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Kaiser S, Verboket RD, Frank J, Marzi I, Janko M. Effectiveness of combined local therapy with antibiotics and fibrin vs. vacuum-assisted wound therapy in soft tissue infections: a retrospective study. Eur J Trauma Emerg Surg 2024:10.1007/s00068-024-02483-1. [PMID: 38466400 DOI: 10.1007/s00068-024-02483-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2024] [Accepted: 02/20/2024] [Indexed: 03/13/2024]
Abstract
PURPOSE Soft tissue infections can be severe and life-threatening. Their treatment consists currently in radical surgical wound debridement and combined systemic antimicrobial therapy. Different side effects are possible. Local antibiotic therapy represents a new approach to reduce side effects and improve healing. The aim of this study is to assess the effectiveness of the local sprayed use of antibiotics with fibrin sealing compared with negative pressure wound therapy as an established treatment of soft-tissue infections. METHODS In this retrospective study, patients with soft tissue infections who underwent surgical treatment were analysed. One group consists of patients, who received local fibrin-antibiotic spray (FAS) (n = 62). Patients treated by vacuum-assisted wound therapy (VAWT) as the established treatment were the control group (n = 57). Main outcomes were differences in the success of healing, the duration until healing and the number of needed operations. RESULTS Clinical healing could be achieved for 55 patients (98.21%) in the FAS group vs. 47 patients (92.16%) in the VAWT group (p = 0.19). Time to require this was 10.65 ± 10.38 days in the FAS group and 22.85 ± 14.02 days in the VAWT group (p < 0.001). In the FAS group, patients underwent an average of 1.44 ± 0.72 vs.3.46 ± 1.66 operations in the VAWT group (p < 0.001). CONCLUSION Compared to vacuum-assisted wound therapy in soft tissue infections, local fibrin-antibiotic spray shows faster clinical healing and less needed operations. Leading to shorter hospital stays and more satisfied patients. The combination of sprayed fibrin and antibiotics can be seen as a promising and effective method.
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Affiliation(s)
- S Kaiser
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital, Goethe University Frankfurt, Theodor‑Stern‑Kai 7, 60590, Frankfurt am Main, Germany
| | - R D Verboket
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital, Goethe University Frankfurt, Theodor‑Stern‑Kai 7, 60590, Frankfurt am Main, Germany.
| | - J Frank
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital, Goethe University Frankfurt, Theodor‑Stern‑Kai 7, 60590, Frankfurt am Main, Germany
| | - I Marzi
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital, Goethe University Frankfurt, Theodor‑Stern‑Kai 7, 60590, Frankfurt am Main, Germany
| | - M Janko
- Department of Trauma, Hand and Reconstructive Surgery, University Hospital, Goethe University Frankfurt, Theodor‑Stern‑Kai 7, 60590, Frankfurt am Main, Germany
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Kejwal MB, Verboket RD, Sommer K, Dust F, Thomas D, Störmann P, Frank J, Henrich D, Marzi I, Janko MC. Local Gentamicin Fixation with Sprayed Fibrin-An In Vivo Animal Study Reveals New Options to Treat Soft Tissue Infections. J Clin Med 2023; 12:jcm12103390. [PMID: 37240497 DOI: 10.3390/jcm12103390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 05/05/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
For acute and chronic soft tissue infections, radical surgical debridement is required and is considered the gold standard, along with its immediate systemic antibiotic therapy. Treatment with local antibiotics and/or antibiotic-containing materials is commonly used as an additional tool in clinical practice. Spraying with fibrin and antibiotics is a newer technique that has been studied for some antibiotics. However, for gentamicin, data are not yet available on absorption, optimal application, antibiotic fate at the site and transfer of antibiotic into the blood. In an animal study involving 29 Sprague Dawley rats, 116 back wounds were sprayed with gentamicin using either gentamicin alone or one of two possible spray combinations of gentamicin and fibrin. Simultaneous application of gentamicin and fibrin via a spray system to soft tissue wounds resulted in significant antibiotic concentration over a long period of time. The technique is easy and cost-effective. The systemic crossover was significantly minimized in our study, which may have led to fewer side effects in patients. These results could lead to an improvement in local antibiotic therapy.
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Affiliation(s)
- Meike B Kejwal
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - René D Verboket
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Katharina Sommer
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Fabian Dust
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Dominique Thomas
- Institute of Clinical Pharmacology, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Philipp Störmann
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Johannes Frank
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Dirk Henrich
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Ingo Marzi
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
| | - Maren C Janko
- Department of Trauma, Hand and Reconstructive Surgery, Hospital of the Goethe University, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60596 Frankfurt am Main, Germany
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Strickland AD, Lang C, Manhartseder S, Reichsoellner R, Valliant E, Schädl B, Gulle H, Slezak P. In vitro and Ex vivo Assessments of the Compatibility of Fibrin Sealant with Antimicrobial Compounds. Surg Infect (Larchmt) 2023; 24:82-90. [PMID: 36706256 DOI: 10.1089/sur.2022.315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Background: Fibrin sealants are used as antimicrobial-releasing carriers for preventing surgical site infections; however, it is important to determine the release kinetics and antimicrobial effects of drugs added to fibrin sealants and the effects of drugs on clot/clotting properties. Materials and Methods: The antimicrobial and antibiofilm activity of cefazolin, colistin, gentamicin, oxacillin, tobramycin, and silver nitrate released from fibrin sealant were characterized using in vitro and ex vivo assays against bacteria commonly found on the skin. The effects of antimicrobial agents on the physical structure of the fibrin sealant were assessed with scanning electron microscopy (SEM) and on the clotting rate and strength of fibrin clots using run-off tests and rheology. Results: Generally, antibiotic agents were released gradually from fibrin sealant and were stable after release, with antimicrobial effects evident up to three days. Cefazolin, gentamicin, and oxacillin prevented biofilm formation of Staphylococcus aureus in porcine skin explants; gentamicin and colistin prevented biofilm formation of Pseudomonas aeruginosa. Gentamicin, cefazolin, colistin, and tobramycin did not affect the structural integrity or viscoelastic properties of fibrin sealant; changes were observed with oxacillin (SEM) and particularly silver nitrate (SEM and rheology). No antimicrobial agents caused deterioration of clotting time (run-off tests). Conclusions: From the antimicrobial agents tested, gentamicin and cefazolin showed prolonged release from fibrin sealant, sustained antimicrobial activity, and biofilm prevention properties against Staphylococcus aureus; similar results were observed for gentamicin and colistin against Pseudomonas aeruginosa. For each of these findings, the physical structure of the fibrin sealant, clotting rate, and strength of fibrin clots were unaffected.
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Affiliation(s)
| | - Clemens Lang
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria
| | - Stefan Manhartseder
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | - Raffael Reichsoellner
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
| | | | - Barbara Schädl
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria.,University Clinic of Dentistry, Medical University of Vienna, Vienna, Austria
| | - Heinz Gulle
- Baxter Medical Products GmbH, Vienna, Austria
| | - Paul Slezak
- Ludwig Boltzmann Institute for Traumatology, The Research Center in Cooperation with AUVA, Vienna, Austria.,Austrian Cluster for Tissue Regeneration, Vienna, Austria
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Janko M, Dust F, Wagner PV, Gurke R, Frank J, Henrich D, Marzi I, Verboket RD. Local Fixation of Colistin With Fibrin Spray: An in vivo Animal Study for the Therapy of Skin and Soft Tissue Infections. Front Surg 2022; 9:749600. [PMID: 35372468 PMCID: PMC8968937 DOI: 10.3389/fsurg.2022.749600] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Accepted: 02/11/2022] [Indexed: 11/13/2022] Open
Abstract
Objective Skin and soft tissue infections (SSTI) are a commonly known entity of diseases associated with difficult treatment procedures. The current gold standard when there is a rapidly progressing infection of soft tissues with a risk of sepsis is radical surgical debridement accompanied by systemic antibiotic therapy. In clinical settings, local antibiotics alone or formulated within carrier material are commonly used alongside this therapy regimen. One possibility of local antibiotic application is the fixation of colistin with fibrin glue spray. It is not yet sufficiently researched how the local antibiotic concentrations remain as high as possible over time. Methods We conducted an animal study including 29 male Wistar rats inducing sterile back sores reaching the muscle fascia. We sprayed only colistin, simultaneously or consecutively, with fibrin glue in different groups in order to measure the tissue concentration of the antibiotic applied locally. Results After liquid chromatography and quadrupole mass spectrometry analysis, it could be demonstrated that in comparison to the colistin group, tissue concentrations of colistin stayed significantly higher in the wound tissue when it was fixed with fibrin glue. This was observed in both groups, the simultaneous as well as in the consecutively fibrin glue sprayed groups after colistin application. Conclusion The fixation of colistin with the fibrin-glue-spray technique as a carrier for local antibiotic therapy is an easy and inexpensive method and shows promising potential for the treatment of SSTI.
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Affiliation(s)
- Maren Janko
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
- *Correspondence: Maren Janko
| | - Fabian Dust
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - Pia Viktoria Wagner
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt, Germany
| | - Robert Gurke
- Fraunhofer Institute for Translational Medicine and Pharmacology ITMP, Frankfurt, Germany
- Pharmazentrumfrankfurt/ZAFES, Department of Clinical Pharmacology, Johann Wolfgang Goethe University, Frankfurt, Germany
| | - Johannes Frank
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - Dirk Henrich
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
| | - René Danilo Verboket
- Department of Trauma-, Hand and Reconstructive Surgery, Hospital of the Goethe-University, Goethe-University, Frankfurt, Germany
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Leiblein M, Wagner N, Adam EH, Frank J, Marzi I, Nau C. Clostridial Gas Gangrene - A Rare but Deadly Infection: Case series and Comparison to Other Necrotizing Soft Tissue Infections. Orthop Surg 2020; 12:1733-1747. [PMID: 33015993 PMCID: PMC7767692 DOI: 10.1111/os.12804] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 08/07/2020] [Accepted: 08/18/2020] [Indexed: 02/06/2023] Open
Abstract
Objective Clostridial gas gangrene (GG) or clostridial myonecrosis is a very rare but life‐threatening necrotizing soft tissue infection (NSTI) caused by anaerobic, spore‐forming, and gas‐producing clostridium subspecies. It is the most rapidly spreading and lethal infection in humans, also affecting muscle tissue. The high mortality, of up to 100%, in clostridial GG is mediated by potent bacterial exotoxins. Necrotizing fasciitis (NF) is an important differential diagnosis, most often caused by group A streptococci, primarily not affecting musculature but the subcutaneous tissue and fascia. In the early stages of the infection, it is difficult to distinguish between GG and NF. Therefore, we compare both infection types, identify relevant differences in initial clinical presentation and later course, and present the results of our patients in a retrospective review. Methods Patients diagnosed with GG from 2008 to 2018 in our level one trauma center were identified. Their charts were reviewed retrospectively and data analyzed in terms of demographic information, microbiological and histological results, therapeutic course, outcome, and mortality rates. The laboratory risk indicator for NF (LRINEC) score was applied on the first blood work acquired. Results were compared to those of a second group diagnosed with NF. Results Five patients with GG and nine patients with NF were included in the present study. Patients with GG had a mortality rate of 80% compared to 0% in patients with NF. In eight patients with NF, affected limbs could be salvaged; one NF underwent amputation. LRINEC did not show significant differences between the groups; however, C‐reactive protein was significantly increased (P = 0.009) and hemoglobin (Hb) was significantly decreased (P = 0.02) in patients with GG. Interleukin‐6 and procalcitonin levels did not show significant difference. Patients with GG were older (70.2 vs 50 years). Of the isolated bacteria, 86% were sensitive to the initial calculated antibiotic treatment with ampicillin‐sulbactam or imipenem plus metronidazole plus clindamycin. Conclusion Both GG and NF need full‐scale surgical, antibiotic, and intensive care treatment, especially within the first days. Among patients with NSTI, those with clostridial GG have a significantly increased mortality risk due to early septic shock caused by clostridial toxins. In the initial stages, clinical differences are hardly detectable. Immediate surgical debridement is the key to successful therapy for NSTI and needs to be performed as early as possible. However, patients should be treated in a center with an experienced interdisciplinary intensive care team based on a predetermined treatment plan.
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Affiliation(s)
- Maximilian Leiblein
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Nils Wagner
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Elisabeth H Adam
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Johannes Frank
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Ingo Marzi
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
| | - Christoph Nau
- Department of Trauma, Hand, and Reconstructive Surgery, Intensive Care Medicine and Pain Therapy, University Hospital Frankfurt, Frankfurt, Germany
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Leiblein M, Verboket R, Marzi I, Wagner N, Nau C. Nonunions of the humerus - Treatment concepts and results of the last five years. Chin J Traumatol 2019; 22:187-195. [PMID: 31109830 PMCID: PMC6667773 DOI: 10.1016/j.cjtee.2019.04.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2019] [Revised: 04/10/2019] [Accepted: 04/15/2019] [Indexed: 02/04/2023] Open
Abstract
PURPOSE Fractures of the humerus account for 5%-8% of all fractures. Nonunion is found with an incidence of up to 15%, depending on the location of the fracture. In case of a manifest nonunion the surgeon faces a challenging problem and has to conceive a therapy based on the underlying pathology. The aim of this study was to describe our treatment concepts for this entity and present our results of the last five years. METHODS Twenty-six patients were treated for nonunion of the humerus between January 2013 and December 2017. Their charts were reviewed retrospectively and demographic data, pathology, surgical treatment and outcome were assessed. RESULTS The most frequent location for a nonunion was the humeral shaft, with the most common trauma mechanism being multiple falls. Most often atrophic nonunion (n = 14), followed by hypertrophic and infection-caused nonunion (each n = 4), were found. Our treatment concept could be applied in 19 patients, of which in 90% of those who were available for follow-up consolidation could be achieved. CONCLUSION Humeral nonunion is a heterogeneous entity that has to be analyzed precisely and be treated correspondingly. We therefore present a treatment concept based on the underlying pathology.
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