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Hollyer I, Ivanov D, Kappagoda S, Lowenberg DW, Goodman SB, Amanatullah DF. Selecting a high-dose antibiotic-laden cement knee spacer. J Orthop Res 2023; 41:1383-1396. [PMID: 37127938 DOI: 10.1002/jor.25570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 04/17/2023] [Indexed: 05/03/2023]
Abstract
Prosthetic joint infection [PJI] after total knee arthroplasty (TKA) remains a common and challenging problem for joint replacement surgeons and patients. Once the diagnosis of PJI has been made, patient goals and characteristics as well as the infection timeline dictate treatment. Most commonly, this involves a two-stage procedure with the removal of all implants, debridement, and placement of a static or dynamic antibiotic spacer. Static spacers are commonly indicated for older, less healthy patients that would benefit from soft tissue rest after initial debridement. Mobile spacers are typically used in younger, healthier patients to improve quality of life and reduce soft-tissue contractures during antibiotic spacer treatment. Spacers are highly customizable with regard to antibiotic choice, cement variety, and spacer design, each with reported advantages, drawbacks, and indications that will be covered in this article. While no spacer is superior to any other, the modern arthroplasty surgeon must be familiar with the available modalities to optimize treatment for each patient. Here we propose a treatment algorithm to assist surgeons in deciding on treatment for PJI after TKA.
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Affiliation(s)
- Ian Hollyer
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - David Ivanov
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Shanthi Kappagoda
- Division of Infectious Diseases and Geographic Medicine, Stanford Univeristy, Stanford, California, USA
| | - David W Lowenberg
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Stuart B Goodman
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University, Redwood City, California, USA
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2
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Cyphert EL, Zhang N, Learn GD, Hernandez CJ, von Recum HA. Recent Advances in the Evaluation of Antimicrobial Materials for Resolution of Orthopedic Implant-Associated Infections In Vivo. ACS Infect Dis 2021; 7:3125-3160. [PMID: 34761915 DOI: 10.1021/acsinfecdis.1c00465] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
While orthopedic implant-associated infections are rare, revision surgeries resulting from infections incur considerable healthcare costs and represent a substantial research area clinically, in academia, and in industry. In recent years, there have been numerous advances in the development of antimicrobial strategies for the prevention and treatment of orthopedic implant-associated infections which offer promise to improve the limitations of existing delivery systems through local and controlled release of antimicrobial agents. Prior to translation to in vivo orthopedic implant-associated infection models, the properties (e.g., degradation, antimicrobial activity, biocompatibility) of the antimicrobial materials can be evaluated in subcutaneous implant in vivo models. The antimicrobial materials are then incorporated into in vivo implant models to evaluate the efficacy of using the material to prevent or treat implant-associated infections. Recent technological advances such as 3D-printing, bacterial genomic sequencing, and real-time in vivo imaging of infection and inflammation have contributed to the development of preclinical implant-associated infection models that more effectively recapitulate the clinical presentation of infections and improve the evaluation of antimicrobial materials. This Review highlights the advantages and limitations of antimicrobial materials used in conjunction with orthopedic implants for the prevention and treatment of orthopedic implant-associated infections and discusses how these materials are evaluated in preclinical in vivo models. This analysis serves as a resource for biomaterial researchers in the selection of an appropriate orthopedic implant-associated infection preclinical model to evaluate novel antimicrobial materials.
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Affiliation(s)
- Erika L. Cyphert
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Ningjing Zhang
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Greg D. Learn
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
| | - Christopher J. Hernandez
- Sibley School of Mechanical and Aerospace Engineering, Cornell University, Ithaca, New York 14853, United States
- Hospital for Special Surgery, New York, New York 10021, United States
| | - Horst A. von Recum
- Department of Biomedical Engineering, Case Western Reserve University, 10900 Euclid Avenue, Cleveland, Ohio 44106, United States
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3
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Wekwejt M, Chen S, Kaczmarek-Szczepańska B, Nadolska M, Łukowicz K, Pałubicka A, Michno A, Osyczka AM, Michálek M, Zieliński A. Nanosilver-loaded PMMA bone cement doped with different bioactive glasses - evaluation of cytocompatibility, antibacterial activity, and mechanical properties. Biomater Sci 2021; 9:3112-3126. [PMID: 33704333 DOI: 10.1039/d1bm00079a] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Nanosilver-loaded PMMA bone cement (BC-AgNp) is a novel cement developed as a replacement for conventional cements. Despite its favorable properties and antibacterial activity, BC-AgNp still lacks biodegradability and bioactivity. Hence, we investigated doping with bioactive glasses (BGs) to create a new bioactive BC characterized by time-varying porosity and gradual release of AgNp. The BC Cemex was used as the base material and modified simultaneously with the AgNp and BGs: melted 45S5 and 13-93B3 glasses with various particle sizes and sol-gel derived SiO2/CaO microparticles. The effect of BG addition was examined by microscopic analysis, an assessment of setting parameters, wettability, FTIR and UV-VIS spectroscopy, mechanical testing, and hemo- and cytocompatibility and antibacterial efficiency studies. The results show that it is possible to incorporate various BGs into BC-AgNp, which leads to different properties depending on the type and size of BGs. The smaller particles of melted BGs showed higher porosity and better antibacterial properties with the moderate deterioration of mechanical properties. The sol-gel derived BGs, however, displayed a tendency for agglomeration and random distribution in BC-AgNp. The BGs with greater solubility more efficiently improve the antibacterial properties of BC-AgNp. Besides, the unreacted MMA monomer release could negatively influence the cellular response. Despite that, cements doped with different BGs are suitable for medical applications.
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Affiliation(s)
- M Wekwejt
- Department of Biomaterials Technology, Faculty of Mechanical Engineering and Ship Technology, Gdańsk University of Technology, Gdańsk, Poland.
| | - S Chen
- Centre for Functional and Surface Functionalized Glass, TnU AD, Trenčín, Slovakia
| | - B Kaczmarek-Szczepańska
- Department of Chemistry of Biomaterials and Cosmetics, Faculty of Chemistry, Nicolaus Copernicus University in Toruń, Toruń, Poland
| | - M Nadolska
- Faculty of Applied Physics and Mathematics, Gdańsk University of Technology, Gdańsk, Poland
| | - K Łukowicz
- Department of Biology and Cell Imaging, Institute of Zoology and Biomedical Research, Faculty of Biology, Jagiellonian University, Kraków, Poland
| | - A Pałubicka
- Department of Laboratory Diagnostics and Microbiology with Blood Bank, Specialist Hospital in Kościerzyna, Kościerzyna, Poland
| | - A Michno
- Chair of Clinical Biochemistry, Department of Laboratory Medicine, Medical University of Gdańsk, Gdańsk, Poland
| | - A M Osyczka
- Department of Biology and Cell Imaging, Institute of Zoology and Biomedical Research, Faculty of Biology, Jagiellonian University, Kraków, Poland
| | - M Michálek
- Centre for Functional and Surface Functionalized Glass, TnU AD, Trenčín, Slovakia
| | - A Zieliński
- Department of Biomaterials Technology, Faculty of Mechanical Engineering and Ship Technology, Gdańsk University of Technology, Gdańsk, Poland.
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4
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Gandomkarzadeh M, Mahboubi A, Moghimi HR. Release behavior, mechanical properties, and antibacterial activity of ciprofloxacin-loaded acrylic bone cement: a mechanistic study. Drug Dev Ind Pharm 2020; 46:1209-1218. [DOI: 10.1080/03639045.2020.1788058] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Affiliation(s)
- Marzieh Gandomkarzadeh
- Department of Pharmaceutics and Nanotechnology, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Students’ Research Committee, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Arash Mahboubi
- Department of Pharmaceutics and Nanotechnology, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Food Safety Research Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran
| | - Hamid Reza Moghimi
- Department of Pharmaceutics and Nanotechnology, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Protein Technology Research Center, School of Pharmacy, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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5
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Wekwejt M, Michno A, Truchan K, Pałubicka A, Świeczko-Żurek B, Osyczka AM, Zieliński A. Antibacterial Activity and Cytocompatibility of Bone Cement Enriched with Antibiotic, Nanosilver, and Nanocopper for Bone Regeneration. NANOMATERIALS (BASEL, SWITZERLAND) 2019; 9:E1114. [PMID: 31382557 PMCID: PMC6722923 DOI: 10.3390/nano9081114] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 12/11/2022]
Abstract
Bacterial infections due to bone replacement surgeries require modifications of bone cement with antibacterial components. This study aimed to investigate whether the incorporation of gentamicin or nanometals into bone cement may reduce and to what extent bacterial growth without the loss of overall cytocompatibility and adverse effects in vitro. The bone cement Cemex was used as the base material, modified either with gentamicin sulfate or nanometals: Silver or copper. The inhibition of bacterial adhesion and growth was examined against five different bacterial strains along with integrity of erythrocytes, viability of blood platelets, and dental pulp stem cells. Bone cement modified with nanoAg or nanoCu revealed greater bactericidal effects and prevented the biofilm formation better compared to antibiotic-loaded bone cement. The cement containing nanoAg displayed good cytocompatibility without noticeable hemolysis of erythrocytes or blood platelet disfunction and good viability of dental pulp stem cells (DPSC). On the contrary, the nanoCu cement enhanced hemolysis of erythrocytes, reduced the platelets aggregation, and decreased DPSC viability. Based on these studies, we suggest the modification of bone cement with nanoAg may be a good strategy to provide improved implant fixative for bone regeneration purposes.
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Affiliation(s)
- Marcin Wekwejt
- Biomaterials Division, Department of Materials Engineering and Bonding, Gdańsk University of Technology, 80-233 Gdańsk, Poland.
| | - Anna Michno
- Chair of Clinical Biochemistry, Department of Laboratory Medicine, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Karolina Truchan
- Department of Biology and Cell Imaging, Institute of Zoology and Biomedical Research, Faculty of Biology, Jagiellonian University, 30-387 Kraków, Poland
| | - Anna Pałubicka
- Department of Laboratory Diagnostics and Microbiology with Blood Bank, Specialist Hospital in Kościerzyna, 83-400 Kościerzyna, Poland
- Department of Surgical Oncologic, Medical University of Gdańsk, 80-210 Gdańsk, Poland
| | - Beata Świeczko-Żurek
- Biomaterials Division, Department of Materials Engineering and Bonding, Gdańsk University of Technology, 80-233 Gdańsk, Poland
| | - Anna Maria Osyczka
- Department of Biology and Cell Imaging, Institute of Zoology and Biomedical Research, Faculty of Biology, Jagiellonian University, 30-387 Kraków, Poland
| | - Andrzej Zieliński
- Biomaterials Division, Department of Materials Engineering and Bonding, Gdańsk University of Technology, 80-233 Gdańsk, Poland
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Martínez-Moreno J, Mir-Palomo S, Merino V, Nácher A, Merino-Sanjuán M. Development of antibiotic loaded biodegradable matrices to prevent superficial infections associated to total knee arthroplasty. Colloids Surf B Biointerfaces 2019; 181:1-5. [PMID: 31102726 DOI: 10.1016/j.colsurfb.2019.05.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 05/09/2019] [Accepted: 05/10/2019] [Indexed: 02/01/2023]
Abstract
Development of a pharmaceutical form for the superficial infections related with arthroplasties would be helpful for clinical practice. In this context, we set out to evaluate ciprofloxacin and gentamicin elution from systems based on chitosan. Films and semisolid hydrogels containing chitosan alone (2%) or in combination with gelatin (6%) or different proportions (from 12% to 36%) of tetrakis-(hydroxymethyl)-phosphonium-chloride (THPC) were tested as delivery systems. Different antibiotic doses were assayed (0.5 mg/cm2,1 mg/cm2 and 2 mg/cm2). Antibiotic release was studied for each formulation. In vitro cytocompatibility studies and a simulation exercise for bioactivity evaluation were performed. Samples containing chitosan or chitosan-gelatin released the antibiotics at very high rates. On the contrary, ciprofloxacin released was kept for 6 days from THPC-chitosan films and hydrogels. From hydrogel formulations release could be changed by varying the percentage of THPC. The system containing 12%-THPC-chitosan with 2 mg/cm2 of ciprofloxacin showed that 100% of patient would be covered during 72 h post-surgery. The concentration of 12%-THPC did not show cytotoxicity in NIH3T3 mouse fibroblasts after 48 h. THPC is suitable as crosslinker for chitosan when ciprofloxacin is incorporated showing a sustained release during 6 days.
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Affiliation(s)
- Javier Martínez-Moreno
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
| | - Silvia Mir-Palomo
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
| | - Virginia Merino
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain.
| | - Amparo Nácher
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
| | - Matilde Merino-Sanjuán
- Departamento de Farmacia y Tecnología Farmacéutica y Parasitología, Facultad de Farmacia. Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain; Instituto Interuniversitario de Investigación de Reconocimiento Molecular y Desarrollo Tecnológico (IDM), Universitat Politècnica de València, Universitat de València. Av. Vicente Andrés Estelles s/n, Burjassot, Valencia, Spain
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7
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Boelch SP, Jordan MC, Arnholdt J, Steinert AF, Rudert M, Luedemann M. Antibiotic elution and compressive strength of gentamicin/vancomycin loaded bone cements are considerably influenced by immersion fluid volume. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2019; 30:29. [PMID: 30762118 DOI: 10.1007/s10856-019-6229-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2017] [Accepted: 01/30/2019] [Indexed: 06/09/2023]
Abstract
The effect of doubling the immersion fluid (eluate) volume on antibiotic concentrations and on mechanical stability from vancomycin and gentamicin loaded bone cements was investigated in vitro. Antibiotic loaded bone cements containing premixed 1.34% gentamicin antibiotic concentration in the cement powder (wt), premixed 1.19% gentamicin wt and 4.76% vancomycin wt and premixed 1.17% wt gentamicin additionally manually blended with 4.68% wt vancomycin were tested. Six specimens per group were immersed in 4 ml and 8 ml for 6 weeks while the eluate was exchanged every 24 h. The antibiotic concentrations were repeatedly measured. Then the specimens were tested for compressive strength. Doubling the eluate volume significantly decreased gentamicin and vancomycin concentrations from 6 h and 24 h on, except for the gentamicin concentration of the additionally manually blended formulation after 3 weeks. The additionally manually blended vancomycin formulation produced significantly higher gentamicin concentrations in 8 ml compared to the other formulations. The reduction ratios of the vancomycin concentrations were significantly smaller than the reduction ratios of the gentamicin concentrations for the manually blended vancomycin formulation. Vancomycin containing formulations showed significantly lower compressive strengths than the vancomycin free formulation after immersion. Doubling the eluate volume lead to significant compressive strength reduction of the vancomycin containing formulations. Eluate volume change influences antibiotic elution dependent on the antibiotic combination and loading technique. The reducing effect is higher on vancomycin than on gentamicin elution. Compressive strength of gentamicin/vancomycin loaded bone cements after immersion is eluate volume dependent.
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Affiliation(s)
- Sebastian P Boelch
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany.
| | - Martin C Jordan
- Julius-Maximilians University Wuerzburg, Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, 6 Oberduerrbacher Strasse, D-97080, Wuerzburg, Germany
| | - Joerg Arnholdt
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Andre F Steinert
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
- Hospital Agatharied, Department of Orthopaedic and Trauma Surgery, Norbert-Kerkel Platz, 83734, Hausham, Germany
| | - Maximilian Rudert
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Martin Luedemann
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
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Martínez-Moreno J, Merino V, Nácher A, Rodrigo JL, Climente M, Merino-Sanjuán M. Antibiotic-loaded Bone Cement as Prophylaxis in Total Joint Replacement. Orthop Surg 2018; 9:331-341. [PMID: 29178309 DOI: 10.1111/os.12351] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2017] [Accepted: 06/10/2017] [Indexed: 12/14/2022] Open
Abstract
One of its most serious complications associated with arthroplasty is the development of infections. Although its prevalence is only between 0.5% and 3%, in some cases it can lead to death. Therefore, an important challenge in joint surgery is the prevention of infections when an arthroplasty is performed. The use of antibiotic-loaded cements could be a suitable tool due to numerous advantages. The main advantage of the use of antibiotic loading into bone cement derives directly from antibiotic release in the effect site, allowing achievement of high concentrations at the site of action, and minimal or no systemic toxicity. This route of administration was first described by Buchholz and Engelbrecht. In the case of infection treatment, this is an established method and its good results have been confirmed. However, its role in infection prevention, and, therefore, the use of these systems in clinical practice, has proved controversial because of the uncertainty about the development of possible antibiotic resistance after prolonged exposure time, their effectiveness, the cost of the systems, toxicity and loosening of mechanical properties. This review discusses all these topics, focusing on effectiveness and safety, antibiotic decisions, cement type, mixing method, release kinetics and future perspectives. The final objective is to provide the orthopaedic surgeons the right information in their clinical practice based on current evidence.
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Affiliation(s)
- Javier Martínez-Moreno
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain.,Pharmacy Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Virginia Merino
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
| | - Amparo Nácher
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
| | - José Luis Rodrigo
- Traumatology Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Mónica Climente
- Pharmacy Service, University Hospital Doctor Peset of Valencia, Valencia, Spain
| | - Matilde Merino-Sanjuán
- Department of Pharmacy and Pharmaceutical Technology, Faculty of Pharmacy, Institute of Molecular Recognition and Technological Development, Mixed Center Polytechnic University of Valencia, University of Valencia, Valencia, Spain
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Lee JH, Han CD, Cho SN, Yang IH, Lee WS, Baek SH, Shin JW, Husein KEI, Park KK. How Long Does Antimycobacterial Antibiotic-loaded Bone Cement Have In Vitro Activity for Musculoskeletal Tuberculosis? Clin Orthop Relat Res 2017; 475:2795-2804. [PMID: 28795294 PMCID: PMC5638744 DOI: 10.1007/s11999-017-5470-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Accepted: 08/02/2017] [Indexed: 01/31/2023]
Abstract
BACKGROUND Antibiotic-loaded bone cement is accepted as an effective treatment modality for musculoskeletal tuberculosis. However, comparative information regarding combinations and concentrations of second-line antimycobacterial drugs, such as streptomycin and amoxicillin and clavulanic acid, are lacking. QUESTIONS/PURPOSES (1) In antibiotic-loaded cement, is there effective elution of streptomycin and Augmentin® (amoxicillin and clavulanic acid) individually and in combination? (2) What is the antibacterial activity duration for streptomycin- and amoxicillin and clavulanic acid -loaded cement? METHODS Six different types of bone cement discs were created by mixing 40 g bone cement with 1 or 2 g streptomycin only, 0.6 g or 1.2 g Augmentin® (amoxicillin and clavulanic acid) only, and a combination of 1 g streptomycin plus 0.6 g amoxicillin and clavulanic acid and 2 g streptomycin plus 1.2 g amoxicillin and clavulanic acid. Five bone discs of each type were incubated in phosphate buffered saline for 30 days with renewal of the phosphate buffered saline every day. The quantity of streptomycin and/or amoxicillin and clavulanic acid in eluates were measured by a liquid chromatography-mass spectrometry system, and the antimycobacterial activity of eluates against Mycobacterium tuberculosis H37Rv, were calculated by comparing the minimal inhibitory concentration of each eluate with that of tested drugs using broth dilution assay on microplate. RESULTS Streptomycin was detected in eluates for 30 days (in 1 g and 2 g discs), whereas 1.2 g amoxicillin and clavulanate eluted until Day 7 and 0.6 g amoxicillin and clavulanate until Day 3. All eluates in streptomycin-containing discs (streptomycin only, and in combination with amoxicillin and clavulanic acid) had effective antimycobacterial activity for 30 days, while amoxicillin and clavulanate-only preparations were only active until Day 14. The antimycobacterial activity of eluates of 2 g streptomycin plus 1.2 g amoxicillin and clavulanate were higher than those of discs containing 1 g streptomycin plus 0.6 g amoxicillin and clavulanate until Day 3, without differences (Day 3, 1 g streptomycin plus 0.6 g amoxicillin and clavulanate: 17.5 ± 6.85 ug/mL; 2 g streptomycin plus 1.2 g amoxicillin and clavulanate: 32.5 ± 16.77 ug/mL; p = 0.109). After Day 7, however, values of the two combinations remained no different than that of Day 30 (Day 30, 1 g streptomycin plus 0.6 g amoxicillin and clavulanate: 0.88 ± 0.34 ug/mL; 2 g streptomycin plus 1.2 g amoxicillin and clavulanate: 0.59 ± 0.94 ug/mL; p = 0.107). CONCLUSIONS Streptomycin, in the form of antibiotic-loaded bone cement, had effective elution characteristics and antimycobacterial effects during a 30-day period, whereas amoxicillin and clavulanate only had effective elution and antimycobacterial characteristics during the early period of this study. The two drugs did not interfere with each other during the elution test. CLINICAL RELEVANCE This research revealed that combinations of streptomycin and amoxicillin and clavulanate mixed with bone cement are effective for 30 days. Further trials to determine various different combinations of drugs are necessary to improve the effectiveness of treatments for musculoskeletal tuberculosis.
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Affiliation(s)
- Jae Hoo Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752 Korea
| | - Chang Dong Han
- Department of Orthopaedic Surgery, Seoul Bumin Hospital, Seoul, Korea
| | - Sang-Nae Cho
- Department of Microbiology and Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Ick Hwan Yang
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752 Korea
| | - Woo Suk Lee
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752 Korea
| | - Seung-Hun Baek
- Department of Microbiology and Institute for Immunology and Immunological Diseases, Yonsei University College of Medicine, Seoul, Korea
| | - Jae Won Shin
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752 Korea
| | | | - Kwan Kyu Park
- Department of Orthopaedic Surgery, Yonsei University College of Medicine, 134 Sinchon-dong, Seodaemun-gu, Seoul, 120-752 Korea
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10
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Martínez-Moreno J, Merino V, Nácher A, Rodrigo JL, Bonet Yuste BB, Merino-Sanjuán M. Bioactivity of Ceftazidime and Fluconazole Included in Polymethyl Methacrylate Bone Cement for Use in Arthroplasty. J Arthroplasty 2017; 32:3126-3133.e1. [PMID: 28690040 DOI: 10.1016/j.arth.2017.04.057] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2016] [Revised: 04/11/2017] [Accepted: 04/25/2017] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The microorganisms that most frequently cause prosthetic joint infection are methicillin-resistant Staphylococcus aureus and gram-negative aerobic bacillus. Studies have documented the efficacy of mixing antibiotics with polymethyl methacrylate, but that of antifungal drugs has not received much attention. The objective of this in vitro study was to characterize the elution profile and bioactivity of ceftazidime and fluconazole when incorporated into bone cement in proportions intended for prophylaxis and treatment of bone infections. METHODS Antibiotic-loaded bone cement cylinders in a proportion of 1:40 and 4:40 (ratio of grams of antibiotic to grams of cement) were assayed. Drug delivery was investigated in a flow-through dissolution apparatus (SotaxCE7). To assess bioactivity, antibiotic concentrations were simulated in the joint space of 1000 patients. Antibacterial properties were evaluated by counting colony forming units and the inhibition-halo test. RESULTS The ratio of released ceftazidime and fluconazole was 453% and 648%, respectively, higher when used for treatment proportions than prophylaxis proportions. A bioactivity simulation exercise showed that the efficacy of ceftazidime/fluconazole determined as the amount of drug is released at the active site in the first 3 days after surgery would depend on the sensitivity of the microorganism and would increase substantially after drain removal. The microbiology study showed that biofilm formation by Pseudomonas aeruginosa could be a problem when ceftazidime was used in treatment or prophylaxis proportions. CONCLUSION Our in vitro findings suggest that ceftazidime and fluconazole can be added into polymethyl methacrylate for the prevention/treatment of infections associated to joint surgery. Their efficacy depends on the sensitivity of the microorganism causing the infection.
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Affiliation(s)
- J Martínez-Moreno
- Departamento de Farmacia y Tecnología Farmaceutica y Parasitología, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnologico, Centro Mixto Universidad Politecnica de Valencia-Universidad de Valencia, Valencia, Spain; Servicio de Farmacia, Hospital Universitario Doctor Peset, Valencia, Spain
| | - V Merino
- Departamento de Farmacia y Tecnología Farmaceutica y Parasitología, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnologico, Centro Mixto Universidad Politecnica de Valencia-Universidad de Valencia, Valencia, Spain
| | - A Nácher
- Departamento de Farmacia y Tecnología Farmaceutica y Parasitología, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnologico, Centro Mixto Universidad Politecnica de Valencia-Universidad de Valencia, Valencia, Spain
| | - J L Rodrigo
- Servicio de Traumatología, Hospital Universitario Doctor Peset, Valencia, Spain
| | | | - M Merino-Sanjuán
- Departamento de Farmacia y Tecnología Farmaceutica y Parasitología, Facultad de Farmacia, Valencia, Spain; Instituto de Reconocimiento Molecular y Desarrollo Tecnologico, Centro Mixto Universidad Politecnica de Valencia-Universidad de Valencia, Valencia, Spain
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Boelch SP, Jordan MC, Arnholdt J, Rudert M, Luedemann M, Steinert AF. Loading with vancomycin does not decrease gentamicin elution in gentamicin premixed bone cement. JOURNAL OF MATERIALS SCIENCE. MATERIALS IN MEDICINE 2017; 28:104. [PMID: 28534287 DOI: 10.1007/s10856-017-5915-6] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Accepted: 05/10/2017] [Indexed: 06/07/2023]
Abstract
Antibiotic loaded bone cements are used as drug delivery systems for the treatment of periprosthetic joint infections. They can be loaded with antibiotics during industrial component production (premixing) and during cement preparation (manually blending). Although double premixed antibiotic loaded bone cements are available, manually blending of a gentamicin premixed antibiotic loaded bone cement with vancomycin is still popular. We compared in vitro antibiotic elution and compressive strength of 0.5 g gentamicin premixed bone cement (PALACOS® R + G), 0.5 g gentamicin premixed bone cement (PALACOS® R + G) manually blended with 2.0 g vancomycin, 0.5 g gentamicin and 2.0 g vancomycin premixed bone cement (COPAL® G + V), 1 g gentamicin and clindamycin premixed bone cement (COPAL® G + C) and bone cement without an antibiotic (PALACOS® R) as control. Antibiotic concentration measurements were performed for 6 weeks and then compression strength was tested. Concentrations of gentamicin showed no significant differences between PALACOS® R + G, PALACOS® R + G with vancomycin and COPAL G® + V. After 48 h COPAL G® + C produced significantly higher gentamicin concentrations than the other formulations. After 12 h PALACOS® R + G with vancomycin produced significantly higher vancomycin concentrations, but had the lowest compression strength. We found no influence of vancomycin addition on gentamicin elution, irrespectively of the loading method. However, the manually vancomycin blended ALBC produced higher vancomycin concentrations. Compression strength after aging is reduced by loading with vancomycin.
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Affiliation(s)
- Sebastian P Boelch
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany.
| | - Martin C Jordan
- Julius-Maximilians University Wuerzburg, Department of Trauma, Hand, Plastic and Reconstructive Surgery, University Hospital Wuerzburg, 6 Oberduerrbacher Strasse, D-97080, Wuerzburg, Germany
| | - Joerg Arnholdt
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Maximilian Rudert
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Martin Luedemann
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
| | - Andre F Steinert
- Julius-Maximilians University Wuerzburg, Department of Orthopaedic Surgery, Koenig-Ludwig-Haus, 11 Brettreichstrasse, D-97074, Wuerzburg, Germany
- Hospital Agatharied, Department of Orthopaedic and Trauma Surgery, Norbert-Kerkel Platz, 83734, Hausham, Germany
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