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Laperche J, Barrett CC, Boduch A, Glasser J, Clippert D, Garcia DR, Antoci V. Mechanically stable rifampin antibiotic cement inhibits Pseudomonas aeruginosa biofilm surface growth. J Orthop Res 2024; 42:547-554. [PMID: 37884321 DOI: 10.1002/jor.25720] [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: 07/17/2023] [Revised: 10/07/2023] [Accepted: 10/16/2023] [Indexed: 10/28/2023]
Abstract
Rifampin has been proven to be effective in the treatment of prosthetic infections due to its ability to intercalate into biofilms. The use of rifampin in antibiotic spacers is not well described, which would be especially important in the local periprosthetic environment where parenteral doses have poor penetration. The null hypothesis tests if rifampin use in polymethyl methacrylate (PMMA) cement will show no clinically significant impact on mechanical strength at antibiotic concentrations that remain bactericidal. Test antibiotic cement samples supplemented with 0, 30, 50, 100, 150, or 200 mg of rifampin into a standard 40 g bag were tested for compression to failure using published ASTM standards. The samples were then inoculated with Pseudomonas aeruginosa and either evaluated for lipopolysaccharide (LPS) presence as a marker of biofilm or tested by elution as the Kirby Bauer assay. Rifampin concentrations of 30 and 50 mg, showed no statistically different mechanical characteristics from control PMMA (p > 0.05). The 100-mg sample fell within the acceptable range of compressive strength and had significantly less LPS and bacterial presence compared to the control at 12 and 24 h. The ability of PMMA with 100 mg of rifampin to maintain its structural integrity and have significant bacterial inhibition at 12 and 24 h makes it a great candidate as an antibiotic bone cement additive. PMMA loaded with up to 100 mg of rifampin shows promise in the treatment and prevention of periprosthetic joint infection for total knee and total hip arthroplasty.
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Affiliation(s)
- Jacob Laperche
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
- Frank H. Netter School of Medicine, Quinnipiac University, North Haven, Connecticut, USA
| | - Caitlin C Barrett
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
| | - Abigail Boduch
- Department of Orthopedic Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Jillian Glasser
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
| | - Drew Clippert
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
| | - Dioscaris R Garcia
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Valentin Antoci
- Joint Replacement Center, University Orthopedics, East Providence, Rhode Island, USA
- Department of Orthopedic Surgery, Rhode Island Hospital, Providence, Rhode Island, USA
- Department of Orthopedic Surgery, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
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2
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Moore K, Li A, Gupta N, Gupta TT, Delury C, Aiken SS, Laycock PA, Stoodley P. Killing of a Multispecies Biofilm Using Gram-Negative and Gram-Positive Targeted Antibiotic Released from High Purity Calcium Sulfate Beads. Microorganisms 2023; 11:2296. [PMID: 37764142 PMCID: PMC10538001 DOI: 10.3390/microorganisms11092296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Revised: 08/31/2023] [Accepted: 09/07/2023] [Indexed: 09/29/2023] Open
Abstract
BACKGROUND Multispecies biofilm orthopedic infections are more challenging to treat than mono-species infections. In this in-vitro study, we aimed to determine if a multispecies biofilm, consisting of Gram positive and negative species with different antibiotic susceptibilities could be treated more effectively using high purity antibiotic-loaded calcium sulfate beads (HP-ALCSB) containing vancomycin (VAN) and tobramycin (TOB) in combination than alone. METHODS Three sets of species pairs from bioluminescent strains of Pseudomonas aeruginosa (PA) and Staphylococcus aureus (SA) and clinical isolates, Enterococcus faecalis (EF) and Enterobacter cloacae were screened for compatibility. PA + EF developed intermixed biofilms with similar cell concentrations and so were grown on 316L stainless steel coupons for 72 h or as 24 h agar lawn biofilms and then treated with HP-ALCSBs with single or combination antibiotics and assessed by viable count or bioluminescence and light imaging to distinguish each species. Replica plating was used to assess viability. RESULTS The VAN + TOB bead significantly reduced the PA + EF biofilm CFU and reduced the concentration of surviving antibiotic tolerant variants by 50% compared to single antibiotics. CONCLUSIONS The combination of Gram-negative and positive targeted antibiotics released from HP-ALCSBs may be more effective in treating multispecies biofilms than monotherapy alone.
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Affiliation(s)
- Kelly Moore
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (K.M.); (A.L.); (N.G.); (T.T.G.)
| | - Anthony Li
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (K.M.); (A.L.); (N.G.); (T.T.G.)
| | - Niraj Gupta
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (K.M.); (A.L.); (N.G.); (T.T.G.)
| | - Tripti Thapa Gupta
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (K.M.); (A.L.); (N.G.); (T.T.G.)
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.D.); (S.S.A.); (P.A.L.)
| | - Sean S. Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.D.); (S.S.A.); (P.A.L.)
| | - Phillip A. Laycock
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.D.); (S.S.A.); (P.A.L.)
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (K.M.); (A.L.); (N.G.); (T.T.G.)
- Department of Orthopedics, The Ohio State University, Columbus, OH 43203, USA
- Department of Microbiology, The Ohio State University, Columbus, OH 43210, USA
- National Centre for Advanced Tribology at Southampton (nCATS), Department of Mechanical Engineering, University of Southampton, Southampton SO17 1BJ, UK
- National Biofilm Innovation Centre (NBIC), University of Southampton, Southampton SO17 1BJ, UK
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Kwan JC, Flannagan RS, Vásquez Peña M, Heinrichs DE, Holdsworth DW, Gillies ER. Induction Heating Triggers Antibiotic Release and Synergistic Bacterial Killing on Polymer-Coated Titanium Surfaces. Adv Healthc Mater 2023; 12:e2202807. [PMID: 37053473 PMCID: PMC11469058 DOI: 10.1002/adhm.202202807] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 03/30/2023] [Indexed: 04/15/2023]
Abstract
Infection is a major complication associated with orthopedic implants. It often involves the development of biofilms on metal substrates, which act as barriers to the host's immune system and systemic antibiotic treatment. The current standard of treatment is revision surgery, often involving the delivery of antibiotics through incorporation into bone cements. However, these materials exhibit sub-optimal antibiotic release kinetics and revision surgeries have drawbacks of high cost and recovery time. Herein, a new approach is presented using induction heating of a metal substrate, combined with an antibiotic-loaded poly(ester amide) coating undergoing a glass transition just above physiological temperature to enable thermally triggered antibiotic release. At normal physiological temperature, the coating provides a rifampicin depot for >100 days, while heating of the coating accelerates drug release, with >20% release over a 1-h induction heating cycle. Induction heating or antibiotic-loaded coating alone each reduce Staphylococcus aureus (S. aureus) viability and biofilm formation on Ti, but the combination causes synergistic killing of S. aureus as measured by crystal violet staining, determination of bacterial viability (>99.9% reduction), and fluorescence microscopy of bacteria on surfaces. Overall, these materials provide a promising platform enabling externally triggered antibiotic release to prevent and/or treat bacterial colonization of implants.
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Affiliation(s)
- Jan C. Kwan
- School of Biomedical EngineeringThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5B9Canada
- Bone and Joint InstituteThe University of Western OntarioThe Sandy Kirkley Centre for Musculoskeletal ResearchUniversity Hospital B6‐200LondonOntarioN6G 2V4Canada
| | - Ronald S. Flannagan
- Department of Microbiology and ImmunologyThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5C1Canada
| | - Mónica Vásquez Peña
- School of Biomedical EngineeringThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5B9Canada
- Bone and Joint InstituteThe University of Western OntarioThe Sandy Kirkley Centre for Musculoskeletal ResearchUniversity Hospital B6‐200LondonOntarioN6G 2V4Canada
| | - David E. Heinrichs
- Department of Microbiology and ImmunologyThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5C1Canada
| | - David W. Holdsworth
- School of Biomedical EngineeringThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5B9Canada
- Bone and Joint InstituteThe University of Western OntarioThe Sandy Kirkley Centre for Musculoskeletal ResearchUniversity Hospital B6‐200LondonOntarioN6G 2V4Canada
- Imaging Research LaboratoriesRobarts Research InstituteThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 2B8Canada
- Department of Medical BiophysicsThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5C1Canada
| | - Elizabeth R. Gillies
- School of Biomedical EngineeringThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5B9Canada
- Bone and Joint InstituteThe University of Western OntarioThe Sandy Kirkley Centre for Musculoskeletal ResearchUniversity Hospital B6‐200LondonOntarioN6G 2V4Canada
- Department of ChemistryThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5B7Canada
- Department of Chemical and Biochemical EngineeringThe University of Western Ontario1151 Richmond StreetLondonOntarioN6A 5B9Canada
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Bourget-Murray J, Azad M, Gofton W, Abdelbary H, Garceau S, Grammatopoulos G. Is the routine use of local antibiotics in the management of periprosthetic joint infections justified? Hip Int 2023; 33:4-16. [PMID: 36447342 DOI: 10.1177/11207000221139467] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Periprosthetic joint infection (PJI) following total hip and total knee arthroplasty continues to be a leading cause of re-operation and revision arthroplasty. Not only is the treatment of PJI notoriously challenging, but success rates are variable. Regardless of the surgical strategy used, successful management of PJI requires a comprehensive surgical debridement focused at eradicating the underlying biofilm followed by appropriate antimicrobial therapy. Although systemic antimicrobial delivery continues to be a cornerstone in the treatment of PJI, many surgeons have started using local antibiotics to deliver higher concentrations of antibiotics directly into the vulnerable joint and adjacent soft tissues, which often have compromised vascularity. Available evidence on the use of topical powder, bone cement, and calcium sulphate carriers for local delivery of antibiotics during the initial treatment of PJI is limited to studies that are extremely heterogeneous. There is currently no level-1 evidence to support routinely using these products. Further, appropriately powered, prospective studies are needed to quantify the safety and efficacy of antibiotic-located calcium-sulphate carriers to justify their added costs. These products should not encourage surgeons to deviate from best practice guidelines, such as those recommended during the International Consensus Meeting on Musculoskeletal Infections.
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Affiliation(s)
| | - Marisa Azad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wade Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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Hawkins AN, Licea SJ, Sleeper SA, Swearingen MC. Calcium sulfate beads made with antibacterial essential oil-water emulsions exhibit growth inhibition against Staphylococcus aureus in agar pour plates. PLoS One 2022; 17:e0271209. [PMID: 35802739 PMCID: PMC9269935 DOI: 10.1371/journal.pone.0271209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 06/24/2022] [Indexed: 11/21/2022] Open
Abstract
Calcium sulfate bone void filler beads are fully absorbable in the body, and are often used in complicated orthopedic infection cases to release a relatively high dose of antibiotics locally to the body site over time. However, the antibiotic resistance crisis and/or inability to treat chronic biofilm infections remains to be a formidable and increasing health threat. In this report, we tested the hypothesis that plant essential oils (PEOs) with anti-staphylococcal qualities could inhibit the growth of Staphylococcus aureus (a major etiological agent of periprosthetic joint infection) in agar pour plates when infused in calcium sulfate beads. To begin, we conducted a screen of 57 single plant PEOs for anti-staphylococcal activity via disk diffusions assays. We observed that 55/57 of the PEOs had significant growth inhibitory activity compared to the null hypothesis, and 41/57 PEOs exhibited activity similar-to-or-higher-than a vancomycin minimum inhibitory control. When PEOs were infused in beads, we observed that 17/57 PEOs tested exhibited significant bacterial growth inhibition when encased in S. aureus-seeded agar compared to a null hypothesis of six millimeters (bead size). However, none of the PEO-beads had activity similar to a vancomycin bead control made according to a clinically relevant formula. To the best of our knowledge, this is the first report and screen of PEOs for growth inhibitory activity when infused in lab-made calcium sulfate beads. These data indicate that antibacterial PEOs warrant further investigations, and may be useful in developing new treatment strategies for periprosthetic joint infection.
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Affiliation(s)
- Allison N. Hawkins
- Department of Biological Sciences, Florida Gulf Coast University, Fort Myers, Florida, United States of America
| | - Sara J. Licea
- Department of Biological Sciences, Florida Gulf Coast University, Fort Myers, Florida, United States of America
| | - Sierra A. Sleeper
- Department of Biological Sciences, Florida Gulf Coast University, Fort Myers, Florida, United States of America
| | - Matthew C. Swearingen
- Department of Biological Sciences, Florida Gulf Coast University, Fort Myers, Florida, United States of America
- * E-mail:
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Fletcher J, Porter R, Boulton Z, Brown L, Knight B, Romanczuk L, Aiken S, Delury C, Michell S. In vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure) against polymicrobial communities and individual bacterial strains derived from diabetic foot infections. J Med Microbiol 2022; 71. [PMID: 35604937 DOI: 10.1099/jmm.0.001517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Diabetic foot infection (DFI) is the main reason for diabetes-related hospitalisation and is a major cause of diabetes-related amputation. DFIs are often complicated by ischaemia in the affected limb, the presence of polymicrobial biofilms and increasingly the occurrence of antibiotic resistant bacteria.Hypothesis/Gap statement. Antibiotic loaded beads could inhibit the growth of polymicrobial DFI communities with differing compositions in vitro.Aim. This study investigates the in vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure, Biocomposites Ltd., UK) against polymicrobial DFI communities and individual bacterial strains derived from DFIs.Methodology. Debrided tissue obtained from the base of infected diabetic foot ulcers was homogenised and spread over the surface of Columbia blood agar (CBA) and fastidious anaerobe agar (FAA) plates. Calcium sulfate beads containing a combination of vancomycin and gentamicin were then placed on the surface of the agar and following incubation, zones of inhibition (ZOI) were measured. For individual bacterial strains isolated from the infected tissue, calcium sulfate beads containing vancomycin, gentamicin, flucloxacillin or rifampicin and beads containing a combination of vancomycin and gentamicin or flucloxacillin and rifampicin were tested for their ability to inhibit growth.Results. Calcium sulfate beads loaded with a combination of vancomycin and gentamicin were able to inhibit bacterial growth from all polymicrobial tissue homogenates tested, with ZOI diameters ranging from 15 to 40 mm. In the case of individual bacterial strains, beads containing combinations of vancomycin and gentamicin or flucloxacillin and rifampicin were able to produce ZOI with Gram-positive facultatitive anaerobic strains such as Staphylococcus aureus and Enterococcus faecalis, Gram-negative facultative anaerobic strains such as Pseudomonas aeruginosa and obligate anaerobic strains such as Finegoldia magna even where acquired resistance to one of the antibiotics in the combination was evidenced.Conclusion. The local use of calcium sulfate beads containing a combination of two antibiotics demonstrated high efficacy against polymicrobial DFI communities and individual DFI bacterial strains in in vitro zone of inhibition tests. These results show promise for clinical application, but further research and clinical studies are required.
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Affiliation(s)
- Julie Fletcher
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
| | - Rob Porter
- Microbiology Department, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Zoe Boulton
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Laura Brown
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Bridget Knight
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Lidia Romanczuk
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Sean Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Stephen Michell
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
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7
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Qiao Z, Zhang W, Jiang H, Li X, An W, Yang H. 3D-printed composite scaffold with anti-infection and osteogenesis potential against infected bone defects. RSC Adv 2022; 12:11008-11020. [PMID: 35425051 PMCID: PMC8991078 DOI: 10.1039/d2ra00214k] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Accepted: 04/03/2022] [Indexed: 12/15/2022] Open
Abstract
In the field of orthopedics, an infected bone defect is a refractory disease accompanied by bone infection and defects as well as aggravated circulation. There are currently no personalized scaffolds that can treat bone infections using local stable and sustained-release antibiotics while providing mechanical support and bone induction to promote bone repair in the process of absorption in vivo. In our previous study, rifampicin/moxifloxacin-poly lactic-co-glycolic acid (PLGA) microspheres were prepared and tested for sustained release and antibacterial activity. The composite scaffold of poly-l-lactic acid (PLLA)/Pearl had a positive effect on mechanics supports and promoted osteogenesis. Therefore, in this study, the personalized scaffolds of PLLA/Pearl were first prepared by 3D printing. Then, rifampicin/moxifloxacin-PLGA (RM-P) microspheres were loaded into the scaffold pores to prepare the PLLA/Pearl/RM-P scaffolds. In this in vitro study, we investigated the structural characteristics and cytocompatibility of 3D-printed composite scaffolds, which indicates the integrity of the components in the scaffolds. The PLLA/Pearl and PLLA/Pearl/RM-P composite scaffolds can promote adhesion, proliferation, and differentiation of human bone marrow mesenchymal stem cells. Moreover, a rabbit model of infected bone defects of the radius was established. PLLA, PLLA/Pearl, and PLLA/Pearl/RM-P scaffolds were implanted into the bone nidus. The therapeutic effect of the three scaffolds on the infected bone defects was evaluated through imaging and microbiological and histological analysis after surgery. Among the three scaffolds, only the PLLA/Pearl/RM-P scaffold had anti-infection and bone defect repair in vivo. 3D printing provides support for personalized scaffold structures, and composite materials ensure that the scaffolds exert anti-infection and bone repair effects. Our study suggests that the PLLA/Pearl/RM-P scaffold is a promising new material in the clinical treatment of infected bone defects. Indication the mechanism of dual-functional scaffold in the treatment of infected bone defects.![]()
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Affiliation(s)
- Zewen Qiao
- Department of Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750021 China +86-951-6743243
| | - Wenping Zhang
- Department of Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750021 China +86-951-6743243
| | - Haifeng Jiang
- Department of Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750021 China +86-951-6743243
| | - Xiang Li
- School of Mechanical Engineering, Shanghai Jiao Tong University Shanghai 200240 China
| | - Weijun An
- Department of Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750021 China +86-951-6743243
| | - Haibo Yang
- Department of Orthopedics, General Hospital of Ningxia Medical University Yinchuan 750021 China +86-951-6743243
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8
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Schmidtchen A, Puthia M. Rapid in vitro and in vivo Evaluation of Antimicrobial Formulations Using Bioluminescent Pathogenic Bacteria. Bio Protoc 2022; 12:e4302. [DOI: 10.21769/bioprotoc.4302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/21/2021] [Accepted: 12/01/2021] [Indexed: 11/02/2022] Open
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Brooks JR, Dusane DH, Moore K, Gupta T, Delury C, Aiken SS, Laycock PA, Sullivan AC, Granger JF, Dipane MV, McPherson EJ, Stoodley P. Pseudomonas aeruginosa biofilm killing beyond the spacer by antibiotic-loaded calcium sulfate beads: an in vitro study. J Bone Jt Infect 2021; 6:119-129. [PMID: 34084700 PMCID: PMC8137860 DOI: 10.5194/jbji-6-119-2021] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Accepted: 03/04/2021] [Indexed: 12/11/2022] Open
Abstract
Introduction: Bacterial biofilms are an important virulence factor in
chronic periprosthetic joint infection (PJI) and other orthopedic infection
since they are highly tolerant to antibiotics and host immunity. Antibiotics
are mixed into carriers such as bone cement and calcium sulfate bone void
fillers to achieve sustained high concentrations of antibiotics required to
more effectively manage biofilm infections through local release. The effect
of antibiotic diffusion from antibiotic-loaded calcium sulfate beads
(ALCS-B) in combination with PMMA bone cement spacers on the spread and
killing of Pseudomonas aeruginosa Xen41 (PA-Xen41) biofilm was investigated using a “large agar
plate” model scaled for clinical relevance. Methods: Bioluminescent
PA-Xen41 biofilms grown on discs of various orthopedic materials were placed within a large agar plate containing a PMMA full-size mock “spacer”
unloaded or loaded with vancomycin and tobramycin, with or without ALCS-B.
The amount of biofilm spread and log reduction on discs at varying distances
from the spacer was assessed by bioluminescent imaging and viable cell
counts. Results: For the unloaded spacer control, PA-Xen41 spread from the
biofilm to cover the entire plate. The loaded spacer generated a 3 cm zone of
inhibition and significantly reduced biofilm bacteria on the discs
immediately adjacent to the spacer but low or zero reductions on those further away. The combination of ALCS-B and a loaded PMMA spacer greatly
reduced bacterial spread and resulted in significantly greater biofilm
reductions on discs at all distances from the spacer. Discussion: The
addition of ALCS-B to an antibiotic-loaded spacer mimic increased the area of antibiotic coverage and efficacy against biofilm, suggesting that a
combination of these depots may provide greater physical antibiotic coverage
and more effective dead space management, particularly in zones where the
spread of antibiotic is limited by diffusion (zones with little or no fluid
motion).
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Affiliation(s)
- Jacob R Brooks
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Devendra H Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Kelly Moore
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Tripti Gupta
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Sean S Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Phillip A Laycock
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Anne C Sullivan
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Jeffrey F Granger
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA
| | - Matthew V Dipane
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Edward J McPherson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at UCLA, Santa Monica, California, USA
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.,Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, Ohio, USA.,National Centre for Advanced Tribology at Southampton (nCATS), National Biofilm Innovation Centre (NBIC), Department of Mechanical Engineering, University of Southampton, Southampton, UK
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10
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Xu YM, Peng HM, Feng B, Weng XS. Progress of antibiotic-loaded bone cement in joint arthroplasty. Chin Med J (Engl) 2020; 133:2486-2494. [PMID: 32960839 PMCID: PMC7575178 DOI: 10.1097/cm9.0000000000001093] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Indexed: 11/26/2022] Open
Abstract
Bone cement, consisting of polymethyl methacrylate, is a bioinert material used for prothesis fixation in joint arthroplasty. To treat orthopedic infections, such as periprosthetic joint infection, antibiotic-loaded bone cement (ALBC) was introduced into clinical practice. Recent studies have revealed the limitations of the antibacterial effect of ALBC. Moreover, with the increase in high infection risk patients and highly resistant microbes, more researches and modification of ALBC are required. This paper reviewed latest findings about ALBC for most popular and destructive pathogens, summarized the influence of antibiotic kind, drug dosage, application method, and environment towards characteristic of ALBC. Subsequently, new cement additives and clinical applications of ALBC in joint arthroplasty were also discussed.
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Affiliation(s)
- Yi-Ming Xu
- Department of Orthopedics, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College, Beijing 100730, China
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11
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Novel Aminoglycoside-Tolerant Phoenix Colony Variants of Pseudomonas aeruginosa. Antimicrob Agents Chemother 2020; 64:AAC.00623-20. [PMID: 32540981 DOI: 10.1128/aac.00623-20] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2020] [Accepted: 06/09/2020] [Indexed: 01/13/2023] Open
Abstract
Pseudomonas aeruginosa is an opportunistic bacterial pathogen and is known to produce biofilms. We previously showed the emergence of colony variants in the presence of tobramycin-loaded calcium sulfate beads. In this study, we characterized the variant colonies, which survived the antibiotic treatment, and identified three distinct phenotypes-classically resistant colonies, viable but nonculturable colonies (VBNC), and phoenix colonies. Phoenix colonies, described here for the first time, grow out of the zone of clearance of antibiotic-loaded beads from lawn biofilms while there are still very high concentrations of antibiotic present, suggesting an antibiotic-resistant phenotype. However, upon subculturing of these isolates, phoenix colonies return to wild-type levels of antibiotic susceptibility. Compared with the wild type, phoenix colonies are morphologically similar aside from a deficiency in green pigmentation. Phoenix colonies do not recapitulate the phenotype of any previously described mechanisms of resistance, tolerance, or persistence and, thus, form a novel group with their own phenotype. Growth under anaerobic conditions suggests that an alternative metabolism could lead to the formation of phoenix colonies. These findings suggest that phoenix colonies could emerge in response to antibiotic therapies and lead to recurrent or persistent infections, particularly within biofilms where microaerobic or anaerobic environments are present.
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12
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Lochab V, Jones TH, Dusane DH, Peters CW, Stoodley P, Wozniak DJ, Subramaniam VV, Prakash S. Ultrastructure imaging of Pseudomonas aeruginosa lawn biofilms and eradication of the tobramycin-resistant variants under in vitro electroceutical treatment. Sci Rep 2020; 10:9879. [PMID: 32555250 PMCID: PMC7303171 DOI: 10.1038/s41598-020-66823-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 05/22/2020] [Indexed: 12/12/2022] Open
Abstract
Electrochemically generated bactericidal compounds have been shown to eradicate bacterial lawn biofilms through electroceutical treatment. However, the ultrastructure of biofilms exposed to these species has not been studied. Moreover, it is unknown if the efficacy of electroceutical treatment extends to antibiotic-resistant variants that emerge in lawn biofilms after antibiotic treatment. In this report, the efficacy of the in vitro electroceutical treatment of Pseudomonas aeruginosa biofilms is demonstrated both at room temperature and in an incubator, with a ~4 log decrease (p < 0.01) in the biofilm viability observed over the anode at both conditions. The ultrastructure changes in the lawn biofilms imaged using transmission electron microscopy demonstrate significant bacterial cell damage over the anode after 24 h of electroceutical treatment. A mix of both damaged and undamaged cells was observed over the cathode. Finally, both eradication and prevention of the emergence of tobramycin-resistant variants were demonstrated by combining antibiotic treatment with electroceutical treatment on the lawn biofilms.
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Affiliation(s)
- Varun Lochab
- Department of Mechanical & Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Travis H Jones
- Department of Mechanical & Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Devendra H Dusane
- Department of Microbial Infection & Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Casey W Peters
- Department of Microbial Infection & Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Paul Stoodley
- Department of Microbial Infection & Immunity, The Ohio State University, Columbus, Ohio, USA
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
- National Centre for Advanced Tribology, Mechanical Engineering, University of Southampton, Southampton, UK
| | - Daniel J Wozniak
- Department of Microbial Infection & Immunity, The Ohio State University, Columbus, Ohio, USA
| | - Vish V Subramaniam
- Department of Mechanical & Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA
| | - Shaurya Prakash
- Department of Mechanical & Aerospace Engineering, The Ohio State University, Columbus, Ohio, USA.
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13
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Luo S, Jiang T, Long L, Yang Y, Yang X, Luo L, Li J, Chen Z, Zou C, Luo S. A dual PMMA/calcium sulfate carrier of vancomycin is more effective than PMMA-vancomycin at inhibiting Staphylococcus aureus growth in vitro. FEBS Open Bio 2020; 10:552-560. [PMID: 32052585 PMCID: PMC7137790 DOI: 10.1002/2211-5463.12809] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 02/01/2020] [Accepted: 02/11/2020] [Indexed: 12/13/2022] Open
Abstract
Both antibiotic-impregnated poly(methyl acrylate, methyl methacrylate) (PMMA) and antibiotic-impregnated calcium sulfate have been successfully used as local antibiotic delivery vehicles for the management of chronic osteomyelitis. Here, we examined the antibiotic elution characteristics and antibacterial properties of a composite drug delivery system consisting of PMMA/calcium sulfate carrying vancomycin (dual carrier-v) against Staphylococcus aureus, with PMMA loaded with vancomycin (PMMA-v) as a control. Vancomycin gradually degraded from dual carrier-v and PMMA-v up to about 8 and 6 weeks, respectively. At different elution time points, the inhibition zones of the dual carrier-v were larger than the inhibition zones of the PMMA-v (P < 0.05). The colony inhibition rate of the dual carrier-v was 95.57%, whereas it was 77.87% for PMMA-v. Scanning electron microscopy was used to demonstrate biofilm formation on the surface of plates treated with vancomycin-unloaded PMMA, whereas there was no biofilm formation on the surface of plates treated with dual carrier-v or PMMA-v. The dual carrier-v was more effective at antibacterial adhesion at each time point after immersion in simulated body fluid as compared with PMMA-v (P < 0.05). In conclusion, our results suggest that the dual carrier-v can release higher concentrations of antibiotics and inhibit bacteria growth more effectively in vitro as compared with PMMA-v. The dual carrier-v thus may have potential as an alternative strategy for osteomyelitis management.
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Affiliation(s)
- Shanchao Luo
- Yulin Orthopedics Hospital of Chinese and Western Medicine, Yulin, China.,Guangxi Postdoctoral Innovation Practice Base, Beihai People's Hospital, Beihai, China.,Postdoctoral Mobile Station of Clinical Medicine, Guangxi Medical University, Nanning, China
| | - Tongmeng Jiang
- Department of Orthopaedics, Affiliated Hospital of Guilin Medical University, China
| | - Lina Long
- Yulin Orthopedics Hospital of Chinese and Western Medicine, Yulin, China
| | - Yingnian Yang
- Yulin Orthopedics Hospital of Chinese and Western Medicine, Yulin, China
| | - Xiaoping Yang
- Yulin Orthopedics Hospital of Chinese and Western Medicine, Yulin, China
| | - Lan Luo
- Yulin Orthopedics Hospital of Chinese and Western Medicine, Yulin, China
| | - Jinli Li
- Yulin Orthopedics Hospital of Chinese and Western Medicine, Yulin, China
| | - Zhiyu Chen
- Guangxi Postdoctoral Innovation Practice Base, Beihai People's Hospital, Beihai, China
| | - Chongqi Zou
- Yulin Orthopedics Hospital of Chinese and Western Medicine, Yulin, China
| | - Shixing Luo
- Guangxi Postdoctoral Innovation Practice Base, Beihai People's Hospital, Beihai, China
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14
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Coenye T, Kjellerup B, Stoodley P, Bjarnsholt T. The future of biofilm research - Report on the '2019 Biofilm Bash'. Biofilm 2019; 2:100012. [PMID: 33447799 PMCID: PMC7798458 DOI: 10.1016/j.bioflm.2019.100012] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Revised: 11/25/2019] [Accepted: 11/25/2019] [Indexed: 12/22/2022] Open
Abstract
In May 2019, 29 scientists with expertise in various subdisciplines of biofilm research got together in Leavenworth (WA, USA) at an event designated as the ‘2019 Biofilm Bash’. The goal of this informal two-day meeting was first to identify gaps in our knowledge, and then to come up with ways how the biofilm community can fill these gaps. The meeting was organized around six questions that covered the most important items brought forward by the organizers and participants. The outcome of these discussions is summarized in the present paper. We are aware that these views represent a small subset of our field, and that inevitably we will have inadvertently overlooked important developing research areas and ideas. We are nevertheless hopeful that this report will stimulate discussions and help create new ways of how we can advance our field.
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Affiliation(s)
- Tom Coenye
- Laboratory of Pharmaceutical Microbiology, Ghent University, Ghent, Belgium.,ESCMID Study Group on Biofilms, Basel, Switzerland
| | - Birthe Kjellerup
- Department of Civil and Environmental Engineering, University of Maryland, College Park, MD, USA.,Fischell Department of Bioengineering, University of Maryland, College Park, MD, USA
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH, USA.,Department of Orthopaedics, The Ohio State University, Columbus, OH, USA.,National Biofilms Innovation Centre (NBIC), UK.,National Centre for Advanced Tribology at Southampton, University of Southampton, Southampton, UK
| | - Thomas Bjarnsholt
- ESCMID Study Group on Biofilms, Basel, Switzerland.,Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark.,Department of Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
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15
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Dusane DH, Brooks JR, Sindeldecker D, Peters CW, Li A, Farrar NR, Diamond SM, Knecht CS, Plaut RD, Delury C, Aiken SS, Laycock PA, Sullivan A, Granger JF, Stoodley P. Complete Killing of Agar Lawn Biofilms by Systematic Spacing of Antibiotic-Loaded Calcium Sulfate Beads. MATERIALS 2019; 12:ma12244052. [PMID: 31817373 PMCID: PMC6947297 DOI: 10.3390/ma12244052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2019] [Revised: 11/27/2019] [Accepted: 11/29/2019] [Indexed: 12/21/2022]
Abstract
Background:Pseudomonas aeruginosa (PA) and Staphylococcus aureus (SA) are the major causative agents of acute and chronic infections. Antibiotic-loaded calcium sulfate beads (ALCSB) are used in the management of musculoskeletal infections such as periprosthetic joint infections (PJI). Methods: To determine whether the number and spatial distribution of ALCSB are important factors to totally eradicate biofilms, ALCSBs containing vancomycin and tobramycin were placed on 24 h agar lawn biofilms as a single bead in the center, or as 16 beads placed as four clusters of four, a ring around the edge and as a group in the center or 19 beads evenly across the plate. Bioluminescence was used to assess spatial metabolic activity in real time. Replica plating was used to assess viability. Results: For both strains antibiotics released from the beads completely killed biofilm bacteria in a zone immediately adjacent to each bead. However, for PA extended incubation revealed the emergence of resistant colony phenotypes between the zone of eradication and the background lawn. The rate of biofilm clearing was greater when the beads were distributed evenly over the plate. Conclusions: Both number and distribution pattern of ALCSB are important to ensure adequate coverage of antibiotics required to eradicate biofilms.
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Affiliation(s)
- Devendra H. Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Jacob R. Brooks
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Devin Sindeldecker
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Casey W. Peters
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Anthony Li
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Nicholas R. Farrar
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Scott M. Diamond
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Cory S. Knecht
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
| | - Roger D. Plaut
- Division of Bacterial, Parasitic, and Allergenic Products, Center for Biologics Evaluation and Research, Food and Drug Administration, Silver Spring, MD 20993, USA;
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.D.); (S.S.A.); (P.A.L.)
| | - Sean S. Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.D.); (S.S.A.); (P.A.L.)
| | - Phillip A. Laycock
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.D.); (S.S.A.); (P.A.L.)
| | - Anne Sullivan
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (A.S.); (J.F.G.)
| | - Jeffrey F. Granger
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (A.S.); (J.F.G.)
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (D.H.D.); (J.R.B.); (D.S.); (C.W.P.); (A.L.); (N.R.F.); (S.M.D.); (C.S.K.)
- Department of Orthopaedics, The Ohio State University, Wexner Medical Center, Columbus, OH 43210, USA; (A.S.); (J.F.G.)
- National Centre for Advanced Tribology at Southampton (nCATS) and National Biofilm Innovation Centre (NBIC), Department of Mechanical Engineering, University of Southampton, Southampton SO17 1BJ, UK
- Correspondence: ; Tel.: +1-614-292-7871
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16
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Bistolfi A, Ferracini R, Albanese C, Vernè E, Miola M. PMMA-Based Bone Cements and the Problem of Joint Arthroplasty Infections: Status and New Perspectives. MATERIALS (BASEL, SWITZERLAND) 2019; 12:E4002. [PMID: 31810305 PMCID: PMC6926619 DOI: 10.3390/ma12234002] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 11/14/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023]
Abstract
Polymethyl methacrylate (PMMA)-based bone cement is a biomaterial that has been used over the last 50 years to stabilize hip and knee implants or as a bone filler. Although PMMA-based bone cement is widely used and allows a fast-primary fixation to the bone, it does not guarantee a mechanically and biologically stable interface with bone, and most of all it is prone to bacteria adhesion and infection development. In the 1970s, antibiotic-loaded bone cements were introduced to reduce the infection rate in arthroplasty; however, the efficiency of antibiotic-containing bone cement is still a debated issue. For these reasons, in recent years, the scientific community has investigated new approaches to impart antibacterial properties to PMMA bone cement. The aim of this review is to summarize the current status regarding antibiotic-loaded PMMA-based bone cements, fill the gap regarding the lack of data on antibacterial bone cement, and explore the progress of antibacterial bone cement formulations, focusing attention on the new perspectives. In particular, this review highlights the innovative study of composite bone cements containing inorganic antibacterial and bioactive phases, which are a fascinating alternative that can impart both osteointegration and antibacterial properties to PMMA-based bone cement.
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Affiliation(s)
- Alessandro Bistolfi
- AO Citta’ della Salute e della Scienza. CTO Hospital, Department of Orthopedics. Via Zuretti 29, 10126 Turin, Italy; (A.B.); (C.A.)
| | - Riccardo Ferracini
- IRCCS Ospedale Policlinico San Martino, Department of Surgical Sciences and Integrated Diagnostics, University of Genova, Largo R. Benzi 10, 16132 Genova, Italy;
| | - Carlo Albanese
- AO Citta’ della Salute e della Scienza. CTO Hospital, Department of Orthopedics. Via Zuretti 29, 10126 Turin, Italy; (A.B.); (C.A.)
| | - Enrica Vernè
- Department of Applied Science and Technology, PolitoBIOMed Lab, Politecnico di Torino, C.so Duca Degli Abruzzi 24, 10129 Torino, Italy;
| | - Marta Miola
- Department of Applied Science and Technology, PolitoBIOMed Lab, Politecnico di Torino, C.so Duca Degli Abruzzi 24, 10129 Torino, Italy;
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17
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Ma AH, Hoffman C, Mcneil JI. Acute Tubular Necrosis Associated With High Serum Vancomycin and Tobramycin Levels After Revision of Total Knee Arthroplasty With Antibiotic-Containing Calcium Sulfate Beads. Open Forum Infect Dis 2019; 6:ofz141. [PMID: 31041345 PMCID: PMC6483752 DOI: 10.1093/ofid/ofz141] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2019] [Accepted: 04/08/2019] [Indexed: 12/02/2022] Open
Abstract
We present the case of a 59-year-old male who developed acute tubular necrosis with a serum tobramycin level of 15.9 mg/L after instillation of tobramycin and vancomycin calcium sulfate beads for infected total knee arthroplasty. We emphasize standardizing surgical protocols to mitigate nephrotoxicity based on current efficacy and safety data.
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Affiliation(s)
- Adrienne H Ma
- Department of Pharmacy, The George Washington University Hospital, Washington, DC
| | - Courtney Hoffman
- Department of Pharmacy, MedStar Montgomery Medical Center, Olney, Maryland
| | - John I Mcneil
- Infectious Disease Medicine, Silver Spring, Maryland
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18
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Salvage of rib stabilization hardware with antibiotic beads. Am J Surg 2019; 218:869-875. [PMID: 30857639 DOI: 10.1016/j.amjsurg.2019.02.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Revised: 02/21/2019] [Accepted: 02/26/2019] [Indexed: 11/21/2022]
Abstract
BACKGROUND Surgical stabilization of rib fractures (SSRF) can be used to improve pulmonary mechanics; however, hardware infection is a morbid complication. Antibiotic impregnated beads have been used to suppress infection in orthopedic practices. We aimed to determine the efficacy of antibiotic beads for infected and at-risk SSRF hardware. METHODS This is a single institution retrospective review of adults (18 years or older) that received SSRF between 2009 and 2017. Infected and at-risk hardware were managed with antibiotic beads. The primary outcome was bony union of rib fractures. RESULTS There were 285 SSRF patients. Infection rate was 3.5%. Antibiotic beads were placed in 17 patients - 9 for infected hardware and 8 for prophylaxis. Increased body mass index (p = 0.04) and hemorrhagic shock at admission (p = 0.03) were risk factors for infection. There was 100% bony union post-operatively. CONCLUSION SSRF hardware infection is morbid. Antibiotic beads can salvage SSRF hardware until bony union.
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19
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Dusane DH, Lochab V, Jones T, Peters CW, Sindeldecker D, Das A, Roy S, Sen CK, Subramaniam VV, Wozniak DJ, Prakash S, Stoodley P. Electroceutical Treatment of Pseudomonas aeruginosa Biofilms. Sci Rep 2019; 9:2008. [PMID: 30765750 PMCID: PMC6375951 DOI: 10.1038/s41598-018-37891-y] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 11/30/2018] [Indexed: 02/08/2023] Open
Abstract
Electroceutical wound dressings, especially those involving current flow with silver based electrodes, show promise for treating biofilm infections. However, their mechanism of action is poorly understood. We have developed an in vitro agar based model using a bioluminescent strain of Pseudomonas aeruginosa to measure loss of activity and killing when direct current was applied. Silver electrodes were overlaid with agar and lawn biofilms grown for 24 h. A 6 V battery with 1 kΩ ballast resistor was used to treat the biofilms for 1 h or 24 h. Loss of bioluminescence and a 4-log reduction in viable cells was achieved over the anode. Scanning electron microscopy showed damaged cells and disrupted biofilm architecture. The antimicrobial activity continued to spread from the anode for at least 2 days, even after turning off the current. Based on possible electrochemical ractions of silver electrodes in chlorine containing medium; pH measurements of the medium post treatment; the time delay between initiation of treatment and observed bactericidal effects; and the presence of chlorotyrosine in the cell lysates, hypochlorous acid is hypothesized to be the chemical agent responsible for the observed (destruction/killing/eradication) of these biofilm forming bacteria. Similar killing was obtained with gels containing only bovine synovial fluid or human serum. These results suggest that our in vitro model could serve as a platform for fundamental studies to explore the effects of electrochemical treatment on biofilms, complementing clinical studies with electroceutical dressings.
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Affiliation(s)
- Devendra H Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Varun Lochab
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Travis Jones
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Casey W Peters
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Devin Sindeldecker
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Amitava Das
- Department of Surgery, IU Health Comprehensive Wound Center, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.,Comprehensive Wound Center and Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, 43210, USA
| | - Sashwati Roy
- Department of Surgery, IU Health Comprehensive Wound Center, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.,Comprehensive Wound Center and Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, 43210, USA
| | - Chandan K Sen
- Department of Surgery, IU Health Comprehensive Wound Center, Indiana Center for Regenerative Medicine and Engineering, Indiana University School of Medicine, Indianapolis, IN, 46202, USA.,Comprehensive Wound Center and Department of Surgery, The Ohio State University Wexner Medical Center, Columbus, Ohio, 43210, USA
| | - Vish V Subramaniam
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Daniel J Wozniak
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, 43210, USA
| | - Shaurya Prakash
- Department of Mechanical and Aerospace Engineering, The Ohio State University, Columbus, Ohio, 43210, USA.
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio, 43210, USA. .,Department of Orthopaedics, The Ohio State University, Columbus, Ohio, 43210, USA. .,National Centre for Advanced Tribology, Mechanical Engineering, University of Southampton, Southampton, UK.
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20
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General Assembly, Prevention, Local Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S75-S84. [PMID: 30352772 DOI: 10.1016/j.arth.2018.09.056] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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21
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Kurebayashi L, Melo Junior ATD, Andrade-Silva FB, Kojima KE, Silva JDS. CLINICAL EVALUATION OF PATIENTS WITH VANCOMYCIN SPACER RETAINED FOR MORE THAN 12 MONTHS. ACTA ORTOPEDICA BRASILEIRA 2019; 27:55-58. [PMID: 30774532 PMCID: PMC6362697 DOI: 10.1590/1413-785220192701213649] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Objective: There is no consensus in the literature regarding the time taken to remove antibiotic spacers in the treatment of bone infections. The aim of this study is to evaluate the clinical results of patients with prolonged retention of the same. Methods: Patients selected were diagnosed with post-osteosynthesis infection and/or osteomyelitis and were submitted to treatment using an orthopedic cement spacer (polymethylmethacrylate) with vancomycin, retaining it for a period of more than 12 months. They were clinically evaluated to determine the presence of local or systemic infectious signs via hemogram, investigations of inflammatory markers, liver, renal and, with radiographic control. Results: Eighteen patients were included in the study. The mean retention time of the spacer was 30.4 months (15 – 61 months). No patient had clinical signs of local or systemic infectious relapse at the time of evaluation. Seven patients (39%) presented non-disabling pain in the operated limb. Seventeen patients (94%) presented a reduction in C-reactive protein values compared to the preoperative period. Radiographically, no migration, no spacer failure, or bone sequestration occurred. Conclusion: In this retrospective case series, cement spacer retention with vancomycin for more than 12 months was associated with good clinical results, without relapse of the infectious condition. Nível de Evidência IV. Estudos Terapêuticos - Investigação dos Resultados do Tratamento.
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22
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Moley JP, McGrath MS, Granger JF, Stoodley P, Dusane DH. Reduction in Pseudomonas aeruginosa and Staphylococcus aureus biofilms from implant materials in a diffusion dominated environment. J Orthop Res 2018; 36:3081-3085. [PMID: 29924414 DOI: 10.1002/jor.24074] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/11/2018] [Indexed: 02/04/2023]
Abstract
Antibiotic-loaded calcium sulfate beads (CS-B) are used to treat biofilm-related periprosthetic joint infections (PJI). A previous study has shown that such beads are effective in reducing lawns biofilms grown on agar plates; however, the ability of CS-B to eradicate biofilms grown on solid orthopedic material surfaces has not been investigated. We grew biofilms of bioluminescent strains of Pseudomonas aeruginosa Xen41 and a USA300 MRSA Staphylococcus aureus SAP231 on ultra-high molecular weight polyethylene (PE), hydroxyapatite (HA), and 316L stainless steel (SS) coupons for three days under static growth conditions, with daily nutrient exchange. The coupons were rinsed with sterile phosphate buffered saline (PBS) to remove planktonic bacteria and placed in a petri dish, surrounded by four either antibiotic vancomycin and tobramycin loaded (CS-BV+T ) or unloaded beads (CS-BU ). A thin layer of agar was overlaid to simulate a periprosthetic infection where an implant abuts soft tissue and then incubated for 72 h. The amount of biofilm was measured by bioluminescence imaging (BLI) for activity and viable cell count (CFUs). Coupons exposed to CS-BV+T showed a significant reduction in the amount of biofilm within 24 h, regardless of the bacterial strain or material type. The coupons exposed to control CS-BU had no effect on bacteria over 72 h. Statement of Clinical Significance: Antibiotic-loaded calcium sulfate beads (CS-B) were effective in significantly reducing mature biofilms of P. aeruginosa and S. aureus from orthopedic relevant surfaces in our in vitro agar model. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:3081-3085, 2018.
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Affiliation(s)
- James P Moley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio 43210
| | - Mary S McGrath
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio 43210
| | - Jeffrey F Granger
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio 43210
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio 43210.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio 43210
| | - Devendra H Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, Ohio 43210
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23
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Knecht CS, Moley JP, McGrath MS, Granger JF, Stoodley P, Dusane DH. Antibiotic loaded calcium sulfate bead and pulse lavage eradicates biofilms on metal implant materials in vitro. J Orthop Res 2018; 36:2349-2354. [PMID: 29603341 DOI: 10.1002/jor.23903] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 03/27/2018] [Indexed: 02/04/2023]
Abstract
Pulse lavage (PL) debridement and antibiotic loaded calcium sulfate beads (CS-B) are both used for the treatment of biofilm related periprosthetic joint infection (PJI). However, the efficacy of these alone and in combination for eradicating biofilm from orthopaedic metal implant surfaces is unclear. The purpose of the study was to understand the efficacy of PL and antibiotic loaded CS-B in eradicating bacterial biofilms on 316L stainless steel (SS) alone and in combination in vitro. Biofilms of bioluminescent strains of Pseudomonas aeruginosa Xen41 and a USA300 MRSA Staphylococcus aureus SAP231 were grown on SS coupons for 3 days. The coupons were either, (i) debrided for 3 s with PL, (ii) exposed to tobramycin (TOB) and vancomycin (VAN) loaded CS-B for 24 h, or (iii) exposed to both. An untreated biofilm served as a control. The amount of biofilm was measured by bioluminescence, viable plate count and confocal microscopy using live/dead staining. PL alone reduced the CFU count of both strains of biofilms by approximately 2 orders of magnitude, from an initial cell count on metal surface of approximately 109 CFU/cm2 . The antibiotic loaded CS-B caused an approximate six log reduction and the combination completely eradicated viable biofilm bacteria. Bioluminescence and confocal imaging corroborated the CFU data. While PL and antibiotic loaded CS-B both significantly reduced biofilm, the combination of two was more effective than alone in removing biofilms from SS implant surfaces. © 2018 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:2349-2354, 2018.
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Affiliation(s)
- Cory S Knecht
- Department of Orthopaedics, Cleveland Clinic, Akron General, Akron, Ohio
| | - James P Moley
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210
| | - Mary S McGrath
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210
| | - Jeffrey F Granger
- Department of Orthopaedics, The Ohio State University, Columbus, Ohio 43210
| | - Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210.,Department of Orthopaedics, The Ohio State University, Columbus, Ohio 43210.,National Centre for Advanced Tribology at Southampton (nCATS), University of Southampton, Southampton SO17 1BJ, United Kingdom
| | - Devendra H Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, 716 Biomedical Research Tower (BRT), 460 W 12th Ave, Columbus, Ohio 43210
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24
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Xiang Y, Xuan YY, Li G. Successful treatment for acute prosthetic joint infection due to MRSA and Candida albicans: a case report and literature review. Ther Clin Risk Manag 2018; 14:1133-1139. [PMID: 29950850 PMCID: PMC6016578 DOI: 10.2147/tcrm.s165247] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Methicillin-resistant Staphylococcus aureus (MRSA) and Candidal prosthetic joint infections (PJIs) are very rare, and the optimal management for these patients is still unknown. A 54-year-old man with traumatic arthritis due to previous electric injury successfully retained the implant despite the successive infection with MRSA and Candida albicans after total knee arthroplasty (TKA). Continuous lavage with vancomycin was used to control MRSA infection and repeated local washout plus oral swallow with voriconazole tablet were administered to eradicate C. albicans. Additional three reported cases were identified by the criteria of selecting patients with concomitant and/or successive MRSA and Candidal PJIs. Different methods were applied with variable outcomes. Therefore, several risk factors such as intra-articular corticosteroid injection, high frequency of door openings in the operating room, excessive blood loss and allogeneic red blood cell transfusions should be avoided. Debridement, antibiotics and implant retention (DAIR) can be an alternative in dedicated patients to control acute MRSA and Candidal PJIs. Particularly, repeated intra-articular washout with susceptible drugs and a prolonged duration of oral antibiotics was essential for microbial control.
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Affiliation(s)
- Yong Xiang
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Yi-Yi Xuan
- Department of Rheumatology and Immunology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
| | - Guangheng Li
- Department of Orthopedic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, Henan, People's Republic of China
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25
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Das Ghatak P, Mathew-Steiner SS, Pandey P, Roy S, Sen CK. A surfactant polymer dressing potentiates antimicrobial efficacy in biofilm disruption. Sci Rep 2018; 8:873. [PMID: 29343818 PMCID: PMC5772662 DOI: 10.1038/s41598-018-19175-7] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2017] [Accepted: 12/13/2017] [Indexed: 12/26/2022] Open
Abstract
A 100% water-soluble surfactant polymer dressing (SPD) that is bio-compatible and non-ionic has been reported to improve wound closure in preliminary clinical studies. The mechanism of action of SPD in wound healing remains unclear. Biofilm infection is a significant problem that hinders proper wound closure. The objective of this study was to characterize the mechanism of action of SPD inhibition of bacterial biofilm development. Static biofilms (48 h) of the primary wound pathogens Pseudomonas aeruginosa (PA01), Staphylococcus aureus (USA300) were grown on polycarbonate membranes and treated with SPD with and without antibiotics for an additional 24 h. The standard antibiotics - tobramycin (10 μg/ml) for PA01 and rifampicin (10 μg/ml) for USA300, were used in these studies. Following 24 h treatment with and without antibiotics, the biofilms were characterized using scanning electron microscopy (SEM) structural imaging, in vitro imaging system (IVIS) proliferation imaging, colony forming units (CFU), viability assay, quantitative PCR (qPCR) for virulence gene expression. Because SPD is a surfactant based dressing, it potentially has a direct effect on Gram negative bacteria such as Pseudomonas primarily due to the lipid-based outer membrane of the bacteria. SPD is a surfactant based dressing that has potent anti-biofilm properties directly or in synergy with antibiotics.
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Affiliation(s)
- Piya Das Ghatak
- Department of Surgery, Davis Heart and Lung Research Institute, Center for Regenerative Medicine & Cell-Based Therapies, Wexner Medical Center, The Ohio State University, Columbus, 43210, United States of America
- Center for Regenerative Medicine and Cell-Based Therapies, The Ohio State University, Columbus, 43210, United States of America
| | - Shomita S Mathew-Steiner
- Department of Surgery, Davis Heart and Lung Research Institute, Center for Regenerative Medicine & Cell-Based Therapies, Wexner Medical Center, The Ohio State University, Columbus, 43210, United States of America
- Center for Regenerative Medicine and Cell-Based Therapies, The Ohio State University, Columbus, 43210, United States of America
| | - Priyanka Pandey
- Department of Surgery, Davis Heart and Lung Research Institute, Center for Regenerative Medicine & Cell-Based Therapies, Wexner Medical Center, The Ohio State University, Columbus, 43210, United States of America
- Center for Regenerative Medicine and Cell-Based Therapies, The Ohio State University, Columbus, 43210, United States of America
| | - Sashwati Roy
- Department of Surgery, Davis Heart and Lung Research Institute, Center for Regenerative Medicine & Cell-Based Therapies, Wexner Medical Center, The Ohio State University, Columbus, 43210, United States of America
- Center for Regenerative Medicine and Cell-Based Therapies, The Ohio State University, Columbus, 43210, United States of America
| | - Chandan K Sen
- Department of Surgery, Davis Heart and Lung Research Institute, Center for Regenerative Medicine & Cell-Based Therapies, Wexner Medical Center, The Ohio State University, Columbus, 43210, United States of America.
- Center for Regenerative Medicine and Cell-Based Therapies, The Ohio State University, Columbus, 43210, United States of America.
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26
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Preem L, Mahmoudzadeh M, Putrinš M, Meos A, Laidmäe I, Romann T, Aruväli J, Härmas R, Koivuniemi A, Bunker A, Tenson T, Kogermann K. Interactions between Chloramphenicol, Carrier Polymers, and Bacteria–Implications for Designing Electrospun Drug Delivery Systems Countering Wound Infection. Mol Pharm 2017; 14:4417-4430. [DOI: 10.1021/acs.molpharmaceut.7b00524] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Affiliation(s)
- Liis Preem
- Institute
of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
| | - Mohammad Mahmoudzadeh
- Drug
research program, Division of Pharmaceutical Biosciences, Faculty
of Pharmacy, University of Helsinki, Viikinkaari 5E,
P.O. Box 56, FI-00014 Helsinki, Finland
| | - Marta Putrinš
- Institute
of Technology, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
| | - Andres Meos
- Institute
of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
| | - Ivo Laidmäe
- Institute
of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
| | - Tavo Romann
- Institute
of Chemistry, University of Tartu, Ravila 14a, 50411 Tartu, Estonia
| | - Jaan Aruväli
- Institute
of Ecology and Earth Sciences, University of Tartu, Ravila 14a, 50411 Tartu, Estonia
| | - Riinu Härmas
- Institute
of Chemistry, University of Tartu, Ravila 14a, 50411 Tartu, Estonia
| | - Artturi Koivuniemi
- Drug
research program, Division of Pharmaceutical Biosciences, Faculty
of Pharmacy, University of Helsinki, Viikinkaari 5E,
P.O. Box 56, FI-00014 Helsinki, Finland
| | - Alex Bunker
- Drug
research program, Division of Pharmaceutical Biosciences, Faculty
of Pharmacy, University of Helsinki, Viikinkaari 5E,
P.O. Box 56, FI-00014 Helsinki, Finland
| | - Tanel Tenson
- Institute
of Technology, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
| | - Karin Kogermann
- Institute
of Pharmacy, University of Tartu, Nooruse 1, 50411 Tartu, Estonia
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27
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Morejón Alonso L, Mendizábal Ruiz AP, Muñiz Flores JA, Rodríguez Herrera DL, Rodríguez García O, Ledea Lozano OE, Delgado García-Menocal JA, Fuentes Estévez G. Evaluation of acrylic bone cements with single and combined antibiotics: Release behavior andin vitroantibacterial effectiveness. INT J POLYM MATER PO 2017. [DOI: 10.1080/00914037.2017.1383250] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
| | | | | | | | - Ofelia Rodríguez García
- Departamento de Farmacobiología, CUCEI, Universidad de Guadalajara, Guadalajara, Jalisco, México
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