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Zou C, Guo W, Mu W, Wahafu T, Li Y, Hua L, Xu B, Cao L. Synovial vancomycin and meropenem concentrations in periprosthetic joint infection treated by single-stage revision combined with intra-articular infusion. Bone Joint Res 2024; 13:535-545. [PMID: 39353609 DOI: 10.1302/2046-3758.1310.bjr-2024-0024.r2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/04/2024] Open
Abstract
Aims We aimed to determine the concentrations of synovial vancomycin and meropenem in patients treated by single-stage revision combined with intra-articular infusion following periprosthetic joint infection (PJI), thereby validating this drug delivery approach. Methods We included 14 patients with PJI as noted in their medical records between November 2021 and August 2022, comprising eight hip and seven knee joint infections, with one patient experiencing bilateral knee infections. The patients underwent single-stage revision surgery, followed by intra-articular infusion of vancomycin and meropenem (50,000 µg/ml). Synovial fluid samples were collected to assess antibiotic concentrations using high-performance liquid chromatography. Results The peak concentrations of vancomycin and meropenem in the joint cavity were observed at one hour post-injection, with mean values of 14,933.9 µg/ml (SD 10,176.3) and 5,819.1 µg/ml (SD 6,029.8), respectively. The trough concentrations at 24 hours were 5,495.0 µg/ml (SD 2,360.5) for vancomycin and 186.4 µg/ml (SD 254.3) for meropenem. The half-life of vancomycin was 6 hours, while that of meropenem ranged between 2 and 3.5 hours. No significant adverse events related to the antibiotic administration were observed. Conclusion This method can achieve sustained high antibiotic concentrations within the joint space, exceeding the reported minimum biofilm eradication concentration. Our study highlights the remarkable effectiveness of intra-articular antibiotic infusion in delivering high intra-articular concentrations of antibiotics. The method provided sustained high antibiotic concentrations within the joint cavity, and no severe side-effects were observed. These findings offer evidence to improve clinical treatment strategies. However, further validation is required through studies with larger sample sizes and higher levels of evidence.
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Affiliation(s)
- Chen Zou
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Wentao Guo
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Wenbo Mu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Tuerhongjiang Wahafu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Yicheng Li
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Long Hua
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Boyong Xu
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
| | - Li Cao
- Department of Orthopaedics, First Affiliated Hospital of Xinjiang Medical University, Urumqi, China
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Bates TJ, Burgess MB, Garcia GR, Akers KS, Mangum LC, Lynch TB, Wenke JC, Pierrie SN. Intravenous Cefazolin Achieves Sustained High Interstitial Concentrations in Open Lower Extremity Fractures. Clin Orthop Relat Res 2024; 482:375-383. [PMID: 37606954 PMCID: PMC10776155 DOI: 10.1097/corr.0000000000002808] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/07/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Infection remains a serious clinical concern in patients with open fractures, despite timely antibiotic administration and surgical debridement. Soft tissue and periosteal stripping may alter local tissue homeostasis and antibiotic pharmacokinetics in the injured limb. The tissue (interstitial) concentration of intravenously administered antibiotics at an open fracture site has not been characterized using direct sampling techniques. QUESTION/PURPOSE We performed this study to evaluate the concentration and pharmacokinetics of intravenously delivered cefazolin at an open fracture site after surgical debridement. METHODS Twelve patients with an open fracture distal to the knee who presented at a regional Level I trauma center were approached for enrollment in this nonrandomized, observational study. Of the 12 patients, eight adults (one female, seven male) with a median age of 32 years (range 23 to 51 years) were enrolled and underwent successful sample collection for analysis. Three patients had incomplete datasets because of equipment malfunction and one elected not to participate. Seven patients had open tibia fractures, and one patient had an open fibula fracture associated with a closed tibia fracture. There were six Gustilo-Anderson Type II injuries and two Type IIIA injuries. Empiric antibiotics were administered in the prehospital setting or in the emergency department according to institutional protocol. When patients were taken to the operating room, a 2-g intravenous dose of cefazolin was administered. After surgical debridement, fracture stabilization, and wound closure, a microdialysis catheter was placed transdermally into the injury zone (within 5 cm of the fracture site) and a second catheter was placed in the contralateral uninjured (control) limb. Additional doses of cefazolin were administered every 8 hours postoperatively. Baseline and periodic interstitial fluid and whole blood (plasma) samples were collected in the operating room and at prespecified times for 24 hours postoperatively. Free cefazolin in the interstitial fluid and plasma samples were analyzed by ultra-high-performance liquid chromatography using C 18 column separation with quadrupole time-of-flight mass spectrometry detection. Data from the second postoperative dose of cefazolin were used to characterize pharmacokinetic parameters through a noncompartmental analysis using time-concentration curves of free cefazolin and assuming first-order elimination. For pharmacodynamic analyses, the modal cefazolin minimum inhibitory concentration (MIC) of Staphylococcus aureus (1 µg/mL) was used. RESULTS With the samples available, no difference was observed in the median free cefazolin exposure over 24 hours ( f area under the curve [AUC] 0→24hrs ) between injured limbs (352 μg∙hr/mL [IQR 284 to 594 μg∙hr/mL]) and uninjured limbs (341 μg∙hr/mL [IQR 263 to 438 μg∙hr/mL]; p = 0.64). The median time to achieve the maximum concentration of free cefazolin ( f T max ) for injured limbs was delayed (2.7 hours [IQR 2.2 to 3.1 hours]) compared with control limbs (1.7 hours [IQR 1.2 to 2.0 hours]; p = 0.046). The time to the maximum concentration for plasma was not different from that of control limbs (p = 0.08). The time the cefazolin concentration was above the modal S. aureus MIC (T > MIC) in the injured and control limbs over 24 hours was 100% (IQR 100% to 100%) and 100% (IQR 97% to 100%), respectively. CONCLUSION These preliminary findings suggest that current prophylactic cefazolin dosing regimens result in successful antibiotic delivery to the traumatized limb in moderately severe open fractures. Although cefazolin delivery to open-fracture wound beds was delayed compared with healthy tissues, the cefazolin concentration was sustained above the European Union Committee Antimicrobial Susceptibility Testing modal MIC for S. aureus , demonstrating a high likelihood of a prophylactic antimicrobial environment at an open fracture site with this empiric antimicrobial regimen. Importantly, patients in this analysis had Gustilo-Anderson Types II and IIIA injuries. Further research with a larger patient cohort is needed to determine whether antibiotic delivery to traumatized soft tissues in patients with higher-grade open fractures (Gustilo-Anderson Types IIIB and IIIC) demonstrates similar pharmacokinetic characteristics. LEVEL OF EVIDENCE Level II, therapeutic study.
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Affiliation(s)
- Taylor J. Bates
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | | | | | - Kevin S. Akers
- US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Lee C. Mangum
- US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
| | - Thomas B. Lynch
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
| | - Joseph C. Wenke
- US Army Institute of Surgical Research, Fort Sam Houston, TX, USA
- Department of Orthopaedic Surgery and Rehabilitation, University of Texas Medical Branch, Galveston, TX, USA
- Shriners Children’s Texas, Galveston, TX, USA
| | - Sarah N. Pierrie
- Department of Orthopaedic Surgery, Brooke Army Medical Center, Fort Sam Houston, TX, USA
- Department of Orthopaedics and Sports Medicine, University of Cincinnati Medical Center, Cincinnati, OH, USA
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3
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Landersdorfer CB, Lee WL, Nation RL, Kong DCM, Buising K, Peel TN, Choong PFM. Penetration of Vancomycin into Noninfected Bone in Patients Undergoing Total Joint Arthroplasty Evaluated by a Minimal Physiologically Based Population Pharmacokinetic Modeling Approach. Mol Pharm 2023; 20:1509-1518. [PMID: 36512679 DOI: 10.1021/acs.molpharmaceut.2c00724] [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: 12/14/2022]
Abstract
Arthroplasty is a healthcare priority and represents high volume, high cost surgery. Periprosthetic joint infection (PJI) results in significant mortality, thus it is vital that the risk for PJI is minimized. Vancomycin is recommended for surgical prophylaxis in total joint arthroplasty (TJA) by current clinical practice guidelines endorsed by the Infectious Diseases Society of America. This study aimed to develop a new assay to determine vancomycin concentrations in serum and bone, and a minimal physiologically based population PK (mPBPK) model to evaluate vancomycin bone penetration in noninfected patients. Eleven patients undergoing TJA received 0.5-2.0 g intravenous vancomycin over 12-150 min before surgery. Excised bone specimens and four blood samples were collected per patient. Bone samples were pulverized under liquid nitrogen using a cryogenic mill. Vancomycin concentrations in serum and bone were analyzed by liquid chromatography-tandem mass spectrometry and subjected to mPBPK modeling. Vancomycin serum and bone concentrations ranged from 9.30 to 86.6 mg/L, and 1.94-37.0 mg/L, respectively. Average bone to serum concentration ratio was 0.41 (0.16-1.0) based on the collected samples. The population mean total body clearance was 2.12L/h/kg0.75. Inclusion of total body weight as a covariate substantially decreased interindividual variability in clearance. The bone/blood partition coefficient (Kpbone) was estimated at 0.635, reflecting the average bone/blood concentration ratio at steady-state. The model predicted median ratio of vancomycin area under the curve (AUC) for bone/AUC for serum was 44%. Observed vancomycin concentrations in bone were overall consistent with perfusion-limited distribution from blood to bone. An mPBPK model overall well described vancomycin concentrations in serum and bone.
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Affiliation(s)
- Cornelia B Landersdorfer
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria3052, Australia
| | - Wee Leng Lee
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria3052, Australia
| | - Roger L Nation
- Drug Delivery, Disposition, and Dynamics, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria3052, Australia
| | - David C M Kong
- Centre for Medicine Use and Safety, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, Victoria3052, Australia
| | - Kirsty Buising
- Department of Medicine, University of Melbourne, Melbourne, Victoria3010, Australia.,Victorian Infectious Diseases Service, Royal Melbourne Hospital, Melbourne, Victoria3050, Australia
| | - Trisha N Peel
- Department of Infectious Diseases, Alfred Hospital and Central Clinical School, Monash University, Melbourne, Victoria3004, Australia.,Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria3065, Australia
| | - Peter F M Choong
- Department of Surgery, St Vincent's Hospital Melbourne, The University of Melbourne, Melbourne, Victoria3065, Australia.,Department of Orthopaedics, St Vincent's Hospital, Melbourne, Victoria3065, Australia
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Wang X, Fang X, Gao X, Wang H, Li S, Li C, Qing Y, Qin Y. Strong adhesive and drug-loaded hydrogels for enhancing bone-implant interface fixation and anti-infection properties. Colloids Surf B Biointerfaces 2022; 219:112817. [PMID: 36084513 DOI: 10.1016/j.colsurfb.2022.112817] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Revised: 08/25/2022] [Accepted: 08/27/2022] [Indexed: 11/19/2022]
Abstract
The bonding strength of the bone-titanium (Ti) implant interface is critical for patients undergoing joint replacement. However, current bone adhesives used in clinic have shortcomings, such as biological inertness, cytotoxicity, and lack of osteogenic ability. In this study, a simple and low-cost hydrogel-based bone adhesive was prepared to improve the osseointegration ability and anti-infection ability of the bone-implant interface. A multifunctional hydrogel was prepared by incorporating nano-hydroxyapatite (HA) on polyethyleneimine (PEI) and polyacrylic acid (PAA) (PEI/PAA-HA). It was shown that PEI/PAA-HA hydrogel exhibited good self-healing and strong adhesive ability. The adhesive strengths of bone-Ti and Ti-Ti were measured as 2.30 ± 0.15 MPa and 1.07 ± 0.07 MPa, respectively. Vancomycin (VAN) was loaded into the PEI/PAA-HA hydrogel (PEI/PAA-HA-VAN) via a simple immersion method. The PEI/PAA-HA-VAN showed excellent antibacterial effect by sustained release of VAN. In addition, the PEI/PAA-HA-VAN hydrogel exhibited excellent cytocompatibility promoting the expression of osteogenic genes and the deposition of mineralized matrix. Collectively, this strong adhesive hydrogel showed great potential in enhancing bone-implant interface fixation.
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Affiliation(s)
- Xingyue Wang
- Orthopaedic Medical Center, The Second Hospital of Jilin University, Changchun 130041, China
| | - Xu Fang
- State Key Laboratory of Supramolecular Structure and Materials, College of Chemistry, Jilin University, Changchun 130012, China
| | - Xin Gao
- State Key Laboratory of Supramolecular Structure and Materials, College of Chemistry, Jilin University, Changchun 130012, China
| | - Hao Wang
- State Key Laboratory of Supramolecular Structure and Materials, College of Chemistry, Jilin University, Changchun 130012, China
| | - Shihuai Li
- Orthopaedic Medical Center, The Second Hospital of Jilin University, Changchun 130041, China
| | - Chen Li
- Orthopaedic Medical Center, The Second Hospital of Jilin University, Changchun 130041, China
| | - Yunan Qing
- Orthopaedic Medical Center, The Second Hospital of Jilin University, Changchun 130041, China.
| | - Yanguo Qin
- Orthopaedic Medical Center, The Second Hospital of Jilin University, Changchun 130041, China.
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5
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Mazzitelli M, Gatti M, Scaglione V, Mengato D, Trevenzoli M, Sattin A, Pea F, Cattelan AM. Off-Label Use of Dalbavancin for Sequential Treatment of Spondylodiscitis by Methicillin-Resistant Staphylococcus aureus: A Retrospective Single-Centre Experience. Antibiotics (Basel) 2022; 11:antibiotics11101377. [PMID: 36290035 PMCID: PMC9598816 DOI: 10.3390/antibiotics11101377] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2022] [Revised: 09/24/2022] [Accepted: 10/07/2022] [Indexed: 12/02/2022] Open
Abstract
Background: Our aim was to describe the clinical outcome and safety of the sequential treatment with off-label dalbavancin in patients with spondylodiscitis that is caused by methicillin-resistant Staphylococcus aureus (MRSA). Methods: We retrospectively included all patients >18 years of age with spondylodiscitis that is caused by MRSA that was treated with dalbavancin from January 2018−January 2021, recording the instances of clinical cure/failure, adverse events, and the need to be re-hospitalized after the initiation of dalbavancin. In 2/15 patients, we performed therapeutic drug monitoring (TDM) for dalbavancin. Results: We included 15 patients, 53.3% of them were females, with a median age of 67.9 years (57.4−78.5); 100% patients reported back pain, while a fever was present only in 2/15 cases. The spondylodiscitis was localized in 86.6% cases at the lumbar level. A median of a 2-week in-hospital intravenous vancomycin was followed by dalbavancin with a median duration of 12 weeks (12−16). All patients reported a clinical cure, except for a woman who is still on a suppressive treatment. No patient needed to be re-hospitalized, access to emergency department, or experienced adverse events. The TDM for dalbavancin showed that more than 90% of the determinations were above the pharmacodynamic target against staphylococci. Conclusions: The results from our unique, even if it was small, cohort demonstrated that dalbavancin can be a safe/effective option as a sequential treatment in patients with serious infections requiring prolonged antibiotic therapy, such as spondylodiscitis.
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Affiliation(s)
- Maria Mazzitelli
- Infectious and Tropical Diseases Unit, Padua University Hospital, Via Giustiniani, 35128 Padua, Italy
- Correspondence:
| | - Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
- SSD Clinical Pharmacology, IRCSS Azienda Ospedaliero-Universitaria Sant’Orsola di Bologna, 40138 Bologna, Italy
| | - Vincenzo Scaglione
- Infectious and Tropical Diseases Unit, Padua University Hospital, Via Giustiniani, 35128 Padua, Italy
| | - Daniele Mengato
- Pharmacy Unit, Padua University Hospital, 35100 Padua, Italy
| | - Marco Trevenzoli
- Infectious and Tropical Diseases Unit, Padua University Hospital, Via Giustiniani, 35128 Padua, Italy
| | - Andrea Sattin
- Infectious and Tropical Diseases Unit, Padua University Hospital, Via Giustiniani, 35128 Padua, Italy
| | - Federico Pea
- Department of Medical and Surgical Sciences, Alma Mater Studiorum, University of Bologna, 40138 Bologna, Italy
- SSD Clinical Pharmacology, IRCSS Azienda Ospedaliero-Universitaria Sant’Orsola di Bologna, 40138 Bologna, Italy
| | - Anna Maria Cattelan
- Infectious and Tropical Diseases Unit, Padua University Hospital, Via Giustiniani, 35128 Padua, Italy
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6
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Finazzi S, Luci G, Olivieri C, Langer M, Mandelli G, Corona A, Viaggi B, Di Paolo A. Tissue Penetration of Antimicrobials in Intensive Care Unit Patients: A Systematic Review—Part I. Antibiotics (Basel) 2022; 11:antibiotics11091164. [PMID: 36139944 PMCID: PMC9495190 DOI: 10.3390/antibiotics11091164] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/14/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022] Open
Abstract
The challenging severity of some infections, especially in critically ill patients, makes the diffusion of antimicrobial drugs within tissues one of the cornerstones of chemotherapy. The knowledge of how antibacterial agents penetrate tissues may come from different sources: preclinical studies in animal models, phase I–III clinical trials and post-registration studies. However, the particular physiopathology of critically ill patients may significantly alter drug pharmacokinetics. Indeed, changes in interstitial volumes (the third space) and/or in glomerular filtration ratio may influence the achievement of bactericidal concentrations in peripheral compartments, while inflammation can alter the systemic distribution of some drugs. On the contrary, other antibacterial agents may reach high and effective concentrations thanks to the increased tissue accumulation of macrophages and neutrophils. Therefore, the present review explores the tissue distribution of beta-lactams and other antimicrobials acting on the cell wall and cytoplasmic membrane of bacteria in critically ill patients. A systematic search of articles was performed according to PRISMA guidelines, and tissue/plasma penetration ratios were collected. Results showed a highly variable passage of drugs within tissues, while large interindividual variability may represent a hurdle which must be overcome to achieve therapeutic concentrations in some compartments. To solve that issue, off-label dosing regimens could represent an effective solution in particular conditions.
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Affiliation(s)
- Stefano Finazzi
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020 Ranica, Italy
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Giacomo Luci
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
| | - Carlo Olivieri
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
- Anesthesia and Intensive Care, Sant’Andrea Hospital, ASL VC, 13100 Vercelli, Italy
| | - Martin Langer
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
| | - Giulia Mandelli
- Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 24020 Ranica, Italy
| | - Alberto Corona
- ICU and Accident & Emergency Department, ASST Valcamonica, 25043 Breno, Italy
| | - Bruno Viaggi
- Associazione GiViTI, c/o Istituto di Ricerche Farmacologiche Mario Negri IRCCS, 20156 Milan, Italy
- Department of Anesthesiology, Neuro-Intensive Care Unit, Florence Careggi University Hospital, 50139 Florence, Italy
| | - Antonello Di Paolo
- Department of Clinical and Experimental Medicine, University of Pisa, 56126 Pisa, Italy
- Correspondence:
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7
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Koch BCP, Zhao Q, Oosterhoff M, van Oldenrijk J, Abdulla A, de Winter BCM, Bos K, Muller AE. The mysteries of target site concentrations of antibiotics in bone and joint infections: what is known? A narrative review. Expert Opin Drug Metab Toxicol 2022; 18:587-600. [PMID: 36008360 DOI: 10.1080/17425255.2022.2117607] [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: 11/04/2022]
Abstract
INTRODUCTION Currently, antibiotic treatment is often a standard dosing regimen in bone and joint infections (BJI). However, it remains unknown if exposure at the target-site is adequate. The aim of this review is to gain more insight in the relationship between the target site concentration of antibiotic and the minimal inhibitory concentration to target the bacteria in bone and joint infections (BJI). AREAS COVERED A literature search was performed by Erasmus MC Medical library. Bone, bone tissue and synovial concentration of antibiotics were covered in humans. In addition, we reported number of patients, dose, sampling method, analytical method and tissue and plasma concentrations. We used the epidemiological cut-off value (ECOFF) values of the targeted micro-organisms. If more than 3 publications were available on the antibiotic, we graphically presented ECOFFS values against reported antibiotic concentrations. EXPERT OPINION For most antibiotics the literature is sparse. In addition, a lot of variable and total antibiotic concentrations are published. Ciprofloxacin, cefazolin, cefuroxime, vancomycin and linezolid seem to have adequate average exposure if correlating total concentration to ECOFF, when standard dosing is used. With regards to other antibiotics, results are inconclusive. More extensive pharmacokinetic/pharmacodynamic modeling in BJI is needed.
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Affiliation(s)
- Birgit C P Koch
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Rotterdam Clinical Pharmacometrics Group
| | - Qiaolin Zhao
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,Rotterdam Clinical Pharmacometrics Group
| | - Maartje Oosterhoff
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Jakob van Oldenrijk
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Alan Abdulla
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Rotterdam Clinical Pharmacometrics Group
| | - Brenda C M de Winter
- Department of Hospital Pharmacy, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Rotterdam Clinical Pharmacometrics Group
| | - Koen Bos
- Department of Orthopaedics and Sports Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Anouk E Muller
- CATOR, Center for Antimicrobial Optimized Treatment Rotterdam.,Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.,Department of Medical Microbiology, Haaglanden Medisch Centrum, The Hague, the Netherlands
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8
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Wong S, Reuter SE, Jones GR, Stocker SL. Review and evaluation of vancomycin dosing guidelines for obese individuals. Expert Opin Drug Metab Toxicol 2022; 18:323-335. [PMID: 35815356 DOI: 10.1080/17425255.2022.2098106] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Vancomycin dosing decisions are informed by factors such as body weight and renal function. It is important to understand the impact of obesity on vancomycin pharmacokinetics and how this may influence dosing decisions. Vancomycin dosing guidelines use varied descriptors of body weight and renal function. There is uncertainty whether current dosing guidelines result in attainment of therapeutic targets in obese individuals. AREAS COVERED Literature was explored using PubMed, Embase and Google Scholar for articles from January 1980 to July 2021 regarding obesity-driven physiological changes, their influence on vancomycin pharmacokinetics and body size descriptors and renal function calculations in vancomycin dosing. Pharmacokinetic simulations reflective of international vancomycin dosing guidelines were conducted to evaluate the ability of using total, ideal and adjusted body weight, as well as Cockcroft-Gault and CKD-EPI equations to attain an area-under-the-curve to minimum inhibitory concentration ratio (AUC24/MIC) target (400-650) in obese individuals. EXPERT OPINION Vancomycin pharmacokinetics in obese individuals remains debated. Guidelines that determine loading doses using total body weight, and maintenance doses adjusted based on renal function and adjusted body weight, may be most appropriate for obese individuals. Use of ideal body weight leads to subtherapeutic vancomycin exposure and underestimation of renal function.
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Affiliation(s)
- Sherilyn Wong
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Stephanie E Reuter
- UniSA Clinical and Health Sciences, University of South Australia, Adelaide, Australia
| | - Graham Rd Jones
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Department of Chemical Pathology and Clinical Pharmacology, SydPath, St Vincent's Hospital, Darlinghurst, Australia
| | - Sophie L Stocker
- St Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Sydney School of Pharmacy, The University of Sydney, Sydney, Australia.,Department of Clinical Pharmacology & Toxicology, St Vincent's Hospital Sydney, Darlinghurst, Australia
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9
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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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10
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Gatti M, Barnini S, Guarracino F, Parisio EM, Spinicci M, Viaggi B, D’Arienzo S, Forni S, Galano A, Gemmi F. Orthopaedic Implant-Associated Staphylococcal Infections: A Critical Reappraisal of Unmet Clinical Needs Associated with the Implementation of the Best Antibiotic Choice. Antibiotics (Basel) 2022; 11:antibiotics11030406. [PMID: 35326869 PMCID: PMC8944676 DOI: 10.3390/antibiotics11030406] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Revised: 03/14/2022] [Accepted: 03/16/2022] [Indexed: 12/24/2022] Open
Abstract
Infections associated with orthopaedic implants represent a major health concern characterized by a remarkable incidence of morbidity and mortality. The wide variety of clinical scenarios encountered in the heterogeneous world of infections associated with orthopaedic implants makes the implementation of an optimal and standardized antimicrobial treatment challenging. Antibiotic bone penetration, anti-biofilm activity, long-term safety, and drug choice/dosage regimens favouring outpatient management (i.e., long-acting or oral agents) play a major role in regards to the chronic evolution of these infections. The aim of this multidisciplinary opinion article is to summarize evidence supporting the use of the different anti-staphylococcal agents in terms of microbiological and pharmacological optimization according to bone penetration, anti-biofilm activity, long-term safety, and feasibility for outpatient regimens, and to provide a useful guide for clinicians in the management of patients affected by staphylococcal infections associated with orthopaedic implants Novel long-acting lipoglycopeptides, and particularly dalbavancin, alone or in combination with rifampicin, could represent the best antibiotic choice according to real-world evidence and pharmacokinetic/pharmacodynamic properties. The implementation of a multidisciplinary taskforce and close cooperation between microbiologists and clinicians is crucial for providing the best care in this scenario.
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Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, Alma Mater Studiorum University of Bologna, 40138 Bologna, Italy;
- SSD Clinical Pharmacology, Department for Integrated Infectious Risk Management, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Simona Barnini
- Bacteriology Unit, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy;
| | - Fabio Guarracino
- Department of Anaesthesia and Critical Care Medicine, Azienda Ospedaliero Universitaria Pisana, 56126 Pisa, Italy;
| | - Eva Maria Parisio
- UOSD Microbiologia Arezzo PO San Donato, Azienda Usl Toscana Sud Est, 52100 Arezzo, Italy;
| | - Michele Spinicci
- Department of Experimental and Clinical Medicine, University of Florence, 50134 Florence, Italy;
- Infectious and Tropical Diseases Unit, Careggi University Hospital, 50134 Florence, Italy
| | - Bruno Viaggi
- Neurointensive Care Unit, Department of Anesthesiology, Careggi University Hospital, 50134 Florence, Italy;
| | - Sara D’Arienzo
- Agenzia Regionale di Sanità della Toscana, 50141 Florence, Italy; (S.D.); (S.F.)
| | - Silvia Forni
- Agenzia Regionale di Sanità della Toscana, 50141 Florence, Italy; (S.D.); (S.F.)
| | - Angelo Galano
- SOD Microbiologia e Virologia, Careggi University Hospital, 50134 Florence, Italy;
| | - Fabrizio Gemmi
- Agenzia Regionale di Sanità della Toscana, 50141 Florence, Italy; (S.D.); (S.F.)
- Correspondence:
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11
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García-García J, Azuara G, Fraile-Martinez O, García-Montero C, Álvarez-Mon MA, Ruíz-Díez S, Álvarez-Mon M, Buján J, García-Honduvilla N, Ortega MA, De la Torre B. Modification of the Polymer of a Bone Cement with Biodegradable Microspheres of PLGA and Loading with Daptomycin and Vancomycin Improve the Response to Bone Tissue Infection. Polymers (Basel) 2022; 14:polym14050888. [PMID: 35267711 PMCID: PMC8912454 DOI: 10.3390/polym14050888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/15/2022] [Accepted: 02/22/2022] [Indexed: 12/13/2022] Open
Abstract
Chronic infections are one of the most serious adverse outcomes of prosthetic surgery. Prosthetic revision surgery using a bone cement loaded with antibiotics between the two stages of the surgery is commonly performed. However, this method often fails to reach the minimum inhibitory concentration and promotes antibiotic resistance, thus emphasizing the need for improving the current available therapies. MATERIALS AND METHODS In this study, we performed a study of the in vivo response of a polymer-based construct of poly (lactic-co-glycolic acid) (PLGA) in the solid phase of Palacos R® in combination with vancomycin, daptomycin, and/or linezolid. To test its effectiveness, we applied an in vivo model, using both histological and immunohistochemical analyses to study the bone tissue. RESULTS The presence of PLGA in the combination of vancomycin with daptomycin showed the most promising results regarding the preservation of bone cytoarchitecture and S. aureus elimination. Conversely, the combination of vancomycin plus linezolid was associated with a loss of bone cytoarchitecture, probably related to an increased macrophage response and inefficient antimicrobial activity. CONCLUSIONS The modification of Palacos R® bone cement with PLGA microspheres and its doping with the antibiotic daptomycin in combination with vancomycin improve the tissue response to bone infection.
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Affiliation(s)
- Joaquin García-García
- Service of Orthopedic Surgery of University Hospital Principe de Asturias, 28805 Alcalá de Henares, Madrid, Spain;
| | - Galo Azuara
- Service of Traumatology of University Hospital of Guadalajara, 19002 Guadalajara, Spain;
| | - Oscar Fraile-Martinez
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Cielo García-Montero
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Miguel Angel Álvarez-Mon
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Sara Ruíz-Díez
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
| | - Melchor Álvarez-Mon
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Immune System Diseases-Rheumatology, Oncology Service an Internal Medicine, University Hospital Príncipe de Asturias, (CIBEREHD), 28806 Alcala de Henares, Spain
| | - Julia Buján
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Natalio García-Honduvilla
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
| | - Miguel A. Ortega
- Departments of Medicine and Medical Specialities, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain; (O.F.-M.); (C.G.-M.); (M.A.Á.-M.); (S.R.-D.); (M.Á.-M.); (J.B.); (N.G.-H.)
- Ramón y Cajal Institute of Sanitary Research (IRYCIS), 28034 Madrid, Spain
- Correspondence:
| | - Basilio De la Torre
- Department of Surgery, Medical and Social Sciences, Faculty of Medicine and Health Sciences, University of Alcalá, Alcalá de Henares, 28801 Madrid, Spain;
- Service of Traumatology of University Hospital Ramón y Cajal, 28034 Madrid, Spain
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12
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Tøstesen SK, Stilling M, Hanberg P, Thillemann TM, Falstie-Jensen T, Tøttrup M, Knudsen M, Petersen ET, Bue M. High Cefuroxime Concentrations and Long Elimination in an Orthopaedic Surgical Deadspace—A Microdialysis Porcine Study. Antibiotics (Basel) 2022; 11:antibiotics11020208. [PMID: 35203810 PMCID: PMC8868149 DOI: 10.3390/antibiotics11020208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 02/04/2023] Open
Abstract
Deadspace is the tissue and bony defect in a surgical wound after closure. This space is presumably poorly perfused favouring bacterial proliferation and biofilm formation. In arthroplasty surgery, an obligate deadspace surrounding the prosthesis is introduced and deadspace management, in combination with obtaining therapeutic prophylactic antibiotic concentrations, is important for limiting the risk of acquiring a periprosthetic joint infection (PJI). This study aimed to investigate cefuroxime distribution to an orthopaedic surgical deadspace in comparison with plasma and bone concentrations during two dosing intervals (8 h × 2). In a setup imitating shoulder arthroplasty surgery, but without insertion of a prosthesis, microdialysis catheters were placed for cefuroxime sampling in a deadspace in the glenohumeral joint and in cancellous bone of the scapular neck in eighteen pigs. Blood samples were collected as a reference. Cefuroxime was administered according to weight (20 mg/kg). The primary endpoint was time above the cefuroxime minimal inhibitory concentration of the free fraction of cefuroxime for Staphylococcus aureus (fT > MIC (4 μg/mL)). During the two dosing intervals, mean fT > MIC (4 μg/mL) was significantly longer in deadspace (605 min) compared with plasma (284 min) and bone (334 min). For deadspace, the mean time to reach 4 μg/mL was prolonged from the first dosing interval (8 min) to the second dosing interval (21 min), while the peak drug concentration was lower and half-life was longer in the second dosing interval. In conclusion, weight-adjusted cefuroxime fT > MIC (4 μg/mL) and elimination from the deadspace was longer in comparison to plasma and bone. Our results suggest a deadspace consolidation and a longer diffusions distance, resulting in a low cefuroxime turn-over. Based on theoretical targets, cefuroxime appears to be an appropriate prophylactic drug for the prevention of PJI.
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Affiliation(s)
- Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- Correspondence:
| | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
| | - Theis Muncholm Thillemann
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
| | - Mikkel Tøttrup
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9640 Farsoe, Denmark;
| | - Martin Knudsen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Emil Toft Petersen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
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13
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Marston S, Mirick Mueller G, Sabin A, Hansen GT, Lindgren B, Aparicio C, Armstrong AR, Larsen OH, Schmidt A, Kyle R, Gustilo R, Tsukayama D, Bechtold J, Bue M. Systemic versus free antibiotic delivery in preventing acute exogenous implant related infection in a rat model. J Orthop Res 2022; 40:429-438. [PMID: 33913540 DOI: 10.1002/jor.25052] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 12/15/2020] [Accepted: 04/12/2021] [Indexed: 02/04/2023]
Abstract
We studied systemic ceftriaxone, and free/local tobramycin and doxycycline in a controlled rat model representing a generic acute exogenous joint infection. We hypothesized that evidence of infection (quantitative colony forming units [CFU], qualitative scanning electron microscopy [SEM], histopathology) (1a) would be reduced with local versus systemic antibiotic, (1b) any antibiotic would be superior to control, (2) there would be a difference among antibiotics, and (3) antibiotic would not be detectable in serum at 4-week euthanasia. Study groups included infected and noninfected (1) control (no treatment), (2) systemic ceftriaxone (daily), (3) local tobramycin, and (4) local doxycycline (10 rats/group; power = 0.8). With IACUC approval, a reliable acute exogenous joint infection was created by slowly injecting 50-μl, 104 CFU Staphylococcus aureus, into the distal femoral medullary canal. The antibiotic formulation was introduced locally to the femoral canal and joint space. After 4 weeks, serum, pin, bone, and synovium were obtained. CFU/ml of bone and synovium were quantified using macrotiter method. SEM imaged biofilm on the surface of the pin, histopathology identified tissue response, liquid chromatography/mass spectrometry quantified plasma antibiotic. (1) Groups receiving any antibiotic reported lower CFU/ml in synovium compared with no treatment. (2) In the synovium, free/local tobramycin reduced CFU/ml to a greater extent than free/local doxycycline (p < 0.05). (3) Antibiotic in plasma after the local application was nondetectable in all groups after 4 weeks. SEM revealed no difference in biofilm on pin among all groups.
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Affiliation(s)
- Scott Marston
- University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Arick Sabin
- Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Glen T Hansen
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | | | | | | | - Ole H Larsen
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Andrew Schmidt
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Richard Kyle
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Ramon Gustilo
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Dean Tsukayama
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Joan Bechtold
- University of Minnesota, Minneapolis, Minnesota, USA.,Hennepin Healthcare Research Institute, Minneapolis, Minnesota, USA
| | - Mats Bue
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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14
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Slater J, Stilling M, Hanberg P, Fichtner Bendtsen MA, Jørgensen AR, Søballe K, Jørgensen NP, Bue M. Moxifloxacin Concentrations in the Knee Joint, Tibial Bone, and Soft Tissue When Combined with Rifampicin: A Randomized Porcine Microdialysis Study. J Bone Joint Surg Am 2022; 104:49-54. [PMID: 34731098 DOI: 10.2106/jbjs.21.00549] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Peri and postoperative antibiotics are key adjuvant treatment tools in the management of periprosthetic joint infection (PJI). The aim of this study was to evaluate the effect of rifampicin on the area under the moxifloxacin concentration-time curve from 0 to 24 hours (AUC0-24) in the synovial fluid of the knee joint, tibial bone, and adjacent subcutaneous tissue under steady-state conditions using microdialysis in a porcine model. METHODS Twenty female pigs were randomized to receive oral treatment with moxifloxacin monotherapy (Group A, n = 10) of 400 mg once daily for 3 days or a combination therapy (Group B, n = 10) of 400 mg of moxifloxacin once daily for 3 days and 450 mg of rifampicin twice daily for 7 days. Microdialysis was used for sampling the synovial fluid of the knee joint, tibial cancellous and cortical bone, and adjacent subcutaneous tissues. Plasma samples were taken as a reference. Measurements were obtained for 24 hours. RESULTS Coadministration of moxifloxacin and rifampicin resulted in reductions of the moxifloxacin AUC0-24 in all targeted tissue compartments by 67% to 85% (p < 0.05). The corresponding change in plasma was 20% (p = 0.49). For both groups, the tissue penetration (the ratio of tissue free fraction AUC0-24 to plasma free fraction AUC0-24 [fAUCtissue/fAUCplasma]) was incomplete in all investigated compartments. The highest moxifloxacin tissue penetration was in the knee joint synovial fluid: 0.59 (Group A) and 0.24 (Group B). The lowest tissue penetration was in the cortical bone: 0.17 (Group A) and 0.03 (Group B). CONCLUSIONS We found a significant reduction of the moxifloxacin concentration, expressed as the AUC0-24, in tissues relevant to acute PJI treatment when coadministered with rifampicin. CLINICAL RELEVANCE The concentrations within the targeted tissue compartments were reduced significantly more than the concentrations in plasma, which may be particularly important as plasma concentrations are used in clinical practice to assess moxifloxacin treatment sufficiency.
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Affiliation(s)
- Josefine Slater
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Stilling
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Pelle Hanberg
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Mathias Alrø Fichtner Bendtsen
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Andrea René Jørgensen
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
| | | | - Mats Bue
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, Aarhus, Denmark
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15
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van Os W, Zeitlinger M. Predicting Antimicrobial Activity at the Target Site: Pharmacokinetic/Pharmacodynamic Indices versus Time-Kill Approaches. Antibiotics (Basel) 2021; 10:antibiotics10121485. [PMID: 34943697 PMCID: PMC8698708 DOI: 10.3390/antibiotics10121485] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/01/2021] [Accepted: 12/02/2021] [Indexed: 12/21/2022] Open
Abstract
Antibiotic dosing strategies are generally based on systemic drug concentrations. However, drug concentrations at the infection site drive antimicrobial effect, and efficacy predictions and dosing strategies should be based on these concentrations. We set out to review different translational pharmacokinetic-pharmacodynamic (PK/PD) approaches from a target site perspective. The most common approach involves calculating the probability of attaining animal-derived PK/PD index targets, which link PK parameters to antimicrobial susceptibility measures. This approach is time efficient but ignores some aspects of the shape of the PK profile and inter-species differences in drug clearance and distribution, and provides no information on the PD time-course. Time–kill curves, in contrast, depict bacterial response over time. In vitro dynamic time–kill setups allow for the evaluation of bacterial response to clinical PK profiles, but are not representative of the infection site environment. The translational value of in vivo time–kill experiments, conversely, is limited from a PK perspective. Computational PK/PD models, especially when developed using both in vitro and in vivo data and coupled to target site PK models, can bridge translational gaps in both PK and PD. Ultimately, clinical PK and experimental and computational tools should be combined to tailor antibiotic treatment strategies to the site of infection.
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16
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Schroepf S, Burau D, Muench HG, Derendorf H, Zeitlinger M, Genzel-Boroviczény O, Adam D, Kloft C. Microdialysis sampling to monitor target-site vancomycin concentrations in septic infants: a feasible way to close the knowledge gap. Int J Antimicrob Agents 2021; 58:106405. [PMID: 34289402 DOI: 10.1016/j.ijantimicag.2021.106405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 06/24/2021] [Accepted: 07/03/2021] [Indexed: 10/20/2022]
Abstract
This work is dedicated to the memory of Hartmut Derendorf (1953-2020), a pioneer of modern pharmacokinetics and valued mentor of this project. OBJECTIVES Septic infants/neonates need effective antibiotic exposure, but dosing recommendations are challenging as the pharmacokinetics in this age are highly variable. For vancomycin, which is used as a standard treatment, comprehensive pharmacokinetic knowledge especially at the infection site is lacking. Hence, an exploratory clinical study was conducted to assess the feasibility and safety of microdialysis sampling for vancomycin monitoring at the target site. METHODS Nine infants/neonates with therapeutic indications for vancomycin treatment were administered 15 mg/kg as 1-hour infusions every 8-24 hours. Microdialysis catheters were implanted in the subcutaneous interstitial space fluid of the lateral thigh. Samples were collected every 30 minutes over 24 hours, followed by retrodialysis for catheter calibration. Prior in vitro investigations have evaluated impact factors on relative recovery and retrodialysis. RESULTS In vitro investigations showed the applicability of microdialysis for vancomycin monitoring. Microdialysis sampling was well tolerated in all infants/neonates (23-255 days) without major bleeding or other adverse events. Pharmacokinetic profiles were obtained and showed plausible vancomycin concentration-time courses. CONCLUSIONS Microdialysis as a minimally invasive technique for continuous longer-term sampling is feasible and safe in infants/neonates. Interstitial space fluid profiles were plausible and showed substantial interpatient variation. Hence, a larger microdialysis trial is warranted to further characterise the pharmacokinetics and variability of vancomycin at the target site and ultimately improve vancomycin dosing in these vulnerable patients.
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Affiliation(s)
- Sebastian Schroepf
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany.
| | - Daniela Burau
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
| | - Hans-Georg Muench
- Dr. von Hauner Children's Hospital, Ludwig-Maximilians-University Munich, Muenchen, Germany
| | - Hartmut Derendorf
- Department of Pharmaceutics, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Wien, Austria
| | | | | | - Charlotte Kloft
- Department of Clinical Pharmacy and Biochemistry, Institute of Pharmacy, Freie Universitaet Berlin, Berlin, Germany
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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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The application of topical vancomycin powder for the prevention of surgical site infections in primary total hip and knee arthroplasty: A meta-analysis. Orthop Traumatol Surg Res 2021; 107:102741. [PMID: 33257290 DOI: 10.1016/j.otsr.2020.09.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 09/05/2020] [Accepted: 09/29/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Surgical site infections (SSIs), particularly periprosthetic joint infections (PJI), following a primary total joint arthroplasty (TJA) impose a major burden by increasing morbidity, mortality, disability rate, and health expenditure. Surgeons are increasingly using topical vancomycin powder as a preventative measure, but the effectiveness of this method has been debated in TJA. Thus, we designed a meta-analysis to compare the outcomes after primary TJA between a group treated with topical vancomycin powder and an untreated control group aiming to answer: (1) whether the application of topical vancomycin powder can reduce the infection rate after primary total joint replacement; (2) are the main types of pathogens causing SSIs after the application of topical vancomycin powder different from those of patients not using topical vancomycin? MATERIALS AND METHODS A meta-analysis was conducted in accordance with the PRISMA guidelines. We included retrospective cohort studies and prospective randomized controlled trials of patients who underwent primary total joint arthroplasty with and without vancomycin powder application before wound closure and reported the SSI rates. The English literature in the PubMed (MEDLINE), EMBASE, Web of Science, and the Cochrane Library databases was comprehensively searched. Literature search, data extraction, and quality assessment were conducted by 2 authors. The main outcomes were SSI and PJI rates, and the secondary outcome was the bacterial spectrum. Statistical analyses were performed with the Review Manager (RevMan) Version 5.3. RESULTS Six retrospective cohort studies and 3 prospective cohort studies with 4512 participants were included (2354 in vancomycin group and 2158 in the control group). In the TJA group, the vancomycin powder-treatment resulted in a significantly lower proportion of patients with SSIs (relative risk [RR]=0.40, 95% confidence interval [CI]=0.27-0.61 [p<0.001]) or PJI (RR=0.37, 95% CI=0.23-0.60 (p<0.001)). In the total hip arthroplasty group, the vancomycin powder treatment decreased the rate of SSIs and PJI by 66% (RR=0.34, 95% CI=0.15-0.78 [p=0.01]) and 74% (RR=0.26, 95% CI=0.10-0.67 (p=0.005)), respectively. In the total knee arthroplasty group, the vancomycin powder decreased the rate of SSIs and PJI by 67% (RR=0.43, 95% CI=0.26-0.70 [p<0.001]) and 66% (RR=0.44, 95% CI=0.25-0.77 [p=0.004]) respectively. Staphylococcus aureus (or methicillin-sensitiveStaphylococcus aureus) (6 in vancomycin group versus 11 in control group) was the most common pathogenic bacteria, followed by Staphylococcus epidermidis (1 in vancomycin group versus 2 in control group) and methicillin-resistant Staphylococcus aureus (2 in vancomycin group versus 4 in control group). Pseudomonas aeruginosa was the main gram-negative pathogen, with 3 cases in the control group and 1 case in the vancomycin powder-treatment group. DISCUSSION The local application of vancomycin powder could significantly decrease the rate of SSIs and PJI in primary TJA without modifying the spectrum of bacteria involved. We recommend topical administration of the vancomycin powder before wound closure after a full evaluation of the patients. LEVEL OF EVIDENCE III; meta-analysis.
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Hanberg P, Bue M, Kabel J, Jørgensen AR, Søballe K, Stilling M. Tourniquet-induced ischemia and reperfusion in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone. APMIS 2021; 129:225-231. [PMID: 33496970 DOI: 10.1111/apm.13121] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2020] [Accepted: 01/21/2021] [Indexed: 01/09/2023]
Abstract
This study aimed to evaluated ischemic metabolites in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone before, during, and after tourniquet application in a simultaneous paired comparison of tourniquet-exposed and non-tourniquet-exposed legs. Ten patients scheduled for hallux valgus or hallux rigidus surgery were included. Microdialysis catheters were placed to simultaneously and continuously sample the metabolites glucose, lactate, pyruvate, and glycerol bilaterally for 12 h in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone. A tourniquet was applied on the leg planned for surgery (inflation time: 15 min, mean tourniquet duration time (range): 65 (58;77) min). During tourniquet inflation, a 2- to 3-fold increase of the mean lactate/pyruvate ratio was found for all investigated tissues in the tourniquet-exposed leg compared with the non-tourniquet-exposed leg. The lactate/pyruvate ratio recovery time after tourniquet release was within 30 min for skeletal muscle, 60 min for subcutaneous tissue, and 130 min for calcaneal cancellous bone. Only the tourniquet-exposed skeletal muscles were found to be ischemic during tourniquet inflation, defined by a significant increase of the lactate/pyruvate ratio exceeding the ischemic cutoff level of 25; however, this level decreased below 25 immediately after tourniquet release. The glycerol ratio increased instantly after inflation in the tourniquet-exposed leg in skeletal muscle and subcutaneous tissue, and recovered within 60 (skeletal muscle) and 130 min (subcutaneous tissue) after tourniquet release. These findings suggest that applying tourniquet for approximately 1 h results in limited tissue ischemia and cell damage in subcutaneous tissue, skeletal muscle, and calcaneal cancellous bone.
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Affiliation(s)
- Pelle Hanberg
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark.,Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus N, Denmark
| | - Mats 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
| | - Jesper Kabel
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Andrea René Jørgensen
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus N, Denmark
| | - Kjeld Søballe
- 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
| | - Maiken Stilling
- 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
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20
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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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21
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Bendtsen MAF, Bue M, Hanberg P, Slater J, Thomassen MB, Hansen J, Søballe K, Öbrink-Hansen K, Stilling M. Flucloxacillin bone and soft tissue concentrations assessed by microdialysis in pigs after intravenous and oral administration. Bone Joint Res 2021; 10:60-67. [PMID: 33448872 PMCID: PMC7845458 DOI: 10.1302/2046-3758.101.bjr-2020-0250.r1] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023] Open
Abstract
Aims Flucloxacillin is commonly administered intravenously for perioperative antimicrobial prophylaxis, while oral administration is typical for prophylaxis following smaller traumatic wounds. We assessed the time, for which the free flucloxacillin concentration was maintained above the minimum inhibitory concentration (fT > MIC) for methicillin-susceptible Staphylococcus aureus in soft and bone tissue, after intravenous and oral administration, using microdialysis in a porcine model. Methods A total of 16 pigs were randomly allocated to either intravenous (Group IV) or oral (Group PO) flucloxacillin 1 g every six hours during a 24-hour period. Microdialysis was used for sampling in cancellous and cortical bone, subcutaneous tissue, and the knee joint. In addition, plasma was sampled. The flucloxacillin fT > MIC was evaluated using a low MIC target (0.5 μg/ml) and a high MIC target (2.0 μg/ml). Results Intravenous administration resulted in longer fT > MIC (0.5 μg/ml) compared to oral administration, except for cortical bone. In Group IV, all pigs reached a concentration of 0.5 μg/ml in all compartments. The mean fT > MIC (0.5 μg/ml) was 149 minutes (95% confidence interval (CI) 119 to 179; range 68 to 323) in subcutaneous tissue and 61 minutes (95% CI 29 to 94; range 0 to 121) to 106 minutes (95% CI 76 to 136; range 71 to 154) in bone tissue. In Group PO, 0/8 pigs reached a concentration of 0.5 μg/ml in all compartments. For the high MIC target (2.0 μg/ml), fT > MIC was close to zero minutes in both groups across compartments. Conclusion Although intravenous administration of flucloxacillin 1 g provided higher fT > MIC for the low MIC target compared to oral administration, concentrations were surprisingly low, particularly for bone tissue. Achievement of sufficient bone and soft tissue flucloxacillin concentrations may require a dose increase or continuous administration. Cite this article: Bone Joint Res 2021;10(1):60–67.
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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, 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, 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, Aarhus, Denmark
| | - Maja B Thomassen
- 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, Aarhus, Denmark
| | - Jakob Hansen
- Department of Clinical Medicine, Faculty of Health, Aarhus University, Aarhus, Denmark.,Institute of Forensic Medicine, Aarhus University, Aarhus, Denmark
| | - Kjeld Søballe
- 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, 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, Aarhus, Denmark
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22
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Hanberg P, Bue M, Öbrink-Hansen K, Thomassen M, Søballe K, Stilling M. Timing of Antimicrobial Prophylaxis and Tourniquet Inflation: A Randomized Controlled Microdialysis Study. J Bone Joint Surg Am 2020; 102:1857-1864. [PMID: 32769808 DOI: 10.2106/jbjs.20.00076] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Tourniquets are widely used during extremity surgery. In order to prevent surgical site infection, correct timing of antimicrobial prophylaxis and tourniquet inflation is important. We aimed to evaluate the time for which the free drug concentration of cefuroxime is maintained above the minimum inhibitory concentration (t > MIC) in porcine subcutaneous adipose tissue and calcaneal cancellous bone during 3 clinically relevant tourniquet application scenarios. METHODS Twenty-four female Danish Landrace pigs were included. Microdialysis catheters were placed bilaterally for sampling of cefuroxime concentrations in calcaneal cancellous bone and subcutaneous adipose tissue, and a tourniquet was applied to a randomly picked leg of each pig. Subsequently, the pigs were randomized into 3 groups to receive 1.5 g of cefuroxime by intravenous injection 15 minutes prior to tourniquet inflation (Group A), 45 minutes prior to tourniquet inflation (Group B), and at the time of tourniquet release (Group C). The tourniquet duration was 90 minutes in all groups. Dialysates and venous blood samples were collected for 8 hours after cefuroxime administration. Cefuroxime and various ischemic marker concentrations were quantified. RESULTS Cefuroxime concentrations were maintained above the clinical breakpoint MIC for Staphylococcus aureus (4 µg/mL) in calcaneal cancellous bone and subcutaneous adipose tissue throughout the 90-minute tourniquet duration in Groups A and B. Cefuroxime administration at the time of tourniquet release (Group C) resulted in concentrations of >4 µg/mL for approximately of 3.5 hours in the tissues on the tourniquet side. Furthermore, tourniquet application induced ischemia (increased lactate:pyruvate ratio) and cell damage (increased glycerol) in subcutaneous adipose tissue and calcaneal cancellous bone. Tissue ischemia was sustained for 2.5 hours after tourniquet release in calcaneal cancellous bone. CONCLUSIONS Administration of cefuroxime (1.5 g) in the 15 to 45-minute window prior to tourniquet inflation resulted in sufficient concentrations in calcaneal cancellous bone and subcutaneous adipose tissue throughout the 90-minute tourniquet application. Furthermore, tourniquet-induced tissue ischemia fully resolved 2.5 hours after tourniquet release. CLINICAL RELEVANCE Cefuroxime administration 15 to 45 minutes prior to tourniquet inflation seems to be a safe window. If the goal is to maintain postoperative cefuroxime concentrations above relevant MIC values, our results suggest that a second dose of cefuroxime should be administered at the time of tourniquet release.
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Affiliation(s)
- Pelle Hanberg
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Kristina Öbrink-Hansen
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Maja Thomassen
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Maiken Stilling
- Aarhus Microdialysis Research Group, Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
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Thomassen MB, Hanberg P, Stilling M, Petersen KK, Søballe K, Krag LB, Højskov CS, Bue M. Local concentrations of gentamicin obtained by microdialysis after a controlled application of a GentaColl sponge in a porcine model. J Orthop Res 2020; 38:1793-1799. [PMID: 31943345 DOI: 10.1002/jor.24588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 12/21/2019] [Indexed: 02/04/2023]
Abstract
Local treatment with gentamicin may be an important tool in the prevention and treatment of surgical site infections in high-risk procedures and patients. The aim of this study was to evaluate the pharmacokinetic profile of gentamicin in bone and surrounding tissue, released from a controlled application of a GentaColl sponge in a porcine model. In eight female pigs, a GentaColl sponge of 10 × 10 cm (1.3 mg gentamicin/cm2 ) was placed in a cancellous bone cavity in the proximal tibia. Microdialysis was used for sampling of gentamicin concentrations over 48 hours from the cavity with the implanted GentaColl sponge, cancellous bone parallel to the cavity over and under the epiphyseal plate, cortical bone, the intramedullary canal, subcutaneous tissue, and the joint cavity of the knee. Venous blood samples were obtained as reference. The main finding was a mean peak drug concentration (95% CI) of gentamicin in the cancellous bone cavity containing the implanted GentaColl sponge of 11 315 (9049-13 581) μg/mL, persisting above 1000 μg/mL until approximately 40 hours after application. Moreover, the concentrations were low (<1 μg/mL) in the surrounding tissues as well as in plasma. The mean peak gentamicin concentration from the cancellous bone cavity after a controlled application of a GentaColl sponge was high and may be adequate for the prevention of biofilm formation. However, high MIC strains and uncontrolled application of the GentaColl sponge may jeopardize this conclusion.
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Affiliation(s)
- Maja B Thomassen
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Pelle Hanberg
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
| | - Maiken Stilling
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Klaus K Petersen
- Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Lasse B Krag
- Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Carsten S Højskov
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark.,Institute of Clinical Medicine, Aarhus University Hospital, Aarhus, Denmark.,Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens, Denmark
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24
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Hanberg P, Bue M, Jørgensen AR, Thomassen M, Öbrink-Hansen K, Søballe K, Stilling M. Pharmacokinetics of double-dose cefuroxime in porcine intervertebral disc and vertebral cancellous bone-a randomized microdialysis study. Spine J 2020; 20:1327-1332. [PMID: 32194245 DOI: 10.1016/j.spinee.2020.03.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2019] [Revised: 02/13/2020] [Accepted: 03/07/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Postoperative pyogenic spondylodiscitis is associated with prolonged antimicrobial therapy and high relapse rates. Cefuroxime is a time-dependent antimicrobial widely used for intravenous perioperative prophylaxis in spine surgery. A previous study has indicated that a single dose of cefuroxime (1.5 g) provides insufficient spine tissue concentrations for spine procedures lasting more than 2 to 3 hours. PURPOSE To evaluate the time with concentrations above relevant minimal inhibitory concentrations (T>MIC) in plasma, subcutaneous adipose tissue, vertebral cancellous bone, and intervertebral disc after a twofold increase of the standard dosage of 1.5 g cefuroxime given as one double dose (1×3 g) or two single doses (2×1.5 g) with a four-hour interval. METHODS Sixteen pigs were randomized into two groups: Group 1 received one double dose of cefuroxime (1×3 g) as an intravenous bolus and Group 2 received two single doses of cefuroxime (2×1.5 g) as an intravenous bolus with a four-hour interval. Cefuroxime measurements were obtained from plasma, subcutaneous adipose tissue, vertebral cancellous bone, and intervertebral disc for eight hours thereafter. Microdialysis was applied for sampling in solid tissues. The cefuroxime concentrations were determined using ultra-high performance liquid chromatography. This work was supported by grants from the Health Research Foundation of Central Denmark Region (Level E). The funding source did not play any role in the investigation. RESULTS The time with concentrations above the Staphylococcus aureus clinical breakpoint minimal inhibitory concentration of 4 μg/mL was higher in all compartments for Group 2 compared to Group 1. The mean T>MIC (4 μg/mL) in all compartments ranged between 47% and 67% for Group 1 and 72% and 92% for Group 2. Furthermore, a delayed tissue penetration into all tissues for both groups was demonstrated. CONCLUSIONS This study suggests that cefuroxime should be given at least 45 minutes prior to spine procedures and as two single doses at a maximum interval of four hours for extended spine procedures. Clinical studies verifying these results are warranted. CLINICAL SIGNIFICANCE Administering cefuroxime as two single doses (2×1.5 g) with a four-hour interval compared to one double dose (1×3 g) resulted in higher T>MIC. Furthermore, we found delayed and incomplete cefuroxime tissue penetration.
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Affiliation(s)
- 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.
| | - 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 Thomassen
- Orthopaedic Research Unit, 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
| | - 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
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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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26
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Hashimoto A, Miyamoto H, Kobatake T, Nakashima T, Shobuike T, Ueno M, Murakami T, Noda I, Sonohata M, Mawatari M. The combination of silver-containing hydroxyapatite coating and vancomycin has a synergistic antibacterial effect on methicillin-resistant Staphylococcus aureus biofilm formation. Bone Joint Res 2020; 9:211-218. [PMID: 32566142 PMCID: PMC7284291 DOI: 10.1302/2046-3758.95.bjr-2019-0326.r1] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
Aims Biofilm formation is intrinsic to prosthetic joint infection (PJI). In the current study, we evaluated the effects of silver-containing hydroxyapatite (Ag-HA) coating and vancomycin (VCM) on methicillin-resistant Staphylococcus aureus (MRSA) biofilm formation. Methods Pure titanium discs (Ti discs), Ti discs coated with HA (HA discs), and 3% Ag-HA discs developed using a thermal spraying were inoculated with MRSA suspensions containing a mean in vitro 4.3 (SD 0.8) x 106 or 43.0 (SD 8.4) x 105 colony-forming units (CFUs). Immediately after MRSA inoculation, sterile phosphate-buffered saline or VCM (20 µg/ml) was added, and the discs were incubated for 24 hours at 37°C. Viable cell counting, 3D confocal laser scanning microscopy with Airyscan, and scanning electron microscopy were then performed. HA discs and Ag HA discs were implanted subcutaneously in vivo in the dorsum of rats, and MRSA suspensions containing a mean in vivo 7.2 (SD 0.4) x 106 or 72.0 (SD 4.2) x 105 CFUs were inoculated on the discs. VCM was injected subcutaneously daily every 12 hours followed by viable cell counting. Results Biofilms that formed on HA discs were thicker and larger than those on Ti discs, whereas those on Ag-HA discs were thinner and smaller than those on Ti discs. Viable bacterial counts in vivo revealed that Ag-HA combined with VCM was the most effective treatment. Conclusion Ag-HA with VCM has a potential synergistic effect in reducing MRSA biofilm formation and can thus be useful for preventing and treating PJI. Cite this article:Bone Joint Res. 2020;9(5):211–218.
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Affiliation(s)
- Akira Hashimoto
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Hiroshi Miyamoto
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Tomoki Kobatake
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takema Nakashima
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takeo Shobuike
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Saga, Japan
| | - Masaya Ueno
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Takayuki Murakami
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Saga, Japan; Research Section, Medical Division, KYO CERA Corporation, Yasu, Japan
| | - Iwao Noda
- Department of Pathology and Microbiology, Faculty of Medicine, Saga University, Saga, Japan; Research Section, Medical Division, KYO CERA Corporation, Yasu, Japan
| | - Motoki Sonohata
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
| | - Masaaki Mawatari
- Department of Orthopaedic Surgery, Faculty of Medicine, Saga University, Saga, Japan
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27
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In vitro time-kill kinetics of dalbavancin against Staphylococcus spp. biofilms over prolonged exposure times. Diagn Microbiol Infect Dis 2020; 96:114901. [DOI: 10.1016/j.diagmicrobio.2019.114901] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Revised: 08/08/2019] [Accepted: 09/10/2019] [Indexed: 01/27/2023]
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Population pharmacokinetics of piperacillin in plasma and subcutaneous tissue in patients on continuous renal replacement therapy. Int J Infect Dis 2020; 92:133-140. [PMID: 31978581 DOI: 10.1016/j.ijid.2020.01.010] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2019] [Revised: 01/11/2020] [Accepted: 01/13/2020] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Piperacillin is a β-lactam antimicrobial frequently used in critically ill patients with acute kidney injury treated with continuous renal replacement therapy (CRRT). However, data regarding piperacillin tissue concentrations in this patient population are limited. A prospective observational study was conducted of free piperacillin concentrations during a single 8-h dosing interval in plasma (8 samples) and subcutaneous tissue (SCT) (13 samples), in 10 patients treated with CRRT following piperacillin 4 g given every 8 h as intermittent administration over 3 min. METHODS A population pharmacokinetic model was developed using NONMEM 7.4.3, to simulate alternative administration modes and dosing regimens. SCT concentrations were obtained using microdialysis. Piperacillin concentrations were compared to the clinical breakpoint minimum inhibitory concentration (MIC) for Pseudomonas aeruginosa (16 mg/l), with evaluation of the following pharmacokinetic/pharmacodynamics targets: 50% fT > 1 × MIC, 100% fT > 1 × MIC, and 100% fT > 4 × MIC. RESULTS SCT concentrations were generally lower than plasma concentrations. For the target of 50% free time (fT) > 1 × MIC and 100% fT > 1 × MIC, piperacillin 4 g every 8 h resulted in probability of target attainment (PTA) >90% in both plasma and SCT. PTA > 90% for the target of 100% fT > 4 × MIC was only achieved for continuous infusion. CONCLUSIONS Piperacillin 4 g every 8 h is likely to provide sufficient exposure in both plasma and SCT to treat P.aeruginosa infections in critically ill patients on CRRT, given that targets of 50% fT > 1 × MIC or 100% fT > 1 × MIC are adequate. However, if a more aggressive target of 100% fT > 4 × MIC is adopted, continuous infusion is needed.
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Hanberg P, Lund A, Søballe K, Bue M. Single-dose pharmacokinetics of meropenem in porcine cancellous bone determined by microdialysis: An animal study. Bone Joint Res 2019; 8:313-322. [PMID: 31463039 PMCID: PMC6691366 DOI: 10.1302/2046-3758.87.bjr-2018-0308.r1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Objectives Meropenem may be an important drug in the treatment of open tibial fractures and chronic osteomyelitis. Therefore, the objective of this study was to describe meropenem pharmacokinetics in plasma, subcutaneous adipose tissue (SCT), and cancellous bone using microdialysis in a porcine model. Methods Six female pigs were assigned to receive 1000 mg of meropenem intravenously over five minutes. Measurements of meropenem were obtained from plasma, SCT, and cancellous bone for eight hours thereafter. Microdialysis was applied for sampling in solid tissues. The meropenem concentrations were determined using ultra-high-performance liquid chromatography. Results The penetration of meropenem into cancellous bone, expressed as the ratio of plasma to cancellous bone area under the concentration-curve from zero to the last measured value, was incomplete and delayed. The time with concentration above the minimal inhibitory concentration (T>MIC), for an MIC of 0.5 μg/ml, was shorter for cancellous bone in comparison with both plasma and SCT. For MICs above 0.5 μg/ml, T>MIC in cancellous bone was only shorter than SCT. Considering an MIC of 4 μg/ml, no animals achieved the target of 40% T>MIC in plasma and cancellous bone, while less than 20% achieved it in SCT. Conclusion The main finding of this study was short T>MIC in cancellous bone after intravenous administration of 1000 mg meropenem. Consequently, in order to achieve sufficient tissue concentration in the cases of open tibial fractures and chronic osteomyelitis, supplemental application of meropenem may be necessary.Cite this article: P. Hanberg, A. Lund, K. Søballe, M. Bue. Single-dose pharmacokinetics of meropenem in porcine cancellous bone determined by microdialysis: An animal study. Bone Joint Res 2019;8:342-348. DOI: 10.1302/2046-3758.87.BJR-2018-0308.R1.
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Affiliation(s)
- Pelle Hanberg
- Department of Orthopaedic Surgery, Horsens Regional Hospital and Orthopaedic Research Unit, Aarhus University Hospital, Horsens, Denmark and Aarhus, Denmark
| | - Andrea Lund
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus, Denmark
| | - Mats Bue
- Department of Orthopaedic Surgery, Horsens Regional Hospital and Orthopaedic Research Unit, Aarhus University Hospital, Horsens, Denmark and Aarhus, Denmark
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30
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Thabit AK, Fatani DF, Bamakhrama MS, Barnawi OA, Basudan LO, Alhejaili SF. Antibiotic penetration into bone and joints: An updated review. Int J Infect Dis 2019; 81:128-136. [PMID: 30772469 DOI: 10.1016/j.ijid.2019.02.005] [Citation(s) in RCA: 174] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2018] [Revised: 02/04/2019] [Accepted: 02/08/2019] [Indexed: 01/14/2023] Open
Abstract
Treatment of bone and joint infections can be challenging as antibiotics should penetrate through the rigid bone structure and into the synovial space. Several pharmacokinetic studies measured the extent of penetration of different antibiotics into bone and joint tissues. This review discusses the results of these studies and compares them with minimum inhibitory concentrations (MIC) of common pathogens implicated in bone and joint infections in order to determine which antibiotics may have a greater potential in the treatment of such infections. Clinical outcomes were also evaluated as data were available. More than 30 antibiotics were evaluated. Overall, most antibiotics, including amoxicillin, piperacillin/tazobactam, cloxacillin, cephalosporins, carbapenems, aztreonam, aminoglycosides, fluoroquinolones, doxycycline, vancomycin, linezolid, daptomycin, clindamycin, trimethoprim/sulfamethoxazole, fosfomycin, rifampin, dalbavancin, and oritavancin, showed good penetration into bone and joint tissues reaching concentrations exceeding the MIC90 and/or MIC breakpoints of common bone and joint infections pathogens. Few exceptions include penicillin and metronidazole which showed a lower than optimum penetration into bones, and the latter as well as flucloxacillin had poor profiles in terms of joint space penetration. Of note, studies on joint space penetration were fewer than studies on bone tissue penetration. Although clinical studies in osteomyelitis and septic arthritis are not available for all of the evaluated antibiotics, these pharmacokinetic results indicate that agents with good penetration profiles would have a potential utilization in such infections.
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Affiliation(s)
- Abrar K Thabit
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia.
| | - Dania F Fatani
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Maryam S Bamakhrama
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Ola A Barnawi
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Lana O Basudan
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Shahad F Alhejaili
- Pharmacy Practice Department, Faculty of Pharmacy, King Abdulaziz University, Jeddah, Saudi Arabia
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Polykandriotis E, Horch RE, Jost M, Arkudas A, Kees F, Schmitz M. Can systemically administered antibiotics be detected in wound tissues and surfaces under negative pressure wound therapy? Int Wound J 2019; 16:503-510. [PMID: 30604928 DOI: 10.1111/iwj.13063] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2018] [Revised: 12/09/2018] [Accepted: 12/11/2018] [Indexed: 12/12/2022] Open
Abstract
In this study, we evaluated a new aspect of negative pressure wound therapy (NPWT) as an analytical tool for pharmacokinetic studies. Twenty-one patients with soft tissue defects scheduled to receive NPWT were included in this study. Concomitant to NPWT, all patients received intravenous moxifloxacin (MX). At different time intervals, blood plasma levels of MX were sampled and compared with synchronous concentrations of MX in the exudate obtained from the NPWT drainage system. Serial measurements were performed upon initiation of the therapy as well as in the steady state (after 5 days). At steady state, wound tissue was obtained intraoperatively. High-performance liquid-chromatography (HPLC) was used for analysis. At 1 hour post-administration, the exudate/plasma levels (mg/L) were 1.92/3.07; at 12 hours, 0.80/1.14; at 24 hours, 0.26/0.43; and at 120 hours (steady state), 0.42/0.47. There was a correlation between exudate and plasma levels reaching approximately 0.75. Until now, methods for pharmacokinetic studies concerning interstitial fluid are difficult to apply in the clinical context. The presented method showed limitations, but we believe that, after methodological improvements, measurements of substances in the interstitial fluid by means of NPWT are feasible.
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Affiliation(s)
- Elias Polykandriotis
- Department of Plastic, Hand and Microsurgery, Sana Klinikum Hof, Hof, Germany.,Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany
| | - Raymund E Horch
- Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany
| | - Matthias Jost
- Department of Internal Medicine 6, Gastrenterology, Endocrinology, Klinikum Nuernberg, Nurnberg, Germany
| | - Andreas Arkudas
- Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany
| | - Frieder Kees
- Institute for Pharmacology and Toxicology, University of Regensburg, Regensburg, Germany
| | - Marweh Schmitz
- Department of Plastic and Hand Surgery, University of Erlangen Medical Center, Erlangen, Germany
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32
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Bue M, Hanberg P, Tøttrup M, Thomassen MB, Birke-Sørensen H, Thillemann TM, Andersson TL, Søballe K. Vancomycin concentrations in the cervical spine after intravenous administration: results from an experimental pig study. Acta Orthop 2018; 89:683-688. [PMID: 30080983 PMCID: PMC7025694 DOI: 10.1080/17453674.2018.1501548] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Vancomycin may be an important drug for intravenous perioperative antimicrobial prophylaxis in spine surgery. We assessed single-dose vancomycin intervertebral disc, vertebral cancellous bone, and subcutaneous adipose tissue concentrations using microdialysis in a pig model. Material and methods - 8 female pigs received 1,000 mg of vancomycin intravenously as a single dose over 100 minutes. Microdialysis probes were placed in the C3-C4 intervertebral disc, C3 vertebral cancellous bone, and subcutaneous adipose tissue, and vancomycin concentrations were obtained over 8 hours. Venous blood samples were obtained as reference. Results - Ranging from 0.24 to 0.60, vancomycin tissue penetration, expressed as the ratio of tissue to plasma area under the concentration-time curve from 0 to the last measured value, was incomplete for all compartments. The lowest penetration was found in the intervertebral disc. The time to a mean clinically relevant minimal inhibitory concentration (MIC) of 4 µg/mL was 3, 17, 25, and 156 min for plasma, subcutaneous adipose tissue, vertebral cancellous bone, and the intervertebral disc, respectively. In contrast to the other compartments, a mean MIC of 8 µg/mL was not reached in the intervertebral disc. An approximately 3-times longer elimination rate was observed in the intervertebral disc in comparison with all the other compartments (p < 0.001), and the time to peak drug concentration was higher for all tissues compared with plasma Interpretation - Preoperative administration of 1,000 mg of vancomycin may provide adequate vancomycin tissue concentrations with a considerable delay, though tissue penetration was incomplete. However, in order also to achieve adequate intervertebral disc concentrations in all individuals and accommodating a potentially higher MIC target, supplemental application of vancomycin may be necessary.
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Affiliation(s)
- Mats Bue
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens; ,Orthopaedic Research Unit, Aarhus University Hospital, Aarhus; ,Correspondence:
| | - Pelle Hanberg
- Department of Orthopaedic Surgery, Horsens Regional Hospital, Horsens; ,Orthopaedic Research Unit, Aarhus University Hospital, Aarhus;
| | - Mikkel Tøttrup
- Department of Orthopaedic Surgery, Randers Regional Hospital, Randers; ,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus;
| | | | | | - Theis M Thillemann
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus; ,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus;
| | - Torben L Andersson
- Department of Clinical Biochemistry, Aarhus University Hospital, Aarhus, Denmark
| | - Kjeld Søballe
- Orthopaedic Research Unit, Aarhus University Hospital, Aarhus; ,Department of Orthopaedic Surgery, Aarhus University Hospital, Aarhus;
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