Pathophysiologie der implantatassoziierten Infektion

Ultrasonic Interferometric Procedure for Quantifying the Bone-Implant Interface

The loosening of an artificial joint is a frequent and critical complication in orthopedics and trauma surgery. Due to a lack of accuracy, conventional diagnostic methods such as projection radiography cannot reliably diagnose loosening in its early stages or detect whether it is associated with the formation of a biofilm at the bone-implant interface. In this work, we present a non-invasive ultrasound-based interferometric measurement procedure for quantifying the thickness of the layer between bone and prosthesis as a correlate to loosening. In principle, it also allows for the material characterization of the interface. A well-known analytical model for the superposition of sound waves reflected in a three-layer system was combined with a new method in data processing to be suitable for medical application at the bone-implant interface. By non-linear fitting of the theoretical prediction of the model to the actual shape of the reflected sound waves in the frequency domain, the thickness of the interlayer can be determined and predictions about its physical properties are possible. With respect to determining the layer's thickness, the presented approach was successfully applied to idealized test systems and a bone-implant system in the range of approx. 200 µm to 2 mm. After further optimization and adaptation, as well as further experimental tests, the procedure offers great potential to significantly improve the diagnosis of prosthesis loosening at an early stage and may also be applicable to detecting the formation of a biofilm.

Injectable bone cement containing carboxymethyl cellulose microparticles as a silver delivery system able to reduce implant-associated infection risk

In the challenging quest for a solution to reduce the risk of implant-associated infections in bone substitution surgery, the use of silver ions is promising regarding its broad spectrum on planktonic, sessile as well as multiresistant bacteria. In view of controlling its delivery in situ at the desired dose, we investigated its encapsulation in carboxymethyl cellulose (CMC) microparticles by spray-drying and included the latter in the formulation of a self-setting calcium phosphate bone cement. We implemented an original step-by-step methodology starting from the in vitro study of the antibacterial properties and cytotoxicity of two silver salts of different solubility in aqueous medium and then in the cement to determine the range of silver loading able to confer anti-biofilm and non-cytotoxic properties to the biomaterial. A dose-dependent efficiency of silver was demonstrated on the main species involved in bone-implant infection (S. aureus and S. epidermidis). Loading silver in microspheres instead of loading it directly inside the cement permitted to avoid undesired silver-cement interactions during setting and led to a faster release of silver, i.e. to a higher dose released within the first days combining anti-biofilm activity and preserved cytocompatibility. In addition, a combined interest of the introduction of about 10% (w/w) silver-loaded CMC microspheres in the cement formulation was demonstrated leading to a fully injectable and highly porous (77%) cement, showing a compressive strength analogous to cancellous bone. This injectable silver-loaded biomimetic composite cement formulation constitutes a versatile bone substitute material with tunable drug delivery properties, able to fight against bone implant associated infection. STATEMENT OF SIGNIFICANCE: This study is based on two innovative scientific aspects regarding the literature: i) Choice of silver ions as antibacterial agent combined with their way of incorporation: Carboxymethylcellulose has never been tested into bone cement to control its drug loading and release properties. ii) Methodology to formulate an antibacterial and injectable bone cement: original and multidisciplinary step-by-step methodology to first define, through (micro)biological tests on two silver salts with different solubilities, the targeted range of silver dose to include in carboxymethylcellulose microspheres and, then optimization of silver-loaded microparticles processing to fulfill requirements (encapsulation efficiency and size). The obtained fully injectable composite controls the early delivery of active dose of silver (from 3 h and over 2 weeks) able to fight against bone implant-associated infections.

[Salvage procedure for chronic periprosthetic infection : Use of a rifampicin-loaded polymethyl methacrylate spacer]

Periprosthetic infections with problematic and multiresistant pathogens represent a great challenge for trauma surgeons, especially when repetitive surgical débridement combined with calculated i.v. antibiotic treatment does not lead to resolution of the infection. This can necessitate a deviation from state of the art treatment concepts, such as the additive implementation of a rifampicin-loaded polymethyl methacrylate (PMMA) spacers.

A versatile multicomponent mesoporous silica nanosystem with dual antimicrobial and osteogenic effects

In this manuscript, we propose a simple and versatile methodology to design nanosystems based on biocompatible and multicomponent mesoporous silica nanoparticles (MSNs) for infection management. This strategy relies on the combination of antibiotic molecules and antimicrobial metal ions into the same nanosystem, affording a significant improvement of the antibiofilm effect compared to that of nanosystems carrying only one of these agents. The multicomponent nanosystem is based on MSNs externally functionalized with a polyamine dendrimer (MSN-G3) that favors internalization inside the bacteria and allows the complexation of multiactive metal ions (MSN-G3-Mⁿ⁺). Importantly, the selection of both the antibiotic and the cation may be done depending on clinical needs. Herein, levofloxacin and Zn²⁺ ion, chosen owing to both its antimicrobial and osteogenic capability, have been incorporated. This dual biological role of Zn²⁺ could have and adjuvant effect thought destroying the biofilm in combination with the antibiotic as well as aid to the repair and regeneration of lost bone tissue associated to osteolysis during infection process. The versatility of the nanosystem has been demonstrated incorporating Ag⁺ ions in a reference nanosystem. In vitro antimicrobial assays in planktonic and biofilm state show a high antimicrobial efficacy due to the combined action of levofloxacin and Zn²⁺, achieving an antimicrobial efficacy above 99% compared to the MSNs containing only one of the microbicide agents. In vitro cell cultures with MC3T3-E1 preosteoblasts reveal the osteogenic capability of the nanosystem, showing a positive effect on osteoblastic differentiation while preserving the cell viability. STATEMENT OF SIGNIFICANCE: A simple and versatile methodology to design biocompatible and multicomponent MSNs based nanosystems for infection management is proposed. These nanosystems, containing two antimicrobial agents, levofloxacin and Zn²⁺, have been synthetized by external functionalization of MSNs with a polycationic dendrimer (MSNs-G3), which favours its internalization inside the bacteria and lead the complexation with metal ions through the amines of the dendrimer. The nanosystems offer a notable improvement of the antibiofilm effect (above 99%) than both components separately as well as osteogenic capability with positive effect on the osteoblastic differentiation and preserved cell viability.

[Management of suspected early infection after osteosynthesis]

The infection rate after fracture osteosynthesis depends on many factors. The postoperative infection rate after osteosynthesis (inpatient treatment) was between 1.15% and 2.04% for the years 2017-2019. The total number of postoperative wound infections was estimated at around 225,000 annually in 2018. Essential factors for reducing the infection rate after osteosynthesis are the favorable choice of the timing of the operation and the surgical procedure as well as the treatment of relevant secondary diseases. If a postoperative wound infection is suspected critical assessment of the wounds in the postoperative course is essential in order to be able to identify and treat this complication at an early stage. After osteosynthesis, early diagnosis of a peri-implant infection and differentiated surgical and antibiotic treatment are the prerequisites for the best possible treatment success.

Implant-Associated Infections: A Review of the Safety of Cardiac Implants

Cardiac implantations are among the most critical, and life-saving patient management procedures. Most cardiac implantations are performed to correct abnormalities in the conduction and the rhythm of the heart. Because the implants are intended for long-term use ranging from months to years, the failure of an implant is considered a major setback both in the patients as well as surgeons' perspectives. Implant failures can have multifactorial reasons, amongst which infectious causes need to be adequately addressed. This review attempts to evaluate the nature of implants, etiology, predisposing factors, infection control, and preventive strategies for cardiac implant-associated infections.

KR-12-a5 Reverses Adverse Effects of Lipopolysaccharides on HBMSC Osteogenic Differentiation by Influencing BMP/Smad and P38 MAPK Signaling Pathways

KR-12-a5 is an analogue of the antimicrobial peptide KR-12. Both of these two agents can play key effects in the treatment of infections such as osteomyelitis. Our previous work demonstrated that the osteogenic differentiation of human bone marrow mesenchymal stem cells (HBMSCs) can be enhanced by KR-12. The present study investigated if KR-12-a5 could reverse the adverse effects of lipopolysaccharides (LPS) on HBMSC osteogenesis and the involved molecular mechanisms. We observed the proliferation, cell cycle, and apoptosis of HBMSCs in the presence of KR-12-a5 by a cell counting kit-8 assay and flow cytometry. The osteogenic differentiation of HBMSCs was studied by alkaline phosphatase, Alizarin Red staining, and quantitative assays. Osteogenic differentiation marker levels were detected using real-time quantitative PCR analysis, which demonstrated that KR-12-a5 treatment reversed the inhibition of osteogenesis. Western blot analysis indicated that LPS-activated P38 mitogen-activated protein kinase (MAPK) signaling was inhibited and BMP/Smad pathway was reactivated after KR-12-a5 treatment under induced osteogenic conditions. Furthermore, flow cytometry results demonstrated that KR-12-a5 relieved LPS-induced oxidative stress. Combining the LPS-treated mouse model results, we proved that KR-12-a5 reversed the adverse effects of LPS on HBMSC osteogenic differentiation by influencing the BMP/Smad and P38 MAPK signaling pathways.

Bacitracin promotes osteogenic differentiation of human bone marrow mesenchymal stem cells by stimulating the bone morphogenetic protein-2/Smad axis

Bacitracin, a widely used metallopeptide antibiotic, has been reported to be locally used in treating wounds without systemic adverse reactions. Our preliminary study showed that bacitracin might enhance the osteogenic differentiation of human bone marrow mesenchymal stem cells (HBMSCs). The present study investigated whether bacitracin affects the osteogenic differentiation of HBMSCs and the molecular mechanisms involved. The proliferation of HBMSCs in the presence of bacitracin was examined using a cell counting kit-8 (CCK-8) assay. The effects of bacitracin on the cell cycle and apoptosis of HBMSCs were observed using flow cytometry assay. Staining and quantitative assays for alkaline phosphatase (ALP) staining, collagen deposition (Sirius Red), and mineralization (Alizarin Red) were used to study osteogenic differentiation of HBMSCs. The expression of osteogenic differentiation markers was detected using quantitative reverse transcription polymerase chain reaction (RT-qPCR) analyses. The activation of related signaling pathways was examined using a luciferase reporter assay and western blotting. Bacitracin treatment increased osteogenic differentiation of HBMSCs without cytotoxicity and did not adversely affect cell cycle progression or apoptosis. The luciferase reporter assay showed that bacitracin activated the transcription of bone morphogenetic protein-2 (BMP2) gene, a key gene in the BMP2/Smad signaling axis. Western blotting indicated that this axis was markedly activated by bacitracin stimulation of osteogenesis. Moreover, the activation of Smad phosphorylation and osteogenic differentiation by bacitracin was inhibited by a transforming growth factor (TGF)-β/Smad inhibitor (LDN-193189 HCl) and small interfering RNA (siRNA) gene silencing (si-BMP2). In conclusion, our results suggest that bacitracin can promote osteogenesis of HBMSCs by activating the BMP2/Smad signaling axis.

The antimicrobial peptide KR-12 promotes the osteogenic differentiation of human bone marrow stem cells by stimulating BMP/SMAD signaling

KR-12 is the smallest fragment of human antimicrobial peptide cathelicidin (LL-37), and could play key roles in the treatment of multiple infections, including osteomyelitis. Our preliminary work found that KR-12 enhances the osteogenic differentiation of human bone marrow mesenchymal stem cells (HBMSCs). The present study investigated whether KR-12 affects HBMSC osteogenic differentiation, as well as the molecular mechanisms involved. HBMSC proliferation in the presence of KR-12 was observed with a cell counting 8 assay, and its effects on HBMSC cell cycle progression and apoptosis were examined by flow cytometry. Alkaline phosphatase, Sirius Red, and Alizarin Red staining and quantitative assays were used to study the osteogenic differentiation of HBMSCs. The expression of osteogenic differentiation markers was detected by real-time quantitative PCR analysis. The activation of potentially related pathways was examined by luciferase reporter assay and western blot analysis. KR-12 treatment increased the osteogenic differentiation of HBMSCs without cytotoxicity and did not influence the cell cycle or induce apoptosis. Luciferase reporter assays showed that KR-12 activated the transcription of bone morphogenetic protein 2 (BMP2), a key gene in the BMP/SMAD pathway. Western blot analysis indicated that BMP/SMAD signaling was markedly activated by KR-12 stimulation in osteogenic induction conditions. SMAD phosphorylation was activated by KR-12 treatment, and was inhibited by both a transforming growth factor-β/SMAD inhibitor (LDN-193189 HCL) and BMP2 small interfering RNA (si-BMP2). LDN-193189 HCL and si-BMP2 treatment also abolished the KR-12-induced osteogenic differentiation of HBMSCs. In conclusion, our results suggest that KR-12 promotes HBMSC osteogenesis through the activation of BMP/SMAD signaling.

KR-12 is the smallest fragment of human antimicrobial peptide cathelicidin (LL-37), and could play key roles in the treatment of multiple infections, including osteomyelitis.