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Wang DY, Su L, Poelstra K, Grainger DW, van der Mei HC, Shi L, Busscher HJ. Beyond surface modification strategies to control infections associated with implanted biomaterials and devices - Addressing the opportunities offered by nanotechnology. Biomaterials 2024; 308:122576. [PMID: 38640785 DOI: 10.1016/j.biomaterials.2024.122576] [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: 01/12/2024] [Revised: 04/03/2024] [Accepted: 04/13/2024] [Indexed: 04/21/2024]
Abstract
Biomaterial-associated infection (BAI) is considered a unique infection due to the presence of a biomaterial yielding frustrated immune-cells, ineffective in clearing local micro-organisms. The involvement of surface-adherent/surface-adapted micro-organisms in BAI, logically points to biomaterial surface-modifications for BAI-control. Biomaterial surface-modification is most suitable for prevention before adhering bacteria have grown into a mature biofilm, while BAI-treatment is virtually impossible through surface-modification. Hundreds of different surface-modifications have been proposed for BAI-control but few have passed clinical trials due to the statistical near-impossibility of benefit-demonstration. Yet, no biomaterial surface-modification forwarded, is clinically embraced. Collectively, this leads us to conclude that surface-modification is a dead-end road. Accepting that BAI is, like most human infections, due to surface-adherent biofilms (though not always to a foreign material), and regarding BAI as a common infection, opens a more-generally-applicable and therewith easier-to-validate road. Pre-clinical models have shown that stimuli-responsive nano-antimicrobials and antibiotic-loaded nanocarriers exhibit prolonged blood-circulation times and can respond to a biofilm's micro-environment to penetrate and accumulate within biofilms, prompt ROS-generation and synergistic killing with antibiotics of antibiotic-resistant pathogens without inducing further antimicrobial-resistance. Moreover, they can boost frustrated immune-cells around a biomaterial reducing the importance of this unique BAI-feature. Time to start exploring the nano-road for BAI-control.
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Affiliation(s)
- Da-Yuan Wang
- University of Groningen and University Medical Center Groningen, Department of Biomedical Engineering, Groningen, the Netherlands; Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, State Key Laboratory of Medicinal Chemical Biology, Frontiers Science Center for New Organic Matter, College of Chemistry, Nankai University, Tianjin, 300350, PR China
| | - Linzhu Su
- State Key Laboratory of Advanced Medical Materials and Devices, Tianjin Key Laboratory of Radiation Medicine and Molecular Nuclear Medicine, Key Laboratory of Radiopharmacokinetics for Innovative Drugs, Tianjin Institutes of Health Science, Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300192, PR China
| | - Kees Poelstra
- Allegiant Institute - Nevada Spine Clinic. the Robotic Spine Institute of Las Vegas, Las Vegas, USA
| | - David W Grainger
- Departments of Biomedical Engineering, and of Molecular Pharmaceutics, University of Utah, Salt Lake City, UT, 84112-5820, USA
| | - Henny C van der Mei
- University of Groningen and University Medical Center Groningen, Department of Biomedical Engineering, Groningen, the Netherlands.
| | - Linqi Shi
- Key Laboratory of Functional Polymer Materials of Ministry of Education, Institute of Polymer Chemistry, State Key Laboratory of Medicinal Chemical Biology, Frontiers Science Center for New Organic Matter, College of Chemistry, Nankai University, Tianjin, 300350, PR China.
| | - Henk J Busscher
- University of Groningen and University Medical Center Groningen, Department of Biomedical Engineering, Groningen, the Netherlands.
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Weber J, Henssler L, Zeman F, Pfeifer C, Alt V, Nerlich M, Huber M, Herbst T, Koller M, Schneider-Brachert W, Kerschbaum M, Holzmann T. Nanosilver/DCOIT-containing surface coating effectively and constantly reduces microbial load in emergency room surfaces. J Hosp Infect 2023; 135:90-97. [PMID: 36958698 DOI: 10.1016/j.jhin.2023.01.024] [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: 10/12/2022] [Revised: 01/13/2023] [Accepted: 01/23/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND Colonization of near-patient surfaces in hospitals plays an important role as a source of healthcare-associated infections. Routine disinfection methods only result in short-term elimination of pathogens. AIM To investigate the efficiency of a newly developed antimicrobial coating containing nanosilver in long-term reduction of bacterial burden in hospital surfaces to close the gap between routine disinfection cycles. METHODS In this prospective, double-blinded trial, frequently touched surfaces of a routinely used treatment room in an emergency unit of a level-I hospital were treated with a surface coating (nanosilver/DCOIT-coated surface, NCS) containing nanosilver particles and another organic biocidal agent (4,5-dichloro-2-octyl-4-isothiazolin-3-one, DCOIT), whereas surfaces of another room were treated with a coating missing both the nanosilver- and DCOIT-containing ingredient and served as control. Bacterial contamination of the surfaces was examined using contact plates and liquid-based swabs daily for a total trial duration of 90 days. After incubation, total microbial counts and species were assessed. FINDINGS In a total of 2880 antimicrobial samples, a significant reduction of the overall bacterial load was observed in the NCS room (median: 0.31 cfu/cm2; interquartile range: 0.00-1.13) compared with the control coated surfaces (0.69 cfu/cm2; 0.06-2.00; P < 0.001). The nanosilver- and DCOIT-containing surface coating reduced the relative risk of a critical bacterial load (defined as >5 cfu/cm2) by 60% (odds ratio 0.38, P < 0.001). No significant difference in species distribution was detected between NCS and control group. CONCLUSION Nanosilver-/DCOIT-containing surface coating has shown efficiency for sustainable reduction of bacterial load of frequently touched surfaces in a clinical setting.
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Affiliation(s)
- J Weber
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - L Henssler
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany.
| | - F Zeman
- Center of Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - C Pfeifer
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany; Department of Orthopedic Trauma and Hand Surgery, Innklinikum Altötting-Mühldorf, Altötting, Germany
| | - V Alt
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Nerlich
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Huber
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - T Herbst
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - M Koller
- Center of Clinical Studies, University Hospital Regensburg, Regensburg, Germany
| | - W Schneider-Brachert
- Institute of Medical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
| | - M Kerschbaum
- Department for Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - T Holzmann
- Institute of Medical Microbiology and Hygiene, University Hospital Regensburg, Regensburg, Germany
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Meyer JA, Zhu M, Cavadino A, Coleman B, Munro JT, Young SW. Infection and periprosthetic fracture are the leading causes of failure after aseptic revision total knee arthroplasty. Arch Orthop Trauma Surg 2021; 141:1373-1383. [PMID: 33515323 DOI: 10.1007/s00402-020-03698-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 12/03/2020] [Indexed: 10/22/2022]
Abstract
AIM The purpose of this study was to clarify the medium to long term survival of aseptic revision total knee arthroplasty (RTKAs) and identify the common modes of failure following RTKAs. MATERIALS AND METHODS A multi-center, retrospective study included all aseptic RTKAs performed at three tertiary referral hospitals between 2003 and 2016. Patients were excluded if the revision was for prosthetic joint infection (PJI) or they had previously undergone revision surgery. Minor revisions not involving the tibial or femoral components were also excluded. Demographics, surgical data and post-operative outcomes were recorded and analyzed. Survival analysis was performed and the reasons for revision failure identified. RESULTS Of 235 aseptic RTKAs identified, 14.8% underwent re-revision at mean follow-up of 8.3 years. Survivorship of RTKA was 93% at 2 years and 83% at 8 years. Average age at revision was 72.9 years (range 53-91.5). The most common reasons for failure following RTKA were periprosthetic joint infection (PJI) (40%), periprosthetic fracture (25.7%) and aseptic loosening (14.3%). Of those whose RTKA failed, the average survival was 3.33 years (8 days-11.4 years). No demographic or surgical factors were found to influence RTKA survival on univariate or multivariate analysis. CONCLUSION PJI and periprosthetic fracture are the leading causes of re-revision surgery following aseptic revision TKA. Efforts to improve outcomes of aseptic revision TKA should focus on these areas, particularly prevention of PJI.
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Affiliation(s)
- Juliette A Meyer
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Mark Zhu
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Alana Cavadino
- School of Medicine, University of Auckland, Auckland, New Zealand
| | - Brendan Coleman
- Department of Orthopaedics, Counties Manukau District Health Board, Auckland, New Zealand
| | - Jacob T Munro
- Department of Orthopaedics, Auckland District Health Board, Auckland, New Zealand
| | - Simon W Young
- School of Medicine, University of Auckland, Auckland, New Zealand. .,Department of Orthopaedics, Waitemata District Health Board, 124 Shakespeare Rd, Auckland, 0620, New Zealand.
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Ueoka K, Kabata T, Tokoro M, Kajino Y, Inoue D, Takagi T, Ohmori T, Yoshitani J, Ueno T, Yamamuro Y, Taninaka A, Tsuchiya H. Antibacterial Activity in Iodine-coated Implants Under Conditions of Iodine Loss: Study in a Rat Model Plus In Vitro Analysis. Clin Orthop Relat Res 2021; 479:1613-1623. [PMID: 33847603 PMCID: PMC8208413 DOI: 10.1097/corr.0000000000001753] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 03/08/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND We developed iodine-coated titanium implants to suppress microbial activity and prevent periprosthetic joint infection (PJI); their efficacy was demonstrated in animal and in vitro models. The iodine content in iodine-coated implants naturally decreases in vivo. However, to our knowledge, the effect of reduced iodine content on the implant's antimicrobial activity has not been evaluated to date. QUESTIONS/PURPOSES (1) How much does the iodine content on the implant surface decrease after 4 and 8 weeks in vivo in a rat model? (2) What effect does the reduced iodine content have on the antimicrobial effect of the implant against multiple bacteria in an in vitro model? METHODS This experiment was performed in two parts: an in vivo experiment to determine attenuation of iodine levels over time in rats, and an in vitro experiment in which we sought to assess whether the reduced iodine content observed in the in vivo experiment was still sufficient to deliver antimicrobial activity against common pathogens seen in PJI. For the in vivo experiment, three types of titanium alloy washers were implanted in rats: untreated (Ti), surface-anodized to produce an oxide film (Ti-O), and with an iodine layer on the oxidation film (Ti-I). The attenuation of iodine levels in rats was measured over time using inductively coupled plasma-mass spectrometry. Herein, only the Ti-I washer was used, with five implanted in each rat that were removed after 4 or 8 weeks. For the 4- and 8-week models, two rats and 15 washers were used. For the in vitro study, to determine the antibacterial effect, three types of washers (Ti, Ti-O, and Ti-I) (nine washers in total) were implanted in each rat. Then, the washers were removed and the antibacterial effect of each washer was examined on multiple bacterial species using the spread plate method and fluorescence microscopy. For the spread plate method, six rats were used, and five rats were used for the observation using fluorescence microscopy; further, 4- and 8-week models were made for each method. Thus, a total of 22 rats and 198 washers were used. Live and dead bacteria in the biofilm were stained, and the biofilm coverage percentage for quantitative analysis was determined using fluorescence microscopy in a nonblinded manner. Ti-I was used as the experimental group, and Ti and Ti-O were used as control groups. The total number of rats and washers used throughout this study was 24 and 213, respectively. RESULTS Iodine content in rats implanted with Ti-I samples decreased to 72% and 65% after the in vivo period of 4 and 8 weeks, respectively (p = 0.001 and p < 0.001, respectively). In the in vitro experiment, the Ti-I implants demonstrated a stronger antimicrobial activity than Ti and Ti-O implants in the 4- and 8-week models. Both the median number of bacterial colonies and the median biofilm coverage percentage with live bacteria on Ti-I were lower than those on Ti or Ti-O implants for each bacterial species in the 4- and 8-week models. There was no difference in the median biofilm coverage percentage of dead bacteria. In the 8-week model, the antibacterial activity using the spread plate method had median (interquartile range) numbers of bacteria on the Ti, Ti-O, and Ti-I implants of 112 (104 to 165) × 105, 147 (111 to 162) × 105, and 55 (37 to 67) × 105 of methicillin-sensitive Staphylococcus aureus (Ti-I versus Ti, p = 0.026; Ti-I versus Ti-O, p = 0.009); 71 (39 to 111) × 105, 50 (44 to 62) × 105, and 26 (9 to 31)× 105 CFU of methicillin-resistant S. aureus (Ti-I versus Ti, p = 0.026; Ti-I versus Ti-O, p = 0.034); and 77 (74 to 83) × 106, 111 (95 to 117) × 106, and 30 (21 to 45) × 106 CFU of Pseudomonas aeruginosa (Ti-I versus Ti, p = 0.004; Ti-I versus Ti-O, p = 0.009). Despite the decrease in the iodine content of Ti-I after 8 weeks, it demonstrated better antibacterial activity against all tested bacteria than the Ti and Ti-O implants. CONCLUSION Iodine-coated implants retained their iodine content and antibacterial activity against methicillin-sensitive S. aureus, methicillin-resistant S. aureus, and P. aeruginosa for 8 weeks in vivo in rats. To evaluate the longer-lasting antibacterial efficacy, further research using larger infected animal PJI models with implants in the joints of both males and females is desirable. CLINICAL RELEVANCE Iodine-coated titanium implants displayed an antibacterial activity for 8 weeks in rats in vivo. Although the findings in a rat model do not guarantee efficacy in humans, they represent an important step toward clinical application.
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Affiliation(s)
- Ken Ueoka
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Tamon Kabata
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Masaharu Tokoro
- Department of Parasitology, Advanced Preventive Medical Sciences Research Center, Kanazawa University, Kanazawa, Japan
| | - Yoshitomo Kajino
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Daisuke Inoue
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Tomoharu Takagi
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Takaaki Ohmori
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Junya Yoshitani
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Takuro Ueno
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Yuki Yamamuro
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Atsushi Taninaka
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopedic Surgery, Graduate School of Medical Sciences, Kanazawa University, Kanazawa, Japan
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Ueoka K, Kajino Y, Kabata T, Inoue D, Yoshitani J, Ueno T, Yamamuro Y, Shirai T, Tsuchiya H. The feasibility of iodine-supported processing for titanium with different surfaces. J Orthop Sci 2020; 25:1095-1100. [PMID: 32143853 DOI: 10.1016/j.jos.2019.12.013] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2019] [Revised: 12/04/2019] [Accepted: 12/05/2019] [Indexed: 11/18/2022]
Abstract
BACKGROUND The reduction of microbial infections can substantially improve the success of implant surgery. The iodine-supported implants that were developed by us for infection prevention were featured at the recent International Consensus Meeting on Musculoskeletal Infection and were partly incorporated into the consensus guidelines. For future clinical application, we examined (1) whether iodine can be added to metals with different surface roughness, (2) differences in surface roughness before and after processing, and (3) the effect of sterilization on the iodine content. METHODS Four Ti-6Al-4V metals were prepared with different surface roughness values by polishing, blasting and plasma spraying. Before and after processing, the surface structure of metals was observed using a scanning electron microscope and stylus instruments. Before and after sterilization, iodine contents were measured by X-ray fluorescence spectroscopy. RESULTS After processing, sufficient iodine contents with an antimicrobial effect were detected for each metal. These iodine contents decreased after sterilization but were higher than the lowest content of iodine observed to have an antimicrobial effect in a previous study, indicating that the antimicrobial effect persists even after sterilization. After processing, surface roughness was greater for polishing metal. With general surface processing, iodine processing was possible. CONCLUSIONS Our results indicated that surface roughness is affected by the processing method and that the iodine content should be set according to the sterilization method. Considering these factors, iodine processing can be used for clinical applications.
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Affiliation(s)
- Ken Ueoka
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yoshitomo Kajino
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan.
| | - Tamon Kabata
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Daisuke Inoue
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Junya Yoshitani
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Takuro Ueno
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Yuki Yamamuro
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Toshiharu Shirai
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
| | - Hiroyuki Tsuchiya
- Department of Orthopaedic Surgery, Graduate School of Medical Science, Kanazawa University, Kanazawa, Japan
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Webb ML. CORR Insights®: Does an Antimicrobial Incision Drape Prevent Intraoperative Contamination? A Randomized Controlled Trial of 1187 Patients. Clin Orthop Relat Res 2020; 478:1016-1018. [PMID: 32187092 PMCID: PMC7170697 DOI: 10.1097/corr.0000000000001220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Alt V, Chen AF. Antimicrobial coatings for orthopaedic implants - Ready for use? J Bone Jt Infect 2020; 5:125-127. [PMID: 32566450 PMCID: PMC7295647 DOI: 10.7150/jbji.46508] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 04/01/2020] [Indexed: 12/25/2022] Open
Affiliation(s)
- Volker Alt
- Department of Trauma Surgery, University Hospital Regensburg, Regensburg, Germany
| | - Antonia F. Chen
- Department of Orthopaedic Surgery at Brigham and Women's Hospital, Harvard Medical School, Boston, USA
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Affiliation(s)
- Mengnai Li
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio
| | - Andrew Glassman
- Department of Orthopaedics, Wexner Medical Center, The Ohio State University, Columbus, Ohio
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Gehrke T, Lausmann C, Citak M. Still fighting prosthetic joint infection after knee replacement. THE LANCET. INFECTIOUS DISEASES 2019; 19:560. [PMID: 31005558 DOI: 10.1016/s1473-3099(19)30067-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Accepted: 01/07/2019] [Indexed: 12/11/2022]
Affiliation(s)
- Thorsten Gehrke
- Department of Orthopaedics, Helios ENDO-Klinik Hamburg, 22767 Hamburg, Germany; Department of Orthopaedic Surgery
| | - Christian Lausmann
- Department of Orthopaedics, Helios ENDO-Klinik Hamburg, 22767 Hamburg, Germany; Department of Orthopaedic Surgery
| | - Mustafa Citak
- Department of Orthopaedics, Helios ENDO-Klinik Hamburg, 22767 Hamburg, Germany; Department of Orthopaedic Surgery.
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