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Barksfield R, Hamal P, Hamal D, Porteous A, Murray J. The Safety of Glycopeptide-Impregnated Calcium Sulphate Following Debridement, Antibiotics and Implant Retention (DAIR) for Infected Total Knee Replacement. Cureus 2024; 16:e57955. [PMID: 38738147 PMCID: PMC11083777 DOI: 10.7759/cureus.57955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/09/2024] [Indexed: 05/14/2024] Open
Abstract
Background and objective The impact of prosthetic joint infection (PJI) stretches far beyond the physical nature of the disease. It can result in psychological and social consequences, with significant morbidity and mortality for patients. Calcium sulphate-based delivery agents are effective in the management of PJI, yet with associated risks of systemic adverse events. This study aims to evaluate the risk of systemic adverse events when using calcium-sulphate-based local antibiotic delivery agents in the management of PJIs. Methodology We identified 43 patients who underwent debridement, antibiotics and implant retention (DAIR) for infected total knee arthroplasty (TKA) between 2008 and 2014. Patients in the control groupunderwent conventional intravenous and then oral antibiotic administration, while those in the intervention groupunderwent additional local antibiotic therapy via a calcium sulphate alpha hemihydrate matrix. Case notes and laboratory results data were compiled to establish the safety and efficacy of local glycopeptide delivery. Results Serum vancomycin levels were within the safe therapeutic range for all patients in the intervention group with no difference in serum assays between treatment groups (intervention 7.7 mg/L; control 8.0 mg/L; P = 0.85). Renal function for the study cohort improved at every time point post-operatively when referenced against pre-operative renal function (P < 0.05). There was no difference in renal function between intervention and control groups on day 1, one week, six weeks or 12 weeks post-operatively (P = 0.78, 0.89, 0.20 and 0.50). Conclusions Local glycopeptide delivery via a calcium sulphate alpha hemihydrate matrix did not result in systemic adverse consequences specifically not raising the systemic level of glycopeptide, nor reducing renal function. Implications for future research Although demonstrates a safety profile and potential therapeutic benefit, the long-term efficacy of this approach needs to be established. Importantly, selection bias may contribute to masking clinically significant differences in post-operative outcomes.
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Affiliation(s)
- Richard Barksfield
- Orthopaedics, Gloucestershire Hospitals NHS Foundation Trust, Gloucester, GBR
| | - Pravakar Hamal
- Orthopaedics, University Hospital of Llandough, Cardiff, GBR
| | - Divakar Hamal
- Intensive Care Unit, Kings College London, London, GBR
| | - Andrew Porteous
- Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, GBR
| | - James Murray
- Trauma and Orthopaedics, North Bristol NHS Trust, Bristol, GBR
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Madadi AK, Sohn MJ. Pharmacokinetic Interpretation of Applying Local Drug Delivery System for the Treatment of Deep Surgical Site Infection in the Spine. Pharmaceutics 2024; 16:94. [PMID: 38258104 PMCID: PMC10819048 DOI: 10.3390/pharmaceutics16010094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 12/21/2023] [Accepted: 01/08/2024] [Indexed: 01/24/2024] Open
Abstract
Surgical site infections (SSIs) after spinal surgery present significant challenges, including poor antibiotic penetration and biofilm formation on implants, leading to frequent treatment failures. Polymethylmethacrylate (PMMA) is widely used for localized drug delivery in bone infections, yet quantifying individual drug release kinetics is often impractical. This retrospective study analyzed 23 cases of deep SSIs (DSSIs) following spinal surgery treated with antibiotic-loaded PMMA. A mathematical model estimated personalized drug release kinetics from PMMA, considering disease types, pathogens, and various antibiotics. The study found that vancomycin (VAN), ceftriaxone (CRO), and ceftazidime (CAZ) reached peak concentrations of 15.43%, 15.42%, and 15.41%, respectively, within the first two days, which was followed by a lag phase (4.91-4.92%) on days 2-3. On days 5-7, concentrations stabilized, with CRO at 3.22% and CAZ/VAN between 3.63% and 3.65%, averaging 75.4 µg/cm2. Key factors influencing release kinetics include solubility, diffusivity, porosity, tortuosity, and bead diameter. Notably, a patient with a low glomerular filtration rate (ASA IV) was successfully treated with a shortened 9-day intravenous VAN regimen, avoiding systemic complications. This study affirms the effectiveness of local drug delivery systems (DDS) in treating DSSIs and underscores the value of mathematical modeling in determining drug release kinetics. Further research is essential to optimize release rates and durations and to mitigate risks of burst release and tissue toxicity.
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Affiliation(s)
- Ahmad Khalid Madadi
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjingu, Busan 47392, Republic of Korea;
| | - Moon-Jun Sohn
- Department of Biomedical Science, Graduate School of Medicine, Inje University, 75, Bokji-ro, Busanjingu, Busan 47392, Republic of Korea;
- Department of Neurosurgery, Neuroscience & Radiosurgery Hybrid Research Center, College of Medicine, Inje University Ilsan Paik Hospital, Juhwa-ro 170, Ilsanseo-gu, Goyang City 10380, Republic of Korea
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3
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Doub JB, Yu G, Johnson A, Mao Y, Kjellerup BV. The stability of Staphylococcal bacteriophage in presence of local vancomycin concentrations used in clinical practice. EUROPEAN JOURNAL OF ORTHOPAEDIC SURGERY & TRAUMATOLOGY : ORTHOPEDIE TRAUMATOLOGIE 2024; 34:653-657. [PMID: 37679422 DOI: 10.1007/s00590-023-03720-w] [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: 05/29/2023] [Accepted: 08/27/2023] [Indexed: 09/09/2023]
Abstract
PURPOSE To evaluate the stability of a clinically used Staphylococcal bacteriophage with doses of vancomycin that are encountered with local administration of vancomycin for musculoskeletal infections. METHODS A Staphylococcal bacteriophage was evaluated for stability in different pH ranges. Then that same bacteriophage was evaluated for stability with different concentrations of vancomycin and with vancomycin biodegradable antibiotic beads. RESULTS The bacteriophage had stability within a pH range of 4-10. There was a statistically significant (P < 0.05) decrease in the amount of bacteriophage over 24 h for vancomycin concentrations of 10 mg/mL and 100 mg/mL compared to lower vancomycin concentrations (1 mg/mL, 0.1 mg/mL and normal saline). However, no statistically significant decrease in the amount of bacteriophage was seen with biodegradable vancomycin beads over 24 h. CONCLUSION These findings have important clinical ramifications in that they show local administration of bacteriophages with concomitant local vancomycin powder therapy should be avoided. Moreover, these findings should spearhead further research into bacteriophage stability in in vivo environments.
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Affiliation(s)
- James B Doub
- The Doub Translational Bacterial Research Laboratory, Division of Infectious Diseases, University of Maryland School of Medicine, 725 West Lombard Street, Baltimore, MD, 21201, USA.
| | - Guangchao Yu
- Clinical Laboratory Center, The First Affiliated Hospital of Jinan University, Guangzhou, People's Republic of China
- The Kjellerup Biofilm Laboratory, Department of Civil and Environmental Engineering, University of Maryland, College Park, MD, USA
| | - Aaron Johnson
- Department of Orthopedic Surgery, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Yuzhu Mao
- The Kjellerup Biofilm Laboratory, Department of Civil and Environmental Engineering, University of Maryland, College Park, MD, USA
| | - Birthe V Kjellerup
- The Kjellerup Biofilm Laboratory, Department of Civil and Environmental Engineering, University of Maryland, College Park, MD, USA
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Thankappan A, Nasimudeen N, Chaudhari AS, Raju A, Rasiya R. Open Intra-articular Distal Femur Fracture with 21 cm Bone Loss Managed by Early Vascularized Fibula Grafting and Antibiotic Loaded Synthetic Calcium Sulfate Beads - A Case Report. J Orthop Case Rep 2023; 13:100-105. [PMID: 38025364 PMCID: PMC10664212 DOI: 10.13107/jocr.2023.v13.i11.4022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 09/28/2023] [Indexed: 12/01/2023] Open
Abstract
Introduction Open fractures with massive bone defect presents as challenging clinical scenario in clinical practice. If neglected, this can result in infection, non-union or severe limb length discrepancy. Autogenous vascularized fibula grafting along with stable fixation in the form of internal fixation is a viable option in such situations. Synthetic calcium sulfate is a suitable antibiotic carrier to deliver antibiotics locally to prevent infection. We report the case of an adult male who had an open fracture of the distal femur with segmental bone loss of 21 cm, managed with autogenous vascularized fibula graft and locking plates. We used antibiotic-loaded absorbable synthetic calcium sulfate beads locally during the procedure. Case Report A 52-year-old male, a known case of uncontrolled diabetes mellitus, presented to the emergency department with a comminuted open intra-articular fracture of the left distal femur with bone loss of 21 cm (arbeitsgemeinschaft fur osteosynthesefragen 33C3) following a road traffic accident. He was initially treated with meticulous debridement and internal fixation with locking compression plate. Considering the massive bone defect of 21 cm, he was planned for fibula grafting at a later stage. After 6 weeks, he underwent vascularized fibula grafting from opposite leg and an additional medial plate to stabilize the graft and augment the initial fixation. He was on regular follow-up in the outpatient department. The fracture united with no signs of infection or residual limb length discrepancy. At the latest follow-up at 7 months, he is walking independently without support and is having a functional range of knee movements. There were no post-operative complications in the right leg from where fibula was harvested. Conclusion Autogenous vascularized fibula graft together with a locking compression plate is a practical choice in managing open fractures with segmental bone loss. The high concentration of local antibiotic delivery with the help of synthetic calcium sulfate beads helped prevent infection, which is the most dreaded complication associated with open fractures. In addition, the calcium sulfate beads promote endochondral ossification resulting in early bone union.
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Affiliation(s)
| | - Nizaj Nasimudeen
- Department of Orthopaedics, Apollo Adlux Hospital, Kochi, Kerala, India
| | - Ashish S Chaudhari
- Department of Plastic Reconstruction and Aesthetic Surgery, Apollo Adlux Hospital, Kochi, Kerala, India
| | - Aebel Raju
- Department of Orthopaedics, Apollo Adlux Hospital, Kochi, Kerala, India
| | - R Rasiya
- Department of Orthopaedics, Apollo Adlux Hospital, Kochi, Kerala, India
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Humez M, Domann E, Thormann KM, Fölsch C, Strathausen R, Vogt S, Alt V, Kühn KD. Daptomycin-Impregnated PMMA Cement against Vancomycin-Resistant Germs: Dosage, Handling, Elution, Mechanical Stability, and Effectiveness. Antibiotics (Basel) 2023; 12:1567. [PMID: 37998769 PMCID: PMC10668807 DOI: 10.3390/antibiotics12111567] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Revised: 10/20/2023] [Accepted: 10/23/2023] [Indexed: 11/25/2023] Open
Abstract
BACKGROUND The number of periprosthetic joint infections caused by vancomycin-resistant pathogens is increasing. Currently, no PMMA cement is commercially available to cover VRE. Daptomycin shows promising results in treating infection, offering a good safety profile and a reduced risk of developing resistance. The purpose of this in vitro study was to investigate the mechanical stability, handling properties, elution behavior, and antimicrobial effectiveness of PMMA cement loaded with three different daptomycin concentrations in comparison to commercially available antibiotic-loaded bone cement (ALBC). METHODS Mechanical properties and handling characteristics (ISO 5833, DIN 53435), HPLC elution, antimicrobial effectiveness with proliferation assay (DIN 17025), and inhibition zone testing were investigated. RESULTS All tested daptomycin concentrations met the ISO and DIN standards for mechanical strength. Loading of 40 g of PMMA cement with 0.5 g of daptomycin did not show any antimicrobial effectiveness, in contrast to 1.0 g and 1.5 g. PMMA cement with 1.5 g of daptomycin was the best in terms of elution and effectiveness, and it showed good ISO mechanical strength; ISO doughing was sticky for a little longer and setting was faster compared to the vancomycin-containing reference cement. CONCLUSION PMMA cement containing 0.5 g of gentamicin and 1.5 g of daptomycin could be a good alternative to the already established COPAL® (Wehrheim, Germany) G+V for the treatment of PJIs caused by VRE.
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Affiliation(s)
- Martina Humez
- Institute of Hygiene and Environmental Medicine, Justus-Liebig-Universität Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (E.D.); (K.M.T.)
- Heraeus Medical GmbH, Philipp-Reis-Str. 8-13, 61273 Wehrheim, Germany; (R.S.); (S.V.)
| | - Eugen Domann
- Institute of Hygiene and Environmental Medicine, Justus-Liebig-Universität Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (E.D.); (K.M.T.)
| | - Kai M. Thormann
- Institute of Hygiene and Environmental Medicine, Justus-Liebig-Universität Giessen, Schubertstrasse 81, 35392 Giessen, Germany; (E.D.); (K.M.T.)
- Institute of Microbiology and Molecular Biology, Justus-Liebig-Universität Giessen, Heinrich-Buff-Ring 26, 35392 Giessen, Germany
| | - Christian Fölsch
- Department of Orthopaedic Surgery, Justus-Liebig-University, Klinikstrasse 33, 35392 Giessen, Germany;
| | - Rainer Strathausen
- Heraeus Medical GmbH, Philipp-Reis-Str. 8-13, 61273 Wehrheim, Germany; (R.S.); (S.V.)
| | - Sebastian Vogt
- Heraeus Medical GmbH, Philipp-Reis-Str. 8-13, 61273 Wehrheim, Germany; (R.S.); (S.V.)
| | - Volker Alt
- Department of Trauma Surgery, University Medical Centre, Regensburg, Franz-Josef-Strauß-Allee 11, 93053 Regensburg, Germany;
| | - Klaus-Dieter Kühn
- Department of Orthopaedics and Trauma, Medical University of Graz, Auenbruggerplatz 5, 8036 Graz, Austria
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Hartman EA, Pena Hernandez D, Hendrix GK, Risselada M, Weng HY, Papich MG, Kim SY. Effects of storage up to 1 year on the in vitro antimicrobial activity of preformulated antibiotic-impregnated calcium sulfate beads. Vet Surg 2023. [PMID: 37574868 DOI: 10.1111/vsu.14014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 07/12/2023] [Accepted: 07/31/2023] [Indexed: 08/15/2023]
Abstract
OBJECTIVE To compare antimicrobial activity as demonstrated by the zone of inhibition (ZOI) produced by antibiotic-impregnated calcium sulfate (CaSO4 ) beads after storage for 0, 3, 6, 9, and 12 months. STUDY DESIGN Controlled laboratory study. SAMPLE POPULATION Three-millimeter diameter CaSO4 beads impregnated with vancomycin (125 mg/mL), or amikacin (250 mg/mL), or without antibiotic (control). METHODS Calcium sulfate beads were created at the onset of the study. Individual beads were separated in sterile containers and stored in a closed cabinet at room temperature and humidity for 0, 3, 6, 9, or 12 months until testing. The ZOI against methicillin-resistant Staphylococcus pseudintermedius, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa was recorded with serial replating on a fresh lawn of bacteria every 24 h until beads failed to produce a ZOI. The ZOIs and their changes were compared with mixed-effects linear models. Eluted concentrations of vancomycin measured with high-performance liquid chromatography were reported. RESULTS At 24 h, ZOIs were comparable regardless of time since formulation, except vancomycin against P. aeruginosa, which failed to generate a ZOI. The daily changes of ZOI and duration of activity of antibiotics did not vary between storage length (p > .05). There was no consistent change in eluted drug concentration between storage length of beads. CONCLUSION Light protected storage at room temperature for up to 12 months did not impair the in vitro activity of antibiotic-impregnated CaSO4 beads, as demonstrated through ZOIs. CLINICAL SIGNIFICANCE When stored correctly, antibiotic-impregnated CaSO4 beads can be used at least up to 12 months after formulation.
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Affiliation(s)
- Emily Allyson Hartman
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Daniela Pena Hernandez
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- The Indiana Animal Disease Diagnostic Laboratory, West Lafayette, Indiana, USA
| | - Gena Kenitra Hendrix
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
- The Indiana Animal Disease Diagnostic Laboratory, West Lafayette, Indiana, USA
| | - Marije Risselada
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Hsin-Yi Weng
- Department of Comparative Pathobiology, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
| | - Mark G Papich
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, USA
| | - Sun Young Kim
- Department of Veterinary Clinical Sciences, Purdue University College of Veterinary Medicine, West Lafayette, Indiana, USA
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Choudhry B, Mitchell J, Milner S. A surgeon's trial success of curing pedal eumycetoma. BMJ Case Rep 2023; 16:e218559. [PMID: 37507126 PMCID: PMC10387635 DOI: 10.1136/bcr-2016-218559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/30/2023] Open
Abstract
Mycetoma is a chronic infection of underlying fungal (eumycetoma) or bacterial (actinomycetoma) origin. It is characterised by a clinical triad of tumour-like swelling, actively draining sinuses and macroscopic grains of characteristic colours.We the case of a 66-year-old woman on immunosuppressive therapy presenting with eumycetoma of the foot (Madura foot). The fungal organism cultured was Acrophialophora fusisporaThis case was managed with a combination of extensive surgical debridement, and packing with calcium sulfate (Stimulan) beads impregnated with vancomycin and voriconazole. As far as the authors are aware, this is a novel adjunct to the surgical treatment of deep fungal infection in the foot.Eumycetoma treated with surgery and oral antifungal therapy leads to cure rates of 25%-35%. This novel treatment seems to bear further investigation for the potential to improve cure rates. At 8 months follow-up, our patient appears to be making good progress with no current signs of recurrence.
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Casiraghi A, Galante C, Rohayem M, Vittone G, Domenicucci M, Cattaneo S, Paderno M, Grava G, Van Hauwermeiren E, Milano G. Implant retention with serial debridement and use of antibiotic-loaded calcium sulfate beads in acute fracture-related infection (FRI) after pelvic ring or acetabular fractures: A retrospective case series of 7 cases. Injury 2023; 54:1082-1087. [PMID: 36740475 DOI: 10.1016/j.injury.2023.01.045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/27/2023]
Abstract
BACKGROUND The development of a pelvic wound infection in the presence of hardware after open reduction and internal fixation presents a clinical dilemma and there is little literature to aid in decision-making. The purpose of this study was to describe the possibility of debridement, antibiotic pearls and retention of the implant (DAPRI) procedure to eradicate the infection. METHODS Tumor-like debridement, antibiotic pearls and retention of the implant (DAPRI) aimed to remove the biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulfate antibiotic-added beads. Wound status, radiological signs of bone healing, gait and functional activity of the patient were evaluated. RESULTS Seven patients underwent this technique. The mean follow up time was nine months (range: 6 -16 months). Complete wound healing was achieved in all the patients with no major complications. Average time of bony union was 4.3 months (range: 3-6 months) with no need for implant removal. CONCLUSION The DAPRI technique might represent a safe and more conservative treatment for management of early fracture-related infections (FRI) of the pelvis and acetabulum.
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Affiliation(s)
| | - Claudio Galante
- Department of Bone and Joint Surgery, ASST Spedali Civili, Brescia, Italy.
| | - Mohamed Rohayem
- Orthopedic surgery department, Tanta University Hospitals, Egypt
| | - Giulio Vittone
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Domenicucci
- Department of Bone and Joint Surgery, ASST Spedali Civili, Brescia, Italy
| | - Stefano Cattaneo
- Department of Bone and Joint Surgery, ASST Spedali Civili, Brescia, Italy
| | - Marco Paderno
- Department of Bone and Joint Surgery, ASST Spedali Civili, Brescia, Italy
| | - Giuseppe Grava
- Department of Bone and Joint Surgery, ASST Spedali Civili, Brescia, Italy
| | | | - Giuseppe Milano
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Lacqua A, Helmer P. Treatment of Septic Tenosynovitis and Osteoarthritis in an American White Pekin ( Anas platyrhynchos domesticus) with Repeated Intravenous Regional Limb Perfusion and Antibiotic-Impregnated Calcium Sulfate Beads. J Avian Med Surg 2023; 36:414-420. [PMID: 36935214 DOI: 10.1647/21-00056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
A 2-year-old female American white pekin (Anas platyrhynchos domesticus) was assessed for a 2-month history of chronic lameness and swelling involving the left leg. Radiographic images of the left leg showed soft tissue swelling of the digits and tarsometatarsus with osteolysis of the tarsometatarsal-phalangeal joint. A complete blood count revealed marked leukocytosis and hyperproteinemia. A Streptococcus species was isolated from a bacterial culture of fluid obtained from the left tarsometatarsal-phalangeal joint. Biweekly intravenous regional limb perfusions of the left leg with ampicillin-sulbactam and amikacin were performed on the patient. Despite initial improvement in left leg lameness and swelling, follow-up radiographic images showed progressive osteolysis of the tarsometatarsal-phalangeal joint and associated digits. Surgical placement of antibiotic-impregnated calcium sulfate beads into the left tarsometatarsal-phalangeal joint was next performed with concurrent, repeated intravenous regional limb perfusion using the same antibiotic. Following the placement of antibiotic-impregnated beads and continued intravenous regional limb perfusion, the duck had decreased lameness and swelling of the left leg. Repeated antibiotic treatment through intravenous regional limb perfusion and concurrent placement of antibiotic-impregnated calcium sulfate beads is a practical treatment option for complicated distal limb infections in avian species. This therapeutic protocol has great potential in treating aggressive distal leg infections in many avian species because regional limb perfusion alone may not penetrate the joint adequately to achieve complete resolution of infection.
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Affiliation(s)
- Andrew Lacqua
- Avian and Exotics Service, BluePearl Pet Hospital, Clearwater, FL 33762, USA,
| | - Peter Helmer
- Avian and Exotics Service, BluePearl Pet Hospital, Clearwater, FL 33762, USA
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Topaz M, Chorin E, Schwartz AL, Hochstadt A, Shotan A, Ashkenazi I, Kazatsker M, Carmel NN, Topaz G, Oron Y, Margolis G, Nof E, Beinart R, Glikson M, Mazo A, Milman A, Dekel M, Banai S, Rosso R, Viskin S. Regional Antibiotic Delivery for Implanted Cardiovascular Electronic Device Infections. J Am Coll Cardiol 2023; 81:119-133. [PMID: 36631206 DOI: 10.1016/j.jacc.2022.10.022] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 09/19/2022] [Accepted: 10/14/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Present guidelines endorse complete removal of cardiovascular implantable electronic devices (pacemakers/defibrillators), including extraction of all intracardiac electrodes, not only for systemic infections, but also for localized pocket infections. OBJECTIVES The authors evaluated the efficacy of delivering continuous, in situ-targeted, ultrahigh concentration of antibiotics (CITA) into the infected subcutaneous device pocket, obviating the need for device/lead extraction. METHODS The CITA group consisted of 80 patients with pocket infection who were treated with CITA during 2007-2021. Of them, 9 patients declined lead extraction because of prohibitive operative risk, and 6 patients had questionable indications for extraction. The remaining 65 patients with pocket infection, who were eligible for extraction, but opted for CITA treatment, were compared with 81 patients with pocket infection and similar characteristics who underwent device/lead extraction as primary therapy. RESULTS A total of 80 patients with pocket infection were treated with CITA during 2007-2021. CITA was curative in 85% (n = 68 of 80) of patients, who remained free of infection (median follow-up 3 years [IQR: 1.0-6.8 years]). In the case-control study of CITA vs device/lead extraction, cure rates were higher after device/lead extraction than after CITA (96.2% [n = 78 of 81] vs 84.6% [n = 55 of 65]; P = 0.027). However, rates of serious complications were also higher after extraction (n = 12 [14.8%] vs n = 1 [1.5%]; P = 0.005). All-cause 1-month and 1-year mortality were similar for CITA and device/lead extraction (0.0% vs 3.7%; P = 0.25 and 12.3% vs 13.6%; P = 1.00, respectively). Extraction was avoided in 90.8% (n = 59 of 65) of extraction-eligible patients treated with CITA. CONCLUSIONS CITA is a safe and effective alternative for patients with pocket infection who are unsuitable or unwilling to undergo extraction. (Salvage of Infected Cardiovascular Implantable Electronic Devices [CIED] by Localized High-Dose Antibiotics; NCT01770067).
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Affiliation(s)
- Moris Topaz
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Emeritus Plastic Surgery Unit, Hillel Yaffe Medical Center, Hadera, Israel.
| | - Ehud Chorin
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Arie Lorin Schwartz
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Aviram Hochstadt
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Avraham Shotan
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel; Heart Institute, Laniado Medical Center, Netanya, Israel; Adelson School of Medicine, Ariel University, Samaria, Israel
| | | | - Mark Kazatsker
- Heart Institute, Hillel Yaffe Medical Center, Hadera, Israel
| | | | - Guy Topaz
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Department of Internal Medicine, Meir Medical Center, Kfar Saba, Israel
| | - Yoram Oron
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Gilad Margolis
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Eyal Nof
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heart Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Roy Beinart
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heart Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Michael Glikson
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heart Institute, Sheba Medical Center, Tel-Hashomer, Israel; Jesselson Integrated Heart Center, Shaare Zedek Medical Center and Hebrew University, Jerusalem, Israel
| | - Anna Mazo
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Anat Milman
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Heart Institute, Sheba Medical Center, Tel-Hashomer, Israel
| | - Michal Dekel
- Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel; Infectious Disease Unit, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel
| | - Shmuel Banai
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Raphael Rosso
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Sami Viskin
- Department of Cardiology, Sourasky Tel Aviv Medical Center, Tel Aviv, Israel; Sackler School of Medicine, Tel Aviv University, Tel Aviv, Israel.
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Bourget-Murray J, Azad M, Gofton W, Abdelbary H, Garceau S, Grammatopoulos G. Is the routine use of local antibiotics in the management of periprosthetic joint infections justified? Hip Int 2023; 33:4-16. [PMID: 36447342 DOI: 10.1177/11207000221139467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Periprosthetic joint infection (PJI) following total hip and total knee arthroplasty continues to be a leading cause of re-operation and revision arthroplasty. Not only is the treatment of PJI notoriously challenging, but success rates are variable. Regardless of the surgical strategy used, successful management of PJI requires a comprehensive surgical debridement focused at eradicating the underlying biofilm followed by appropriate antimicrobial therapy. Although systemic antimicrobial delivery continues to be a cornerstone in the treatment of PJI, many surgeons have started using local antibiotics to deliver higher concentrations of antibiotics directly into the vulnerable joint and adjacent soft tissues, which often have compromised vascularity. Available evidence on the use of topical powder, bone cement, and calcium sulphate carriers for local delivery of antibiotics during the initial treatment of PJI is limited to studies that are extremely heterogeneous. There is currently no level-1 evidence to support routinely using these products. Further, appropriately powered, prospective studies are needed to quantify the safety and efficacy of antibiotic-located calcium-sulphate carriers to justify their added costs. These products should not encourage surgeons to deviate from best practice guidelines, such as those recommended during the International Consensus Meeting on Musculoskeletal Infections.
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Affiliation(s)
| | - Marisa Azad
- Division of Infectious Diseases, Department of Medicine, Mayo Clinic, Rochester, MN, USA
| | - Wade Gofton
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Hesham Abdelbary
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
| | - Simon Garceau
- Division of Orthopaedic Surgery, The Ottawa Hospital, Ottawa, Ontario, Canada
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12
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Alowais SA, Wali HA, Tabb D, Alamer A, Ahmed N, Baloch SA, Floyd JCP. Assessing tobramycin levels and renal function following the implantation of CaSO4 beads impregnated with tobramycin: A prospective cohort study. Medicine (Baltimore) 2022; 101:e32276. [PMID: 36626517 PMCID: PMC9750579 DOI: 10.1097/md.0000000000032276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
This study aimed to evaluate the risk of serum tobramycin concentrations exceeding therapeutic levels after administration of calcium sulfate (CaSO4) beads containing either 240 mg or 400 mg tobramycin and 1000 mg vancomycin. This single-center, prospective. This single-center, prospective study included included Piedmont Columbus, Regional orthopedic surgery patients. Following the implantation of tobramycin into CaSO4 beads, serially measured serum tobramycin concentrations were evaluated after 6, 12, 24, and 48 hours. In addition to that, serum tobramycin concentration was evaluated after 5 days. None of the patients who received 240 mg tobramycin-impregnated beads had a tobramycin level >2 μg/mL. Six hours after implantation, the tobramycin level in 2 out of 2 (100%) patients who received 400 mg of tobramycin-impregnated beads was >2 μg/mL. One day following the surgery, the median serum creatinine was 0.85 mg/dL, with an interquartile range of 0.73 to 1.04 mg/dL. No cases of acute kidney injury were observed. This cohort demonstrated that non-nephrotoxic serum tobramycin levels could be achieved in CaSO4 beads mixed with 240 mg or 400 mg of tobramycin.
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Affiliation(s)
- Shuroug A. Alowais
- Department of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdulaziz Medical City, National Guard Health Affairs, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
- Piedmont Columbus Regional Midtown, Columbus, GA
- * Correspondence: Shuroug A. Alowais, Assistant Professor of Pharmacy Practice, College of Pharmacy, King Saud bin Abdulaziz University for Health Sciences, Riyadh 14611, Saudi ArabiaClinical Pharmacy Specialist, Infectious Diseases, King Abdulaziz Medical City, National Guard Health Affairs, Riyadh 14611, Saudi Arabia (e-mail: )
| | - Haytham A. Wali
- Piedmont Columbus Regional Midtown, Columbus, GA
- Department of Pharmacy Practice, College of Clinical Pharmacy, King Faisal University, Al-Ahsa, Saudi Arabia
| | - Deanne Tabb
- Piedmont Columbus Regional Midtown, Columbus, GA
| | - Ahmad Alamer
- Department of Pharmacy Practice, College of Pharmacy, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Nehad Ahmed
- Department of Pharmacy Practice, College of Pharmacy, Prince Sattam bin Abdulaziz University, Alkharj, Saudi Arabia
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13
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Aguilera-Correa JJ, Gisbert-Garzarán M, Mediero A, Fernández-Aceñero MJ, de-Pablo-Velasco D, Lozano D, Esteban J, Vallet-Regí M. Antibiotic delivery from bone-targeted mesoporous silica nanoparticles for the treatment of osteomyelitis caused by methicillin-resistant Staphylococcus aureus. Acta Biomater 2022; 154:608-625. [PMID: 36341887 DOI: 10.1016/j.actbio.2022.10.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 10/13/2022] [Accepted: 10/19/2022] [Indexed: 12/14/2022]
Abstract
Osteomyelitis is a hard-to-treat infection of the bone and bone marrow that is mainly caused by Staphylococcus aureus, with an increasing incidence of methicillin-resistant S. aureus (MRSA). Owing to the aggressiveness of these bacteria in colonizing and destroying the bone, systemic antibiotic treatments fail to eradicate the infection. Instead, it normally entails surgery to remove the dead or infected bone. In this work, we report bone-targeted mesoporous silica nanoparticles for the treatment of osteomyelitis. The nanoparticles have been engineered with a functional gelatine/colistin coating able to hamper premature release from the mesopores while effectively disaggregating the bacterial biofilm. Because antibiotic resistance is a global emergency, we have designed two sets of identical nanoparticles, carrying each of them a clinically relevant antibiotic, that have demonstrated to have synergistic effect. The bone-targeted nanoparticles have been thoroughly evaluated in vitro and in vivo, obtaining a notable reduction of the amount of bacteria in the bone in just 24 h after only one dose, and paving the way for localized, nanoparticle-mediated treatment of MRSA-caused osteomyelitis. STATEMENT OF SIGNIFICANCE: In this work, we propose the use of bone-targeted mesoporous silica nanoparticles to address S. aureus-caused osteomyelitis that render synergistic therapeutic effect via multidrug delivery. Because the bacterial biofilm is responsible for an aggressive surgical approach and prolonged antibiotic treatment, the nanoparticles have been functionalized with a functional coating able to both disaggregate the biofilm, hamper premature antibiotic release and protect the intact bone. These engineered nanoparticles are able to effectively target bone tissue both in vitro and in vivo, showing high biocompatibility and elevated antibacterial effect.
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Affiliation(s)
- J J Aguilera-Correa
- Departamento de Química en Ciencias Farmacéuticas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; CIBER de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain
| | - M Gisbert-Garzarán
- Departamento de Química en Ciencias Farmacéuticas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
| | - A Mediero
- Bone and Joint Unit, IIS- Fundación Jimenez Diaz, UAM, Avenida Reyes Católicos, 2 28037 Madrid, Spain
| | | | | | - D Lozano
- Departamento de Química en Ciencias Farmacéuticas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain
| | - J Esteban
- CIBER de Enfermedades Infecciosas (CIBERINFEC), 28029 Madrid, Spain; Clinical Microbiology Department, IIS-Fundación Jiménez Diaz, UAM, Avenida Reyes Católicos, 2 28037 Madrid, Spain.
| | - M Vallet-Regí
- Departamento de Química en Ciencias Farmacéuticas, Universidad Complutense de Madrid, Instituto de Investigación Sanitaria Hospital 12 de Octubre i+12, Plaza Ramón y Cajal s/n, 28040 Madrid, Spain; CIBER de Bioingeniería, Biomateriales y Nanomedicina (CIBER-BBN), 28029 Madrid, Spain.
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14
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de Lachica JCV, Reyes SSS, Ureña JAP, Fragoso MAR. Decrease in acute periprosthetic joint infections incidence with vancomycin-loaded calcium sulfate beads in patients with non-modifiable risk factors. A randomized clinical trial. J ISAKOS 2022; 7:201-205. [PMID: 35973626 DOI: 10.1016/j.jisako.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/28/2022] [Accepted: 08/03/2022] [Indexed: 12/24/2022]
Abstract
OBJECTIVES The influence of local antibiotic therapy in orthopedic surgery remains unclear. In this trial, we evaluated the incidence of periprosthetic joint infections (PJI), after local or intravenous (IV) antibiotic prophylaxis. The aim of this intervention was to compare the PJI incidence in a population with non-modifiable risk factors after local prophylaxis with vancomycin-loaded calcium sulfate beads versus a control group. METHODS A total of 83 subjects were evaluated, inclusion criteria included participants over 60 years of age, with at least one main risk factor for PJI who underwent total hip or knee joint replacement between June 2019 and May 2020. Cases were randomized, and the intervention group received local prophylactic antibiotic therapy with calcium sulfate beads impregnated with vancomycin; conventional IV prophylactic antibiotic therapy was administered for the control group. C-reactive protein (CRP) and erythrocyte sedimentation rate (ERS) serum biomarkers were analyzed on the day 5 and weeks 4, 8, and 12. When needed, the synovial fluid sample was obtained and cultured for the early acute PJI diagnosis. RESULTS Acute PJI was found in 27 patients (67.5%) in the control group and 4 (9.3%) in the intervention group. The variable analysis identified that local prophylaxis with calcium sulfate beads reduces the incidence of acute knee or hip PJI in patients with non-modifiable risk factors compared to conventional prophylaxis (p < 0.0001) with a relative risk of 0.13 (CI:0.05-0.35). Length of hospital stay was also shorter in the intervention group at 4.6 days, compared to 15.25 days in the control group; p < 0.001. CONCLUSIONS Local antibiotic prophylaxis in patients with non-modifiable risk factors undergoing hip or knee replacement reduces the incidence of acute PJI compared to IV antibiotics. CLINICAL TRIALS NCT03976466 (clnicaltrials.gov) LEVEL OF EVIDENCE: II.
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Affiliation(s)
- Julio C Velez de Lachica
- Institute of Social Security of Mexican State and Districts (ISSEMyM), Avenida paseo del ferrocarril numero 88, Los reyes Ixtacala, 54055, Mexico.
| | - Silvia S Serrano Reyes
- Institute of Social Security of Mexican State and Districts (ISSEMyM), Avenida paseo del ferrocarril numero 88, Los reyes Ixtacala, 54055, Mexico.
| | - Juan A Pages Ureña
- Institute of Social Security of Mexican State and Districts (ISSEMyM), Avenida paseo del ferrocarril numero 88, Los reyes Ixtacala, 54055, Mexico.
| | - Miguel A Ruiz Fragoso
- Institute of Social Security of Mexican State and Districts (ISSEMyM), Avenida paseo del ferrocarril numero 88, Los reyes Ixtacala, 54055, Mexico.
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15
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Sebastian S, Tandberg F, Liu Y, Raina DB, Tägil M, Collin M, Lidgren L. Extended local release and improved bacterial eradication by adding rifampicin to a biphasic ceramic carrier containing gentamicin or vancomycin. Bone Joint Res 2022; 11:787-802. [DOI: 10.1302/2046-3758.1111.bjr-2022-0101.r1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
Aims There is a lack of biomaterial-based carriers for the local delivery of rifampicin (RIF), one of the cornerstone second defence antibiotics for bone infections. RIF is also known for causing rapid development of antibiotic resistance when given as monotherapy. This in vitro study evaluated a clinically used biphasic calcium sulphate/hydroxyapatite (CaS/HA) biomaterial as a carrier for dual delivery of RIF with vancomycin (VAN) or gentamicin (GEN). Methods The CaS/HA composites containing RIF/GEN/VAN, either alone or in combination, were first prepared and their injectability, setting time, and antibiotic elution profiles were assessed. Using a continuous disk diffusion assay, the antibacterial behaviour of the material was tested on both planktonic and biofilm-embedded forms of standard and clinical strains of Staphylococcus aureus for 28 days. Development of bacterial resistance to RIF was determined by exposing the biofilm-embedded bacteria continuously to released fractions of antibiotics from CaS/HA-antibiotic composites. Results Following the addition of RIF to CaS/HA-VAN/GEN, adequate injectability and setting of the CaS/HA composites were noted. Sustained release of RIF above the minimum inhibitory concentrations of S. aureus was observed until study endpoint (day 35). Only combinations of CaS/HA-VAN/GEN + RIF exhibited antibacterial and antibiofilm effects yielding no viable bacteria at study endpoint. The S. aureus strains developed resistance to RIF when biofilms were subjected to CaS/HA-RIF alone but not with CaS/HA-VAN/GEN + RIF. Conclusion Our in vitro results indicate that biphasic CaS/HA loaded with VAN or GEN could be used as a carrier for RIF for local delivery in clinically demanding bone infections. Cite this article: Bone Joint Res 2022;11(11):787–802.
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Affiliation(s)
- Sujeesh Sebastian
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Felix Tandberg
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Yang Liu
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Deepak B. Raina
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Magnus Tägil
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
| | - Mattias Collin
- Division of Infection Medicine, Department of Clinical Sciences, Lund University Faculty of Medicine, Lund, Sweden
| | - Lars Lidgren
- Department of Clinical Sciences, Orthopedics, Lund University Faculty of Medicine, Lund, Sweden
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16
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Fletcher J, Porter R, Boulton Z, Brown L, Knight B, Romanczuk L, Aiken S, Delury C, Michell S. In vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure) against polymicrobial communities and individual bacterial strains derived from diabetic foot infections. J Med Microbiol 2022; 71. [PMID: 35604937 DOI: 10.1099/jmm.0.001517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Introduction. Diabetic foot infection (DFI) is the main reason for diabetes-related hospitalisation and is a major cause of diabetes-related amputation. DFIs are often complicated by ischaemia in the affected limb, the presence of polymicrobial biofilms and increasingly the occurrence of antibiotic resistant bacteria.Hypothesis/Gap statement. Antibiotic loaded beads could inhibit the growth of polymicrobial DFI communities with differing compositions in vitro.Aim. This study investigates the in vitro efficacy of antibiotic loaded calcium sulfate beads (Stimulan Rapid Cure, Biocomposites Ltd., UK) against polymicrobial DFI communities and individual bacterial strains derived from DFIs.Methodology. Debrided tissue obtained from the base of infected diabetic foot ulcers was homogenised and spread over the surface of Columbia blood agar (CBA) and fastidious anaerobe agar (FAA) plates. Calcium sulfate beads containing a combination of vancomycin and gentamicin were then placed on the surface of the agar and following incubation, zones of inhibition (ZOI) were measured. For individual bacterial strains isolated from the infected tissue, calcium sulfate beads containing vancomycin, gentamicin, flucloxacillin or rifampicin and beads containing a combination of vancomycin and gentamicin or flucloxacillin and rifampicin were tested for their ability to inhibit growth.Results. Calcium sulfate beads loaded with a combination of vancomycin and gentamicin were able to inhibit bacterial growth from all polymicrobial tissue homogenates tested, with ZOI diameters ranging from 15 to 40 mm. In the case of individual bacterial strains, beads containing combinations of vancomycin and gentamicin or flucloxacillin and rifampicin were able to produce ZOI with Gram-positive facultatitive anaerobic strains such as Staphylococcus aureus and Enterococcus faecalis, Gram-negative facultative anaerobic strains such as Pseudomonas aeruginosa and obligate anaerobic strains such as Finegoldia magna even where acquired resistance to one of the antibiotics in the combination was evidenced.Conclusion. The local use of calcium sulfate beads containing a combination of two antibiotics demonstrated high efficacy against polymicrobial DFI communities and individual DFI bacterial strains in in vitro zone of inhibition tests. These results show promise for clinical application, but further research and clinical studies are required.
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Affiliation(s)
- Julie Fletcher
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
| | - Rob Porter
- Microbiology Department, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Zoe Boulton
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Laura Brown
- Macleod Diabetes and Endocrine Centre, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Bridget Knight
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Lidia Romanczuk
- National Institute for Health Research Exeter Clinical Research Facility, Royal Devon and Exeter NHS Foundation Trust, Barrack Road, Exeter, EX2 5DW, UK
| | - Sean Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire, ST5 5NL, UK
| | - Stephen Michell
- Biosciences, University of Exeter, Stocker Road, Exeter, EX4 4QD, UK
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17
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McPherson E, Jennings J, Yunis O, Harris M, Dipane M, Curtin N, Chowdhry M, Wassef A, Bumgardner J, Noel S. Simulated large joint fluid model for evaluating intra-articular antibiotic delivery systems: initial evaluation using antibiotic-loaded calcium sulfate beads. J Bone Jt Infect 2022; 7:117-125. [PMID: 35620590 PMCID: PMC9128367 DOI: 10.5194/jbji-7-117-2022] [Citation(s) in RCA: 2] [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: 10/08/2021] [Accepted: 05/05/2022] [Indexed: 11/25/2022] Open
Abstract
Introduction: Local antimicrobial delivery via calcium sulfate
(CaSO4) beads is used as an adjunctive treatment for periprosthetic
joint infection. There is limited clinical information describing the
performance of antimicrobial-loaded CaSO4 (ALCS) in large-scale applications. We developed a simulated large joint model to study properties
of eluting ALCS. Methods: The in vitro testing platform was an adapted
standardized model for tribological testing of prosthetic total hips and
total knees (ASTM F732). The model was 70 mL total fluid volume, 25 % bovine serum, and 75 % phosphate-buffered saline, using ISO standard 14242-1 for human synovial fluid simulation. Four brands of CaSO4 were
evaluated. Each 10 mL of CaSO4 was loaded with 1.2 grams (g) of tobramycin and 1 g of vancomycin powders. A 35 mL bead volume, equaling 175 beads, of each product was placed in incubated flasks. The test period was 6 weeks with scheduled interval fluid exchanges. Fluid samples were tested
for antibiotic and calcium concentrations and pH. Results: Antibiotic elution showed an initial burst on Day 1, followed by a logarithmic
reduction over 1 week. Tobramycin fully eluted within 2.5 weeks. Vancomycin showed sustained release over 6 weeks. Calcium ion concentrations were high, with gradual decrease after 3 weeks. All four CaSO4 products
were inherently acidic. Fluid became more acidic with the addition of
antibiotics primarily driven by vancomycin. Discussion: Clinicians should be
cognizant of tobramycin elution burst with ALCS in large loads. The main
driver of acidic pH levels was vancomycin. We propose that joint
complications may result from lowered fluid acidity, and we suggest clinical study of synovial pH.
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Affiliation(s)
- Edward J. McPherson
- Department of Orthopaedic Surgery, David Geffen School of Medicine at
UCLA, Santa Monica, 90404, USA
| | - Jessica A. Jennings
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
| | - Omar Yunis
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
| | - Michael A. Harris
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
| | - Matthew V. Dipane
- Department of Orthopaedic Surgery, David Geffen School of Medicine at
UCLA, Santa Monica, 90404, USA
| | - Nora L. Curtin
- Department of Orthopaedic Surgery, David Geffen School of Medicine at
UCLA, Santa Monica, 90404, USA
| | - Madhav Chowdhry
- Nuffield Department of Primary Care Health Sciences, Kellogg College,
University of Oxford, Oxford, OX1 2JD, UK
| | - Andrew J. Wassef
- Long Beach Lakewood Orthopedic Institute, Long Beach, 90808, USA
| | - Joel D. Bumgardner
- Department of Biomedical Engineering, University of Memphis, Memphis,
38152, USA
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18
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Levack AE, Turajane K, Driscoll DA, Yang X, Miller AO, Bostrom MP, Wellman DS, Carli AV. Identifying alternative antibiotics that elute from calcium sulfate beads for treatment of orthopedic infections. J Orthop Res 2022; 40:1143-1153. [PMID: 34191350 PMCID: PMC8716667 DOI: 10.1002/jor.25135] [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: 01/25/2021] [Revised: 05/17/2021] [Accepted: 06/25/2021] [Indexed: 02/04/2023]
Abstract
There has been increasing interest in the use of a synthetic absorbable calcium sulfate (CaSO4 ) for local antibiotic delivery in orthopaedic infections. The purpose of this study was to quantify elution kinetics of six antibiotics (amikacin, meropenem, fosfomycin, minocycline, cefazolin, and dalbavancin) from a clinically relevant CaSO4 bead model and compare elution and antimicrobial activity to the current clinical gold standards: vancomycin and tobramycin. Antibiotic-loaded synthetic CaSO4 beads were immersed in phosphate buffered saline and incubated at 37°C. Eluent was harvested at eight time points over 28 days. Antibiotic concentrations were measured by high performance liquid chromatography to quantify elution rates. CaSO4 beads demonstrated burst release kinetics. Dalbavancin, cefazolin, and minocycline all demonstrated similar elution profiles to vancomycin. Amikacin and meropenem demonstrated favorable elution profiles and durations of above-minimum inhibitory concentration when compared to tobramycin. Clinical Significance: This study provides important novel data regarding the utility of amikacin, meropenem and dalbavancin as alternative choices to place in CaSO4 carriers when treating orthopaedic infections.
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Affiliation(s)
- Ashley E. Levack
- Orthopaedic Trauma Service, Hospital for Special Surgery; New York, NY, USA,Loyola University Medical Center, Maywood, IL, USA
| | - Kathleen Turajane
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA
| | - Daniel A. Driscoll
- Orthopaedic Trauma Service, Hospital for Special Surgery; New York, NY, USA
| | - Xu Yang
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA
| | - Andy O. Miller
- Infectious Diseases, Hospital for Special Surgery; New York, NY, USA
| | - Mathias P. Bostrom
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA,Adult Reconstruction, Hospital for Special Surgery; New York, NY, USA
| | - David S. Wellman
- Orthopaedic Trauma Service, Hospital for Special Surgery; New York, NY, USA,Westchester Medical Center, Valhalla NY, USA
| | - Alberto V. Carli
- Musculoskeletal Integrity Program, Hospital for Special Surgery; New York, NY, USA,Adult Reconstruction, Hospital for Special Surgery; New York, NY, USA
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19
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Tarity TD, Xiang W, Jones CW, Gkiatas I, Nocon A, Selemon NA, Carli A, Sculco PK. Do Antibiotic-Loaded Calcium Sulfate Beads Improve Outcomes After Debridement, Antibiotics, and Implant Retention? A Matched Cohort Study. Arthroplast Today 2022; 14:90-95. [PMID: 35252512 PMCID: PMC8891996 DOI: 10.1016/j.artd.2022.01.023] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 01/13/2022] [Indexed: 12/23/2022] Open
Abstract
Background Dissolvable antibiotic-loaded calcium sulfate beads are used as an intraoperative adjunct during debridement with antibiotics and implant retention (DAIR) for periprosthetic joint infections (PJI) to reduce the historically higher failure rates than one- or two-stage exchange. This study evaluated clinical outcomes after DAIRs performed with and without these antibiotic beads. The primary outcome was post-DAIR failure secondary to recurrent PJI at 2 years. The secondary outcome was early failure secondary to recurrent PJI within 90 days. Material and methods DAIRs performed for acute or acute hematogenous PJI at a single institution were retrospectively identified between 2013 and 2018. All DAIRs with adjunctive antibiotic beads (cases) were then exactly matched to a cohort of DAIRs without beads (controls) based on Charlson Comorbidity Index. The McNemar’s test and Wilcoxon signed-rank test were used to evaluate differences in outcomes and patient characteristics. Results Twenty DAIR cases (with antibiotic beads) were matched with 20 DAIR controls. There was no difference in age, sex, body mass index, joint, erythrocyte sedimentation rate, C-reactive protein, microbiology profile, antibiotic-resistance profile, or intraoperative lavage adjuncts between groups. There were no statistically significant differences between cases and controls for either overall infection-related failure at 2 years (P = .21) or early infection-related failure at 90 days (P = 1.00). Conclusion Adjunctive dissolvable antibiotic-loaded calcium sulfate beads did not reduce the incidence of recurrent PJIs at 2 years or 90 days postoperatively after DAIR. Given the added cost of these antibiotic dissolvable beads without clinical benefits, we cannot recommend their use as an adjunct treatment during DAIRs.
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Affiliation(s)
- T David Tarity
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - William Xiang
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Christopher W Jones
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Ioannis Gkiatas
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Allina Nocon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Nicolas A Selemon
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA
| | - Alberto Carli
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA.,Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
| | - Peter K Sculco
- Stavros Niarchos Foundation Complex Joint Reconstruction Center, Hospital for Special Surgery, New York, NY, USA.,Adult Reconstruction and Joint Replacement, Hospital for Special Surgery, New York, NY, USA
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20
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Dalbert A, Bächinger D, Soyka M, Röösli C, Inci I, Schuurmans MM, Achermann Y, Huber A. Calcium sulfate matrix as local antibiotic carrier in the mastoid. Clin Case Rep 2022; 10:e05516. [PMID: 35310312 PMCID: PMC8908096 DOI: 10.1002/ccr3.5516] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 02/07/2022] [Accepted: 02/16/2022] [Indexed: 11/30/2022] Open
Abstract
We describe the use of calcium sulfate beads as antibiotic carrier in a patient, who suffered from chronic mastoiditis with consecutive otogenic meningitis due to Burkholderia cenocepacia. Our findings suggest a possible role of calcium sulfate matrix as a local antibiotic carrier in the mastoid in complicated mastoiditis cases.
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Affiliation(s)
- Adrian Dalbert
- Department of Otorhinolaryngology, Head & Neck Surgery University Hospital ZurichUniversity of Zurich Zurich Switzerland
| | - David Bächinger
- Department of Otorhinolaryngology, Head & Neck Surgery University Hospital ZurichUniversity of Zurich Zurich Switzerland
| | - Michael Soyka
- Department of Otorhinolaryngology, Head & Neck Surgery University Hospital ZurichUniversity of Zurich Zurich Switzerland
| | - Christof Röösli
- Department of Otorhinolaryngology, Head & Neck Surgery University Hospital ZurichUniversity of Zurich Zurich Switzerland
| | - Ilhan Inci
- Department of Thoracic Surgery University Hospital ZurichUniversity of Zurich Zurich Switzerland
| | - Macé M. Schuurmans
- Department of Pulmonology University Hospital ZurichUniversity of Zurich Zurich Switzerland
| | - Yvonne Achermann
- Department of Infectious Diseases University Hospital Zurich and Internal MedicineSpital Zollikerberg Zollikerberg Switzerland
| | - Alexander Huber
- Department of Otorhinolaryngology, Head & Neck Surgery University Hospital ZurichUniversity of Zurich Zurich Switzerland
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21
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Xu L, Song H, Ren Y, Fang J, Zhou C, Zhang H, Meng X, Cheng G, Zhuo R, Qin C. Antibiotic-Impregnated Calcium Sulfate vs. Wound Irrigation-Suction to Treat Chronic Calcaneal Osteomyelitis. Foot Ankle Int 2022; 43:331-342. [PMID: 34719970 DOI: 10.1177/10711007211049768] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Chronic osteomyelitis of calcaneus is not rare but is very hard to treat. Irrigation-suction and antibiotic-impregnated calcium sulfate following debridement are commonly used in managing chronic osteomyelitis, but their effects have rarely been compared. We aimed to compare the effectiveness of antibiotic-impregnated calcium sulfate with irrigation-suction in the treatment of patients with chronic calcaneal osteomyelitis. METHODS From January 2011 to June 2018, adult patients at our institute with chronic osteomyelitis receiving treatment of either antibiotic-impregnated calcium sulfate (CS group) or irrigation-suction (IS group) following thorough debridement were screened and selected according to the inclusion and exclusion criteria. The clinical presentation, laboratory tests, complications, and the ultimate single-staged cure rate and recurrence were compared. RESULTS A total of 61 patients, including 41 in the CS group and 20 in the IS group, were included in our study. Of the patients, 85.4% in the CS group and 60.0% in the IS group (P = .006) were successfully cured in the single stage, respectively, without infection recurrence. Lower infection recurrence rates with shorter hospital stay were found in the CS group than the IS group. Inflammatory biomarkers after surgery with both treatments were slightly decreased and not significantly different from preoperative or between-groups postoperative. Exudate from incision was found primarily in the CS group. CONCLUSION This study demonstrates that both antibiotic-impregnated calcium sulfate and irrigation-suction after careful and thorough surgical debridement are generally effective in treating chronic calcaneal osteomyelitis. Antibiotic-impregnated calcium sulfate achieved a higher single-staged cure rate but was associated with an increased postoperative wound exudate. LEVEL OF EVIDENCE Level III, retrospective cohort study.
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Affiliation(s)
- Lei Xu
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China
| | - Huijuan Song
- Department of Nursing, Southern Medical University Nanfang Hospital, No.1838, Guangzhou Ave. North, Baiyun District, Guangzhou, China
| | - Ying Ren
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China.,Department of Nursing, Southern Medical University Nanfang Hospital, No.1838, Guangzhou Ave. North, Baiyun District, Guangzhou, China
| | - Jia Fang
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China
| | - Chunhao Zhou
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China
| | - Hongan Zhang
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China
| | - Xiangqing Meng
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China
| | - Guoyun Cheng
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China
| | - Ribo Zhuo
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China
| | - Chenghe Qin
- Department of Orthopedics and Traumatology, Guangdong Second Provincial General Hospital, the Second Clinical Medical School of Southern Medical University, 466 Xingang Road C., Haizhu District, Guangzhou, 510317, China.,Department of Orthopedics and Traumatology, Southern Medical University Nanfang Hospital, No.1838, Guangzhou Ave. North, Baiyun District, Guangzhou, China
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22
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Role of Implantable Drug Delivery Devices with Dual Platform Capabilities in the Prevention and Treatment of Bacterial Osteomyelitis. Bioengineering (Basel) 2022; 9:bioengineering9020065. [PMID: 35200418 PMCID: PMC8869141 DOI: 10.3390/bioengineering9020065] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/01/2022] [Accepted: 02/03/2022] [Indexed: 11/26/2022] Open
Abstract
As medicine advances and physicians are able to provide patients with innovative solutions, including placement of temporary or permanent medical devices that drastically improve quality of life of the patient, there is the persistent, recurring problem of chronic bacterial infection, including osteomyelitis. Osteomyelitis can manifest as a result of traumatic or contaminated wounds or implant-associated infections. This bacterial infection can persist as a result of inadequate treatment regimens or the presence of biofilm on implanted medical devices. One strategy to mitigate these concerns is the use of implantable medical devices that simultaneously act as local drug delivery devices (DDDs). This classification of device has the potential to prevent or aid in clearing chronic bacterial infection by delivering effective doses of antibiotics to the area of interest and can be engineered to simultaneously aid in tissue regeneration. This review will provide a background on bacterial infection and current therapies as well as current and prospective implantable DDDs, with a particular emphasis on local DDDs to combat bacterial osteomyelitis.
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23
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Shademani A, Jackson JK, Thompson CJ, Chiao M. Controlled and localized antibiotics delivery using magnetic-responsive beads for synergistic treatment of orthopedic infection. J Biomed Mater Res A 2022; 110:1036-1051. [PMID: 34997805 DOI: 10.1002/jbm.a.37350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2021] [Revised: 12/06/2021] [Accepted: 12/09/2021] [Indexed: 11/07/2022]
Abstract
Antibiotic-loaded bone cement beads have been a reliable passive delivery system for the localized treatment of osteomyelitis; however, low, and unregulated drug release rates limit the ability of this system to maintain therapeutic concentrations. This problem is further amplified by drug-resistant pathogens that might invade or evolve under these conditions. Furthermore, currently available bone cements are incompatible with some antibiotics. The proposed device resembles conventional bone cement beads but contains an on-demand drug delivery magnetic sponge that provides actively controlled release of antibiotics. The slightly porous structure facilitates some drug diffusion while further drug release may be controlled remotely via magnetic actuation. Additionally, a combination of silver nitrate and gentamicin are used in the device as these agents are shown to display a synergistic antibacterial activity in vitro using checkerboard and time-kill assays. The device releases gentamicin and silver in both actuation and diffusion modes over 7 days. The in vitro bacterial studies demonstrate the efficacy of the released agents alone, and synergistically in combination, against Methicillin-resistant Staphylococcus aureus and Escherichia coli. The proposed device offers a facile fabrication process which allows control of the release profile by engineering hole configurations or manipulating magnetic field strength to provide the most effective therapy.
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Affiliation(s)
- Ali Shademani
- School of Biomedical Engineering, University of British Columbia, Vancouver, British Columbia, Canada
| | - John K Jackson
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Charles J Thompson
- Department of Microbiology and Immunology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mu Chiao
- Department of Mechanical Engineering, University of British Columbia, Vancouver, British Columbia, Canada
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24
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Aguilera-Correa J, Gisbert-Garzarán M, Mediero A, Carias-Cálix R, Jiménez-Jiménez C, Esteban J, Vallet-Regí M. Arabic gum plus colistin coated moxifloxacin-loaded nanoparticles for the treatment of bone infection caused by Escherichia coli. Acta Biomater 2022; 137:218-237. [PMID: 34653694 DOI: 10.1016/j.actbio.2021.10.014] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Revised: 09/20/2021] [Accepted: 10/07/2021] [Indexed: 12/16/2022]
Abstract
Osteomyelitis is an inflammatory process of bone and bone marrow that may even lead to patient death. Even though this disease is mainly caused by Gram-positive organisms, the proportion of bone infections caused by Gram-negative bacteria, such as Escherichia coli, has significantly increased in recent years. In this work, mesoporous silica nanoparticles have been employed as platform to engineer a nanomedicine able to eradicate E. coli- related bone infections. For that purpose, the nanoparticles have been loaded with moxifloxacin and further functionalized with Arabic gum and colistin (AG+CO-coated MX-loaded MSNs). The nanosystem demonstrated high affinity toward E. coli biofilm matrix, thanks to AG coating, and marked antibacterial effect because of the bactericidal effect of moxifloxacin and the disaggregating effect of colistin. AG+CO-coated MX-loaded MSNs were able to eradicate the infection developed on a trabecular bone in vitro and showed pronounced antibacterial efficacy in vivo against an osteomyelitis provoked by E. coli. Furthermore, AG+CO-coated MX-loaded MSNs were shown to be essentially non-cytotoxic with only slight effect on cell proliferation and mild hepatotoxicity, which might be attributed to the nature of both antibiotics. In view of these results, these nanoparticles may be considered as a promising treatment for bone infections caused by enterobacteria, such as E. coli, and introduce a general strategy against bone infections based on the implementation of antibiotics with different but complementary activity into a single nanocarrier. STATEMENT OF SIGNIFICANCE: In this work, we propose a methodology to address E.coli bone infections by using moxifloxacin-loaded mesoporous silica nanoparticles coated with Arabic gum containing colistin (AG+CO-coated MX-loaded MSNs). The in vitro evaluation of this nanosystem demonstrated high affinity toward E. coli biofilm matrix thanks to the Arabic gum coating, a disaggregating and antibacterial effect of colistin, and a remarkable antibiofilm action because of the bactericidal ability of moxifloxacin and colistin. This anti-E. coli capacity of AG+CO-coated MX-loaded MSNs was brought out in an in vivo rabbit model of osteomyelitis where the nanosystem was able to eradicate more than 90% of the bacterial load within the infected bone.
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25
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Gelatin Methacryloyl Hydrogels for the Localized Delivery of Cefazolin. Polymers (Basel) 2021; 13:polym13223960. [PMID: 34833259 PMCID: PMC8618379 DOI: 10.3390/polym13223960] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Revised: 11/08/2021] [Accepted: 11/12/2021] [Indexed: 12/13/2022] Open
Abstract
The tuneability of hydrogels renders them promising candidates for local drug delivery to prevent and treat local surgical site infection (SSI) while avoiding the systemic side-effects of intravenous antibiotic injections. Here, we present a newly developed gelatin methacryloyl (GelMA)-based hydrogel drug delivery system (GelMA-DDS) to locally deliver the broad-spectrum antibiotic cefazolin for SSI prophylaxis and treatment. Antibiotic doses from 3 µg to 90 µg were loaded in photocrosslinked GelMA hydrogel discs with 5 to 15% w/v polymer concentration and drug encapsulation efficiencies, mechanical properties, crosslinking and release kinetics, as well as bacterial growth inhibition were assessed. Our results demonstrate that all GelMA groups supported excellent drug encapsulation efficiencies of up to 99%. Mechanical properties of the GelMA-DDS were highly tuneable and unaffected by the loading of small to medium doses of cefazolin. The diffusive and the proteolytic in vitro drug delivery of all investigated cefazolin doses was characterized by a burst release, and the delivered cefazolin amount was directly proportional to the encapsulated dose. Accelerated enzymatic degradation of the GelMA-DDS followed zero-order kinetics and was dependent on both the cefazolin dose and GelMA concentration (3-13 h). Finally, we demonstrate that cefazolin delivered from GelMA induced a dose-dependent antibacterial efficacy against S. aureus, in both a broth and a diffusive assay. The cefazolin-loaded GelMA-DDS presented here provides a highly tuneable and easy-to-use local delivery system for the prophylaxis and treatment of SSI.
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26
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Antifungal loaded calcium sulfate beads as a potential therapeutic in combating Candida auris. Antimicrob Agents Chemother 2021; 66:e0171321. [PMID: 34694875 PMCID: PMC8765289 DOI: 10.1128/aac.01713-21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Candida auris provides a substantial global nosocomial threat clinically. With the recent emergence that the organism can readily colonize skin niches, it will likely continue to pose a risk in health care units, particularly to patients undergoing surgery. The purpose of this study was to investigate the efficacy of antifungal-loaded calcium sulfate (CS) beads in combatting C. auris infection. We demonstrate that the CS-packed beads have the potential to interfere with planktonic and sessile C. auris.
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27
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Huang Q, Ren C, Li M, Xu Y, Li Z, Lin H, Zhang K, Ma T. Antibiotic calcium sulfate-loaded hybrid transport versus traditional Ilizarov bone transport in the treatment of large tibial defects after trauma. J Orthop Surg Res 2021; 16:568. [PMID: 34544458 PMCID: PMC8454113 DOI: 10.1186/s13018-021-02723-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2021] [Accepted: 09/13/2021] [Indexed: 01/10/2023] Open
Abstract
Background The purpose of this study was to compare the clinical effects of antibiotic calcium sulfate-loaded hybrid transport (ACSLHT) and traditional Ilizarov bone transport (TIBT) in the treatment of large tibial defects after trauma. Methods Eighty-five patients with large tibial defects after trauma were selected for retrospective study. The range of tibial defects was 6–22 cm. After thorough debridement and infection controlled, bone transport technique was used to reconstruct tibial defects. Forty-four patients were treated with ACSLHT technique (the ACSLHT group), while the other 41 were treated with TIBT technique (the TIBT group). Time in external fixator was evaluated by EFI score. Enneking score was used to evaluate limb functions. SAS score was used to evaluate postoperative anxiety status. In addition, complication incidence was compared, including axis deviation, docking site nonunion, infection recurrence and so on. Results There was no significant difference in preoperative general data between ACSLHT and TIBT group. EFI score in ACSLHT and TIBT group was 0.6 ± 0.1 cm/month and 1.7 ± 0.3 cm/month, respectively (P < 0.05). Enneking score of ACSLHT and TIBT group was 86.5% and 75.1% (P < 0.05). SAS score of ACSLHT group was significantly lower than that of TIBT group (P < 0.05). Complication incidence in ACSLHT group was significantly lower than that in TIBT group (P < 0.05). Conclusions Compared with TIBT group, ACSLHT group had shorter time in external fixator, better limb functions, lower postoperative anxiety score and lower complication incidence which is worth of clinical promotion.
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Affiliation(s)
- Qiang Huang
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Cheng Ren
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Ming Li
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - YiBo Xu
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Zhong Li
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Hua Lin
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China
| | - Kun Zhang
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China.
| | - Teng Ma
- Department of Orthopaedic Surgery, Hong Hui Hospital, Xi'an Jiaotong University College of Medicine, Xi'an, 710054, Shaanxi, China.
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28
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Melicherčík P, Klapková E, Nyč O, Kotaška K, Neščáková M, Landor I, Jahoda D. Antimicrobial efficacy and activity perseverance in arthroplasty of calcium sulfate beads containing vancomycin prepared ahead of time and stored in ready-to-use formula. Folia Microbiol (Praha) 2021; 67:63-69. [PMID: 34505961 DOI: 10.1007/s12223-021-00916-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 08/20/2021] [Indexed: 10/20/2022]
Abstract
The use of local therapy with antibiotics in a suitable carrier is essential in the treatment and prevention of infections in orthopedic surgery and traumatology. In our orthopedic surgery department, a synthetic calcium sulfate hemihydrate (CaSO4·½H2O) is used as an antibiotic carrier, enabling the application of most types of intravenous antibiotics in the form of powder and liquid. This type of carrier with antibiotics is prepared in the theater during the procedure. During a surgical procedure, a small dead space is created (hand and foot area), which must be filled with an antibiotic carrier, and the situations arise where a large amount of the carrier is not used and thrown away. Therefore, we verified the efficacy of vancomycin in the pre-prepared carrier by an orientation microbiological method and by measuring the concentrations of the vancomycin released in active form and its two crystalline degradation products. Based on the agar diffusion test, we did not measure any difference in the effectiveness of the antibiotic in the carrier after its 12-day storage. Although vancomycin concentrations decreased by approximately 32% at the end of 12 days of storage, the concentrations of the released active form of vancomycin are many times higher than the minimum inhibitory concentrations for resistant strains of Staphylococcus aureus. Thus, the calcium sulfate carrier with vancomycin can be prepared several days in advance before its application, certainly up to 12 days.
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Affiliation(s)
- P Melicherčík
- Department of Orthopedics, First Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - E Klapková
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic.
| | - O Nyč
- Department of Medical Microbiology, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic
| | - K Kotaška
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic
| | - M Neščáková
- Department of Medical Chemistry and Clinical Biochemistry, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic.,Department of Internal Medicine, Second Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague, Czech Republic
| | - I Landor
- Department of Orthopedics, First Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
| | - D Jahoda
- Department of Orthopedics, First Faculty of Medicine, University Hospital Motol, Charles University, V Úvalu 84, 150 06, Prague 5, Czech Republic
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Assessing the Bioactive Profile of Antifungal-Loaded Calcium Sulfate against Fungal Biofilms. Antimicrob Agents Chemother 2021; 65:AAC.02551-20. [PMID: 33753336 PMCID: PMC8316021 DOI: 10.1128/aac.02551-20] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/14/2021] [Indexed: 11/20/2022] Open
Abstract
Calcium sulfate (CS) has been used clinically as a bone- or void-filling biomaterial, and its resorptive properties have provided the prospect for its use as a release mechanism for local antibiotics to control biofilms. Here, we aimed to test CS beads loaded with three antifungal drugs against planktonic and sessile fungal species to assess whether these antifungal beads could be harnessed to provide consistent release of antifungals at biofilm-inhibitory doses. A panel of different fungal species (n = 15) were selected for planktonic broth microdilution testing with fluconazole (FLZ), amphotericin B (AMB), and caspofungin (CSP). After establishing planktonic inhibition, antifungal CS beads were introduced to fungal biofilms (n = 5) to assess biofilm formation and cell viability through a combination of standard quantitative and qualitative biofilm assays. Inoculation of a hydrogel substrate, packed with antifungal CS beads, was also used to assess diffusion through a semidry material, to mimic active infection in vivo In general, antifungals released from loaded CS beads were all effective at inhibiting the pathogenic fungi over 7 days within standard MIC ranges for these fungi. We observed a significant reduction of pregrown fungal biofilms across key fungal pathogens following treatment, with visually observable changes in cell morphology and biofilm coverage provided by scanning electron microscopy. Assessment of biofilm inhibition also revealed reductions in total and viable cells across all organisms tested. These data show that antifungal-loaded CS beads produce a sustained antimicrobial effect that inhibits and kills clinically relevant fungal species in vitro as planktonic and biofilm cells.
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30
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Ene R, Nica M, Ene D, Cursaru A, Cirstoiu C. Review of calcium-sulphate-based ceramics and synthetic bone substitutes used for antibiotic delivery in PJI and osteomyelitis treatment. EFORT Open Rev 2021; 6:297-304. [PMID: 34150324 PMCID: PMC8183146 DOI: 10.1302/2058-5241.6.200083] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Infection in orthopaedic and trauma surgery remains a destructive complication with particularly challenging diagnosis and treatment due to bacterial antibiotic resistance and biofilm formation. Along with surgical debridement and systemic antibiotics, an important type of adjuvant therapy is local antibiotic delivery, with the purpose of eliminating bacterial colonization and biofilm development. Calcium sulphate, as a synthetic absorbable biomaterial used for local antibiotic delivery, has experienced an increasing popularity during the last decade, with multiple promoted advantages such as predictable antibiotic elution kinetics, complete and quick biodegradation, good biocompatibility, and limited associated complications. A series of commercially available antibiotic-delivery systems based on calcium sulphate are under investigation and in clinical use, with different presentations, compositions, and application techniques. The current article presents the main available calcium-sulphate-based products and the existing data about the clinical and preclinical research results, stemming from their implementation as local antibiotic carriers for surgical site and implant-associated infections treatment and prevention.
Cite this article: EFORT Open Rev 2021;6:297-304. DOI: 10.1302/2058-5241.6.200083
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Affiliation(s)
- Razvan Ene
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,Bucharest Emergency Clinical Hospital, Romania
| | - Mihai Nica
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,University Emergency Hospital Bucharest, Romania
| | - Dragos Ene
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,Bucharest Emergency Clinical Hospital, Romania
| | - Adrian Cursaru
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,University Emergency Hospital Bucharest, Romania
| | - Catalin Cirstoiu
- Carol Davila University of Medicine and Pharmacy, Orthopedics and Traumatology Department, Bucharest, Romania.,University Emergency Hospital Bucharest, Romania
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Xiong G, Fogel H, Tobert D, Cha T, Schwab J, Bono C, Hershman S. Vancomycin-impregnated calcium sulfate beads compared with vancomycin powder in adult spinal deformity patients undergoing thoracolumbar fusion. NORTH AMERICAN SPINE SOCIETY JOURNAL (NASSJ) 2021; 5:100048. [PMID: 35141614 PMCID: PMC8819864 DOI: 10.1016/j.xnsj.2020.100048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 12/16/2020] [Accepted: 12/23/2020] [Indexed: 10/26/2022]
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32
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Peterson LC, Kim SE, Lewis DD, Johnson MD, Ferrigno CRA. Calcium sulfate antibiotic-impregnated bead implantation for deep surgical site infection associated with orthopedic surgery in small animals. Vet Surg 2021; 50:748-757. [PMID: 33491800 DOI: 10.1111/vsu.13570] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 11/12/2020] [Accepted: 12/11/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To report the outcomes and complications associated with antibiotic-impregnated calcium sulfate beads for prevention and treatment of orthopedic-related surgical site infection (SSI) in companion animals. STUDY DESIGN Retrospective case series. ANIMALS Client-owned cats (n = 2) and dogs (n = 14). METHODS Medical records of 16 cases in which implantation of antibiotic-impregnated calcium sulfate beads was performed for the prevention or treatment of SSI were reviewed. Information collected included signalment, prior surgery, reason for bead placement, antibiotics used, bacterial culture results, and clinical outcomes. RESULTS Surgical site infection resolved in six of 10 animals treated therapeutically and did not occur in six of six animals treated prophylactically. Susceptibility of the causative bacteria to the antibiotic implanted was confirmed in five of six cases with resolved SSI treated therapeutically but in only one of four cases with unresolved SSI treated therapeutically. Complications directly related to bead placement were evident in only one case in which beads extruded from external skeletal fixator pin tracts 7 days after implantation. At final follow-up, 11 of 12 animals without SSI had satisfactory limb use and no clinical, cytologic, or radiographic evidence of infection. CONCLUSION Implantation was well tolerated. Resolution of SSI was inconsistent; however, when bacteria were susceptible to the antibiotic implanted, SSI resolved in all but one case. CLINICAL SIGNIFICANCE Antibiotic-impregnated calcium sulfate beads could be considered for prevention or treatment of orthopedic SSI in small animals. A prospective clinical study is required to obtain additional information, including the value of preoperative bacterial culture.
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Affiliation(s)
- Lindsay C Peterson
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Stanley E Kim
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Daniel D Lewis
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Matthew D Johnson
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Cassio R A Ferrigno
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
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Doub JB, Bork JT, Heil E, Stafford K, Banoub M, Karwowski JK, Toursavadkohi S. Effectiveness and Safety of Biodegradable Calcium Sulfate Antibiotic Beads as Adjuvant Therapy in Vascular Graft Infections. Open Forum Infect Dis 2021; 8:ofaa650. [PMID: 33553481 PMCID: PMC7849989 DOI: 10.1093/ofid/ofaa650] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/29/2020] [Indexed: 12/02/2022] Open
Abstract
This is a retrospective cohort study evaluating the safety and effectiveness of biodegradable calcium sulfate antibiotic beads in vascular graft infections compared with standard of care. No differences in acute kidney injury or hypercalcemia were observed between the cohorts. Recurrence of infection did not occur in the 13-patient bead cohort compared with 14 patients who had recurrence in the 45-patient nonbead cohort with a number needed to treat of 4.0.
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Affiliation(s)
- James B Doub
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Jacqueline T Bork
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Emily Heil
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - Kristen Stafford
- Division of Infectious Diseases, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mary Banoub
- Department of Pharmacy Practice and Science, University of Maryland School of Pharmacy, Baltimore, Maryland, USA
| | - John K Karwowski
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Shahab Toursavadkohi
- Division of Vascular Surgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Hasan R, Wohlers A, Shreffler J, Mulinti P, Ostlie H, Schaper C, Brooks B, Brooks A. An Antibiotic-Releasing Bone Void Filling (ABVF) Putty for the Treatment of Osteomyelitis. MATERIALS (BASEL, SWITZERLAND) 2020; 13:E5080. [PMID: 33187199 PMCID: PMC7698155 DOI: 10.3390/ma13225080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Revised: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 12/18/2022]
Abstract
The number of total joint replacements (TJR) is on the rise with a corresponding increase in the number of infected TJR, which necessitates revision surgeries. Current treatments with either non-biodegradable, antibiotic-releasing polymethylmethacrylate (PMMA) based bone cement, or systemic antibiotic after surgical debridement do not provide effective treatment due to fluctuating antibiotic levels at the site of infection. Here, we report a biodegradable, easy-to-use "press-fitting" antibiotic-releasing bone void filling (ABVF) putty that not only provides efficient antibiotic release kinetics at the site of infection but also allows efficient osseointegration. The ABVF formulation was prepared using poly (D,L-lactide-co-glycolide) (PLGA), polyethylene glycol (PEG), and polycaprolactone (PCL) as the polymer matrix, antibiotic vancomycin, and osseointegrating synthetic bone PRO OSTEON for bone-growth support. ABVF was homogenous, had a porous structure, was moldable, and showed putty-like mechanical properties. The ABVF putty released vancomycin for 6 weeks at therapeutic level. Furthermore, the released vancomycin showed in vitro antibacterial activity against Staphylococcus aureus for 6 weeks. Vancomycin was not toxic to osteoblasts. Finally, ABVF was biodegradable in vivo and showed an effective infection control with the treatment group showing significantly higher bone growth (p < 0.001) compared to the control group. The potential of infection treatment and osseointegration makes the ABVF putty a promising treatment option for osteomyelitis after TJR.
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Affiliation(s)
- Raquib Hasan
- Department of Pharmaceutical Sciences, North Dakota State University, Fargo, ND 58102, USA; (R.H.); (J.S.); (P.M.)
| | - Abbey Wohlers
- Department of Pharmacy, North Dakota State University, Fargo, ND 58102, USA;
| | - Jacob Shreffler
- Department of Pharmaceutical Sciences, North Dakota State University, Fargo, ND 58102, USA; (R.H.); (J.S.); (P.M.)
| | - Pranothi Mulinti
- Department of Pharmaceutical Sciences, North Dakota State University, Fargo, ND 58102, USA; (R.H.); (J.S.); (P.M.)
| | - Hunter Ostlie
- School of Medicine, St. George’s University, University Centre Grenada, West Indies, Grenada;
| | - Codi Schaper
- College of Veterinary Medicine, Kansas State University, Manhattan, KS 66502, USA;
| | - Benjamin Brooks
- Department of Biomedical Sciences, Rocky Vista University, Ivins, UT 84734, USA;
| | - Amanda Brooks
- Department of Pharmaceutical Sciences, North Dakota State University, Fargo, ND 58102, USA; (R.H.); (J.S.); (P.M.)
- Department of Research and Scholarly Activity, Rocky Vista University, Ivins, UT 84734, USA
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Allen B, Moore C, Seyler T, Gall K. Modulating antibiotic release from reservoirs in 3D-printed orthopedic devices to treat periprosthetic joint infection. J Orthop Res 2020; 38:2239-2249. [PMID: 32100898 DOI: 10.1002/jor.24640] [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: 07/03/2019] [Revised: 01/28/2020] [Accepted: 02/19/2020] [Indexed: 02/04/2023]
Abstract
Periprosthetic joint infection is a costly debilitating affliction following total joint arthroplasty. Despite a relatively low incidence rate, periprosthetic joint infection is an increasing problem due to a substantial increase in arthroplasty surgeries over time. The current treatment is replacing the primary implant with a temporary bone cement spacer that releases antibiotics over time. However, the spacer is mechanically weak with an ineffective antibiotic release. Alternatively, three-dimensional (3D)-printed reservoirs in high-strength devices have the potential to release antibiotics long term in a controlled manner. In this study, 3D-printed reservoirs were loaded with calcium sulfate embedded with gentamicin. In vitro antibiotic release is tuned by varying reservoir parameters, such as channel length, diameter, and quantity. In addition, a straightforward computational model effectively predicts antibiotic release curves to rapidly design devices with a preferred release profile. Overall, this study highlights a novel approach to potentially develop high-strength joint implants with the long-term effective release of antibiotics to treat the periprosthetic joint infection.
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Affiliation(s)
- Brian Allen
- Department of Mechanical Engineering and Materials Science, Edmund T. Pratt Jr. School of Engineering, Duke University, Durham, North Carolina
| | - Christina Moore
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Thorsten Seyler
- Department of Orthopaedic Surgery, Duke University Medical Center, Durham, North Carolina
| | - Ken Gall
- Department of Mechanical Engineering and Materials Science, Edmund T. Pratt Jr. School of Engineering, Duke University, Durham, North Carolina
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Min JG, Sanchez Rangel UJ, Franklin A, Oda H, Wang Z, Chang J, Fox PM. Topical Antibiotic Elution in a Collagen-Rich Hydrogel Successfully Inhibits Bacterial Growth and Biofilm Formation In Vitro. Antimicrob Agents Chemother 2020; 64:e00136-20. [PMID: 32690648 PMCID: PMC7508589 DOI: 10.1128/aac.00136-20] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Accepted: 07/01/2020] [Indexed: 01/24/2023] Open
Abstract
Chronic wounds are a prominent concern, accounting for $25 billion of health care costs annually. Biofilms have been implicated in delayed wound closure, but they are susceptible to developing antibiotic resistance and treatment options continue to be limited. A novel collagen-rich hydrogel derived from human extracellular matrix presents an avenue for treating chronic wounds by providing appropriate extracellular proteins for healing and promoting neovascularization. Using the hydrogel as a delivery system for localized secretion of a therapeutic dosage of antibiotics presents an attractive means of maximizing delivery while minimizing systemic side effects. We hypothesize that the hydrogel can provide controlled elution of antibiotics leading to inhibition of bacterial growth and disruption of biofilm formation. The rate of antibiotic elution from the collagen-rich hydrogel and the efficacy of biofilm disruption was assessed with Pseudomonas aeruginosa Bacterial growth inhibition, biofilm disruption, and mammalian cell cytotoxicity were quantified using in vitro models. The antibiotic-loaded hydrogel showed sustained release of antibiotics for up to 24 h at therapeutic levels. The treatment inhibited bacterial growth and disrupted biofilm formation at multiple time points. The hydrogel was capable of accommodating various classes of antibiotics and did not result in cytotoxicity in mammalian fibroblasts or adipose stem cells. The antibiotic-loaded collagen-rich hydrogel is capable of controlled antibiotic release effective for bacteria cell death without native cell death. A human-derived hydrogel that is capable of eluting therapeutic levels of antibiotic is an exciting prospect in the field of chronic wound healing.
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Affiliation(s)
- Jung Gi Min
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Uriel J Sanchez Rangel
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Austin Franklin
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Hiroki Oda
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Zhen Wang
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - James Chang
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Paige M Fox
- Division of Plastic & Reconstructive Surgery, Department of Surgery, Stanford University School of Medicine, Stanford, California, USA
- Division of Plastic & Reconstructive Surgery, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
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Ghirardelli S, Fidanza A, Prati P, Iannotti F, Indelli PF. Debridement, antibiotic pearls, and retention of the implant in the treatment of infected total hip arthroplasty. Hip Int 2020; 30:34-41. [PMID: 32907425 DOI: 10.1177/1120700020929314] [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] [Indexed: 02/04/2023]
Abstract
In this article the authors describe a modified surgical technique developed to enhance the classical irrigation and debridement procedure to improve the possibilities of retaining a total hip arthroplasty (THA) undergoing acute periprosthetic joint infection (PJI). This technique, debridement antibiotic pearls and retention of the implant (DAPRI), aims to remove the intra-articular biofilm allowing a higher and prolonged local antibiotic concentration by using calcium sulphate antibiotic-added beads. The combination of 3 different surgical techniques (tumour-like synovectomy, Argon Beam application and chlorhexidine gluconate brushing) might enhance the disruption and removal of the bacterial biofilm which is the main responsible of antibiotics and antibodies resistance. The timing of the diagnosis (6 weeks from the original surgery or 1 week from clinical symptoms appearance in the case of an hematogenous infection) and the preoperative isolation of the germ are fundamental in order to obtain a satisfactory outcome. A 12-week course of postoperative antibiotic therapy (6 weeks I.V. and 6 weeks oral) complete the postoperative protocol used by the authors.The DAPRI technique might represent a safe and more conservative treatment for acute and early hematogenous PJI.
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Affiliation(s)
- Stefano Ghirardelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
| | - Andrea Fidanza
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
| | - Paolo Prati
- ASST Bergamo Ovest, Treviglio Hospital, Treviglio, Italy
| | - Ferdinando Iannotti
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
| | - Pier F Indelli
- Department of Orthopaedic Surgery and Bioengineering, Stanford University School of Medicine, Stanford, CA, USA
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Extensive eggshell-like debridement technique plus antibiotic-loaded calcium sulphate for one-stage treatment of chronic calcaneal osteomyelitis. Foot Ankle Surg 2020; 26:644-649. [PMID: 31521521 DOI: 10.1016/j.fas.2019.08.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 07/17/2019] [Accepted: 08/12/2019] [Indexed: 02/04/2023]
Abstract
BACKGROUND Management of chronic calcaneal osteomyelitis is challenging. At present, there is still no widely accepted, simple, and effective surgical method to eradicate the infection and prevent osteomyelitis recurrence. The objective of this study was to assess the outcomes of one-stage treatment of chronic calcaneal osteomyelitis with a shape-preserving debridement technique combined with antibiotic-loaded calcium sulphate. METHODS Between 2012 and 2018, 33 patients (33 limbs) with chronic calcaneal osteomyelitis were treated with a novel debridement technique, named "eggshell-like debridement", plus antibiotic-impregnated calcium sulphate. The infection remission rate, recurrence rate, and amputation rate were analyzed. The American Orthopedic Foot and Ankle Society (AOFAS) ankle and hindfoot score was used to assess postoperative hindfoot function. RESULTS 26 patients (81.8%) achieved infection remission without recurrence. In the patients with osteomyelitis remission, pain, limitation of movement, sinus tracts, and typical redness and swelling were generally eliminated. Most of the patients could tolerate full weight-bearing without pain. The average AOFAS ankle and hindfoot score was 88 points (range, 67-100 points), implying the foot function was mostly restored. 6 patients (18.2%) had osteomyelitis recurrence but no amputation was required to elimilate the infection. CONCLUSIONS Eggshell-like debridement combined with antibiotic-loaded calcium sulphate is an effective method for one-stage management of chronic calcaneal osteomyelitis. With the application of this technique, secondary autogenous bone or muscle flap grafts are unnecessary. The surgical procedure can be simplified whlie the hindfoot function is well preserved.
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Stoodley P, Brooks J, Peters CW, Jiang N, Delury CP, Laycock PA, Aiken SS, Dusane DH. Prevention and Killing Efficacy of Carbapenem Resistant Enterobacteriaceae (CRE) and Vancomycin Resistant Enterococci (VRE) Biofilms by Antibiotic-Loaded Calcium Sulfate Beads. MATERIALS 2020; 13:ma13153258. [PMID: 32707995 PMCID: PMC7436038 DOI: 10.3390/ma13153258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/14/2020] [Accepted: 07/17/2020] [Indexed: 11/17/2022]
Abstract
Carbapenem-resistant Enterobacteriaceae (CRE) and vancomycin-resistant Enterococci (VRE) have emerged as multidrug-resistant (MDR) pathogens associated with periprosthetic joint infections (PJI). In this study, we evaluated the efficacy of antibiotic-loaded calcium sulfate beads (ALCSB) in inhibiting bacterial growth, encouraging biofilm formation and killing preformed biofilms of CRE and VRE. Three strains of Klebsiella pneumoniae (KP) and a strain of Enterococcus faecalis (EF) were used. ALCSB of 4.8-mm diameter were loaded with vancomycin (V) and gentamicin (G), V and rifampicin (R), V and tobramycin (T) or R and meropenem (M), and placed onto tryptic soy agar (TSA), spread with one of the test strains and incubated for 24 h at 37 °C. Beads were transferred daily onto fresh TSA spread plates and the zone of inhibition (ZOI) was recorded until no inhibition was observed. ALCSB containing R + M or R + V produced the most extensive ZOI up to 5 weeks. Biofilm prevention efficacy was investigated by challenging ALCSB daily with 5 × 105 CFU/mL bacterial cells and analyzing for biofilm formation at challenges 1, 2 and 3. In the biofilm killing experiments, ALCSB were added to pre-grown 3-day biofilms of KP and EF strains, which were then analyzed at days 1 and 3 post-exposure. The CFU counts and confocal images of the attached cells showed that ALCSB treatment reduced colonization and biofilm formation significantly (5–7 logs) with combinations of R + M or R + V, compared to unloaded beads. This study provides evidence that the local release of antibiotics from ALCSB may be useful in treating the biofilms of multidrug-resistant strains of CRE and VRE.
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Affiliation(s)
- Paul Stoodley
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
- National Centre for Advanced Tribology, Faculty of Engineering and Institute for Life Sciences, University of Southampton, Southampton SO17 1BJ, UK
- Department of Orthopaedic, The Ohio State University, Columbus, OH 43210, USA
| | - Jacob Brooks
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
| | - Casey W. Peters
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
| | - Nan Jiang
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
| | - Craig P. Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.P.D.); (P.A.L.); (S.S.A.)
| | - Phillip A. Laycock
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.P.D.); (P.A.L.); (S.S.A.)
| | - Sean S. Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK; (C.P.D.); (P.A.L.); (S.S.A.)
| | - Devendra H. Dusane
- Department of Microbial Infection and Immunity, The Ohio State University, Columbus, OH 43210, USA; (P.S.); (J.B.); (C.W.P.); (N.J.)
- Center for Clinical and Translational Research, The Research Institute at Nationwide Children′s Hospital, 700 Children′s Drive, Columbus, OH 43205, USA
- Correspondence:
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The Role of Poly(Methyl Methacrylate) in Management of Bone Loss and Infection in Revision Total Knee Arthroplasty: A Review. J Funct Biomater 2020; 11:jfb11020025. [PMID: 32290191 PMCID: PMC7353497 DOI: 10.3390/jfb11020025] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/03/2020] [Accepted: 04/06/2020] [Indexed: 02/07/2023] Open
Abstract
Poly(methyl methacrylate) (PMMA) is widely used in joint arthroplasty to secure an implant to the host bone. Complications including fracture, bone loss and infection might cause failure of total knee arthroplasty (TKA), resulting in the need for revision total knee arthroplasty (rTKA). The goals of this paper are: (1) to identify the most common complications, outside of sepsis, arising from the application of PMMA following rTKA, (2) to discuss the current applications and drawbacks of employing PMMA in managing bone loss, (3) to review the role of PMMA in addressing bone infection following complications in rTKA. Papers published between 1970 to 2018 have been considered through searching in Springer, Google Scholar, IEEE Xplore, Engineering village, PubMed and weblinks. This review considers the use of PMMA as both a bone void filler and as a spacer material in two-stage revision. To manage bone loss, PMMA is widely used to fill peripheral bone defects whose depth is less than 5 mm and covers less than 50% of the bone surface. Treatment of bone infections with PMMA is mainly for two-stage rTKA where antibiotic-loaded PMMA is inserted as a spacer. This review also shows that using antibiotic-loaded PMMA might cause complications such as toxicity to surrounding tissue, incomplete antibiotic agent release from the PMMA, roughness and bacterial colonization on the surface of PMMA. Although PMMA is the only commercial bone cement used in rTKA, there are concerns associated with using PMMA following rTKA. More research and clinical studies are needed to address these complications.
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Couture A, Lavergne V, Sandman E, Leduc JM, Benoit B, Leduc S, Rouleau DM. Calcium sulphate mixed with antibiotics does not decrease efficacy against Cutibacterium acnes (formerly Propionibacterium acnes), in vitro study. J Orthop 2020; 19:138-142. [PMID: 32025121 DOI: 10.1016/j.jor.2019.11.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Accepted: 11/23/2019] [Indexed: 10/25/2022] Open
Abstract
Background This study explored the in vitro efficacy of antibiotics mixed with calcium sulfate (ACS) against Cutibacterium acnes (C. acnes). Methods C. acnes isolates from orthopaedic infection sites were tested for antimicrobial susceptibility with ACS. Minimal inhibitory concentrations (MIC) were determined with a gradient diffusion method (Etest® strips). Results When tested with Etest®, all 22 isolates were susceptible to penicillin, ceftriaxone, vancomycin, and two were resistant to clindamycin (MICs of 4 and 8 mg/L). Penicillin and rifampin had the largest inhibition zone diameters. Conclusions Antibiotics retained activity against C. acnes when mixed with calcium sulfate.
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Affiliation(s)
- Anne Couture
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada
| | - Valéry Lavergne
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Emilie Sandman
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Jean-Michel Leduc
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Benoit Benoit
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Stéphane Leduc
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Dominique M Rouleau
- Université de Montréal, 2900 Boul., Edouard-Montpetit, Montreal, QC, H3T 1J4, Canada.,Hôpital Du Sacré-Cœur, Montréal, 5400 Boul. Gouin Ouest, Montreal, QC, H4J 1C5, Canada
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Qin CH, Zhou CH, Song HJ, Cheng GY, Zhang HA, Fang J, Tao R. Infected bone resection plus adjuvant antibiotic-impregnated calcium sulfate versus infected bone resection alone in the treatment of diabetic forefoot osteomyelitis. BMC Musculoskelet Disord 2019; 20:246. [PMID: 31122219 PMCID: PMC6533721 DOI: 10.1186/s12891-019-2635-8] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2019] [Accepted: 05/16/2019] [Indexed: 12/12/2022] Open
Abstract
Background Managing with diabetic foot osteomyelitis (DFO) is challenging. Even after infective bone resection and thorough debridement, DFO is still difficult to cure and has a high recurrence rate. This retrospective study aims to compare the outcomes of two treatment methods, infected bone resection combined with adjuvant antibiotic-impregnated calcium sulfate and infected bone resection alone, for the treatment of diabetic foot osteomyelitis. Methods Between 2015 to 2017, 48 limbs (46 patients) with DFO met the criteria were included for assessment. 20 limbs (18 patients) were included in the calcium sulfate group (the CS group) in which vancomycin and/or gentamicin-impregnated calcium sulfate was used as an adjuvant after infected bone resection while 28 limbs (28 patients) as the control group were undergone infected bone resection only. Systemic antibiotics, postoperative wound care and offloading were continued to be applied following surgery in both groups. The time to healing, healing rate, recurrence rate and amputation rate were compared between the two groups. Results In total, 90% (18/20) limbs in the CS group as compared to 78.6% (22/28) infected limbs in the control group went to heal (P = 0.513). The Mean time to healing was 13.3 weeks in the CS group and 11.2 weeks in control group (P = 0.132). Osteomyelitis recurrence rate was 0% (0/18) in the CS group and 36.4% (8/22) in the control group (P = 0.014). Postoperative leakage in calcium sulfate group was 30.0% (6/20) with a mean duration of 8.5 weeks. Amputation rate in the control group was 7.1% (2/28) compared to 0% (0/20) in the CS group (P = 0.153). Conclusions Antibiotic-impregnated calcium sulfate as an adjuvant prevents the recurrence of DFO but cannot improve the healing rate, reduce the postoperative amputation rate or shorten the time to healing. Prolonged postoperative leakage as the most common complication can be managed with regular dressing. Level of Evidence III, Retrospective Comparative Study.
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Affiliation(s)
- Cheng-He Qin
- Department of Orthopaedics and Traumatology, Guangdong Second Provincial General Hospital, Guangzhou, 510317, People's Republic of China.
| | - Chun-Hao Zhou
- Department of Orthopaedics and Traumatology, Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Hui-Juan Song
- Department of Nursing, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Guo-Yun Cheng
- Department of Orthopaedics and Traumatology, Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Hong-An Zhang
- Department of Orthopaedics and Traumatology, Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
| | - Jia Fang
- Department of Orthopaedics and Traumatology, Guangdong Second Provincial General Hospital, Guangzhou, 510317, People's Republic of China
| | - Rui Tao
- Department of Orthopaedics and Traumatology, Provincial Key Laboratory of Bone and Cartilage Regenerative Medicine, Nanfang Hospital, Southern Medical University, Guangzhou, 510515, People's Republic of China
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Oliver RA, Lovric V, Christou C, Walsh WR. Evaluation of comparative soft tissue response to bone void fillers with antibiotics in a rabbit intramuscular model. J Biomater Appl 2019; 34:117-129. [PMID: 30987506 PMCID: PMC6587362 DOI: 10.1177/0885328219838382] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Management of osseous and soft tissue dead space can be a significant challenge in the clinical setting. Calcium sulphate and calcium phosphate-based biomaterials are increasingly being used as alternatives to PMMA for local release of antibiotics, in particular to fill dead space following surgical debridement. This study aims to observe the in-vivo absorption characteristics and tissue response of three commercially available calcium sulphate-based materials combined with gentamicin in an established soft tissue rabbit model. The implant materials (1cc) were placed into four intramuscular sites in 18 New Zealand White rabbits (n = 6). In-life blood samples and radiographs were taken from each animal following implantation. Animals were sacrificed at 0, 1, 7, 21, 42 and 63 days post-operatively (n = 3) and implant sites analysed by micro-computed tomography and histology. Radiographically and histologically, recrystallized calcium sulphate (RCS) absorbed the fastest with complete absorption by day 21. Calcium sulphate/HA composite (CSHA) and Calcium sulphate/calcium carbonate (CSCC) absorbed slower and were detectable at day 63. Residual bead analysis revealed the presence of detectable gentamicin at 24 h and 7 days for CSHA and RCS but none in CSCC. Systemic levels of gentamicin were only detected between 1 h and 24 h. Serological inflammatory cytokine expression for IL-6, TNF-α and IL-1β indicated no unusual inflammatory response to the implanted materials. Calcium sulphate materials loaded with gentamicin are effective in resolving a surgically created dead space without eliciting any adverse host response.
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Affiliation(s)
- Rema A Oliver
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - Vedran Lovric
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - Chris Christou
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
| | - William R Walsh
- Surgical & Orthopaedic Research Laboratories, University of New South Wales, Prince of Wales Hospital, Randwick, Australia
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Funk GA, Menuey EM, Cole KA, Schuman TP, Kilway KV, McIff TE. Radical scavenging of poly(methyl methacrylate) bone cement by rifampin and clinically relevant properties of the rifampin-loaded cement. Bone Joint Res 2019; 8:81-89. [PMID: 30915214 PMCID: PMC6397418 DOI: 10.1302/2046-3758.82.bjr-2018-0170.r2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [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
Objectives The objective of this study was to characterize the effect of rifampin incorporation into poly(methyl methacrylate) (PMMA) bone cement. While incompatibilities between the two materials have been previously noted, we sought to identify and quantify the cause of rifampin’s effects, including alterations in curing properties, mechanical strength, and residual monomer content. Methods Four cement groups were prepared using commercial PMMA bone cement: a control; one with 1 g of rifampin; and one each with equimolar amounts of ascorbic acid or hydroquinone relative to the amount of rifampin added. The handling properties, setting time, exothermic output, and monomer loss were measured throughout curing. The mechanical strength of each group was tested over 14 days. A radical scavenging assay was used to assess the scavenging abilities of rifampin and its individual moieties. Results Compared with control, the rifampin-incorporated cement had a prolonged setting time and a reduction in exothermic output during polymerization. The rifampin cement showed significantly reduced strength and was below the orthopaedic weight-bearing threshold of 70 MPa. Based on the radical scavenging assay and strength tests, the hydroquinone structure within rifampin was identified as the polymerization inhibitor. Conclusion The incorporation of rifampin into PMMA bone cement interferes with the cement’s radical polymerization. This interference is due to the hydroquinone moiety within rifampin. This combination alters the cement’s handling and curing properties, and lowers the strength below the threshold for weight-bearing applications. Additionally, the incomplete polymerization leads to increased toxic monomer output, which discourages its use even in non-weight-bearing applications. Cite this article: G. A. Funk, E. M. Menuey, K. A. Cole, T. P. Schuman, K. V. Kilway, T. E. McIff. Radical scavenging of poly(methyl methacrylate) bone cement by rifampin and clinically relevant properties of the rifampin-loaded cement. Bone Joint Res 2019;8:81–89. DOI: 10.1302/2046-3758.82.BJR-2018-0170.R2.
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Affiliation(s)
- G A Funk
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - E M Menuey
- Department of Chemistry, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - K A Cole
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - T P Schuman
- Department of Chemistry, Missouri University of Science and Technology, Rolla, Missouri, USA
| | - K V Kilway
- Department of Chemistry, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - T E McIff
- Department of Orthopedic Surgery, University of Kansas Medical Center, Kansas City, Kansas, USA
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45
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Results of the Induced Membrane Technique in the Management of Traumatic Bone Loss in the Lower Limb: A Cohort Study. J Orthop Trauma 2019; 33:131-136. [PMID: 30562247 DOI: 10.1097/bot.0000000000001384] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
OBJECTIVE To present our technique and early results using the Masquelet technique. DESIGN Retrospective cohort study. PATIENTS/PARTICIPANTS Thirteen patients with 14 open fractures of the femur and tibia were included between November 2013 and December 2014. INTERVENTION A Masquelet technique was used to manage the open fractures. MAIN OUTCOME MEASURE Infection and union rate. RESULTS The mean follow-up was 17 months. The mean bone defect was 56.6 mm. Eight fractures (57.1%) progressed to union at an average of 42.1 weeks. Infection developed in 3 fractures (21.4%). Overall, the induced membrane technique was abandoned in 5 (35.7%) cases. CONCLUSIONS The induced membrane technique showed a substantial rate of failure in the acute trauma setting in the lower limb. In the absence of sound published evidence, the authors now use the technique in selected cases only. LEVEL OF EVIDENCE Therapeutic Level IV. See Instructions for Authors for a complete description of levels of evidence.
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Hoogerboord CM, Cwinn M, Minor SF. Conservative treatment of infected mesh by use of gentamycin impregnated calcium sulphate antibiotic beads: a report of two cases. Hernia 2019; 23:407-409. [PMID: 30778856 DOI: 10.1007/s10029-019-01910-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 02/09/2019] [Indexed: 11/26/2022]
Affiliation(s)
- C M Hoogerboord
- Department of Surgery, Dalhousie University, Halifax, NS, Canada.
| | - M Cwinn
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
| | - S F Minor
- Department of Surgery, Dalhousie University, Halifax, NS, Canada
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Gorvetzian JW, Kunkel RP, Demas CP. A Single Center Retrospective Evaluation of a Surgical Strategy to Combat Persistent Soft Tissue Wounds Utilizing Absorbable Antibiotic Beads. Adv Wound Care (New Rochelle) 2019; 8:49-57. [PMID: 30809422 DOI: 10.1089/wound.2018.0795] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2018] [Accepted: 08/30/2018] [Indexed: 12/19/2022] Open
Abstract
Objective: To determine whether use of absorbable antibiotic-imbued beads in chronic soft tissue wounds presents a viable therapeutic modality. Approach: Retrospective analysis of all cases utilizing calcium sulfate antibiotic beads was conducted. Cases comprised complex wound and breast reconstruction performed by the senior author (C.P.D.) over 4 years at the University of New Mexico Hospital. All-cause need for reoperation and reoperation for infection in the 90 days following bead-assisted surgery were compared to traditional surgical intervention in the 90-day period preceding bead-assisted surgery. Paired-samples t-test and corrected Cohen's d were calculated for outcome significance and effect size. Results: A total of 60 patients underwent 84 bead-assisted surgeries. There was a significant decrease in rate of reoperation following bead surgery (M = 0.32) compared with prebead surgery (M = 2.2), p < 0.001. Rate of reoperation for infection significantly decreased from 1.7 before bead surgery to 0.05 following bead surgery, p < 0.001. Results remained significant when stratified by complex wound or breast reconstruction, p < 0.01. Cohen's d ranged from 1.25 to 2.13, with probability of superiority between 80% and 93%. Innovation: Use of antibiotic-laden materials is well established in the orthopedic literature, but poorly characterized in soft tissue applications. Biofilms are increasingly implicated as a unifying pathologic foe underlying chronic wound infection and nonhealing. Antibiotic beads have demonstrated activity against biofilm in vitro. This study demonstrates diminished reoperative burden for these wounds following antibiotic bead surgery, possibly as a result of in vivo biofilm antagonism. Conclusion: Antibiotic bead-assisted surgery was associated with significantly decreased infectious and all-cause reoperations for chronic and infected wounds.
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Affiliation(s)
- Joseph W. Gorvetzian
- Health Sciences Center, University of New Mexico School of Medicine, Albuquerque, New Mexico
| | - Ryan P. Kunkel
- Division of Plastic Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
| | - Christopher P. Demas
- Division of Plastic Surgery, University of New Mexico Hospital, Albuquerque, New Mexico
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Lulu GA, Karunanidhi A, Mohamad Yusof L, Abba Y, Mohd Fauzi F, Othman F. In vivo efficacy of tobramycin-loaded synthetic calcium phosphate beads in a rabbit model of staphylococcal osteomyelitis. Ann Clin Microbiol Antimicrob 2018; 17:46. [PMID: 30593272 PMCID: PMC6309062 DOI: 10.1186/s12941-018-0296-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2018] [Accepted: 12/12/2018] [Indexed: 11/25/2022] Open
Abstract
Background Osteomyelitis is an acute or chronic inflammatory process of the bone following infection with pyogenic organisms like Staphylococcus aureus. Tobramycin (TOB) is a promising aminoglycoside antibiotic used to treat various bacterial infections, including S. aureus. The aim of this study was to investigate the efficacy of tobramycin-loaded calcium phosphate beads (CPB) in a rabbit osteomyelitis model. Methods Tobramycin (30 mg/mL) was incorporated into CPB by dipping method and the efficacy of TOB-loaded CPB was studied in a rabbit osteomyelitis model. For juxtaposition, CPB with and without TOB were prepared. Twenty-five New Zealand white rabbits were grouped (n = 5) as sham (group 1), TOB-loaded CPB without S. aureus (group 2), S. aureus only (group 3), S. aureus + CPB (group 4), and S. aureus + TOB-loaded CPB (group 5). Groups infected with S. aureus followed by CPB implantation were immediately subjected to surgery at the mid-shaft of the tibia. After 28 days post-surgery, all rabbits were euthanized and the presence or absence of chronic osteomyelitis and the extent of architectural destruction of the bone were assessed by radiology, bacteriology and histological studies. Results Tobramycin-loaded CPB group potentially inhibited the growth of S. aureus causing 3.2 to 3.4 log10 reductions in CFU/g of bone tissue compared to the controls. Untreated groups infected with S. aureus showed signs of chronic osteomyelitis with abundant bacterial growth and alterations in bone architecture. The sham group and TOB-loaded CPB group showed no evidence of bacterial growth. Conclusions TOB-incorporated into CPB for local bone administration was proven to be more successful in increasing the efficacy of TOB in this rabbit osteomyelitis model and hence could represent a good alternative to other formulations used in the treatment of osteomyelitis. Electronic supplementary material The online version of this article (10.1186/s12941-018-0296-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Godday Anebow Lulu
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Arunkumar Karunanidhi
- Department of Medical Microbiology and Parasitology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia.,Department of Pharmacology and Chemistry, Faculty of Pharmacy, Universiti Teknologi MARA, 42300, Bandar Puncak Alam, Selangor Darul Ehsan, Malaysia
| | - Loqman Mohamad Yusof
- Department of Companion Animal Medicine and Surgery, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia.
| | - Yusuf Abba
- Department of Veterinary Pathology and Microbiology, Faculty of Veterinary Medicine, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia
| | - Fazlin Mohd Fauzi
- Department of Pharmacology and Chemistry, Faculty of Pharmacy, Universiti Teknologi MARA, 42300, Bandar Puncak Alam, Selangor Darul Ehsan, Malaysia
| | - Fauziah Othman
- Department of Human Anatomy, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia. .,Research Laboratory of Anatomy and Histology, Faculty of Medicine and Health Sciences, Universiti Putra Malaysia, 43400, Serdang, Selangor Darul Ehsan, Malaysia.
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Laycock PA, Cooper JJ, Howlin RP, Delury C, Aiken S, Stoodley P. In Vitro Efficacy of Antibiotics Released from Calcium Sulfate Bone Void Filler Beads. MATERIALS 2018; 11:ma11112265. [PMID: 30428581 PMCID: PMC6266743 DOI: 10.3390/ma11112265] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2018] [Revised: 11/07/2018] [Accepted: 11/10/2018] [Indexed: 12/28/2022]
Abstract
15 different antibiotics were individually mixed with commercially available calcium sulfate bone void filler beads. The antibiotics were: amikacin, ceftriaxone, cefuroxime, ciprofloxacin, clindamycin, colistamethate sodium, daptomycin, gentamicin, imipenem/cilastatin, meropenem, nafcillin, rifampicin, teicoplanin, tobramycin and vancomycin. The efficacy of specific released antibiotics was validated by zone of inhibition (ZOI) testing using a modified Kirby–Bauer disk diffusion method against common periprosthetic joint infection pathogens. With a subset of experiments (daptomycin, rifampin, vancomycin alone and rifampin and vancomycin in combination), we investigated how release varied over 15 days using a repeated ZOI assay. We also tested the ability of these beads to kill biofilms formed by Staphylococcus epidermidis 35984, a prolific biofilm former. The results suggested that certain antibiotics could be combined and released from calcium sulfate with retained antibacterial efficacy. The daptomycin and rifampin plus vancomycin beads showed antimicrobial efficacy for the full 15 days of testing and vancomycin in combination with rifampin prevented resistant mutants. In the biofilm killing assay, all of the antibiotic combinations showed a significant reduction in biofilm bacteria after 24 h. The exposure time was an important factor in the amount of killing, and varied among the antibiotics.
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Affiliation(s)
- Phillip A Laycock
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK.
| | - John J Cooper
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK.
| | - Robert P Howlin
- National Institute for Health Research Southampton Respiratory Biomedical Research Unit, Southampton Centre for Biomedical Research, University of Southampton NHS Foundation Trust, Southampton SO17 1BJ, UK.
| | - Craig Delury
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK.
| | - Sean Aiken
- Biocomposites Ltd., Keele Science Park, Keele, Staffordshire ST5 5NL, UK.
| | - Paul Stoodley
- National Centre for Advanced Tribology at Southampton (nCATS), Dept, Mechanical Engineering, University of Southampton, Southampton SO17 IBJ, UK.
- Department of Microbial Infection and Immunity and Orthopedics, The Ohio State University, Columbus, OH 43210, USA.
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50
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Wahl P, Rönn K, Bohner M, Decosterd LA, Meier C, Schläppi M, Festa S, Gautier E. In vitro study of new combinations for local antibiotic therapy with calcium sulphate - Near constant release of ceftriaxone offers new treatment options. J Bone Jt Infect 2018; 3:212-221. [PMID: 30416946 PMCID: PMC6215989 DOI: 10.7150/jbji.26218] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 09/17/2018] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Local application of antibiotics provides high concentrations at the site of interest, with minimal systemic toxicity. Carrier materials might help manage dead space. Calcium sulphate (CaSO4) has a dissolution time that only slightly exceeds the usually recommended duration of systemic antibiotic treatments. This in vitro study evaluates compatibility, release kinetics and antibacterial activity of new combinations of antibiotics with CaSO4 as carrier material. METHODS CaSO4 pellets added with 8% w/w antibiotic powder were exposed once in phosphate-buffered saline (PBS) solution and once in bovine plasma, in an elution experiment run over 6 weeks at 37 °C. Antibiotic elution was examined at various time points. Concentration was measured by liquid chromatography with tandem mass spectrometry. Antimicrobial activity was checked with an agar diffusion test. RESULTS Piperacillin-tazobactam, ceftazidime, cefepime, and meropenem showed fast reduction of concentration and activity. Flucloxacillin and cefuroxime remained present in relevant concentrations for 4 weeks. Ciprofloxacin, levofloxacin and clindamycin lasted for 6 weeks, but also at cell toxic concentrations. Ceftriaxone showed a near-constant release with only a small reduction of concentration from 130 to 75 mg/l. Elution profiles from PBS and plasma were comparable. CONCLUSION CaSO4 provides new possibilities in the local treatment of bone and joint infections. Ceftriaxone appears to be of particular interest in combination with CaSO4. Release persists at clinically promising concentrations, and appears to have a depot-like slow release from CaSO4, with only a small reduction in activity and concentration over 6 weeks. To the best of our knowledge, such a particular persistent release never was described before, for any antibiotic in combination with a carrier material for local application.
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Affiliation(s)
- Peter Wahl
- Department of Orthopaedic Surgery, HFR Fribourg - Cantonal Hospital, Fribourg, Switzerland.,Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Karolin Rönn
- Department of Orthopaedic Surgery, HFR Fribourg - Cantonal Hospital, Fribourg, Switzerland.,Schulthess Clinic, Zürich, Switzerland
| | | | - Laurent A Decosterd
- Division of Clinical Pharmacology, University Hospital Centre CHUV, Lausanne, Switzerland
| | - Christoph Meier
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Michel Schläppi
- Division of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Winterthur, Switzerland
| | - Sandrine Festa
- Department of Orthopaedic Surgery, HFR Fribourg - Cantonal Hospital, Fribourg, Switzerland
| | - Emanuel Gautier
- Department of Orthopaedic Surgery, HFR Fribourg - Cantonal Hospital, Fribourg, Switzerland
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