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Piperacillin Steady State Concentrations in Target Tissues Relevant for PJI Treatment—A Randomized Porcine Microdialysis Study Comparing Continuous Infusion with Intermittent Short-Term Infusion. Antibiotics (Basel) 2023; 12:antibiotics12030577. [PMID: 36978444 PMCID: PMC10044349 DOI: 10.3390/antibiotics12030577] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 03/12/2023] [Accepted: 03/13/2023] [Indexed: 03/17/2023] Open
Abstract
(1) Introduction: Piperacillin is a common antibiotic choice in the treatment of periprosthetic joint infections (PJI) caused by Pseudomonas aeruginosa. The aim of this study was to assess and compare the time with free piperacillin concentration above the minimum inhibitory concentration (fT > MIC) at steady state in target tissues relevant for PJI treatment following continuous and intermittent short-term infusion. (2) Methods: 16 pigs were randomized to receive either continuous or intermittent short-term infusion of piperacillin. Steady state piperacillin concentrations were assessed using microdialysis in tibial cortical bone, tibial cancellous bone, synovial fluid of the knee joint, and subcutaneous tissue. MIC-targets of 4, 8, 16, and 64 mg/L were applied. Plasma samples were obtained as reference. (3) Results: Continuous infusion resulted in longer fT > MIC for MIC targets of 4 mg/L and 8 mg/L compared to intermittent short-term infusion in all compartments with the exception of tibial cortical bone. For the MIC-target of 16 mg/L, continuous infusion resulted in a longer fT > MIC in all compartments except for the bone compartments. No differences between groups were seen when applying a MIC-target of 64 mg/L. (4) Conclusions: An aggressive dosing strategy may be necessary to obtain sufficient piperacillin concentrations in all bone compartments, particularly if more aggressive targets are applied. Based on the present study, continuous infusion should be considered in the treatment of PJI.
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2
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Sabater-Martos M, Verdejo MA, Morata L, Muñoz-Mahamud E, Guerra-Farfan E, Martinez-Pastor JC, Soriano A. Antimicrobials in polymethylmethacrylate: from prevention to prosthetic joint infection treatment: basic principles and risk of resistance. ARTHROPLASTY 2023; 5:12. [PMID: 36864538 PMCID: PMC9983184 DOI: 10.1186/s42836-023-00166-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 01/16/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Excellent revisions about antibiotic-loaded bone cement (ALBC) have been recently published. In the present article, we review the principles and limitations of local antibiotic delivery in the context of recent advances in the pathogenesis of prosthetic joint infections (PJI), with particular attention paid to the potential association between ALBC and antimicrobial resistance. MAIN BODY Recalcitrance of PJI is related to the ability of pathogens to adapt to particular environments present in bone tissue and protect themselves from host immunity in different ways. Accordingly, delivery of high local antimicrobial concentrations using ALBC is needed. Most relevant clinical data showing the efficacy of ALBC for PJI prophylaxis and treatment are reviewed, and we dissected the limitations on the basis of the recent findings from animal models and suggested that aminoglycosides, in particular, could not be the best option. One of the major concerns associated with ALBC is the emergence of resistance because of theoretical prolonged exposure to low antibiotic concentrations. We summarize the mechanisms for the selection of resistant microorganisms, and we critically reviewed the evidence from animal models and clinical data from observational and registry studies and concluded that there is no evidence to support this association. CONCLUSION While waiting for better evidence from well-designed clinical trials, ALBC shows a beneficial effect as a prophylaxis in arthroplasty, and to avoid the colonization of spacers used for two-stage revision in patients with PJI. Experimental models and clinical evidence suggest the need to achieve high local antimicrobial concentrations to obtain the highest prophylactic and therapeutic effect. The current evidence does not support the risk of increasing resistance with use of ALBC. In the future, it is necessary to evaluate new carriers and different antimicrobials to improve clinical outcomes.
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Affiliation(s)
- Marta Sabater-Martos
- Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain.
| | - Miguel A. Verdejo
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Laura Morata
- grid.410458.c0000 0000 9635 9413Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Muñoz-Mahamud
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Ernesto Guerra-Farfan
- grid.411083.f0000 0001 0675 8654Department of Orthopedics and Traumatology, Hospital Vall d’Hebron of Barcelona, Passeig de la Vall d’Hebron 119, 08035 Barcelona, Spain
| | - Juan C. Martinez-Pastor
- grid.410458.c0000 0000 9635 9413Department of Orthopedics and Traumatology, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036 Barcelona, Spain
| | - Alex Soriano
- Department of Infectious Diseases, Hospital Clínic of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain. .,University of Barcelona, CIBERINF, Carrer Casanova 143, 08036, Barcelona, Spain.
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Petersen EK, Hanberg P, Knudsen M, Tøstesen SK, Jørgensen AR, Öbrink-Hansen K, Søballe K, Stilling M, Bue M. Intermittent Short-Term Infusion vs. Continuous Infusion of Piperacillin: Steady State Concentrations in Porcine Cervical Spine Tissue Evaluated by Microdialysis. Antibiotics (Basel) 2022; 11:antibiotics11070910. [PMID: 35884164 PMCID: PMC9312177 DOI: 10.3390/antibiotics11070910] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/04/2022] [Accepted: 07/05/2022] [Indexed: 01/25/2023] Open
Abstract
Background: Piperacillin is a central drug in the treatment of Pseudomonas aeruginosa spondylodiscitis. Intermittent short-term infusion (STI) remains standard treatment in most centres, although the application of continuous infusion (CI) has shown promising results in other clinical settings. We aimed to evaluate time above the minimal inhibitory concentration (fT > MIC) of the free fraction of piperacillin in steady state conditions in porcine cervical spine tissue following CI and STI using microdialysis with MIC targets of 4, 8, and 16 μg/mL. Methods: 16 female pigs were randomized to receive piperacillin/tazobactam as STI (4/0.5 g every 6 h) or CI (4/0.5 g as a bolus followed by 12/1.5 g) for 18 h. Microdialysis catheters were placed for sampling of piperacillin concentrations from the intervertebral disc, vertebral cancellous bone, paravertebral muscle, and adjacent subcutaneous tissue during the third dosing interval (12−18 h). Blood samples were collected as reference. Results: CI resulted in fT > MIC > 82% across all compartments and targets, except for intervertebral disc (37%) and vertebral cancellous bone (28%) at MIC = 16 μg/mL. In Group STI, >72% fT > MIC was reached for MIC = 4 μg/mL in all investigated compartments, while for MIC = 16 μg/mL only subcutaneous tissue exhibited fT > MIC > 50%. Conclusion: CI of piperacillin resulted in higher fT > MIC compared to STI infusion across the investigated tissues and targets. CI should therefore be considered in spondylodiscitis cases requiring piperacillin treatment.
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Affiliation(s)
- Elisabeth Krogsgaard Petersen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark
- Correspondence: ; Tel.: +45-5058-2067
| | - Pelle Hanberg
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Martin Knudsen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Sara Kousgaard Tøstesen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Andrea René Jørgensen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Kristina Öbrink-Hansen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Department of Infectious Diseases, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Kjeld Søballe
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Maiken Stilling
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus, Denmark
| | - Mats Bue
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark; (P.H.); (M.K.); (S.K.T.); (A.R.J.); (K.Ö.-H.); (K.S.); (M.S.); (M.B.)
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus, Denmark
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus, Denmark
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Bendtsen MAF, Hanberg P, Slater J, Hansen J, Öbrink-Hansen K, Stilling M, Bue M. Steady-state concentrations of flucloxacillin in porcine vertebral cancellous bone and intervertebral disc following oral and intravenous administration assessed by microdialysis. EUROPEAN SPINE JOURNAL : OFFICIAL PUBLICATION OF THE EUROPEAN SPINE SOCIETY, THE EUROPEAN SPINAL DEFORMITY SOCIETY, AND THE EUROPEAN SECTION OF THE CERVICAL SPINE RESEARCH SOCIETY 2022; 31:1508-1514. [PMID: 35488132 DOI: 10.1007/s00586-022-07208-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 03/03/2022] [Accepted: 04/05/2022] [Indexed: 11/30/2022]
Abstract
AIMS Flucloxacillin is a frequently used antibiotic in the treatment of spondylodiscitis. We assessed steady-state concentrations and time above minimal inhibitory concentration (fT > MIC) of flucloxacillin in the intervertebral disc, vertebral cancellous bone, subcutaneous tissue and plasma, after intravenous and oral administration. METHODS Sixteen pigs were randomized into two groups; Group Peroral (Group PO) and Group Intravenous (Group IV) received 1 g flucloxacillin every 6 h for 24 h orally or intravenously. Microdialysis was used for sampling in the compartments of interest. A flucloxacillin target of 50% fT > MIC was applied for three MIC targets: 0.125, 0.5 and 2.0 μg/mL. RESULTS Intravenous administration resulted in significantly longer fT > MIC for all targets. Target attainment was only reached for the low target of 0.125 μg/mL in Group IV in vertebral cancellous bone, subcutaneous tissue, and plasma (intervertebral disc 47%). In Group IV, mean fT > MIC values in the investigated compartments were in the range of 47-67% of the dosing interval for 0.125 μg/mL, 20-35% for 0.5 μg/mL, and 0-15% for 2.0 μg/mL. In Group PO, mean fT > MIC values for 0.125 μg/mL were in the range of 1-33%. No pigs reached a concentration of 0.5 μg/mL in any of the investigated compartments in Group PO. CONCLUSION Administration of 1 g flucloxacillin every 6 h resulted in surprisingly low steady-state fT > MIC after intravenous and oral administration. However, intravenous administration resulted in significantly higher concentrations across compartments compared to oral administration. Sufficient target tissue concentrations for treatment of spondylodiscitis may require a dose increase or alternative dosing regimens.
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Affiliation(s)
- Mathias A F Bendtsen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark.
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark.
| | - Pelle Hanberg
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Josefine Slater
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Jakob Hansen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Institute of Forensic Medicine, Aarhus University, Aarhus, Denmark
| | - Kristina Öbrink-Hansen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Stilling
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
| | - Mats Bue
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus, Denmark
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5
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Bue M, Thomassen MB, Larsen OH, Jørgensen AR, Stilling M, Søballe K, Hanberg P. Local Vancomycin Concentrations after Intra-articular Injection into the Knee Joint: An Experimental Porcine Study. J Knee Surg 2021; 34:936-940. [PMID: 31887761 DOI: 10.1055/s-0039-3402078] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Intra-articular injection of vancomycin may be an important antimicrobial prophylactic supplement to systemic administration in the prevention of prosthetic joint infections. In eight female pigs, 500 mg of diluted vancomycin was given by intra-articular injection into the knee joint. Microdialysis was used for dense sampling of vancomycin concentrations over 12 hours in the synovial fluid of the knee joint, and in the adjacent femoral and tibial cancellous bone and subcutaneous tissue. Venous blood samples were obtained as reference. The mean (standard deviation [SD]) peak drug concentration of vancomycin in the synovial fluid of the knee joint was 5,277 (5,668) μg/mL. Only one pig failed to reach a peak drug concentration above 1,000 μg/mL. The concentration remained high throughout the sampling interval with a mean (SD) concentration of 337 (259) μg/mL after 690 minutes. For all extraarticular compartments, the pharmacokinetic parameters (area under the concentration time-curve, peak drug concentration, and time to peak drug concentration) were comparable. The highest extraarticular mean (SD) peak drug concentration of 4.4 (2.3) μg/mL was found in subcutaneous tissue. An intra-articular injection of 500 mg diluted vancomycin was found to provide significant prophylactic mean concentrations for at least 12 hours in the synovial fluid of the knee joint. Correspondingly, the adjacent tissue and plasma concentrations were low but remained stable, signifying low risk of systemic toxic side effects and a slow release or uptake from the synovium to the systemic circulation.
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Affiliation(s)
- Mats Bue
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark.,Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Maja B Thomassen
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Ole H Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus N, Denmark
| | - Andrea R Jørgensen
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Maiken Stilling
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Kjeld Søballe
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark
| | - Pelle Hanberg
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark.,Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
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6
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Influence of sub-inhibitory concentrations of antimicrobials on micrococcal nuclease and biofilm formation in Staphylococcus aureus. Sci Rep 2021; 11:13241. [PMID: 34168199 PMCID: PMC8225913 DOI: 10.1038/s41598-021-92619-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2020] [Accepted: 06/03/2021] [Indexed: 02/05/2023] Open
Abstract
A major contributor to biomaterial associated infection (BAI) is Staphylococcus aureus. This pathogen produces a protective biofilm, making eradication difficult. Biofilms are composed of bacteria encapsulated in a matrix of extracellular polymeric substances (EPS) comprising polysaccharides, proteins and extracellular DNA (eDNA). S. aureus also produces micrococcal nuclease (MN), an endonuclease which contributes to biofilm composition and dispersion, mainly expressed by nuc1. MN expression can be modulated by sub-minimum inhibitory concentrations of antimicrobials. We investigated the relation between the biofilm and MN expression and the impact of the application of antimicrobial pressure on this relation. Planktonic and biofilm cultures of three S. aureus strains, including a nuc1 deficient strain, were cultured under antimicrobial pressure. Results do not confirm earlier findings that MN directly influences total biomass of the biofilm but indicated that nuc1 deletion stimulates the polysaccharide production per CFU in the biofilm in in vitro biofilms. Though antimicrobial pressure of certain antibiotics resulted in significantly increased quantities of polysaccharides per CFU, this did not coincide with significantly reduced MN activity. Erythromycin and resveratrol significantly reduced MN production per CFU but did not affect total biomass or biomass/CFU. Reduction of MN production may assist in the eradication of biofilms by the host immune system in clinical situations.
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7
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Jørgensen AR, Hanberg P, Bue M, Thomassen MB, Pedersen Jørgensen N, Stilling M. Double-dose cefuroxime concentrations in bone, synovial fluid of the knee joint and subcutaneous adipose tissue-A randomised porcine microdialysis study. Eur J Pharm Sci 2021; 160:105754. [PMID: 33582285 DOI: 10.1016/j.ejps.2021.105754] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2020] [Revised: 02/05/2021] [Accepted: 02/07/2021] [Indexed: 02/05/2023]
Abstract
This study evaluated target tissue concentrations of double dose cefuroxime administered intravenously as either one 15 min infusion of 3000 mg (Group 1) or two single 15 min infusions of 1500 mg administered 4 h apart (Group 2). Sixteen pigs were randomised into two groups of eight. Cortical and cancellous bone, synovial fluid of the knee joint and subcutaneous adipose tissue concentrations were measured based on sampling via microdialysis. Plasma samples were collected as a reference. Comparison of the groups was based on time with concentrations above relevant minimal inhibitory concentrations (fT>MIC) of 4 μg/mL. The mean time fT>MIC (4 μg/mL) across compartments was longer for Group 2 (280-394 min) than for Group 1 (207-253 min) (p<0.01). Cortical bone showed a tendency towards longer fT>MIC (4 μg/mL) in Group 2 (280 min) than in Group 1 (207 min) (p = 0.053). Within 50 min after administration, the mean concentration of 4 μg/mL was reached in all compartments for both groups. The mean concentrations decreased below 4 μg/mL after approximately 4 h (Group 1) and 3 h (Group 2) from initiation of administration (time zero). During an 8 h interval, double-dose cefuroxime administered as 2 × 1500 mg with a 4 h interval provides longer time above MIC breakpoint for Staphylococcus aureus (4 μg/mL) than a single bolus of 3000 mg cefuroxime. To maintain sufficient tissue concentrations during longer surgeries, re-administration of cefuroxime (1500 mg) should be considered 3 h after the first administration.
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Affiliation(s)
- A R Jørgensen
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.
| | - P Hanberg
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark; Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark.
| | - M Bue
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark; Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark.
| | - M B Thomassen
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.
| | - N Pedersen Jørgensen
- Department of Infectious Diseases, Aarhus University Hospital, Aarhus N, Denmark.
| | - M Stilling
- Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus N, Denmark.
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8
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Olsen Kipp J, Hanberg P, Slater J, Møller Nielsen L, Storgaard Jakobsen S, Stilling M, Bue M. Vancomycin bone and tissue concentrations following tibial intraosseous administration - evaluated in a porcine model. J Bone Jt Infect 2021; 6:99-106. [PMID: 34084697 PMCID: PMC8129907 DOI: 10.5194/jbji-6-99-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 02/03/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction. Systemic perioperative vancomycin may not provide sufficient prophylactic target-site concentrations in the prevention of prosthetic joint infections. Intraosseous vancomycin potentially provides high target-site concentrations. The objective of the present study was to evaluate the local bone and tissue concentrations following tibial intraosseous vancomycin administration in a porcine model. Methods. Eight pigs received 500 mg diluted vancomycin (50 mg/mL) through an intraosseous cannula into the proximal tibial cancellous bone. No tourniquet was applied. Microdialysis was applied for sampling of vancomycin concentrations in adjacent tibial cancellous bone, in cortical bone, in the intramedullary canal of the diaphysis, in the synovial fluid of the knee joint, and in the subcutaneous tissue. Plasma samples were obtained as a systemic reference. Samples were collected for 12 h. Results. High vancomycin concentrations were found in the tibial cancellous bone with a mean peak drug concentration of 1236 (range 28-5295) µ g / mL , which remained high throughout the sampling period. The mean (standard deviation) peak drug concentration in plasma was 19 (2) µ g / mL , which was obtained immediately after administration. Peak drug concentration, time to peak drug concentration, and area under the concentration-time curve were within the same range in the intramedullary canal, the synovial fluid of the knee, and the subcutaneous tissue. Conclusion. Tibial intraosseous administration of vancomycin provided high concentrations in tibial cancellous bone throughout a 12 h period but with an unpredictable and wide range of peak concentration. The systemic absorption was high and immediate, thus mirroring an intravenous administration. Low mean concentrations were found in all the remaining compartments.
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Affiliation(s)
- Josephine Olsen Kipp
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Pelle Hanberg
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Horsens Regional Hospital, Sundvej 30, 8700 Horsens, Denmark
| | - Josefine Slater
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Line Møller Nielsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Stig Storgaard Jakobsen
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Maiken Stilling
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
| | - Mats Bue
- Orthopaedic Research Unit, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Blvd. 99, 8200 Aarhus N, Denmark
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9
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Muñoz-Mahamud E, Fernández-Valencia JÁ, Combalia A, Morata L, Soriano Á. Fluorescent tetracycline bone labeling as an intraoperative tool to debride necrotic bone during septic hip revision: a preliminary case series. J Bone Jt Infect 2021; 6:85-90. [PMID: 34084695 PMCID: PMC8132458 DOI: 10.5194/jbji-6-85-2021] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 01/10/2021] [Indexed: 11/29/2022] Open
Abstract
A plausible cause of persistent infection after septic hip revision may be
the presence of nonviable osteomyelitic bone. Since surgical excision of
these necrotic fragments is often challenging, the use of fluorescent
tetracycline bone labeling (FTBL) as an intraoperative tool may pose an
additional assessment aid to provide a visual index of surgical debridement.
Methods:
We present a single-center study performed in a university hospital from
January 2018 to June 2020, in which all consecutive cases of chronic hip periprosthetic joint
infection (PJI)
undergoing revision using FTBL were retrospectively reviewed. In all
cases, the patient was under treatment with tetracyclines at the moment of
the revision surgery. During the surgery, all bone failing to fluoresce was
considered nonviable and thus removed and sent for both culture and
histology.
Results:
We include three cases in which the FTBL technique was used. In all cases, the
histopathological examinations of the nonfluorescent removed bone were
consistent with chronic osteomyelitis.
Conclusion:
The intraoperative use of FTBL successfully aided the surgeon to detect the
presence of nonviable bone in all the presented cases of chronic prosthetic
hip infection.
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Affiliation(s)
- Ernesto Muñoz-Mahamud
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | | | - Andreu Combalia
- Department of Orthopaedics and Trauma Surgery, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Laura Morata
- Department of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
| | - Álex Soriano
- Department of Infectious Diseases, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain
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10
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Lüthje FL, Skovgaard K, Jensen HE, Blirup-Plum SA, Henriksen NL, Aalbæk B, Jensen LK. Receptor Activator of Nuclear Factor kappa-B Ligand is Not Regulated During Chronic Osteomyelitis in Pigs. J Comp Pathol 2020; 179:7-24. [PMID: 32958151 DOI: 10.1016/j.jcpa.2020.06.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Revised: 03/30/2020] [Accepted: 06/17/2020] [Indexed: 01/12/2023]
Abstract
Bone loss is a major complication of osteomyelitis and from numerous in-vitro studies, it has been concluded that the bone lysis is caused by elevated expression of the receptor activator of nuclear factor κB ligand (RANKL), leading to increased osteoclast activity. However, we failed to find any relationship between bone loss and osseous RANKL expression in a porcine model of acute and chronic implant-associated osteomyelitis (IAO) due to Staphylococcus aureus or in chronic osteomyelitis lesions in slaughter pigs. Surprisingly, we found that the expression of RANKL was reduced during chronic bone infections. This is in line with the few studies conducted on human samples. A significant bone loss was observed in IAO lesions and in lesions from slaughter pigs, but with no indication of osteoclast involvement using histochemistry, immunohistochemistry for RANKL, receptor activator of nuclear factor kappa-B, osteoprotegerin and cathepsin K, and high-throughput quantitative real-time polymerase chain reaction on bone tissue from osteomyelitic lesions. A strong inflammatory response was seen in the infected animals and, therefore, we propose proteolytic enzymes induced by inflammation to be a major component of the bone loss. Furthermore, we found a significant upregulation of the IL26 gene in infected animals, which can inhibit RANKL-induced osteoclastogenesis, but has no homologue in mice. This finding emphasises that neither murine models nor in-vitro studies can mirror human disease development completely. The present study emphasises that the interactions between microorganisms, the immune system and bone cells in osteomyelitis are too complex to be accurately represented by an in-vitro model.
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Affiliation(s)
- F L Lüthje
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark; Department of Biotechnology and Biomedicine, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - K Skovgaard
- Department of Biotechnology and Biomedicine, Technical University of Denmark, Kgs. Lyngby, Denmark
| | - H E Jensen
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark
| | - S A Blirup-Plum
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark
| | - N L Henriksen
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark
| | - B Aalbæk
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark
| | - L K Jensen
- Department of Veterinary and Animal Science, University of Copenhagen, Frederiksberg C, Denmark.
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11
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Bue M, Bergholt NL, Jensen LK, Jensen HE, Søballe K, Stilling M, Hanberg P. Inflammatory proteins in infected bone tissue - An explorative porcine study. Bone Rep 2020; 13:100292. [PMID: 32637468 PMCID: PMC7330156 DOI: 10.1016/j.bonr.2020.100292] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 06/02/2020] [Accepted: 06/22/2020] [Indexed: 12/01/2022] Open
Abstract
Objective To explore the in situ inflammatory proteins in the local extracellular fluid of infected bone tissue. Material and methods Seven pigs went through a two-step surgery performing a traumatically implant-associated Staphylococcus aureus osteomyelitis in the proximal tibia. Five days later, microdialysis catheters (membrane cut off: 20 kDa) were placed in the implant cavity, infected and healthy cancellous bone, and infected and healthy subcutaneous tissue. Plasma samples were collected simultaneously. We employed an antibody-based proximity extension assay (Olink Inflammatory panel) for the measurement of inflammatory molecules within plasma and extracellular fluid of the investigated tissue compartments. Results A higher normalized protein expression in the infected bone tissue in comparison to healthy bone tissue was identified for proteins associated with angiogenesis and bone remodeling: OPG, TGFα, MCP-1, VEGFA, and uPA. Moreover, a parallel detectability of the systemic range of cytokines and chemokines as from the investigated local tissue compartments was demonstrated, indicating the same occurrence of proteins in the local environment as within plasma. Conclusion An angiogenic and osteogenic inflammatory protein composition within the extracellular fluid of infected bone tissue was described. The findings support the current histopathological knowledge and, therefore, microdialysis may represent a valid method for sampling of material for protein investigation of the in vivo inflammatory composition within the extracellular environment in infected bone tissue.
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Affiliation(s)
- Mats Bue
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Natasja Leth Bergholt
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Louise Kruse Jensen
- Department of Veterinary and Animal Sciences, University of Copenhagen, Denmark
| | | | - Kjeld Søballe
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Stilling
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Pelle Hanberg
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark.,Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
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12
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In Vivo Gentamicin Susceptibility Test for Prevention of Bacterial Biofilms in Bone Tissue and on Implants. Antimicrob Agents Chemother 2019; 63:AAC.01889-18. [PMID: 30455228 DOI: 10.1128/aac.01889-18] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 11/12/2018] [Indexed: 12/22/2022] Open
Abstract
The objective of this study was to set up an in vivo gentamicin susceptibility test for biofilm prevention in bone tissue and on implants. Twenty-five pigs were allocated to six groups. Pigs in group A (n = 6) were inoculated with saline. Pigs in groups B (n = 6), C (n = 3), D (n = 3), E (n = 3), and F (n = 4) were inoculated with 10 μl saline containing 104 CFU of Staphylococcus aureus Different concentrations based on the MIC of gentamicin for the specific strain were added to the 10-μl inoculum for groups C (160× MIC), D (1,600× MIC), E (16,000× MIC), and F (160,000× MIC). The inocula were injected into a predrilled tibial implant cavity, followed by insertion of a steel implant (2 by 15 mm). The pigs were euthanized after 5 days. In vitro, all the doses used were found to be bactericidal after up to 6 h. All implant cavities of pigs inoculated with bacteria and bacteria plus 160× MIC or 1,600× MIC of gentamicin were positive for S. aureus In animals in each of groups E (16,000× MIC) and F (160,000× MIC), 2/3 and 1/4 of the implant cavities were S. aureus positive, respectively. By grouping groups C and D (<10,000× MIC) and groups E and F (>10,000× MIC), a significant decrease in the number of implant-attached bacteria was seen only between the high-MIC-value group and group B. Histologically, it was demonstrated that 1,600×, 16,000×, and 160,000× MIC resulted in a peri-implant tissue reaction comparable to that in saline-inoculated animals. In vivo, the antimicrobial tolerance of the inoculated planktonic bacteria was increased by in vivo-specific factors of acute inflammation. This resulted in bacterial aggregation and biofilm formation, which further increased the gentamicin tolerance. Thus, susceptibility patterns in vitro might not reflect the actual in vivo susceptibility locally within a developing infectious area.
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13
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Hyperbaric Oxygen Therapy and Utilization in Infectious Disease. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2018. [DOI: 10.1007/s40138-018-0166-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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