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Rajkovic CJ, Tracz JA, DeMordaunt T, Davidar AD, Perdomo-Pantoja A, Judy BF, Zhang KY, Hernandez VN, Lin J, Lazzari JL, Cottrill E, Witham TF. Synthesis and evaluation of a novel vancomycin-infused, biomimetic bone graft using a rat model of spinal implant-associated infection. NORTH AMERICAN SPINE SOCIETY JOURNAL 2024; 18:100323. [PMID: 38746017 PMCID: PMC11091687 DOI: 10.1016/j.xnsj.2024.100323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/11/2023] [Revised: 04/05/2024] [Accepted: 04/06/2024] [Indexed: 05/16/2024]
Abstract
Background Postoperative infection is a complication of spinal fusion surgery resulting in increased patient morbidity. Strategies including intraoperative application of powdered vancomycin have been proposed to reduce the incidence of infection; however, such antimicrobial effects are short-lived. Methods Instrumentation of the L4-L5 vertebrae was performed mimicking pedicle screw and rod fixation in 30 rats. Titanium instrumentation inoculated with either PBS or 1×105 CFU bioluminescent MRSA, along with biomimetic bone grafts infused with varying concentrations of vancomycin and 125 µg of rhBMP-2 (BioMim-rhBMP-2-VCM) were implanted prior to closure. Infection was quantified during the six-week postoperative period using bioluminescent imaging. Arthrodesis was evaluated using micro-CT. Results Infected animals receiving a bone graft infused with low-dose (0.18 mg/g) or high-dose vancomycin (0.89 mg/g) both exhibited significantly lower bioluminescent signal over the six-week postoperative period than control animals inoculated with MRSA and implanted with bone grafts lacking vancomycin (p=.019 and p=.007, respectively). Both low and high-dose vancomycin-infused grafts also resulted in a statistically significant reduction in average bioluminescence when compared to control animals (p=.027 and p=.047, respectively), independent of time. MicroCT analysis of animals from each group revealed pseudoarthrosis only in the control group, suggesting a correlation between infection and pseudoarthrosis. MRSA-inoculated control animals also had significantly less bone volume formation on micro-CT than the PBS-inoculated control cohort (p<.001), the MRSA+low-dose vancomycin-infused bone graft cohort (p<.001), and the MRSA+high-dose vancomycin-infused bone graft cohort (p<.001). Conclusion BioMim-rhBMP-2-VCM presents a novel tissue engineering approach to simultaneously promoting arthrodesis and antimicrobial prophylaxis in spinal fusion. Despite mixed evidence of potential osteotoxicity of vancomycin reported in literature, BioMim-rhBMP-2-VCM preserved arthrodesis and osteogenesis with increasing vancomycin loading doses due to the graft's osteoinductive composition.
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Affiliation(s)
- Christian J Rajkovic
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Jovanna A Tracz
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Trevor DeMordaunt
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - A Daniel Davidar
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Alexander Perdomo-Pantoja
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
- Department of Neurosurgery, Washington University in St. Louis School of Medicine, 660 S. Euclid Avenue Campus Box 8057, St. Louis, MO 63110, United States
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Kevin Yang Zhang
- Department of Pathology, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Vaughn N Hernandez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Jessica Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Julianna L Lazzari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
| | - Ethan Cottrill
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
- Department of Orthopaedic Surgery, Duke University School of Medicine, DUMC Box 104002, Durham, NC 27710, United States
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 1800 Orleans Street, Baltimore, MD 21287, United States
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Rico Nieto A, Loeches Yagüe B, Quiles Melero I, Talavera Buedo G, Pizones J, Fernández-Baillo Sacristana N. [Translated article] Descriptive study of spinal instrumentation-related infections in a tertiary hospital. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:T201-T208. [PMID: 38232934 DOI: 10.1016/j.recot.2024.01.007] [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: 03/14/2023] [Accepted: 08/11/2023] [Indexed: 01/19/2024] Open
Abstract
INTRODUCTION Spinal instrumentation-related infections (SIRI) are one of the main causes of post-surgical complication and comorbidity. Our objective was to describe the clinical and microbiological characteristics, treatment and prognosis of these infections. MATERIAL AND METHODS We conducted a retrospective study in our institution (2011-2018) including adult patients undergoing spinal instrumentation who met the diagnostic criteria for confirmed infection. Superficial surgical wound and deep intraoperative samples were processed for microbiological culture. The medical and orthopaedic team was always the same. RESULTS Forty-one cases were diagnosed of which 39 patients (95.1%) presented early infection (<3 months after initial surgery) with symptoms in the first two weeks, mean CRP at diagnosis was 133mg/dl and 23% associated bacteremia. The remaining two patients (4.8%) were chronic infections (symptoms >3 months after surgery). The treatment of choice in early infections was the Debridement, Antibiotics and Implant Retention (DAIR) strategy without removal of the bone graft, which successfully resolved 84.2% of the infections. The main aetiology was gram-positive (Staphylococcus aureus: 31.7%), followed by gram-negative and polymicrobial flora. Antibiotics were optimised according to cultures with a mean duration of 12 weeks. CONCLUSIONS In early infections, early diagnosis and DAIR strategy (with bone graft retention) demonstrated a healing rate higher than 80%.
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Affiliation(s)
- A Rico Nieto
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, Spain.
| | - B Loeches Yagüe
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, Spain
| | - I Quiles Melero
- Servicio de Microbiología y Parasitología, Hospital Universitario La Paz, Madrid, Spain
| | - G Talavera Buedo
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, Spain
| | - J Pizones
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, Spain
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Rico Nieto A, Loeches Yagüe B, Quiles Melero I, Talavera Buedo G, Pizones J, Fernández-Baillo Sacristana N. Descriptive study of spinal instrumentation-related infections in a tertiary hospital. Rev Esp Cir Ortop Traumatol (Engl Ed) 2024; 68:201-208. [PMID: 37690513 DOI: 10.1016/j.recot.2023.08.019] [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: 03/14/2023] [Revised: 07/21/2023] [Accepted: 08/11/2023] [Indexed: 09/12/2023] Open
Abstract
INTRODUCTION Spinal instrumentation-related infections (SIRI) are one of the main causes of post-surgical complication and comorbidity. Our objective was to describe the clinical and microbiological characteristics, treatment and prognosis of these infections. MATERIAL AND METHODS We conducted a retrospective study in our institution (2011-2018) including adult patients undergoing spinal instrumentation who met the diagnostic criteria for confirmed infection. Superficial surgical wound and deep intraoperative samples were processed for microbiological culture. The medical and orthopaedic team was always the same. RESULTS Forty-one cases were diagnosed of which 39 patients (95.1%) presented early infection (<3 months after initial surgery) with symptoms in the first two weeks, mean CRP at diagnosis was 133mg/dl and 23% associated bacteremia. The remaining two patients (4.8%) were chronic infections (symptoms >3 months after surgery). The treatment of choice in early infections was the Debridement, Antibiotics and Implant Retention (DAIR) strategy without removal of the bone graft, which successfully resolved 84.2% of the infections. The main etiology was gram-positive (Staphylococcus aureus: 31.7%), followed by gram-negative and polymicrobial flora. Antibiotics were optimized according to cultures with a mean duration of 12 weeks. CONCLUSIONS In early infections, early diagnosis and DAIR strategy (with bone graft retention) demonstrated a healing rate higher than 80%.
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Affiliation(s)
- A Rico Nieto
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, España.
| | - B Loeches Yagüe
- Unidad de Infecciosas y Microbiología Clínica, Hospital Universitario La Paz, Madrid, España
| | - I Quiles Melero
- Servicio de Microbiología y Parasitología, Hospital Universitario La Paz, Madrid, España
| | - G Talavera Buedo
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, España
| | - J Pizones
- Unidad de Raquis, Servicio de Traumatología y Cirugía Ortopédica, Hospital Universitario La Paz, Madrid, España
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El Zein S, Berbari EF, Passerini M, Petri F, Maamari J, Murad MH, Sendi P, Tande AJ. Rifampin Based Therapy for Patients With Staphylococcus aureus Native Vertebral Osteomyelitis: A Systematic Review and Meta-analysis. Clin Infect Dis 2024; 78:40-47. [PMID: 37721158 DOI: 10.1093/cid/ciad560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2023] [Revised: 09/01/2023] [Accepted: 09/15/2023] [Indexed: 09/19/2023] Open
Abstract
BACKGROUND Native vertebral osteomyelitis (NVO) caused by Staphylococcus aureus is associated with high risk of treatment failure and increased morbidity. The role of rifampin-based therapy for the treatment of this condition is controversial. The goal of this systematic review and meta-analysis is to explore the efficacy and safety of rifampin-based therapy for the treatment of S. aureus NVO. METHODS We searched Cochrane, Embase, Medline, Scopus, and Web of Science databases for studies published up to May 2023, focusing on adults with NVO treated with or without rifampin-containing regimens. A random-effects model meta-analysis estimated relative risks and risk difference with 95% confidence intervals (CI). RESULTS Thirteen studies (2 randomized controlled trials and 11 comparative cohort studies), comprising 244 patients with S. aureus NVO who received rifampin and 435 who did not, were analyzed. Meta-analysis showed that rifampin-based regimens were associated with lower risk of clinical failure (risk difference, -14%; 95% CI, -19% to -8%; P < .001; I2 = 0%; relative risk, 0.58; 95% CI, .37-.92, P = .02, I2 = 21%). Only 1 study reported on adverse events. All studies had a high or uncertain risk of bias, and the certainty of evidence was rated as very low. CONCLUSIONS Adjunctive rifampin therapy might be associated with lower risk of S. aureus NVO treatment failure; however, the low certainty of evidence precludes drawing definitive conclusions that would alter clinical practice. A randomized trial is necessary to corroborate these findings.
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Affiliation(s)
- Said El Zein
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Elie F Berbari
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Matteo Passerini
- Department of Infectious Disease, ASST FBF SACCO Fatebenefratelli, Milano, Lombardia, Italy
| | - Francesco Petri
- Department of Infectious Disease, ASST FBF SACCO Fatebenefratelli, Milano, Lombardia, Italy
| | - Julian Maamari
- St. Elizabeth's Medical Center, A Boston University Teaching Hospital, Brighton, Massachusetts, USA
| | - M Hassan Murad
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Aaron J Tande
- Division of Public Health, Infectious Diseases and Occupational Medicine, Department of Medicine, Mayo Clinic, Rochester, Minnesota, USA
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Lombès A, Fernandez-Gerlinger MP, Khalifé M, Kassis-Chikhani N, Jomli A, Mainardi JL, Lebeaux D, Dubert M. Efficacy of single antibiotic therapy versus antibiotic combination in implant-free staphylococcal post-surgical spinal infections: a retrospective observational study. BMC Infect Dis 2024; 24:62. [PMID: 38191326 PMCID: PMC10775553 DOI: 10.1186/s12879-024-08977-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 01/02/2024] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND Post-surgical spinal infections (pSSIs) are a serious complication of spinal surgeries, with Staphylococcus spp. being one of the most prominent bacteria identified. Optimal antimicrobial therapy for staphylococcal spinal infections without spinal implants is not well documented. METHODS This single center retrospective 7-year observational study described and compared the outcome (treatment failure or mortality rate one year after diagnosis) of 20 patients with staphylococcal-implant-free pSSI treated with single or combination antibiotics. RESULTS Median duration of treatment was 40 days (IQR 38-42), with 6 days (IQR 5-7) on intravenous antibiotics and 34 days (IQR 30-36) on oral therapy. Four patients (20%) underwent new surgical debridement, all due to surgical failure, and 1 patient died within the first year without significant differences between both treatment group. CONCLUSION This study raises the possibility of single antibiotic therapy for patients with implant-free post-surgical spinal infections due to Staphylococcus spp.
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Affiliation(s)
- Amélie Lombès
- Mobile infectious disease unit, Service de Microbiologie, AP-HP, Hôpital Européen Georges Pompidou, APHP-Centre, 20 rue Leblanc, 75015, Paris, France.
| | - Marie-Paule Fernandez-Gerlinger
- Mobile infectious disease unit, Service de Microbiologie, AP-HP, Hôpital Européen Georges Pompidou, APHP-Centre, 20 rue Leblanc, 75015, Paris, France
| | - Marc Khalifé
- Orthopedic surgery unit, AP-HP, Hôpital Européen Georges Pompidou, APHP-Centre, 20 rue Leblanc, 75015, Paris, France
- Paris Cité university, 75006, Paris, France
| | - Najiby Kassis-Chikhani
- Infection control unit, AP-HP, Hôpital Européen Georges Pompidou, APHP-Centre, 20 rue Leblanc, 75015, Paris, France
| | - Amira Jomli
- Microbiology laboratory, AP-HP, Hôpital Européen Georges Pompidou, APHP- Centre, 20 rue Leblanc, 75015, Paris, France
| | - Jean-Luc Mainardi
- Mobile infectious disease unit, Service de Microbiologie, AP-HP, Hôpital Européen Georges Pompidou, APHP-Centre, 20 rue Leblanc, 75015, Paris, France
- Microbiology laboratory, AP-HP, Hôpital Européen Georges Pompidou, APHP- Centre, 20 rue Leblanc, 75015, Paris, France
- Paris Cité university, 75006, Paris, France
| | - David Lebeaux
- Mobile infectious disease unit, Service de Microbiologie, AP-HP, Hôpital Européen Georges Pompidou, APHP-Centre, 20 rue Leblanc, 75015, Paris, France
- Paris Cité university, 75006, Paris, France
- 3-FHU PROTHEE, Paris, France
| | - Marie Dubert
- Mobile infectious disease unit, Service de Microbiologie, AP-HP, Hôpital Européen Georges Pompidou, APHP-Centre, 20 rue Leblanc, 75015, Paris, France
- Paris Cité university, 75006, Paris, France
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Coenye T. Biofilm antimicrobial susceptibility testing: where are we and where could we be going? Clin Microbiol Rev 2023; 36:e0002423. [PMID: 37812003 PMCID: PMC10732061 DOI: 10.1128/cmr.00024-23] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/27/2023] [Indexed: 10/10/2023] Open
Abstract
Our knowledge about the fundamental aspects of biofilm biology, including the mechanisms behind the reduced antimicrobial susceptibility of biofilms, has increased drastically over the last decades. However, this knowledge has so far not been translated into major changes in clinical practice. While the biofilm concept is increasingly on the radar of clinical microbiologists, physicians, and healthcare professionals in general, the standardized tools to study biofilms in the clinical microbiology laboratory are still lacking; one area in which this is particularly obvious is that of antimicrobial susceptibility testing (AST). It is generally accepted that the biofilm lifestyle has a tremendous impact on antibiotic susceptibility, yet AST is typically still carried out with planktonic cells. On top of that, the microenvironment at the site of infection is an important driver for microbial physiology and hence susceptibility; but this is poorly reflected in current AST methods. The goal of this review is to provide an overview of the state of the art concerning biofilm AST and highlight the knowledge gaps in this area. Subsequently, potential ways to improve biofilm-based AST will be discussed. Finally, bottlenecks currently preventing the use of biofilm AST in clinical practice, as well as the steps needed to get past these bottlenecks, will be discussed.
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Affiliation(s)
- Tom Coenye
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium
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Pichler L, Li Z, Khakzad T, Perka C, Pumberger M, Schömig F. Microbial spectrum, patient-specific factors, and diagnostics in implant-related postoperative spondylodiscitis. Bone Jt Open 2023; 4:832-838. [PMID: 37918440 PMCID: PMC10622184 DOI: 10.1302/2633-1462.411.bjo-2023-0087.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2023] Open
Abstract
Aims Implant-related postoperative spondylodiscitis (IPOS) is a severe complication in spine surgery and is associated with high morbidity and mortality. With growing knowledge in the field of periprosthetic joint infection (PJI), equivalent investigations towards the management of implant-related infections of the spine are indispensable. To our knowledge, this study provides the largest description of cases of IPOS to date. Methods Patients treated for IPOS from January 2006 to December 2020 were included. Patient demographics, parameters upon admission and discharge, radiological imaging, and microbiological results were retrieved from medical records. CT and MRI were analyzed for epidural, paravertebral, and intervertebral abscess formation, vertebral destruction, and endplate involvement. Pathogens were identified by CT-guided or intraoperative biopsy, intraoperative tissue sampling, or implant sonication. Results A total of 32 cases of IPOS with a mean patient age of 68.7 years (37.6 to 84.1) were included. Diabetes, age > 60 years, and history of infection were identified as risk factors. Patient presentation upon admission included a mean body temperature of 36.7°C (36.1 to 38.0), back pain at rest (mean visual analogue scale (VAS) mean 5/10) and when mobile (mean VAS 6/10), as well as elevated levels of CRP (mean 76.8 mg/l (0.4 to 202.9)) and white blood cell count (mean 9.2 units/nl (2.6 to 32.8)). Pathogens were identified by CT-guided or conventional biopsy, intraoperative tissue sampling, or sonication, and Gram-positive cocci presented as the most common among them. Antibiotic therapy was established in all cases with pathogen-specific treatment in 23 (71.9%) subjects. Overall 27 (84.4%) patients received treatment by debridement, decompression, and fusion of the affected segment. Conclusion Cases of IPOS are rare and share similarities with spontaneous spondylodiscitis. While procedures such as CT-guided biopsy and sonication are valuable tools in the diagnosis of IPOS, MRI and intraoperative tissue sampling remain the gold standard. Research on known principles of PJI such as implant retention versus implant exchange need to be expanded to the field of spine surgery.
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Affiliation(s)
- Lorenz Pichler
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Zhao Li
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Thilo Khakzad
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Carsten Perka
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Friederike Schömig
- Center for Musculoskeletal Surgery Charité – Universitätsmedizin Berlin, Berlin, Germany
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Abbas S, Yasmin A, Maqbool N, Shah AA, Fariq A. Insights into the microbiological and virulence characteristics of bacteria in orthopaedic implant infections: A study from Pakistan. PLoS One 2023; 18:e0292956. [PMID: 37847701 PMCID: PMC10581495 DOI: 10.1371/journal.pone.0292956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Accepted: 10/03/2023] [Indexed: 10/19/2023] Open
Abstract
The exponential increase in the prevalence of multidrug resistant bacteria has resulted in limiting surgical treatment options globally, potentially causing biofilm-related complications, implant failure, and severe consequences. This study aims to isolate and characterize bacteria from post-surgical orthopaedic implant infections and screening for multiple antibiotic resistance. A cross-sectional study was conducted, involving isolation of forty-four dominant pathogenic bacterial isolates from 16 infected implant samples from across Islamabad and Rawalpindi. Out of forty-four, 38% cocci and 61% bacilli were obtained. Approximately 90% of isolates showed multiple antibiotic resistance (MAR) index of more than 0.2. Eleven strains were identified via 16S rRNA gene sequencing as Pseudomonas aeruginosa, Bacillus spp., Planococcus chinensis, Staphylococcus, Escherichia coli and Enterobacter cloacae. The bacterial strain E. coli MB641 showed sensitivity to Polymyxin only, and was resistant to all other antibiotics used. Maximum biofilm forming ability 0.532 ± 0.06, 0.55 ± 0.01 and 0.557 ± 0.07 was observed in Pseudomonas aeruginosa MB663, Pseudomonas aeruginosa MB664 and Bacillus spp. MB647 respectively after 24 hours of incubation. EPS production of bacterial strains was assessed, the polysaccharides and protein content of EPS were found to be in the range of 11-32 μg/ml and 2-10 μg/ml, respectively. Fourier transform infrared spectroscopic analysis of EPS showed the presence of carbohydrates, proteins, alkyl halides, and nucleic acids. X-ray diffraction analysis revealed crystalline structure of EPS extracted from biofilm forming bacteria. These findings suggest a high prevalence of antibiotic-resistant bacteria in orthopaedic implant-associated surgeries, highlighting the urgent need for ongoing monitoring and microorganism testing in infected implants.
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Affiliation(s)
- Sidra Abbas
- Microbiology and Biotechnology Research laboratory, Department of Biotechnology, Fatima Jinnah Women University, Rawalpindi, Pakistan
| | - Azra Yasmin
- Microbiology and Biotechnology Research laboratory, Department of Biotechnology, Fatima Jinnah Women University, Rawalpindi, Pakistan
| | - Nouman Maqbool
- Department of Orthopaedic Surgery, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Asim Ali Shah
- Microbiology Laboratory, Fauji Foundation Hospital, Rawalpindi, Pakistan
| | - Anila Fariq
- Microbiology and Biotechnology Research laboratory, Department of Biotechnology, Fatima Jinnah Women University, Rawalpindi, Pakistan
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DeMourdant T, Rajkovic CJ, Tracz JA, Perdomo-Pantoja A, Judy BF, Hernandez VN, Lin J, Lazzari JL, Dikeman DA, Archer NK, Davis KM, Gordon O, Witham TF. A novel rodent model of chronic spinal implant-associated infection. Spine J 2023; 23:1389-1399. [PMID: 37247639 PMCID: PMC10530089 DOI: 10.1016/j.spinee.2023.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/15/2023] [Accepted: 05/23/2023] [Indexed: 05/31/2023]
Abstract
BACKGROUND CONTEXT Bacterial infection of spinal instrumentation is a significant challenge in spinal fusion surgery. Although the intraoperative local application of powdered vancomycin is common practice for mitigating infection, the antimicrobial effects of this route of administration are short-lived. Therefore, novel antibiotic-loaded bone grafts as well as a reliable animal model to permit the testing of such therapies are needed to improve the efficacy of infection reduction practices in spinal fusion surgery. PURPOSE This study aims to establish a clinically relevant rat model of spinal implant-associated infection to permit the evaluation of antimicrobial bone graft materials used in spinal fusion. STUDY DESIGN Rodent study of chronic spinal implant-associated infection. METHODS Instrumentation anchored in and spanning the vertebral bodies of L4 and L5 was inoculated with bioluminescent methicillin-resistant Staphylococcus aureus bacteria (MRSA). Infection was monitored using an in vivo imaging system (IVIS) for 8 weeks. Spines were harvested and evaluated histologically, and colony-forming units (CFUs) were quantified in harvested implants and spinal tissue. RESULTS Postsurgical analysis of bacterial infection in vivo demonstrated stratification between MRSA and phosphate-buffered saline (PBS) control groups during the first 4 weeks of the 8-week infection period, indicating the successful establishment of acute infection. Over the 8-week chronic infection period, groups inoculated with 1 × 105 MRSA CFU and 1 × 106 MRSA CFU demonstrated significantly higher bioluminescence than groups inoculated with PBS control (p = 0.009 and p = 0.041 respectively). Histological examination at 8 weeks postimplantation revealed the presence of abscesses localized to implant placement in all MRSA inoculation groups, with the most pervasive abscess formation in samples inoculated with 1 × 105 MRSA CFU and 1 × 106 MRSA CFU. Quantification of CFU plated from harvested spinal tissue at 8 weeks post-implantation revealed the 1 × 105 MRSA CFU inoculation group as the only group with a significantly greater average CFU count compared to PBS control (p = 0.017). Further, CFU quantification from harvested spinal tissue was greater than CFU quantification from harvested implants across all inoculation groups. CONCLUSION Our model demonstrated that the inoculation dosage of 1 × 105 MRSA CFU exhibited the most robust chronic infection within instrumented vertebral bodies. This dosage had the greatest difference in bioluminescence signal from control (p < 0.01), the lowest mortality (0% compared to 50% for samples inoculated with 1 × 106 MRSA CFU), and a significantly higher amount of CFUs from harvested spine samples than CFUs from control harvested spine samples. Further, histological analysis confirmed the reliability of this novel rodent model of implanted-associated infection to establish infection and biofilm formation of MRSA for all inoculation groups. CLINICAL SIGNIFICANCE This model is intended to simulate the infection of instrumentation used in spinal fusion surgeries concerning implant locality and material. This model may evaluate potential antimicrobial and osteogenic biomaterials and investigate the relationship between implant-associated infection and failed fusion.
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Affiliation(s)
- Trevor DeMourdant
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA
| | - Christian J Rajkovic
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA
| | - Jovanna A Tracz
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA
| | - Alexander Perdomo-Pantoja
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA; Department of Neurosurgery, Washington University in St. Louis School of Medicine, 660 S. Euclid Ave, St. Louis, MO 63110, USA
| | - Brendan F Judy
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA
| | - Vaughn N Hernandez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA
| | - Jessica Lin
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA
| | - Julianna L Lazzari
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA
| | - Dustin A Dikeman
- Department of Dermatology, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD 21287, USA
| | - Nathan K Archer
- Department of Dermatology, Johns Hopkins University School of Medicine, 601 N. Caroline St, Baltimore, MD 21287, USA
| | - Kimberly M Davis
- Johns Hopkins Bloomberg School of Public Health, 615 N. Wolfe St, Baltimore, MD 21205, USA
| | - Oren Gordon
- Infectious Diseases Unit, Department of Pediatrics, Hadassah Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Ein Kerem PO Box 12271, Jerusalem 9112102 , Israel
| | - Timothy F Witham
- Department of Neurosurgery, Johns Hopkins University School of Medicine, 600 N. Wolfe St, Meyer 7-109 Baltimore, MD 21287, USA.
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Ferry T, Kolenda C, Laurent F, Leboucher G, Merabischvilli M, Djebara S, Gustave CA, Perpoint T, Barrey C, Pirnay JP, Resch G. Personalized bacteriophage therapy to treat pandrug-resistant spinal Pseudomonas aeruginosa infection. Nat Commun 2022; 13:4239. [PMID: 35869081 PMCID: PMC9306240 DOI: 10.1038/s41467-022-31837-9] [Citation(s) in RCA: 38] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2022] [Accepted: 07/04/2022] [Indexed: 12/17/2022] Open
Abstract
Bone and joint infections (BJI) are one of the most difficult-to-treat bacterial infection, especially in the era of antimicrobial resistance. Lytic bacteriophages (phages for short) are natural viruses that can selectively target and kill bacteria. They are considered to have a high therapeutic potential for the treatment of severe bacterial infections and especially BJI, as they also target biofilms. Here we report on the management of a patient with a pandrug-resistant Pseudomonas aeruginosa spinal abscess who was treated with surgery and a personalized combination of phage therapy that was added to antibiotics. As the infecting P. aeruginosa strain was resistant to the phages developed by private companies that were contacted, we set up a unique European academic collaboration to find, produce and administer a personalized phage cocktail to the patient in due time. After two surgeries, despite bacterial persistence with expression of small colony variants, the patient healed with local and intravenous injections of purified phages as adjuvant therapy. Here, the authors describe a patient with a pandrug-resistant Pseudomonas aeruginosa spinal abscess successfully treated with a personalized combination of phage therapy and antibiotics.
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11
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An ionic silver coating prevents implant-associated infection by anaerobic bacteria in vitro and in vivo in mice. Sci Rep 2022; 12:18387. [PMID: 36319854 PMCID: PMC9626628 DOI: 10.1038/s41598-022-23322-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2022] [Accepted: 10/29/2022] [Indexed: 11/07/2022] Open
Abstract
Currently, implants are utilized clinically for bone transplant procedures. However, if infectious osteomyelitis occurs at implant sites, removal of bacteria can be challenging. Moreover, altered blood flow at peri-implant infectious sites can create an anaerobic environment, making it more difficult to treat infection with antibiotics. Thus, it would be beneficial if implants could be modified to exhibit antibacterial activity, even in anaerobic conditions. Here, we show antibacterial activity of silver ions coated on titanium rods, even against the anaerobic bacteria Porphyromonas gingivalis (P. gingivalis), both in vitro and in vivo. Specifically, we implanted silver-coated or control uncoated titanium rods along with P. gingivalis in mouse femoral bone BM cavities and observed significantly inhibited P. gingivalis infection with silver-coated compared with non-coated rods, based on in vivo bio-imaging. Osteonecrosis by infectious osteomyelitis and elevation of the inflammatory factors C-reactive protein and IL-6 promoted by P. gingivalis s were also significantly reduced in the presence of silver-coated rods. Overall, our study indicates that silver ion coating of an implant represents a therapeutic option to prevent associated infection, even in anaerobic conditions or against anaerobic bacteria.
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12
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Does Postoperative Spine Infection Bacterial Gram Type Affect Surgical Debridement or Antibiotic Duration? Spine (Phila Pa 1976) 2022; 47:1497-1504. [PMID: 35867579 DOI: 10.1097/brs.0000000000004405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/26/2022] [Indexed: 02/01/2023]
Abstract
STUDY DESIGN This is a retrospective cohort study. OBJECTIVE The aim was to evaluate differences in readmission rates, number of debridements, and length of antibiotic therapy when comparing bacterial gram type following lumbar spinal fusion infections. SUMMARY OF BACKGROUND DATA Surgical site infections (SSIs) after spinal fusion serve as a significant source of patient morbidity. It remains to be elucidated how bacterial classification of the infecting organism affects the management of postoperative spinal SSI. METHODS Patients who underwent spinal fusion with a subsequent diagnosis of SSI between 2013 and 2019 were retrospectively identified. Patients were grouped based on bacterial infection type (gram-positive, gram-negative, or mixed infections). Poisson regressions analyzed the relationship between the type of bacterial infection and the number of irrigation and debridement (I&D) reoperations, and the duration of intravenous (IV) antibiotic therapy. Significance was set at P <0.05. RESULTS Of 190 patients, 92 had gram-positive (G+) infections, 57 had gram-negative (G-) infections, and 33 had mixed (M) infections. There was no difference in 30 or 90-day readmissions for infection between groups (both P =0.051). Patients in the M group had longer durations of IV antibiotic treatment (G+: 46.4 vs. G-: 41.0 vs. M: 55.9 d, P =0.002). Regression analysis demonstrated mixed infections were 46% more likely to require a greater number of debridements ( P =0.001) and 18% more likely to require an increased duration of IV antibiotic therapy ( P <0.001), while gram-negative infections were 10% less likely to require an increased duration of IV antibiotic therapy ( P <0.001) when compared with G- infections. CONCLUSION Spinal SSI due to a mixed bacterial gram type results in an increased number of debridements and a longer duration of IV antibiotics required to resolve the infection compared with gram-negative or gram-positive infections. LEVEL OF EVIDENCE Level III.
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13
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Li J, Cheung WH, Chow SK, Ip M, Leung SYS, Wong RMY. Current therapeutic interventions combating biofilm-related infections in orthopaedics : a systematic review of in vivo animal studies. Bone Joint Res 2022; 11:700-714. [PMID: 36214177 PMCID: PMC9582863 DOI: 10.1302/2046-3758.1110.bjr-2021-0495.r3] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Aims Biofilm-related infection is a major complication that occurs in orthopaedic surgery. Various treatments are available but efficacy to eradicate infections varies significantly. A systematic review was performed to evaluate therapeutic interventions combating biofilm-related infections on in vivo animal models. Methods Literature research was performed on PubMed and Embase databases. Keywords used for search criteria were “bone AND biofilm”. Information on the species of the animal model, bacterial strain, evaluation of biofilm and bone infection, complications, key findings on observations, prevention, and treatment of biofilm were extracted. Results A total of 43 studies were included. Animal models used included fracture-related infections (ten studies), periprosthetic joint infections (five studies), spinal infections (three studies), other implant-associated infections, and osteomyelitis. The most common bacteria were Staphylococcus species. Biofilm was most often observed with scanning electron microscopy. The natural history of biofilm revealed that the process of bacteria attachment, proliferation, maturation, and dispersal would take 14 days. For systemic mono-antibiotic therapy, only two of six studies using vancomycin reported significant biofilm reduction, and none reported eradication. Ten studies showed that combined systemic and topical antibiotics are needed to achieve higher biofilm reduction or eradication, and the effect is decreased with delayed treatment. Overall, 13 studies showed promising therapeutic potential with surface coating and antibiotic loading techniques. Conclusion Combined topical and systemic application of antimicrobial agents effectively reduces biofilm at early stages. Future studies with sustained release of antimicrobial and biofilm-dispersing agents tailored to specific pathogens are warranted to achieve biofilm eradication. Cite this article: Bone Joint Res 2022;11(10):700–714.
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Affiliation(s)
- Jie Li
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Wing-Hoi Cheung
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Simon K. Chow
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China
| | - Margaret Ip
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong, China
| | - Sharon Y. S. Leung
- School of Pharmacy, The Chinese University of Hong Kong, Hong Kong, China
| | - Ronald M. Y. Wong
- Department of Orthopaedics & Traumatology, The Chinese University of Hong Kong, Hong Kong, China, Ronald Man Yeung Wong. E-mail:
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14
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Laubach M, Kobbe P, Hutmacher DW. Biodegradable interbody cages for lumbar spine fusion: Current concepts and future directions. Biomaterials 2022; 288:121699. [PMID: 35995620 DOI: 10.1016/j.biomaterials.2022.121699] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/16/2022]
Abstract
Lumbar fusion often remains the last treatment option for various acute and chronic spinal conditions, including infectious and degenerative diseases. Placement of a cage in the intervertebral space has become a routine clinical treatment for spinal fusion surgery to provide sufficient biomechanical stability, which is required to achieve bony ingrowth of the implant. Routinely used cages for clinical application are made of titanium (Ti) or polyetheretherketone (PEEK). Ti has been used since the 1980s; however, its shortcomings, such as impaired radiographical opacity and higher elastic modulus compared to bone, have led to the development of PEEK cages, which are associated with reduced stress shielding as well as no radiographical artefacts. Since PEEK is bioinert, its osteointegration capacity is limited, which in turn enhances fibrotic tissue formation and peri-implant infections. To address shortcomings of both of these biomaterials, interdisciplinary teams have developed biodegradable cages. Rooted in promising preclinical large animal studies, a hollow cylindrical cage (Hydrosorb™) made of 70:30 poly-l-lactide-co-d, l-lactide acid (PLDLLA) was clinically studied. However, reduced bony integration and unfavourable long-term clinical outcomes prohibited its routine clinical application. More recently, scaffold-guided bone regeneration (SGBR) with application of highly porous biodegradable constructs is emerging. Advancements in additive manufacturing technology now allow the cage designs that match requirements, such as stiffness of surrounding tissues, while providing long-term biomechanical stability. A favourable clinical outcome has been observed in the treatment of various bone defects, particularly for 3D-printed composite scaffolds made of medical-grade polycaprolactone (mPCL) in combination with a ceramic filler material. Therefore, advanced cage design made of mPCL and ceramic may also carry initial high spinal forces up to the time of bony fusion and subsequently resorb without clinical side effects. Furthermore, surface modification of implants is an effective approach to simultaneously reduce microbial infection and improve tissue integration. We present a design concept for a scaffold surface which result in osteoconductive and antimicrobial properties that have the potential to achieve higher rates of fusion and less clinical complications. In this review, we explore the preclinical and clinical studies which used bioresorbable cages. Furthermore, we critically discuss the need for a cutting-edge research program that includes comprehensive preclinical in vitro and in vivo studies to enable successful translation from bench to bedside. We develop such a conceptual framework by examining the state-of-the-art literature and posing the questions that will guide this field in the coming years.
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Affiliation(s)
- Markus Laubach
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany.
| | - Philipp Kobbe
- Department of Orthopaedics, Trauma and Reconstructive Surgery, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074 Aachen, Germany
| | - Dietmar W Hutmacher
- Australian Research Council (ARC) Training Centre for Cell and Tissue Engineering Technologies, Queensland University of Technology (QUT), Brisbane, QLD, 4000 Australia; Australian Research Council (ARC) Training Centre for Multiscale 3D Imaging, Modelling, and Manufacturing (M3D Innovation), Queensland University of Technology, Brisbane, QLD 4000, Australia; Centre for Biomedical Technologies, School of Mechanical, Medical and Process Engineering, Queensland University of Technology, Brisbane, QLD 4059, Australia; Max Planck Queensland Center for the Materials Science of Extracellular Matrices, Queensland University of Technology, Brisbane, QLD 4000, Australia.
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15
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Karczewski D, Schnake KJ, Osterhoff G, Spiegl U, Scheyerer MJ, Ullrich B, Pumberger M. Postoperative Spinal Implant Infections (PSII)-A Systematic Review: What Do We Know So Far and What is Critical About It? Global Spine J 2022; 12:1231-1246. [PMID: 34151619 PMCID: PMC9210225 DOI: 10.1177/21925682211024198] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
STUDY DESIGN Systematic review. OBJECTIVES Postoperative spinal implant infections (PSII) are an increasing challenge in the daily clinical routine. This review summarizes existing knowledge in the field of PSII, including definitions, epidemiology, classifications, risk factors, pathogenesis, symptoms, diagnosis, and treatment. METHODS A systematic review was performed using a structured PubMed analysis, based on the PRISMA criteria. The search terminology was set as: "spinal implant associated infection OR spinal implant infection OR spinal instrumentation infection OR peri spinal implant infection." PubMed search was limited to the categories randomized controlled trials (RCT), clinical trials, meta-analysis and (systematic) reviews, whereas case reports were excluded. Studies from January 2000 to December 2020 were considered eligible. A total of 572 studies were identified, 82 references included for qualitative synthesis, and 19 for detailed sub analysis (12 meta-analysis, 7 prospective RCT). RESULTS Structural problems in the field of PSII were revealed, including (1) limited level of evidence in clinical studies (missing prospective RCT, metanalyzes), (2) small patient numbers, (3) missing standardized definitions, (4) heterogeneity in patient groups, and (5) redundancy in cited literature. CONCLUSION Evidence-based knowledge about spinal implant-associated infections is lacking. All involved medical fields should come together to define the term PSII and to combine their approaches toward research, training, and patient care.
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Affiliation(s)
- Daniel Karczewski
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité–Universitaetsmedizin Berlin, Berlin, Germany,Daniel Karczewski, Department of Orthopaedics, Center for Musculoskeletal Surgery, Charité—Universitätsmedizin Berlin, Charitéplatz 1, D-10117 Berlin, Germany.
| | - Klaus J. Schnake
- Center for Spinal and Scoliosis Surgery, Malteser Waldkrankenhaus St. Marien, Erlangen, Germany,Department of Orthopedics and Traumatology, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Georg Osterhoff
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Ulrich Spiegl
- Department of Orthopaedics, Trauma and Plastic Surgery, University Hospital Leipzig, Leipzig, Germany
| | - Max J. Scheyerer
- Department of Orthopedic and Trauma Surgery, Medical Faculty, University of Cologne, Cologne, Germany
| | - Bernhard Ullrich
- Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany,Department of Trauma and Reconstructive Surgery, BG Clinic Bergmannstrost, Halle (Saale), Germany
| | - Matthias Pumberger
- Center for Musculoskeletal Surgery, Department of Orthopaedic Surgery, Charité–Universitaetsmedizin Berlin, Berlin, Germany
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16
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17
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Coenye T, Spittaels KJ, Achermann Y. The role of biofilm formation in the pathogenesis and antimicrobial susceptibility of Cutibacterium acnes. Biofilm 2021; 4:100063. [PMID: 34950868 PMCID: PMC8671523 DOI: 10.1016/j.bioflm.2021.100063] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 12/02/2021] [Accepted: 12/03/2021] [Indexed: 12/20/2022] Open
Abstract
Cutibacterium acnes (previously known as Propionibacterium acnes) is frequently found on lipid-rich parts of the human skin. While C. acnes is most known for its role in the development and progression of the skin disease acne, it is also involved in many other types of infections, often involving implanted medical devices. C. acnes readily forms biofilms in vitro and there is growing evidence that biofilm formation by this Gram-positive, facultative anaerobic micro-organism plays an important role in vivo and is also involved in treatment failure. In this brief review we present an overview on what is known about C. acnes biofilms (including their role in pathogenesis and reduced susceptibility to antibiotics), discuss model systems that can be used to study these biofilms in vitro and in vivo and give an overview of interspecies interactions occurring in polymicrobial communities containing C. acnes.
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Affiliation(s)
- Tom Coenye
- Laboratory of Pharmaceutical Microbiology, Ghent University, Gent, Belgium
| | - Karl-Jan Spittaels
- Laboratory of Pharmaceutical Microbiology, Ghent University, Gent, Belgium
| | - Yvonne Achermann
- Division of Infectious Diseases and Hospital Epidemiology, University Hospital Zurich, University of Zurich, Zurich, Switzerland
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18
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Oliva A, Stefani S, Venditti M, Di Domenico EG. Biofilm-Related Infections in Gram-Positive Bacteria and the Potential Role of the Long-Acting Agent Dalbavancin. Front Microbiol 2021; 12:749685. [PMID: 34745053 PMCID: PMC8569946 DOI: 10.3389/fmicb.2021.749685] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2021] [Accepted: 10/04/2021] [Indexed: 01/08/2023] Open
Abstract
Infections caused by Gram-positive bacteria are a major public health problem due to their increasing resistance to antibiotics. Staphylococcus and Enterococcus species' resistance and pathogenicity are enhanced by their ability to form biofilm. The biofilm lifestyle represents a significant obstacle to treatment because bacterial cells become highly tolerant to a wide range of antimicrobial compounds normally effective against their planktonic forms. Thus, novel therapeutic strategies targeting biofilms are urgently needed. The lipoglycopeptide dalbavancin is a long-acting agent for treating acute bacterial skin and skin structure infections caused by a broad range of Gram-positive pathogens. Recent studies have shown promising activity of dalbavancin against Gram-positive biofilms, including methicillin-resistant S. aureus (MRSA), methicillin-resistant S. epidermidis (MRSE), and vancomycin-susceptible enterococci. This review outlines the mechanisms regulating biofilm development in Staphylococcus and Enterococcus species and the clinical impact of biofilm-related infections. In addition, it discusses the clinical implications and potential therapeutic perspectives of the long-acting drug dalbavancin against biofilm-forming Gram-positive pathogens.
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Affiliation(s)
- Alessandra Oliva
- Department of Public Health and Infectious Diseases, "La Sapienza" University of Rome, Rome, Italy
| | - Stefania Stefani
- Laboratory of Molecular Medical Microbiology and Antimicrobial Resistance Research (Mmarl), Department of Biomedical and Biotechnological Sciences (Biometec), University of Catania, Catania, Italy
| | - Mario Venditti
- Department of Public Health and Infectious Diseases, "La Sapienza" University of Rome, Rome, Italy
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19
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[Infections of the spine : Pyogenic spondylodiscitis and implant-associated vertebral osteomyelitis]. Unfallchirurg 2021; 124:489-504. [PMID: 33970304 DOI: 10.1007/s00113-021-01002-w] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/07/2021] [Indexed: 10/21/2022]
Abstract
Pyogenic (unspecific) spondylodiscitis and implant-associated vertebral osteomyelitis (IAVO) are important diseases with the risk of neurological and septic complications. An early diagnosis is essential in which magnetic resonance imaging (MRI), histopathology and microbiological identification of the pathogen play key roles. The goals of conservative treatment in uncomplicated spondylodiscitis are antibiotic infection control and pain management. In the case of sepsis, neurological deficits, segmental instability or epidural abscesses surgical treatment of the infection with stabilization of the spine should be considered. In IAVO the formation of a mature biofilm represents the transition from acute to chronic infection. Acute infections can be treated by extensive debridement in combination with biofilm-active antibiotic treatment while retaining the implant. In chronic infections implant removal or exchange in combination with several weeks of antibiotic treatment is often necessary.
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20
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Palmowski Y, Bürger J, Kienzle A, Trampuz A. Antibiotic treatment of postoperative spinal implant infections. JOURNAL OF SPINE SURGERY 2020; 6:785-792. [PMID: 33447684 DOI: 10.21037/jss-20-456] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Postoperative spinal implant infection (PSII) is a serious complication after spinal surgery. It is associated with increased morbidity and mortality for affected patients as well as significant costs for the healthcare system. Due to the formation of biofilm on foreign material, both diagnosis and treatment of PSII can pose a considerable challenge. Modern treatment protocols allow efficient eradication and good clinical outcomes in the majority of patients. In this article, we review the current antibiotic treatment concepts for PSII including the correct choice of antibiotics and their combination. In cases of late-onset PSII where the implants can be removed, two weeks of intravenous (IV) antibiotics followed by 4 weeks of oral antibiotics seem appropriate. If the implant needs to be retained, a 2-week IV antibiotic treatment should be followed by 10 weeks of oral antibiotic therapy with biofilm activity or, in case of problematic pathogens, a long-term suppression therapy. Initial empiric antibiotic therapy should cover staphylococci, streptococci, enterococci and Gram-negative bacilli as the most common pathogens. Antibiotic adjustments according to the type of pathogen and its antimicrobial susceptibility are essential for successful eradication of infection.
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Affiliation(s)
- Yannick Palmowski
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Justus Bürger
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
| | - Arne Kienzle
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany.,Laboratory of Adaptive and Regenerative Biology, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Andrej Trampuz
- Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery, Berlin, Germany
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21
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Ishak B, Abdul-Jabbar A, Moss GB, Yilmaz E, von Glinski A, Frieler S, Unterberg AW, Blecher R, Altafulla J, Roh J, Hart RA, Oskouian RJ, Chapman JR. De novo methicillin-resistant Staphylococcus aureus vs. methicillin-sensitive Staphylococcus aureus infections of the spine, similar clinical outcome, despite more severe presentation in surgical patients. Neurosurg Rev 2020; 44:2111-2118. [PMID: 32851541 DOI: 10.1007/s10143-020-01376-2] [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: 05/25/2020] [Revised: 07/18/2020] [Accepted: 08/20/2020] [Indexed: 11/28/2022]
Abstract
Vertebral osteomyelitis (VO) is a severe infection of the vertebral body and the adjacent disc space, where Staphylococcus aureus is most commonly isolated. The objective of this retrospective study was to determine risk factors for and compare outcome differences between de novo methicillin-resistant Staphylococcus aureus (MRSA) VO and methicillin-sensitive Staphylococcus aureus (MSSA) VO. A retrospective cohort study was performed by review of the electronic medical records of 4541 consecutive spine surgery patients. Among these 37 underwent surgical treatment of de novo MRSA and MSSA spinal infections. Patient demographics, pre- and postoperative neurological status (ASIA impairment score), surgical treatment, inflammatory laboratory values, nutritional status, comorbidities, antibiotics, hospital stay, ICU stay, reoperation, readmission, and complications were collected. A minimum follow-up (FU) of 12 months was required. Among the 37 patients with de novo VO, 19 were MRSA and 18 were MSSA. Mean age was 52.4 and 52.9 years in the MRSA and MSSA groups, respectively. Neurological deficits were found in 53% of patients with MRSA infection and in 17% of the patients with MSSA infection, which was statistically significant (p < 0.05). Chronic renal insufficiency and malnutrition were found to be significant risk factors for MRSA VO. Preoperative albumin was significantly lower in the MRSA group (p < 0.05). Patients suffering from spinal infection with chronic renal insufficiency and malnutrition should be watched more carefully for MRSA. The MRSA group did not show a significant difference with regard to final clinical outcome despite more severe presentation.
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Affiliation(s)
- Basem Ishak
- Swedish Neuroscience Institute, Seattle, WA, USA. .,Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany.
| | | | - Gregory B Moss
- Department of Infectious Disease, Swedish Medical Center, Seattle, WA, USA
| | - Emre Yilmaz
- Swedish Neuroscience Institute, Seattle, WA, USA.,Department of Trauma Surgery, BG University Hospital Bochum, Bochum, Germany
| | - Alexander von Glinski
- Swedish Neuroscience Institute, Seattle, WA, USA.,Department of Trauma Surgery, BG University Hospital Bochum, Bochum, Germany
| | - Sven Frieler
- Swedish Neuroscience Institute, Seattle, WA, USA.,Department of Trauma Surgery, BG University Hospital Bochum, Bochum, Germany
| | - Andreas W Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Jeffrey Roh
- Swedish Neuroscience Institute, Seattle, WA, USA
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22
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Margaryan D, Renz N, Bervar M, Zahn R, Onken J, Putzier M, Vajkoczy P, Trampuz A. Spinal implant-associated infections: a prospective multicentre cohort study. Int J Antimicrob Agents 2020; 56:106116. [PMID: 32726675 DOI: 10.1016/j.ijantimicag.2020.106116] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 05/19/2020] [Accepted: 07/21/2020] [Indexed: 12/17/2022]
Abstract
This study evaluated the clinical, laboratory, microbiological, radiological and treatment characteristics of patients with early-onset and late-onset spinal implant-associated infections. Patients diagnosed with spinal implant-associated infection between 2015-2019 were prospectively included and treated according to a standardised algorithm. Infections were classified as early-onset (≤6 weeks) and late-onset (>6 weeks). Among 250 patients, 152 (61%) had early-onset and 98 (39%) had late-onset infection. Local inflammatory signs was the most common manifestation in early-onset infections (84%), whereas late-onset infections presented mainly with persisting or increasing local pain (71%). Sonication fluid was more often positive than peri-implant tissue samples (90% vs. 79%; P = 0.016), particularly in late-onset infections (92% vs. 75%; P = 0.005). Predominant pathogens were coagulase-negative staphylococci, Staphylococcus aureus and Cutibacterium spp. Debridement and implant retention was the most common surgical approach in early-onset infections (85%), whereas partial or complete implant exchange was mainly performed in late-onset infections (62%). Of the 250 patients, 220 (88%) received biofilm-active antibiotics, and median treatment duration was 11.7 weeks. Moreover, 49 patients (20%) needed more than one revision for infection and six patients (2.4%) died during hospital stay. Concluding, most spinal implant-associated infections were acquired during surgery and presented within 6 weeks of surgery. Infections presented mainly with local inflammatory signs in early-onset and with persisting or increasing pain in late-onset infections. Sonication was the most sensitive microbiological method, particularly in late-onset infections. Debridement and implant retention was used in well-integrated implants without loosening, independent of the time of infection onset.
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Affiliation(s)
- Donara Margaryan
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Nora Renz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Maja Bervar
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Robert Zahn
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Julia Onken
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Michael Putzier
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany
| | - Peter Vajkoczy
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Department of Neurosurgery, Berlin, Germany
| | - Andrej Trampuz
- Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Center for Musculoskeletal Surgery (CMSC), Berlin, Germany.
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