-PMMBGNs exhibited a dose-dependent inhibitory effect on Methicillin-resistant Staphylococcus aureus (MRSA) bacteria, which are common pathogens causing severe bone infections. Most importantly, the nanoparticles containing 5 mol% copper ions at concentrations of 500 and 1000 μg.mL^-1 showed highly effective antibacterial performance as reflected by a 99.9 % reduction of bacterial viability. Nanoparticles at a concentration of 500 μg.mL^-1 showed no significant cytotoxicity toward preosteoblast cells (∼85-89 % cell viability) compared to the control group. In addition, the nanoscale properties of synthesized Cu-PMMBGNs (∼100 nm in size) facilitated their internalization into preosteoblast cells, which highlights their potential as intracellular carriers in combating intracellular bacteria. Therefore, these copper-doped nanoparticles hold strong promise for use as an antibacterial component in antibacterial bone substitutes such as hydrogels, nanocomposites, and coatings.

Preparation and In Vitro Osteogenic Evaluation of Biomimetic Hybrid Nanocomposite Scaffolds Based on Gelatin/Plasma Rich in Growth Factors (PRGF) and Lithium-Doped 45s5 Bioactive Glass Nanoparticles

Bone tissue engineering is an emerging technique for repairing large bone lesions. Biomimetic techniques expand the use of organic-inorganic spongy-like nanocomposite scaffolds and platelet concentrates. In this study, a biomimetic nanocomposite scaffold was prepared using lithium-doped bioactive-glass nanoparticles and gelatin/PRGF. First, sol-gel method was used to prepare bioactive-glass nanoparticles that contain 0, 1, 3, and 5%wt lithium. The lithium content was then optimized based on antibacterial and MTT testing. By freeze-drying, hybrid scaffolds comprising 5, 10, and 20% bioglass were made. On the scaffolds, human endometrial stem cells (hEnSCs) were cultured for adhesion (SEM), survival, and osteogenic differentiation. Alkaline phosphatase activity and osteopontin, osteocalcin, and Runx2 gene expression were measured. The effect of bioactive-glass nanoparticles and PRGF on nanocomposites' mechanical characteristics and glass-transition temperature (T _g) was also studied. An optimal lithium content in bioactive glass structure was found to be 3% wt. Nanoparticle SEM examination indicated grain deformation due to different sizes of lithium and sodium ions. Results showed up to 10% wt bioactive-glass and PRGF increased survival and cell adhesion. Also, Hybrid scaffolds revealed higher ALP-activity and OP, OC, and Runx2 gene expression. Furthermore, bioactive-glass has mainly increased ALP-activity and Runx2 expression, whereas PRGF increases the expression of OP and OC genes. Bioactive-glass increases scaffold modulus and T _g continuously. Hence, the presence of both bioactive-glass and nanocomposite scaffold improves the expression of osteogenic differentiation biomarkers. Subsequently, it seems that hybrid scaffolds based on biopolymers, Li-doped bioactive-glass, and platelet extracts can be a good strategy for bone repair.

Protein corona mediated liposomal drug delivery for bacterial infection management

Liposomes have been widely investigated as a class of promising antibiotic delivery systems for the treatment of life-threatening bacterial infections. However, the inevitable formation of protein corona on the liposomal surface can heavily impact in vivo performance. A better understanding of the effects of protein corona on liposomal behavior can significantly improve antibacterial liposomal drug development. Here, the critical role of protein corona in mediating liposome-bacteria interactions was elucidated. Adsorption of negatively charged protein on cationic liposome weakened electrostatic attraction-enhanced liposomal binding to the bacteria. Cumulative complement deposition on anionic liposome composed of phosphatidylglycerol (DSPG sLip) contributed to a superior binding affinity of DSPG sLip to planktonic bacteria and biofilms, which was exploited to enhance bacteria-targeted drug delivery. In both S. aureus-related osteomyelitis and pneumonia mice models, DSPG sLip was demonstrated as a promising antibiotic nanocarrier for managing MRSA infection, indicating the benefits of lipid composition-based protein corona modulation in liposomal antibiotic delivery for bacterial infection treatment.

Magnetic Composite Rapidly Treats Staphylococcus aureus-Infected Osteomyelitis through Microwave Strengthened Thermal Effects and Reactive Oxygen Species

It is difficult to effectively treat bacterial osteomyelitis using photothermal therapy or photodynamic therapy due to poor penetration of light. Here, a microwave (MW)-excited magnetic composite of molybdenum disulfide (MoS₂ ) / iron oxide (Fe₃ O₄ ) is reported for the treatment of bacteria-infected osteomyelitis. In in vitro and in vivo experiments, MoS₂ /Fe₃ O₄ is shown to effectively eradicate bacteria-infected mouse tibia osteomyelitis, due to MW thermal enhancement and reactive oxygen species (ROS) (¹ O₂ and ·O₂ ^- ) production under MW radiation. In addition, the mechanism of MW heat generation is proposed by MW network vector analysis. By the density functional theory and finite element method, the ROS generation mechanism is proposed. The synergy or conductive network between dielectric MoS₂ and magnetic Fe₃ O₄ can reach both enhancement of the dielectric and magnetic attenuation capability. In addition, abundant interfaces are generated to enhance the attenuation of electromagnetic waves by MoS₂ and Fe₃ O_4, introducing multiple reflections and interfacial polarization. Therefore, MoS₂ /Fe₃ O₄ has excellent MW absorption ability based on the synergy or conductive network between MoS₂ and magnetic Fe₃ O₄ as well as multiple dielectric reflections and interfacial polarization.

Diagnosis and Treatment Modalities for Osteomyelitis

Osteomyelitis is an infection-related inflammatory disease of the bones. Imaging and laboratory results are typically used to support a clinical diagnosis of osteomyelitis. Microbial cultures and bone biopsies provide conclusive diagnoses. The first imaging procedure that needs to be done is radiography, but its sensitivity is low in the early stages of the disease. The sensitivity of magnetic resonance imaging, both with and without contrast material, is higher for detecting areas of bone necrosis in advanced stages. Patients can be categorised for surgical treatment using a staging system based on major and minor risk factors. The main course of treatment should be antibiotics, which should be chosen depending on the findings of the culture and the characteristics of each patient. Bony debridement surgery is frequently required, and in high-risk patients or those with severe illness, additional surgical intervention can be necessary. Better outcomes are being attained in the treatment of this illness thanks to advancements in surgical treatment, antibiotic therapy, and the current resources for precise diagnosis and tailored responses to each kind of osteomyelitis. The classification systems that are most frequently employed, as well as the general epidemiological ideas, are presented together with the discussion of acute and chronic osteomyelitis. The key recommendations for diagnosing infections clinically, in the laboratory, and through imaging are covered, along with the recommendations for surgical and antibiotic procedures, and the function of hyperbaric oxygen as adjuvant therapy. We evaluate the osteomyelitis-related articles, summarise the most recent developments in diagnostic procedures and therapeutic regimens, evaluate the benefits and drawbacks of various diagnostic modalities and therapeutic approaches, and suggest areas of focus to help current diagnostic and therapeutic approaches.

A self-assembled bilayer polypeptide-engineered hydrogel for spatiotemporal modulation of bactericidal and anti-inflammation process in osteomyelitis treatment

Background

Drug resistance of pathogens and immunosuppression are the main causes of clinical stagnation of osteomyelitis. The ideal treatment strategy for osteomyelitis is to achieve both efficient antibacterial and bone healing through spatiotemporal modulation of immune microenvironment.

Methods

In this study, a bilayer hydrogel based on genetically engineered polypeptide AC10A and AC10ARGD was prepared by self-assembly. Ag2S QDs@DSPE-mPEG2000-Ce6/Aptamer (AD-Ce6/Apt) was loaded in the top layer AC10A hydrogel (AA) for antibacterial, and bone marrow-derived mesenchymal stem cells (BMSCs) were loaded in the lower layer AC10ARGD hydrogel (MAR) for bone healing. The AD-Ce6/Apt can be released from the AA hydrogel to target S. aureus before bacterial biofilm formation and achieved significant bactericidal effect under irradiation with a 660 nm laser. Moreover, AD-Ce6/Apt can induce M1 type polarization of macrophages to activate the immune system and eliminate residual bacteria. Subsequently, BMSCs released from the MAR hydrogel can differentiate into osteoblasts and promote the formation of an anti-inflammatory microenvironment by regulating the M2 type polarization of macrophages. The bilayer AA-MAR hydrogel possessed good biocompatibility.

Results

The in vitro and in vivo results showed that the AA-MAR hydrogel not only realized efficient photodynamic therapy of S. aureus infection, but also promoted the transformation of immune microenvironment to fulfill the different needs of each stage, which ultimately improved bone regeneration and mechanical properties post-surgery.

Conclusion

This work presents an approach for spatiotemporal modulation of immune microenvironment in the treatment of osteomyelitis.

Graphical Abstract

Update on MRI findings of osteomyelitis of long bones in the adult population

OBJECTIVES

To evaluate the usefulness of new and established MRI signs of osteomyelitis in long bones in adults.

METHODS

All patient records over a 9-year period with clinical or MRI suspicion for osteomyelitis were retrospectively reviewed, using strict criteria for proof of infection. Two musculoskeletal radiologists independently reviewed the MRIs of proven osteomyelitis.

RESULTS

Out of 45 MRIs of confirmed osteomyelitis, 2 MRIs (4%) did not show confluent low-signal intensity on T1-weighted images, but all showed confluent high-signal intensity on T2-weighted images. Central hypoenhancing regions of marrow without abscess formation were found in 15-18/35 (43-51%) cases where gadolinium was given. We often found multiple foci of marrow replacement in the same bone. The areas of marrow involvement often had an irregular contour. Penumbra sign, marrow fat globules, and sequestra were uncommon.

CONCLUSION

Multiple foci of bone marrow signal abnormalities, an irregular contour of marrow abnormality, and central marrow hypoenhancement without abscess are common signs of osteomyelitis of long bones in adults. Confluent low T1-signal intensity is not always present.

Concentration of cephalothin in body fluids and tissue samples of Thoroughbred horses

Cephalothin (CET) concentrations in body fluids (plasma, synovial fluid, pleural fluid, peritoneal fluid, and aqueous humor) and tissue samples (bone, lung, jejunum, hoof, and subcutaneous tissue) were investigated to consider the treatment of infectious diseases in horses. CET 22 mg/kg body weight was intravenously administered to 12 horses. Samples were collected from four different horses at 1, 3, and 5 hr after administration. The CET concentration in body fluids other than aqueous humor was maintained above the MIC₉₀ values of Streptococcus zooepidemicus and Staphylococcus aureus until 5 hr, but it was not maintained above that of S. aureus in bone. CET (22 mg/kg twice a day) is effective for septic arthritis, pleuritis, and peritonitis caused by gram-positive bacteria but ineffective for osteomyelitis.

The Risk of Emerging Resistance to Trimethoprim/Sulfamethoxazole in Staphylococcus aureus

Objective

Due to the spread of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA), the demand for trimethoprim/sulfamethoxazole (SXT) is increasing in the world. It is not clear whether the resistant strain emerges by overuse of SXT. We investigated here the emergent risk of the SXT-resistant mutant in S. aureus by an in vitro SXT exposure experiment.

Methods

A total of 40 S. aureus clinical isolates (20 MSSA and 20 MRSA isolates) were exposed to sub-MIC of SXT for consecutive days, and MIC of SXT was determined every day. In addition, the dfrB DNA sequencing was performed to detect the mutation in the SXT-resistant strain.

Results

The SXT-resistant strain began to emerge on the eighth day and accounted for 45% (18/40 clinical isolates) after 14 days. Moreover, one half of these resistant strains showed F98Y mutation in DfrB to retain SXT-resistance without selective pressure.

Conclusion

The emergent risk was SXT exposure of 14 days or more.

Biodegradable Bone Implants as a New Hope to Reduce Device-Associated Infections-A Systematic Review

Bone fractures often require fixation devices that frequently need to be surgically removed. These temporary implants and procedures leave the patient more prone to developing medical device-associated infections, and osteomyelitis associated with trauma is a challenging complication for orthopedists. In recent years, biodegradable materials have gained great importance as temporary medical implant devices, avoiding removal surgery. The purpose of this systematic review was to revise the literature regarding the use of biodegradable bone implants in fracture healing and its impact on the reduction of implant-associated infections. The systematic review followed the PRISMA guidelines and was conducted by searching published studies regarding the in vivo use of biodegradable bone fixation implants and its antibacterial activity. From a total of 667 references, 23 studies were included based on inclusion and exclusion criteria. Biodegradable orthopedic implants of Mg-Cu, Mg-Zn, and Zn-Ag have shown antibacterial activity, especially in reducing infection burden by MRSA strains in vivo osteomyelitis models. Their ability to prevent and tackle implant-associated infections and to gradually degrade inside the body reduces the need for a second surgery for implant removal, with expectable gains regarding patients' comfort. Further in vivo studies are mandatory to evaluate the efficiency of these antibacterial biodegradable materials.

Can intracellular Staphylococcus aureus in osteomyelitis be treated using current antibiotics? A systematic review and narrative synthesis

Approximately 40% of treatments of chronic and recurrent osteomyelitis fail in part due to bacterial persistence. Staphylococcus aureus, the predominant pathogen in human osteomyelitis, is known to persist by phenotypic adaptation as small-colony variants (SCVs) and by formation of intracellular reservoirs, including those in major bone cell types, reducing susceptibility to antibiotics. Intracellular infections with S. aureus are difficult to treat; however, there are no evidence-based clinical guidelines addressing these infections in osteomyelitis. We conducted a systematic review of the literature to determine the demonstrated efficacy of all antibiotics against intracellular S. aureus relevant to osteomyelitis, including protein biosynthesis inhibitors (lincosamides, streptogramins, macrolides, oxazolidines, tetracyclines, fusidic acid, and aminoglycosides), enzyme inhibitors (fluoroquinolones and ansamycines), and cell wall inhibitors (beta-lactam inhibitors, glycopeptides, fosfomycin, and lipopeptides). The PubMed and Embase databases were screened for articles related to intracellular S. aureus infections that compared the effectiveness of multiple antibiotics or a single antibiotic together with another treatment, which resulted in 34 full-text articles fitting the inclusion criteria. The combined findings of these studies were largely inconclusive, most likely due to the plethora of methodologies utilized. Therefore, the reported findings in the context of the models employed and possible solutions for improved understanding are explored here. While rifampicin, oritavancin, linezolid, moxifloxacin and oxacillin were identified as the most effective potential intracellular treatments, the scientific evidence for these is still relatively weak. We advocate for more standardized research on determining the intracellular effectiveness of antibiotics in S. aureus osteomyelitis to improve treatments and patient outcomes.

The value of administering intravenous antibiotics during haemodialysis in the treatment of diabetic foot infections

OBJECTIVE

People with diabetes who are on haemodialysis (HD) are at a high risk of diabetic foot infections (DFI) and related complications. We explored the value of treating DFI with intravenous (IV) antibiotics during HD.

METHOD

This was an observational study of consecutively treated patients with DFIs with IV antibiotics during HD. Data collected included baseline characteristics, IV antibiotics used, details of multidisciplinary interventions and DFI treatment outcome.

RESULTS

A cohort of 11 patients, mean (±standard deviation) age 62.4±12.7 years, had 15 episodes of treatment with IV antibiotics during HD. Of the patients, six (54.5%) were male and nine (81.8%) had type 2 diabetes. The estimated mean glomerular filtration rate (eGFR) was 11.4±3.9ml/minute. All patients had infected foot ulceration, soft tissue infection, six (54.5%) patients had osteomyelitis, and two (18.2%) had wet gangrene. The commonest IV antibiotic used was vancomycin (10/15 episodes, 66.7%). Other IV antibiotics used were daptomycin and meropenem. In three episodes, oral ciprofloxacin was used with IV antibiotics. The mean duration of antibiotic treatment was 9.2±4.9 weeks. Of the episodes, 11 (73.3%) were treated successfully with IV antibiotics alone and two (13.3%) episodes required minor surgical debridement/amputation. Some 10 (90.9%) members of the cohort had peripheral arterial disease and of those, five (50%) underwent angioplasty during IV antibiotic treatment.

CONCLUSION

HD provides a good opportunity for treatment with IV antibiotics in DFI. This mode of administration of IV antibiotics, along with multidisciplinary intervention, is associated with ulcer healing and resolution of infection in over three-quarters of patients with DFI.

DECLARATION OF INTEREST

The authors have no conflicts of interest to declare.

High-strength biodegradable zinc alloy implants with antibacterial and osteogenic properties for the treatment of MRSA-induced rat osteomyelitis

Implant-related infections caused by drug-resistant bacteria remain a major challenge faced by orthopedic surgeons. Furthermore, ideal prevention and treatment methods are lacking in clinical practice. Here, based on the antibacterial and osteogenic properties of Zn alloys, Ag and Li were selected as alloying elements to prepare biodegradable Zn-Li-Ag ternary alloys. Li and Ag addition improved the mechanical properties of Zn-Li-Ag alloys. The Zn-0.8Li-0.5Ag alloy exhibited the highest ultimate tensile strength (>530 MPa). Zn-Li-Ag alloys showed strong bactericidal effects on methicillin-resistant Staphylococcus aureus (MRSA) in vitro. RNA sequencing revealed two MRSA-killing mechanisms exhibited by the Zn-0.8Li-0.5Ag alloy: cellular metabolism disturbance and induction of reactive oxygen species production. To verify that the therapeutic potential of the Zn-0.8Li-0.5Ag alloy is greater than that of Ti intramedullary nails, X-ray, micro-computed tomography, microbiological, and histological analyses were conducted in a rat femoral model of MRSA-induced osteomyelitis. Treatment with Zn-0.8Li-0.5Ag alloy implants resulted in remarkable infection control and favorable bone retention. The in vivo safety of this ternary alloy was confirmed by evaluating vital organ functions and pathological morphologies. We suggest that, with its good antibacterial and osteogenic properties, Zn-0.8Li-0.5Ag alloy can serve as an orthopedic implant material to prevent and treat orthopedic implant-related infections.

Nanotechnology in the Diagnosis and Treatment of Osteomyelitis

Infection remains one of the largest threats to global health. Among those infections that are especially troublesome, osteomyelitis, or inflammation of the bone, typically due to infection, is a particularly difficult condition to diagnose and treat. This difficulty stems not only from the biological complexities of opportunistic infections designed to avoid the onslaught of both the host immune system as well as exogenous antibiotics, but also from changes in the host vasculature and the heterogeneity of infectious presentations. While several groups have attempted to classify and stage osteomyelitis, controversy remains, often delaying diagnosis and treatment. Despite a host of preclinical treatment advances being incubated in academic and company research and development labs worldwide, clinical treatment strategies remain relatively stagnant, including surgical debridement and lengthy courses of intravenous antibiotics, both of which may compromise the overall health of the bone and the patient. This manuscript reviews the current methods for diagnosing and treating osteomyelitis and then contemplates the role that nanotechnology might play in the advancement of osteomyelitis treatment.

Osteocytes Serve as a Reservoir for Intracellular Persisting Staphylococcus aureus Due to the Lack of Defense Mechanisms

Chronic staphylococcal osteomyelitis can persist for long time periods causing bone destruction. The ability of Staphylococcus aureus to develop chronic infections is linked to its capacity to invade and replicate within osteoblasts and osteocytes and to switch to a dormant phenotype called small colony variants. Recently, osteocytes were described as a main reservoir for this pathogen in bone tissue. However, the mechanisms involved in the persistence of S. aureus within these cells are still unknown. Here, we investigated the interaction between S. aureus and osteoblasts or osteocytes during infection. While osteoblasts are able to induce a strong antimicrobial response and eliminate intracellular S. aureus, osteocytes trigger signals to recruit immune cells and enhance inflammation but fail an efficient antimicrobial activity to clear the bacterial infection. Moreover, we found that extracellular signals from osteocytes enhance intracellular bacterial clearance by osteoblasts. Even though both cell types express Toll-like receptor (TLR) 2, the main TLR responsible for S. aureus detection, only osteoblasts were able to increase TLR2 expression after infection. Additionally, proteomic analysis indicates that reduced intracellular bacterial killing activity in osteocytes is related to low antimicrobial peptide expression. Nevertheless, high levels of lipid mediators and cytokines were secreted by osteocytes, suggesting that they can contribute to inflammation. Taken together, our results demonstrate that osteocytes contribute to severe inflammation observed in osteomyelitis and represent the main niche for S. aureus persistence due to their poor capacity for intracellular antimicrobial response.

Epidemiology and Drug Resistance of Fracture-Related Infection of the Long Bones of the Extremities: A Retrospective Study at the Largest Trauma Center in Southwest China

Objective

To describe the demographic characteristics, risk factors, and bacterial resistance of fracture-related infection (FRI) of the long bones of the extremities.

Materials and Methods

This single-center study retrospectively evaluated patients with FRI of the long bones of the extremities at West China Hospital between January 2012 and December 2017, and analyzed the demographic characteristics, risk factors, distribution of pathogenic bacteria, and bacterial drug resistance.

Results

Among 9,900 patients, 535 patients (5.4%) were diagnosed with FRI. The most common site of FRI was tibiofibular (298, 55.7%), with 424 cases (79.2%) of open fractures, and 282 cases (52.7%) due to traffic injuries. The 41–50 years age group had the highest incidence of FRI with 157 (29.3%) cases. Overall, 546 strains of 52 types of bacteria were detected in FRI patients, with 105 strains of multidrug-resistant (MDR) bacteria. Methicillin-resistant Staphylococcus aureus (48, 8.8%) and extended-spectrum-β-lactamase Escherichia coli (32, 5.8%) accounted for the largest proportion. Multivariate logistic regression analysis showed that sex (odds ratio [OR] 1.813; 95% confidence interval [CI], 1.071∼3.070; P = 0.027) and fracture type (OR 3.128; 95% CI, 1.683∼5.815; P < 0.001) were independent risk factors for monomicrobial infection (MI). Female sex (OR 4.190; 95% CI, 1.212∼14.486; P = 0.024) was an independent risk factor for polymicrobial infection (PI).

Conclusion

This study clarified the infection rates, changes in the bacterial spectrum, and drug resistance characteristics, and risk factors of FRI of the long bones of the extremities in the largest trauma center in southwest China.

Skeletal infections: microbial pathogenesis, immunity and clinical management

Osteomyelitis remains one of the greatest risks in orthopaedic surgery. Although many organisms are linked to skeletal infections, Staphylococcus aureus remains the most prevalent and devastating causative pathogen. Important discoveries have uncovered novel mechanisms of S. aureus pathogenesis and persistence within bone tissue, including implant-associated biofilms, abscesses and invasion of the osteocyte lacuno-canalicular network. However, little clinical progress has been made in the prevention and eradication of skeletal infection as treatment algorithms and outcomes have only incrementally changed over the past half century. In this Review, we discuss the mechanisms of persistence and immune evasion in S. aureus infection of the skeletal system as well as features of other osteomyelitis-causing pathogens in implant-associated and native bone infections. We also describe how the host fails to eradicate bacterial bone infections, and how this new information may lead to the development of novel interventions. Finally, we discuss the clinical management of skeletal infection, including osteomyelitis classification and strategies to treat skeletal infections with emerging technologies that could translate to the clinic in the future.

Efficiency of Antimicrobial Peptides Against Multidrug-Resistant Staphylococcal Pathogens

Antibiotics play a vital role in saving millions of lives from fatal infections; however, the inappropriate use of antibiotics has led to the emergence and propagation of drug resistance worldwide. Multidrug-resistant bacteria represent a significant challenge to treating infections due to the limitation of available antibiotics, necessitating the investigation of alternative treatments for combating these superbugs. Under such circumstances, antimicrobial peptides (AMPs), including human-derived AMPs and bacteria-derived AMPs (so-called bacteriocins), are considered potential therapeutic drugs owing to their high efficacy against infectious bacteria and the poor ability of these microorganisms to develop resistance to them. Several staphylococcal species including Staphylococcus aureus, Staphylococcus epidermidis, Staphylococcus haemolyticus, and Staphylococcus saprophyticus are commensal bacteria and known to cause many opportunistic infectious diseases. Methicillin-resistant Staphylococci, especially methicillin-resistant S. aureus (MRSA), are of particular concern among the critical multidrug-resistant infectious Gram-positive pathogens. Within the past decade, studies have reported promising AMPs that are effective against MRSA and other methicillin-resistant Staphylococci. This review discusses the sources and mechanisms of AMPs against staphylococcal species, as well as their potential to become chemotherapies for clinical infections caused by multidrug-resistant staphylococci.

In vitro antibacterial effect of vancomycin hydrogel on methicillin-resistant Staphylococcus aureus

OBJECTIVE

To evaluate the in vitro antibacterial effect of vancomycin hydrogel on methicillin-resistant Staphylococcus aureus (MRSA).

METHODS

We used polylactide glycolide-polyethylene glycol-polylactide glycolide (PLGA-PEG-PLGA) copolymer as a carrier of vancomycin to prepare vancomycin hydrogel. A vancomycin hydrogel group, a PLGA-PEG-PLGA copolymer group, a phosphate-buffered saline (PBS) negative control group and a vancomycin group were set for comparison. Then, we analyzed the in vitro antibacterial effect of each group to determine the minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) and to evaluate the effect of vancomycin hydrogel on the cell activity of bacterial biofilms.

RESULTS

The temperature of the successfully prepared PLGA-PEG-PLGA vancomycin copolymer was slightly lower than normal body temperature. The copolymer reduced both MIC (1 μg/mL) and MBC (2 μg/mL) for MRSA by 1 time. Compared with phosphate buffered saline negative control group and PLGA-PEG-PLGA copolymer group, the MIC vancomycin and vancomycin hydrogel groups showed a reduction of 3 CFU/mL (P<0.05) on the inhibitory effect of original colony count (10⁶ CFU/mL). Though the antibacterial effect of MIC the vancomycin group was significantly better than the vancomycin hydrogel group in the first 12 h, the antibacterial effects of the two were similar after 12 hours. The effect of 1 MIC vancomycin on the cell activity of MRSA biofilm was higher than that of 1 MIC vancomycin hydrogel (P<0.05).

CONCLUSION

Vancomycin hydrogel with a reduced dosage has a similar antibacterial effect to vancomycin. This finding provides a reference for the development of novel sustained-release vancomycin formulations in future treatment of MRSA.

Staphylococcus aureus adhesion to the host

Staphylococcus aureus is a pathobiont capable of colonizing and infecting most tissues within the human body, resulting in a multitude of different clinical outcomes. Adhesion of S. aureus to the host is crucial for both host colonization and the establishment of infections. Underlying the pathogen's success is a complex and diverse arsenal of adhesins. In this review, we discuss the different classes of adhesins, including a consideration of the various adhesion sites throughout the body and the clinical outcomes of each infection type. The development of therapeutics targeting the S. aureus host-pathogen interaction is a relatively understudied area. Due to the increasing global threat of antimicrobial resistance, it is crucial that innovative and alternative approaches are considered. Neutralizing virulence factors, through the development of antivirulence agents, could reduce bacterial pathogenicity and the ever-increasing burden of S. aureus infections. This review provides insight into potentially efficacious adhesion-associated targets for the development of novel decolonizing and antivirulence strategies.

Mini Review Therapeutic Strategies Targeting for Biofilm and Bone Infections

Bone infection results in a complex inflammatory response and bone destruction. A broad spectrum of bacterial species has been involved for jaw osteomyelitis, hematogenous osteomyelitis, vertebral osteomyelitis or diabetes mellitus, such as Staphylococcus aureus (S. aureus), coagulase-negative Staphylococcus species, and aerobic gram-negative bacilli. S. aureus is the major pathogenic bacterium for osteomyelitis, which results in a complex inflammatory response and bone destruction. Although various antibiotics have been applied for bone infection, the emergence of drug resistance and biofilm formation significantly decrease the effectiveness of those agents. In combination with gram-positive aerobes, gram-negative aerobes and anaerobes functionally equivalent pathogroups interact synergistically, developing as pathogenic biofilms and causing recurrent infections. The adhesion of biofilms to bone promotes bone destruction and protects bacteria from antimicrobial agent stress and host immune system infiltration. Moreover, bone is characterized by low permeability and reduced blood flow, further hindering the therapeutic effect for bone infections. To minimize systemic toxicity and enhance antibacterial effectiveness, therapeutic strategies targeting on biofilm and bone infection can serve as a promising modality. Herein, we focus on biofilm and bone infection eradication with targeting therapeutic strategies. We summarize recent targeting moieties on biofilm and bone infection with peptide-, nucleic acid-, bacteriophage-, CaP- and turnover homeostasis-based strategies. The antibacterial and antibiofilm mechanisms of those therapeutic strategies include increasing antibacterial agents’ accumulation by bone specific affinity, specific recognition of phage-bacteria, inhibition biofilm formation in transcription level. As chronic inflammation induced by infection can trigger osteoclast activation and inhibit osteoblast functioning, we additionally expand the potential applications of turnover homeostasis-based therapeutic strategies on biofilm or infection related immunity homeostasis for host-bacteria. Based on this review, we expect to provide useful insights of targeting therapeutic efficacy for biofilm and bone infection eradication.

Successful Treatment with Antibiotics Alone for Infant Rib Osteomyelitis

Pediatric rib osteomyelitis is a rare disease occurring predominantly in the neonatal period and early childhood and accounting for about 1% of all pediatric osteomyelitis. Compared to osteomyelitis in other parts of the body, pediatric rib osteomyelitis shows few localized findings (such as redness and swelling) and often an indolent lesion as well either of which may delay diagnosis and thus make treatment more difficult. A previously healthy one-year-old girl came to our department with a chief complaint of fever lasting for three days. She was admitted to our department to investigate her fever. At the time of admission, radiographs showed decreased permeability in the left lung field; so, we started antimicrobial therapy on the assumption of pneumonia. On the second day of admission, methicillin-susceptible Staphylococcus aureus was detected in the blood culture. A further, more detailed physical examination revealed some slight left anterior chest swelling. We performed a contrast-enhanced CT scan and an MRI and diagnosed her with rib osteomyelitis complicated with a chest wall abscess. She was given intravenous cefazolin for two weeks, switched to oral cephalexin for four weeks, and then recovered completely. She was treated without surgical intervention, having showed a good response to antimicrobial therapy. Osteomyelitis of the ribs in children is reported to be more common in the lower ribs and to occur more frequently in infants. In many cases, the earliest symptoms are nonspecific, so careful examination to detect any subtle abnormalities—such as swelling or mass—is of key importance for early diagnosis in infants. Regarding treatment, most cases of hematogenous osteomyelitis resolve with antimicrobial therapy alone—although surgical intervention may be required in cases of poor response to antimicrobial therapy. Therefore, early diagnosis of rib osteomyelitis through careful physical examination may reduce the chances of requiring surgical intervention.

Transition metal complex laminated bioactive implant alleviates Methicillin Resistant Staphylococcus aureus virulence

Orthopedic implant infections cause a serious threat after implantation. The major source of implant infection is biofilms which are highly tolerant to antibiotics due to the presence of rigid biofilm matrix. Hence to overcome biofilm mediated implant infections, we developed a novel antibiofilm agent, palladium (II) thiazolinyl picolinamide complex (Pd(II)-E). From our study, it was found that Pd(II)-E have profound biofilm inhibition activity and also reduced various virulence factors of Methicillin resistant Staphylococcus aureus (MRSA) including slime synthesis, Phenol soluble modulin (PSM) mediated spreading, Exopolysaccharides production and staphyloxanthin synthesis. Further, Pd(II)-E was coated over the titanium plates which was confirmed using EDX (Energy Dispersive X-Ray) analysis. The Pd(II)-E coated plates were able to prevent the biofilm formation on them which was evident under a Scanning electron microscope (SEM) and several virulent genes were found to be downregulated in the biofilms on the coated titanium plates which confirmed by qPCR. From our findings, it was found that Pd(II)-E coated titanium implants would be an effective alternate approach for preventing biofilm mediated implant infections.

Strategies to Improve the Potency of Oxazolidinones towards Bacterial Biofilms

Biofilms are part of the natural lifecycle of bacteria and are known to cause chronic infections that are difficult to treat. Most antibiotics are developed and tested against bacteria in the planktonic state and are ineffective against bacterial biofilms. The oxazolidinones, including the last resort drug linezolid, are one of the main classes of synthetic antibiotics progressed to clinical use in the last 50 years. They have a unique mechanism of action and only develop low levels of resistance in the clinical setting. With the aim of providing insight into strategies to design more potent antibiotic compounds with activity against bacterial biofilms, we review the biofilm activity of clinically approved oxazolidinones and report on structural modifications to oxazolidinones and their delivery systems which lead to enhanced anti-biofilm activity.

Antimicrobial Photodynamic Therapy Involving a Novel Photosensitizer Combined With an Antibiotic in the Treatment of Rabbit Tibial Osteomyelitis Caused by Drug-Resistant Bacteria

Osteomyelitis is deep tissue inflammation caused by bacterial infection. If such an infection persists, it can lead to dissolution and necrosis of the bone tissue. As a result of the extensive use of antibiotics, drug-resistant bacteria are an increasingly common cause of osteomyelitis, limiting the treatment options available to surgeons. Photodynamic antibacterial chemotherapy has attracted increasing attention as a potential alternative treatment. Its advantages are a broad antibacterial spectrum, lack of drug resistance, and lack of toxic side effects. In this study, we explored the impact of the new photosensitizer LD4 in photodynamic antimicrobial chemotherapy (PACT), both alone and in combination with an antibiotic, on osteomyelitis. A rabbit tibial osteomyelitis model was employed and microbiological, histological, and radiological studies were performed. New Zealand white rabbits (n = 36) were randomly divided into a control group, antibiotic group, PACT group and PACT + antibiotic group for treatment. In microbiological analysis, a reduction in bacterial numbers of more than 99.9% was recorded in the PACT group and the PACT + antibiotic group 5 weeks after treatment (p < 0.01). In histological analysis, repair of the damaged bone tissue was observed in the PACT group, and bone repair in the PACT + antibiotic group was even more significant. In radiological analysis, the X-ray Norden score showed that the severity of bone tissue defects or destruction followed the pattern: PACT + antibiotic group < PACT group < antibiotic group < control group.

Relapsed boyhood tibia polymicrobial osteomyelitis linked to dermatophytosis: a case report

Background

Relapsed childhood polymicrobial osteomyelitis associated with dermatophytosis has not been reported in the literature.

Case presentation

Here we report on a case of a 45-year-old man who had left tibial osteomyelitis for 29 years, accompanied by skin fungal infection of the ipsilateral heel for 20 years, and underwent a second operation due to recurrence of polymicrobial infection 6 years ago. The patient had a history of injury from a rusty object, which penetrated the anterior skin of the left tibia middle segment causing subsequent bone infection, but was asymptomatic after receiving treatments in 1983. The patient was physically normal until dermatophytosis occurred on the ipsilateral heel skin in 1998. The patient complained that the dermatophytosis was gradually getting worse, and the tibial wound site became itchy, red, and swollen. The left tibial infection resurged in May 2012, leading to the patient receiving debridement and antibiotic treatment. H&E and Gram-stained histology was performed on biopsy specimens of sequestrum and surrounding inflammatory tissue. Tissue culture and microbiology examination confirmed polymicrobial infection with Staphylococcus aureus (S. aureus) and Corynebacterium and a fungus. Additionally, the patient also received potassium permanganate for dermatophytosis when he was admitted into the hospital.

Conclusions

Together with longitudinal follow-up of medical history, surgical findings, histopathological and microbiology culture evidence, we conclude that boyhood tibia polymicrobial osteomyelitis with S. aureus and Corynebacterium occurred in this patient, and the fungal activation of dermatophytosis may have led to osteomyelitis relapse.

Early diagnosis and treatment of acute brucellosis knee arthritis complicated by acute osteomyelitis: two cases report

Background

Brucellosis is an endemic systemic infectious disease, the most common complication is bone and joint involvement. Sacroiliac joint and spinal joint are the most frequently involved sites in adults, but knee joint infection is rare, and acute infectious knee arthritis complicated by acute osteomyelitis is even extremely uncommon in adults. Here, we report two cases of acute septic knee arthritis complicated by acute osteomyelitis caused by Brucella melitensis (B. melitensis).

Case presentation

Both patients had a history of traveling in animal husbandry areas within three months. On clinical examination, their right knee joint was tender, swollen, had limited movement and an effusion was present. Imaging examination showed effusion and synovial thickening of the right knee joint, as well as subchondral bone edema of the distal femur and proximal tibia. Laboratory examination showed that the serum agglutination test (SAT) in both patients were positive (1: 640 and 1: 320) without leukocytosis, although the proportion of lymphocytes, erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) significantly increased. Both patients underwent knee joint aspiration. Real-time polymerase chain reaction (Real-time PCR) analysis of synovial fluid showed that there was B. melitensis, and blood bacterial culture was negative. We determined that two patients had acute brucellosis knee arthritis complicated by acute osteomyelitis. Antibiotic treatment was given during hospitalization consisting of doxycycline (0.1 g po bid) and rifampicin (0.6 g po qd) for six weeks, and the changes of inflammatory indexes were closely monitored. At discharge, the symptoms had completely resolved, imaging abnormalities disappeared, and inflammatory indexes returned to normal. There was no recurrence of the disease at 1-year follow-up.

Conclusion

Acute brucellosis knee arthritis complicated by acute osteomyelitis is a rare but serious complication of brucellosis in adults. There is no obvious specificity of clinical manifestation and imaging examination. Early diagnosis and treatment can prevent the occurrence of knee joint deformity and even pathological fracture. Clinicians should fully consider the possibility of brucellosis where the travel or occupational history is suggestive.

Biomimetic Nanomedicine-Triggered in Situ Vaccination for Innate and Adaptive Immunity Activations for Bacterial Osteomyelitis Treatment

The development of bacterial vaccines for inducing an immunoresponse against infectious diseases such as osteomyelitis is of great significance and importance. However, the responsiveness of bacterial immunotherapy remains far from being satisfactory, largely due to the erratic antigen epitopes of bacteria. Herein, we report an in situ vaccination strategy for the immunotherapy of bacterial infection based on an osteomyelitis model using a biomimetic nanomedicine named as HMMP, which was constructed by engineering PpIX-encapsulated hollow MnO_x with a hybrid membrane exfoliated from both macrophage and tumor cell lines. The as-established HMMP features a burst bacterial antigen release as the in situ vaccine by the augmented sonodynamic treatment and the resultant priming of antigen-presenting cells for the following activations of both cellular and humoral adaptive immunities against bacterial infections. This treatment regimen not only triggers initial bacterial regression in the established osteomyelitis model but also simultaneously generates robust systemic antibacterial immunity against poorly immunogenic secondary osteomyelitis in the contralateral knee and additionally confers long-lasting bacteria-specific immune memory responses to prevent infection relapse. Thus, our study provides a proof of concept of in situ vaccination for the activation of both innate and adaptive antibacterial immune responses, providing an individual-independent bacterial immunotherapy.

Role of Animal Models to Advance Research of Bacterial Osteomyelitis

Osteomyelitis is an inflammatory bone disease typically caused by infectious microorganisms, often bacteria, which causes progressive bone destruction and loss. The most common bacteria associated with chronic osteomyelitis is Staphylococcus aureus. The incidence of osteomyelitis in the United States is estimated to be upwards of 50,000 cases annually and places a significant burden upon the healthcare system. There are three general categories of osteomyelitis: hematogenous; secondary to spread from a contiguous focus of infection, often from trauma or implanted medical devices and materials; and secondary to vascular disease, often a result of diabetic foot ulcers. Independent of the route of infection, osteomyelitis is often challenging to diagnose and treat, and the effect on the patient's quality of life is significant. Therapy for osteomyelitis varies based on category and clinical variables in each case. Therapeutic strategies are typically reliant upon protracted antimicrobial therapy and surgical interventions. Therapy is most successful when intensive and initiated early, although infection may recur months to years later. Also, treatment is accompanied by risks such as systemic toxicity, selection for antimicrobial drug resistance from prolonged antimicrobial use, and loss of form or function of the affected area due to radical surgical debridement or implant removal. The challenges of diagnosis and successful treatment, as well as the negative impacts on patient's quality of life, exemplify the need for improved strategies to combat bacterial osteomyelitis. There are many in vitro and in vivo investigations aimed toward better understanding of the pathophysiology of bacterial osteomyelitis, as well as improved diagnostic and therapeutic strategies. Here, we review the role of animal models utilized for the study of bacterial osteomyelitis and their critically important role in understanding and improving the management of bacterial osteomyelitis.

Engineering single-atom catalysts toward biomedical applications

Due to inherent structural defects, common nanocatalysts always display limited catalytic activity and selectivity, making it practically difficult for them to replace natural enzymes in a broad scope of biologically important applications. By decreasing the size of the nanocatalysts, their catalytic activity and selectivity will be substantially improved. Guided by this concept, the advances of nanocatalysts now enter an era of atomic-level precise control. Single-atom catalysts (denoted as SACs), characterized by atomically dispersed active sites, strikingly show utmost atomic utilization, precisely located metal centers, unique metal-support interactions and identical coordination environments. Such advantages of SACs drastically boost the specific activity per metal atom, and thus provide great potential for achieving superior catalytic activity and selectivity to functionally mimic or even outperform natural enzymes of interest. Although the size of the catalysts does matter, it is not clear whether the guideline of "the smaller, the better" is still correct for developing catalysts at the single-atom scale. Thus, it is clearly a new, urgent issue to address before further extending SACs into biomedical applications, representing an important branch of nanomedicine. This review begins by providing an overview of recent advances of synthesis strategies of SACs, which serve as a basis for the discussion of emerging achievements in improving the enzyme-like catalytic properties at an atomic level. Then, we carefully compare the structures and functions of catalysts at various scales from nanoparticles, nanoclusters, and few-atom clusters to single atoms. Contrary to conventional wisdom, SACs are not the most catalytically active catalysts in specific reactions, especially those requiring multi-site auxiliary activities. After that, we highlight the unique roles of SACs toward biomedical applications. To appreciate these advances, the challenges and prospects in rapidly growing studies of SACs-related catalytic nanomedicine are also discussed in this review.

Paediatric Osteomyelitis and Septic Arthritis Pathogen Distribution and Antimicrobial Resistance in a Single Centre: A 15-Year Retrospective Analysis

BACKGROUND

The epidemiological characteristics of the common pathogens underlying acute haematogenous osteoarticular infection (AHOI) and their resistance to drugs have temporal and regional differences.

AIMS

To determine the antimicrobial treatment most effective for culture-negative AHOI patients and those without bacterial cultures.

METHODS

Retrospective analysis of clinical data of children with AHOI who were culture positive from January 2007 to December 2021. And the distribution of the main pathogens and the drug resistance Staphylococcus aureus were analysed in different time periods, age groups and infection types.

RESULTS

A total of 188 cases met the inclusion criteria, including 97 cases of acute haematogenous osteomyelitis (AHO), 75 cases of septic arthritis (SA) and 16 cases of AHO concomitant with SA. The commonest causative pathogen in local children was S. aureus of Gram-positive cocci, followed by Streptococcus, and occasionally Gram-negative bacilli. The distribution of S. aureus had no significant correlation with age or infection type. Staphylococcus aureus accounted for 81.82%, 90.91% and 96.15% of all pathogens, and methicillin-resistant S. aureus (MRSA) accounted for 24.22%, 53.33% and 76.00% of S. aureus in 2007-11, 2012-16 and 2017-21, respectively. The frequency of MRSA infection showed an increasing trend over time.

CONCLUSION

Staphylococcus aureus is still the main pathogen of AHOI in local children. The proportion of MRSA in S. aureus has also increased over time to 76% in the last 5 years, and the increased proportion of MRSA can affect the choice of initial empirical medication.

Surface functionalization with copper endows carbonate apatite honeycomb scaffold with antibacterial, proangiogenic, and pro-osteogenic activities

Osteomyelitis is a potentially devastating inflammatory bone disease that leads to bone destruction and loss. Treatment of osteomyelitis requires the removal of residual bacteria as well as osteogenesis with angiogenesis at the site of treatment. Use of an appropriate amount of copper (Cu) in treatment scaffolds may achieve these goals without the risk of toxicity. In this study, the surface of the carbonate apatite honeycomb scaffold was functionalized with Cu through a dissolution-precipitation reaction. The resulting scaffolds retained the honeycomb structure after immersion in CuCl₂ solution, and Cu was precipitated on the surface as libethenite [Cu₂(OH)PO₄]. The surface Cu concentration was controlled by the concentration of the CuCl₂ solution. Scaffolds with a surface Cu concentration of 23.8 wt% exhibited antibacterial and cytotoxic effects, whereas those with concentrations of ≤4.6 wt% exerted antibacterial effects without negatively affecting the cellular adhesion, proliferation, differentiation, and calcification of osteoblast-like cells. Furthermore, scaffolds with a surface Cu concentration of 4.6 wt% Cu inhibited bacterial growth for at least 28 days and displayed proangiogenic and pro-osteogenic activities in vivo. These data confirm the success in functionalizing scaffolds with Cu that may be utilized as an innovative osteomyelitis therapy.

Long non-coding RNA KCNQ1OT1 overexpression promotes osteogenic differentiation of staphylococcus aureus-infected human bone mesenchymal stem cells by sponging microRNA miR-29b-3p

Osteomyelitis (OM) is an orthopedic disease caused by bone infections in the bone cortex, bone marrow, periosteum, and surrounding soft tissues. Recent studies have implicated non-coding RNAs (ncRNAs) in the development of OM. However, little is known about the role of ncRNAs in the osteogenic differentiation during bone infection. In the present study, we investigated the role of KCNQ1OT1/miR-29b-3p axis in osteogenic differentiation in staphylococcus aureus (SpA)-infected human bone mesenchymal stem cells (hBMSCs). We first examined the expression of lncRNA KCNQ1OT1 and miR-29b-3p in the serum samples of OM patients and healthy controls. We also infected hBMSCs with different concentrations of SpA and studied the osteogenic differentiation after infection. Our results revealed that KCNQ1OT1 was downregulated while miR-29b-3p was upregulated in the serum samples of OM patients, as well as in SpA-infected hBMSCs. Overexpression of KCNQ1OT1 ameliorated the damage in hBMSCs caused by SpA infection. KCNQ1OT1 could support hBMSCs osteogenic differentiation by enhancing ALP activity, alizarin red S accumulation, expressions of osteogenic markers, and attenuating inflammatory responses after SpA infection. We further showed that miR-29b-3p was a downstream target of KCNQ1OT1, mediating the osteogenic differentiation of hBMSCs during SpA infection. Our data suggest that KCNQ1OT1 could ameliorate the SpA-induced suppression of osteogenic differentiation in hBMSCs by sponging miR-29b-3p. Modulating KCNQ1OT1 expression may serve as a strategy to ameliorate osteomyelitis.

Role of Implantable Drug Delivery Devices with Dual Platform Capabilities in the Prevention and Treatment of Bacterial Osteomyelitis

As medicine advances and physicians are able to provide patients with innovative solutions, including placement of temporary or permanent medical devices that drastically improve quality of life of the patient, there is the persistent, recurring problem of chronic bacterial infection, including osteomyelitis. Osteomyelitis can manifest as a result of traumatic or contaminated wounds or implant-associated infections. This bacterial infection can persist as a result of inadequate treatment regimens or the presence of biofilm on implanted medical devices. One strategy to mitigate these concerns is the use of implantable medical devices that simultaneously act as local drug delivery devices (DDDs). This classification of device has the potential to prevent or aid in clearing chronic bacterial infection by delivering effective doses of antibiotics to the area of interest and can be engineered to simultaneously aid in tissue regeneration. This review will provide a background on bacterial infection and current therapies as well as current and prospective implantable DDDs, with a particular emphasis on local DDDs to combat bacterial osteomyelitis.

Ultrasonic Interfacial Engineering of MoS2 -Modified Zn Single-Atom Catalysts for Efficient Osteomyelitis Sonodynamic Ion Therapy

Osteomyelitis is considered as the most serious bone infection, which can lead to the bone destruction or fatal sepsis. Clinical treatments through frequent antibiotics administration and surgical debridement bring inevitable side effects including drug-resistance and disfigurements. It is urgent to develop an antibiotics-free and rapid strategy to treat osteomyelitis. Herein, a bifunctional sonosensitizer that consists of porphyrin-like Zn single-atom catalysts (g-ZnN₄ ) and MoS₂ quantum dots is developed, which exhibits excellent sonodynamic antibacterial efficiency and osteogenic ability. It is found that the construction of heterogeneous interfaces of g-ZnN₄ -MoS₂ fully activates the adsorbed O₂ due to the increased interface charge transfer, enhanced spin-flip, and reduced activation energy of O₂ . The generated ¹ O₂ can kill methicillin-resistant Staphylococcus aureus (MRSA) with an antibacterial efficiency of 99.58% under 20 min of ultrasound (US) irradiation. The Zn single atoms immobilized in g-ZnN₄ can be released steadily in the form of Zn²⁺ for 28 days within safe concentration, realizing the great osteoinductive ability of such a sonosensitizer. For the treatment of MRSA-infected osteomyelitis, the inflammation and bone loss can be significantly suppressed through sonodynamic ion therapy. This work provides another strategy for developing high efficiency sonosensitizer through ultrasound interfacial engineering.