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Lizcano JD, Fernández-Rodríguez D, Goh GS, DeMik DE, Hughes AJ, Parvizi J, Courtney PM, Purtill JJ, Austin MS. In Vivo Intra-Articular Antibiotic Concentrations at 24 Hours After TKA Fall Below the Minimum Inhibitory Concentration for Most Bacteria: A Randomized Study of Commercially Available Bone Cement. J Bone Joint Surg Am 2024:00004623-990000000-01162. [PMID: 39052763 DOI: 10.2106/jbjs.23.01412] [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: 07/27/2024]
Abstract
BACKGROUND The use of antibiotic-loaded bone cement (ALBC) to help reduce the risk of infection after primary total knee arthroplasty (TKA) is controversial. There is a paucity of in vivo data on the elution characteristics of ALBC. We aimed to determine whether the antibiotic concentrations of 2 commercially available ALBCs met the minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) for common infecting organisms. METHODS Forty-five patients undergoing TKA were randomized to receive 1 of the following: bone cement without antibiotic (the negative control; n = 5), a commercially available formulation containing 1 g of tobramycin (n = 20), or a commercially available formulation containing 0.5 g of gentamicin (n = 20). Intra-articular drains were placed, and fluid was collected at 4 and 24 hours postoperatively. An automated immunoassay measuring antibiotic concentration was performed, and the results were compared against published MIC and MBEC thresholds. RESULTS The ALBC treatment groups were predominantly of White (65%) or Black (32.5%) race and were 57.5% female and 42.4% male. The mean age (and standard deviation) was 72.6 ± 7.2 years in the gentamicin group and 67.6 ± 7.4 years in the tobramycin group. The mean antibiotic concentration in the tobramycin group was 55.1 ± 37.7 μg/mL at 4 hours and 19.5 ± 13.0 μg/mL at 24 hours, and the mean concentration in the gentamicin group was 38.4 ± 25.4 μg/mL at 4 hours and 17.7 ± 15.4 μg/mL at 24 hours. Time and antibiotic concentration had a negative linear correlation coefficient (r = -0.501). Most of the reference MIC levels were reached at 4 hours. However, at 24 hours, a considerable percentage of patients had concentrations below the MIC for many common pathogens, including Staphylococcus epidermidis (gentamicin: 65% to 100% of patients; tobramycin: 50% to 85%), methicillin-sensitive Staphylococcus aureus (gentamicin: 5% to 90%; tobramycin: 5% to 50%), methicillin-resistant S. aureus (gentamicin: 5% to 65%; tobramycin: 50%), Streptococcus species (gentamicin: 10% to 100%), and Cutibacterium acnes (gentamicin: 10% to 65%; tobramycin: 100%). The aforementioned ranges reflect variation in the MIC among different strains of each organism. Gentamicin concentrations reached MBEC threshold values at 4 hours only for the least virulent strains of S. aureus and Escherichia coli. Tobramycin concentrations did not reach the MBEC threshold for any of the bacteria at either time point. CONCLUSIONS The elution of antibiotics from commercially available ALBC decreased rapidly following TKA, and only at 4 hours postoperatively did the mean antibiotic concentrations exceed the MIC for most of the pathogens. Use of commercially available ALBC may not provide substantial antimicrobial coverage following TKA. LEVEL OF EVIDENCE Therapeutic Level I. See Instructions for Authors for a complete description of levels of evidence.
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Affiliation(s)
- Juan D Lizcano
- Rothman Orthopaedic Institute, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
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Hamoudi C, Hamon M, Reiter-Schatz A, Debordes PA, Gaudias J, Rondé-Oustau C, Jenny JY. Cement loaded with high-dose gentamicin and clindamycin does not reduce the risk of subsequent infection after aseptic total hip or knee revision arthroplasty: a preliminary study. J Orthop Traumatol 2024; 25:37. [PMID: 39048851 PMCID: PMC11269536 DOI: 10.1186/s10195-024-00775-1] [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: 01/23/2024] [Accepted: 06/15/2024] [Indexed: 07/27/2024] Open
Abstract
PURPOSE The aim of this study was to quantify the prophylactic effect of high-dose gentamicin and clindamycin antibiotic-loaded bone cement (ALBC) during revision total hip (rTHA) or knee (rTKA) arthroplasty for aseptic reasons. The hypothesis was that the raw surgical site infection (SSI) rate is lower when this particular cement is used in comparison with cement loaded with standard-dose gentamicin during rTHA or rTKA for aseptic reasons. METHODS This retrospective study included 290 consecutive patients undergoing aseptic rTHA or rTKA. Two consecutive cohorts were defined: the first (control group) involved 145 patients where ALBC with gentamicin only was used; the second (study group) involved 145 patients where ALBC with high-dose gentamicin and clindamycin was used. The primary endpoint was the raw SSI rate after 24 months. RESULTS The raw SSI rate was 8/145 (6%) in the control group and 13/145 (9%) in the study group (odds ratio 0.62, p = 0.26). There was a significant impact of the presence of any risk factor on the SSI rate (15/100 versus 6/169, odds ratio = 4.25, p = 0.002), but no significant impact of any individual risk factor. No complication or side effect related to ALBC was observed in either group. CONCLUSION These results do not support the routine use of gentamicin and clindamycin ALBC for fixation of revision implants after rTHA and rTKA for aseptic reasons.
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Affiliation(s)
- Ceyran Hamoudi
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Marie Hamon
- Department of Pharmacy, CHU de Caen, Caen, France
| | - Aurélie Reiter-Schatz
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pierre-Antoine Debordes
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jeannot Gaudias
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Cécile Rondé-Oustau
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Jean-Yves Jenny
- Department of Orthopaedic Surgery, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.
- Clinique Sainte-Odile, Groupe Elsan, Haguenau, France.
- Impulse-Ortho, 3 Rue de la Redoute, F-67500, Haguenau, France.
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Adeosun J, Rama E, Thahir A, Krkovic M. Additional doses of prophylactic antibiotics post-arthroplasty: Are there any benefits? J Perioper Pract 2024:17504589241252019. [PMID: 38877723 DOI: 10.1177/17504589241252019] [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: 06/16/2024]
Abstract
Guidelines for prophylactic antibiotic administration in total joint replacement vary considerably in terms of drug, dosage, route of administration and duration of cover. Despite the range of treatment options available, infection remains the most common reason for arthroplasty failure in the decades following a procedure, simultaneously increasing health care costs and lowering patient satisfaction considerably. This work aims to evaluate whether there are benefits to administering further doses of antibiotic post-arthroplasty, in addition to the recommendations of current protocols. We present a review of evidence surrounding infection rates in a variety of prophylactic regimens, and weigh this against further considerations such as cost to the patient and risks of nephrotoxicity. In summary, the available evidence does not suggest a benefit to administering additional doses post-arthroplasty in most cases. However, further doses may benefit those deemed at high risk of infection, or those in areas of high methicillin-resistant Staphylococcus aureus prevalence.
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Affiliation(s)
- James Adeosun
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Essam Rama
- School of Clinical Medicine, University of Cambridge, Cambridge, UK
| | - Azeem Thahir
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Matija Krkovic
- Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Amzallag N, Ashkenazi I, Factor S, Abadi M, Morgan S, Graif N, Snir N, Gold A, Warschawski Y. Addition of gentamicin for antibiotic prophylaxis in hip hemiarthroplasty does not decrease the rate of surgical site infection. Eur J Trauma Emerg Surg 2024; 50:867-873. [PMID: 38006566 DOI: 10.1007/s00068-023-02406-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 11/13/2023] [Indexed: 11/27/2023]
Abstract
BACKGROUND The addition of Gram-negative coverage to antibiotic prophylaxis protocols prior to elective total hip arthroplasty (THA) has been reported to reduce periprosthetic joint infection (PJI). However, it is unknown whether adding a Gram-negative-targeted antibiotic agent improves outcomes in the trauma population. This study aimed to investigate whether the addition of a single, pre-operative dose of Gentamicin is associated with lower rates of PJI in patients undergoing hemiarthroplasty (HA) as treatment for a hip fracture. METHODS We retrospectively reviewed cases of patients who underwent HA as treatment for a hip fracture from January 2011 to January 2022, and had a minimum 1-year of follow-up. Patients were divided into two groups based on the antibiotic prophylaxis they received during surgery: cefazolin (control group) or cefazolin with addition of Gentamicin (case group). The primary outcome was the rate of surgical site infections (SSI), and secondary outcomes included rates of prosthetic joint infection (PJI) and superficial SSIs. RESULTS The final study population consisted of 1521 patients. 336 patients (22.1%) were in the case group and 1185 (77.9%) patients were in the control group. Rates of SSI were comparable between the groups (3.8% for the case group vs. 2.8% in the control group, p = 0.34). This held true for both PJIs (3.5 vs. 2.5%, p = 0.3) and superficial SSIs (0.29 vs. 0.33%, p = 0.91). The distribution of the causing pathogen was similar between the groups (p = 0.84). Gentamicin susceptibility rates of the Gram-negative bacteria associated with PJI were similar between the cohorts (p = 0.51). CONCLUSIONS The addition of a single, pre-operative dose of Gentamicin to the antibiotic prophylaxis protocol of patients undergoing HA as treatment for a hip fracture was not associated with lower rates of SSI, PJI or superficial SSI. The findings of this study indicate that the prophylactic benefits of Gentamicin may not apply to HA as they do to THA.
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Affiliation(s)
- Nissan Amzallag
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Itay Ashkenazi
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Shai Factor
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel.
| | - Mohamed Abadi
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Samuel Morgan
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Nadav Graif
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Nimrod Snir
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Aviram Gold
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
| | - Yaniv Warschawski
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Affiliated to the Sackler Faculty of Medicine Tel Aviv University, 6 Weizman Street, 6423906, Tel-Aviv, Israel
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Chen F, Skelly JD, Chang SY, Song J. Triggered Release of Ampicillin from Metallic Implant Coatings for Combating Periprosthetic Infections. ACS APPLIED MATERIALS & INTERFACES 2024; 16:24421-24430. [PMID: 38690964 PMCID: PMC11099626 DOI: 10.1021/acsami.4c06002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/03/2024]
Abstract
Periprosthetic infections caused by Staphylococcus aureus (S. aureus) pose unique challenges in orthopedic surgeries, in part due to the bacterium's capacity to invade surrounding bone tissues besides forming recalcitrant biofilms on implant surfaces. We previously developed prophylactic implant coatings for the on-demand release of vancomycin, triggered by the cleavage of an oligonucleotide (Oligo) linker by micrococcal nuclease (MN) secreted by the Gram-positive bacterium, to eradicate S. aureus surrounding the implant in vitro and in vivo. Building upon this coating platform, here we explore the feasibility of extending the on-demand release to ampicillin, a broad-spectrum aminopenicillin β-lactam antibiotic that is more effective than vancomycin in killing Gram-negative bacteria that may accompany S. aureus infections. The amino group of ampicillin was successfully conjugated to the carboxyl end of an MN-sensitive Oligo covalently integrated in a polymethacrylate hydrogel coating applied to titanium alloy pins. The resultant Oligo-Ampicillin hydrogel coating released the β-lactam in the presence of S. aureus and successfully cleared nearby S. aureus in vitro. When the Oligo-Ampicillin-coated pin was delivered to a rat femoral canal inoculated with 1000 cfu S. aureus, it prevented periprosthetic infection with timely on-demand drug release. The clearance of the bacteria from the pin surface as well as surrounding tissue persisted over 3 months, with no local or systemic toxicity observed with the coating. The negatively charged Oligo fragment attached to ampicillin upon cleavage from the coating did diminish the antibiotic's potency against S. aureus and Escherichia coli (E. coli) to varying degrees, likely due to electrostatic repulsion by the anionic surfaces of the bacteria. Although the on-demand release of the β-lactam led to adequate killing of S. aureus but not E. coli in the presence of a mixture of the bacteria, strong inhibition of the colonization of the remaining E. coli on hydrogel coating was observed. These findings will inspire considerations of alternative broad-spectrum antibiotics, optimized drug conjugation, and Oligo linker engineering for more effective protection against polymicrobial periprosthetic infections.
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Affiliation(s)
- Feiyang Chen
- Department of Orthopedics and Physical Rehabilitation, Department of Biochemistry and Molecular Biotechnology, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Jordan D. Skelly
- Department of Orthopedics and Physical Rehabilitation, Department of Biochemistry and Molecular Biotechnology, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Shing-Yun Chang
- Department of Orthopedics and Physical Rehabilitation, Department of Biochemistry and Molecular Biotechnology, UMass Chan Medical School, Worcester, MA 01655, USA
| | - Jie Song
- Department of Orthopedics and Physical Rehabilitation, Department of Biochemistry and Molecular Biotechnology, UMass Chan Medical School, Worcester, MA 01655, USA
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Ashkenazi I, Morgan S, Snir N, Gold A, Dekel M, Warschawski Y. Outcomes of Enterobacter cloacae-Associated Periprosthetic Joint Infection Following Hip Arthroplasties. Clin Orthop Surg 2023; 15:902-909. [PMID: 38045589 PMCID: PMC10689214 DOI: 10.4055/cios23102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 05/05/2023] [Accepted: 05/06/2023] [Indexed: 12/05/2023] Open
Abstract
Background Periprosthetic joint infections (PJIs) represent a serious complication following total hip arthroplasty (THA) and are associated with significant morbidity. While recent data suggest that Enterobacter cloacae is an emerging source of PJI, characteristics and outcomes of E. cloacae-associated infections are rarely described. The study aimed to present and describe the findings and outcomes of E. cloacae-associated PJI in our department. Methods This is a retrospective descriptive study of patients who underwent revision THA for E. cloacae-associated PJI between 2011 and 2020 and has a minimum follow-up of 2 years. Outcomes included organism characteristics as well as clinical outcomes, represented by the number of reoperations needed for PJI eradication and the Musculoskeletal Infection Society (MSIS) outcome reporting tool score. Of 108 revision THAs, 12 patients (11.1%) were diagnosed with E. cloacae-associated PJI. Results The majority of cases had a polymicrobial PJI (n=8, 66.7%). Five E. cloacae strains (41.7%) were gentamicin-resistant. Six patients (50.0%) underwent 2 or more revisions, while 3 of them (25.0%) required 4 or more revisions until their PJI was resolved. When utilizing the MSIS outcome score, the first surgical intervention was considered successful (MSIS score tiers 1 and 2) for 5 patients (41.7%) and failed (tiers 3 and 4) for 7 patients (58.3%). Conclusions E. cloacae is emerging as a common source of PJI following hip arthroplasty procedures. The findings of our study suggest that this pathogen is primarily of polymicrobial nature and represents high virulence and poor postoperative outcomes, as represented by both an increased number of required revision procedures and high rates of patients with MSIS outcome scores of 3 and 4. When managing patients with E. cloacae-associated PJI, surgeons should consider these characteristics and inform patients regarding predicted outcomes.
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Affiliation(s)
- Itay Ashkenazi
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Samuel Morgan
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Nimrod Snir
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Aviram Gold
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
| | - Michal Dekel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
- Infectious Disease Unit, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Yaniv Warschawski
- Division of Orthopedics, Tel Aviv Sourasky Medical Center, Tel-Aviv, Israel
- Sackler Faculty of Medicine, Tel Aviv University, Tel-Aviv, Israel
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Geethan I, HarriVishnu M, Sindhanai V, Subashankar A, KanniRaj M. In Vitro Study of Gentamicin Elution from Tendon Grafts. Indian J Orthop 2023; 57:1118-1125. [PMID: 37384018 PMCID: PMC10293150 DOI: 10.1007/s43465-023-00897-4] [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: 02/23/2023] [Accepted: 04/18/2023] [Indexed: 06/30/2023]
Abstract
Background Though vancomycin-soaked graft reduces the infection rate after ACL reconstruction, concerns exist regarding this usage. Gentamicin has been used for graft soakage with satisfactory clinical results but gentamicin's elution characteristics are unknown. Methods Thirty Bovine tendon grafts were harvested from ten limbs under sterile conditions. Three tendons from each of the limbs were allotted into three groups and soaked in either saline, gentamicin or vancomycin. Pre-soakage and post-soakage swabs were cultured. Soaked grafts were immersed in a 10 ml saline solution for 5 min (initial washout) and then in another 10 ml saline solution (sustained release) for 10 min. No 1 Whatman filter paper was immersed in the solutions and placed on culture plates streaked with coagulase-negative Staphylococcus aureus (CONS) and methicillin-resistant Staphylococcus aureus (MRSA), and inhibition was noted. The difference between the two proportions was assessed by two proportion t-test for p < 0.05. Results No organism was cultured in the pre-soakage or post-soakage swab in any specimen. Specimens from one limb were excluded since saline-soakage showed inhibition. Elution from gentamicin-soaked graft inhibited CONS in eight out of nine samples in initial washout and all samples in sustained release solution but inhibited MRSA only in one sample in sustained release solution and the initial washout solution. Vancomycin elution inhibited both organisms in all samples. Conclusions Gentamicin elution from tendon graft achieves minimal inhibitory concentration against susceptible organisms. Though its clinical utility is restricted by limited antimicrobial spectrum, and it could be used where the risk of contamination by MRSA is low.
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Affiliation(s)
- I. Geethan
- Department of Orthopaedics, Dhanalakshmi Srinivasan Medical College, Perambalur, 620021 India
- 20-A, Mahalakshmi Nagar, K K Nagar Post, Trichy, 620021 India
- Knee and Shoulder Surgery, Arthroscopy Centre Trichy, Tiruchirappalli, India
| | - M. HarriVishnu
- Department of Orthopaedics, Dhanalakshmi Srinivasan Medical College, Perambalur, 620021 India
| | - V. Sindhanai
- Department of Microbiology, Dhanalakshmi Srinivasan Medical College, Perambalur, India
| | - A. Subashankar
- Department of Orthopaedics, Dhanalakshmi Srinivasan Medical College, Perambalur, 620021 India
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Shuaishuai W, Tongtong Z, Dapeng W, Mingran Z, Xukai W, Yue Y, Hengliang D, Guangzhi W, Minglei Z. Implantable biomedical materials for treatment of bone infection. Front Bioeng Biotechnol 2023; 11:1081446. [PMID: 36793442 PMCID: PMC9923113 DOI: 10.3389/fbioe.2023.1081446] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 01/18/2023] [Indexed: 01/31/2023] Open
Abstract
The treatment of bone infections has always been difficult. The emergence of drug-resistant bacteria has led to a steady decline in the effectiveness of antibiotics. It is also especially important to fight bacterial infections while repairing bone defects and cleaning up dead bacteria to prevent biofilm formation. The development of biomedical materials has provided us with a research direction to address this issue. We aimed to review the current literature, and have summarized multifunctional antimicrobial materials that have long-lasting antimicrobial capabilities that promote angiogenesis, bone production, or "killing and releasing." This review provides a comprehensive summary of the use of biomedical materials in the treatment of bone infections and a reference thereof, as well as encouragement to perform further research in this field.
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Affiliation(s)
- Wang Shuaishuai
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Zhu Tongtong
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Wang Dapeng
- Department of Orthopedics, Siping Central Hospital, Siping, China
| | - Zhang Mingran
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Wang Xukai
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Yu Yue
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Dong Hengliang
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China
| | - Wu Guangzhi
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China,*Correspondence: Wu Guangzhi, ; Zhang Minglei,
| | - Zhang Minglei
- Department of Orthopedics, China-Japan Union Hospital of Jilin University, Changchun, China,*Correspondence: Wu Guangzhi, ; Zhang Minglei,
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Regulation of Staphylococcus aureus Virulence and Application of Nanotherapeutics to Eradicate S. aureus Infection. Pharmaceutics 2023; 15:pharmaceutics15020310. [PMID: 36839634 PMCID: PMC9960757 DOI: 10.3390/pharmaceutics15020310] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Revised: 01/11/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023] Open
Abstract
Staphylococcus aureus is a versatile pathogen known to cause hospital- and community-acquired, foodborne, and zoonotic infections. The clinical infections by S. aureus cause an increase in morbidity and mortality rates and treatment costs, aggravated by the emergence of drug-resistant strains. As a multi-faceted pathogen, it is imperative to consolidate the knowledge on its pathogenesis, including the mechanisms of virulence regulation, development of antimicrobial resistance, and biofilm formation, to make it amenable to different treatment strategies. Nanomaterials provide a suitable platform to address this challenge, with the potential to control intracellular parasitism and multidrug resistance where conventional therapies show limited efficacy. In a nutshell, the first part of this review focuses on the impact of S. aureus on human health and the role of virulence factors and biofilms during pathogenesis. The second part discusses the large diversity of nanoparticles and their applications in controlling S. aureus infections, including combination with antibiotics and phytochemicals and the incorporation of antimicrobial coatings for biomaterials. Finally, the limitations and prospects using nanomaterials are highlighted, aiming to foster the development of novel nanotechnology-driven therapies against multidrug-resistant S. aureus.
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Bidolegui F, Codesido M, Pereira S, Abraham A, Pires RE, Giordano V. Antibiotic cement-coated plate is a viable and efficient technique for the definitive management of metaphyseal septic nonunions of the femur and tibia. Rev Col Bras Cir 2023; 49:e20223060. [PMID: 36629717 PMCID: PMC10578849 DOI: 10.1590/0100-6991e-20223060-en] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Accepted: 08/25/2022] [Indexed: 01/11/2023] Open
Abstract
OBJECTIVE the management of septic metaphyseal nonunions is challenging, with inconsistent outcomes. Antibiotic cement-coated implants have been demonstrated good outcome for diaphyseal infected nonunions, however there is no data in metaphyseal infected nonunions. METHODS fifteen adult patients with septic metaphyseal nonunions of the femur or tibia were treated with antibiotic cement-coated plates. The antibiotic cement-coated plate was prepared with either gentamicin or vancomycin. Outcome measures were infection control, bone healing, return to pre-injury level on daily activities, and quality of life at the last follow-up visit. A p value of <5% was considered significant. RESULTS Methicillin-susceptible S. aureus was isolated in 53.3% cases. Average postoperative follow-up time was 18 months. Local infection control and radiographic bone healing were adequately achieved in 93.3% patients. No patient presented recurrent symptoms of surgical site infection. Fourteen patients reported to be either able, or on the same level as before injury, with 73.3% reporting no problems in all five dimensions of the EQ-5D-3L. Persistent infection was the only variable associated with a reduced long-term quality of life. CONCLUSION antibiotic cement-coated plate is a viable and efficient surgical technique for the definitive management of juxta-articular metaphyseal septic nonunions of the femur and tibia.
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Affiliation(s)
- Fernando Bidolegui
- - Hospital Sirio Libanés, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Mariano Codesido
- - Hospital Universitario Austral, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Sebastián Pereira
- - Hospital Sirio Libanés, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Agustín Abraham
- - Hospital Universitario Austral, Servicio de Ortopedia y Traumatología - Buenos Aires - Argentina
| | - Robinson Esteves Pires
- - Universidade Federal de Minas Gerais, Departamento do Aparelho Locomotor - Belo Horizonte - MG - Brasil
| | - Vincenzo Giordano
- - Hospital Municipal Miguel Couto, Serviço de Ortopedia e Traumatologia Prof. Nova Monteiro - Rio de Janeiro - RJ - Brasil
- - Clínica São Vicente, Rede D'or São Luiz, Ortopedia - Rio de Janeiro - RJ - Brasil
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Wei J, Zhou S, Gu H, Tong K. Meropenem-loaded Cement Is Effective in Preventing Gram-negative Osteomyelitis in an Animal Model. Clin Orthop Relat Res 2023; 481:177-189. [PMID: 36135966 PMCID: PMC9750670 DOI: 10.1097/corr.0000000000002364] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2022] [Accepted: 07/27/2022] [Indexed: 01/31/2023]
Abstract
BACKGROUND Low-dose antibiotic-loaded acrylic cement is routinely used for preventing skeletal infection or reimplantation in patients with periprosthetic joint infections. However, few reports about the selection of antibiotics in acrylic cement for antigram-negative bacteria have been proposed. QUESTIONS/PURPOSES (1) Does the addition of antibiotics (tobramycin, meropenem, piperacillin, ceftazidime, ciprofloxacin, and aztreonam) to acrylic cement adversely affect compressive strength before and after elution? (2) Which antibiotics have the highest cumulative release within 28 days? (3) Which antibiotics showed antimicrobial activity within 28 days? (4) Does meropenem-loaded cement improve body weight, temperature, and other inflammatory markers compared with control unloaded cement? METHODS This is an in vitro study that assessed the mechanical strength, antibiotic elution, and antibacterial properties of antibiotic-loaded cement, combined with an animal study in a rat model that evaluated key endpoints from the animal study. In the in vitro study, we added 2 g of tobramycin (TOB), meropenem (MEM), piperacillin (PIP), ceftazidime (CAZ), ciprofloxacin (CIP), and aztreonam (ATM) to 40 g of acrylic cement. The compressive strength, elution, and in vitro antibacterial properties of the antibiotic-loaded cement were detected. Thirty male rats were randomly divided into two groups: CON (antibiotic-unloaded cement) and MEM (meropenem-loaded cement, which had the most stable antibacterial properties of the six tested antibiotic-loaded cements in vitro within 28 days). The right tibia of all rats underwent arthroplasty and was implanted with the cement, followed by inoculation with Pseudomonas aeruginosa in the knee. General status, serum biomarkers, radiology, microbiological assay, and histopathological tests were assessed over 14 days postoperatively. RESULTS The compressive strength of all tested antibiotic cement combinations exceeded the 70 MPa threshold (the requirement established in ISO 5833). The cumulative release proportions of the raw antibiotic in cement were 1182.8 ± 37.9 µg (TOB), 355.6 ± 16.2 µg (MEM), 721.2 ± 40.3 µg (PIP), 477.4 ± 37.1 µg (CAZ), 146.5 ± 11.3 µg (CIP), and 372.1 ± 14.5 µg (ATM) within 28 days. Over a 28-day period, meropenem cement demonstrated antimicrobial activities against the four tested gram-negative bacteria ( Escherichia coli , P. aeruginosa , Klebsiella pneumoniae , and Proteus vulgaris ). Ciprofloxacin cement inhibited E. coli growth, ceftazidime and aztreonam cement inhibited K. pneumonia growth, and tobramycin cement inhibited P. aeruginosa . Only meropenem demonstrated antimicrobial activity against all gram-negative bacteria on agar diffusion bioassay. Rats treated with meropenem cement showed improved body weight (control: 280.1 ± 4.2 g, MEM: 288.5 ± 6.6 g, mean difference 8.4 [95% CI 4.3 to 12.6]; p < 0.001), improved knee width (control: 13.5 ± 0.3 mm, MEM: 11.8± 0.4 mm, mean difference 1.7 [95% CI 1.4 to 2.0]; p < 0.001), decreased inflammatory marker (control: 316.7 ± 45.0 mm, MEM: 116.5 ± 21.8 mm, mean difference 200.2 [95% CI 162.3 to 238.2]; p < 0.001), decreased radiographic scores (control: 17.7 ± 2.0 mm, MEM: 10.7± 1.3 mm, mean difference 7.0 [95% CI 5.4 to 8.6]; p < 0.001), improved bone volume/total volume (control: 8.7 ± 3.0 mm, MEM: 28.5 ± 5 .5 mm, mean difference 19.8 [95% CI 13.3 to 26.2]; p < 0.001), decreased Rissing scale scores of the knee gross pathology (control: 3.3 ± 0.5, MEM: 1.1 ± 0.7, mean difference 2.2 [95% CI 1.7 to 2.7]; p < 0.001), decreased Petty scale scores of knee synovium (control: 2.9 ± 0.4 mm, MEM: 0.7 ± 0.7 mm, mean difference 2.1 [95% CI 1.7 to 2.5]; p < 0.001), and decreased bacterial counts of the bone and soft tissues and negative bacterial cultures of cement (p < 0.001, p < 0.001, p < 0.001, p < 0.001, respectively). CONCLUSION In this current study, MEM cement had the most stable in vitro antimicrobial activities, effective in vivo activity while having acceptable mechanical and elution characteristics, and it may be an effective prophylaxis against skeletal infection caused by gram-negative bacteria. CLINICAL RELEVANCE Meropenem-loaded acrylic cement is a potentially effective prevention measure for skeletal infection caused by gram-negative bacteria; however, more related clinical research is needed to further evaluate the safety and efficacy.
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Affiliation(s)
- Jian Wei
- Department of Joint Orthopedics, Liuzhou People's Hospital, Liuzhou, China
| | - Siqi Zhou
- Department of Joint Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Hanwen Gu
- Department of Joint Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Kai Tong
- Department of Joint Orthopedics, Zhongnan Hospital of Wuhan University, Wuhan, China
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Does addition of gentamicin for antibiotic prophylaxis in total knee arthroplasty reduce the rate of periprosthetic joint infection? Arch Orthop Trauma Surg 2022:10.1007/s00402-022-04744-3. [PMID: 36576575 DOI: 10.1007/s00402-022-04744-3] [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: 09/28/2022] [Accepted: 12/20/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND First-generation cephalosporins are used as antibiotic prophylaxis in total joint arthroplasty patients. However, this regimen does not address Gram-negative bacteria causing periprosthetic joint infection (PJI). Previous studies have suggested that the addition of an aminoglycoside as antibiotic prophylaxis in THA reduces surgical site infection (SSI), and less is known on its effect in TKA. This study aimed to investigate if the addition of a single-dose gentamicin, administered pre-operatively, is associated with lower rates of infection in TKA patients. PATIENTS AND METHODS This is a retrospective study of patients who underwent primary TKA as treatment for osteoarthritis between January 2011 and April 2021, with a minimum 1-year follow-up. The mean age was 69.9 (± 9.8), the mean BMI was 29.7 (± 5.5), and most patients had American Society of Anaesthesiology (ASA) score of 2-3 (92.9%). Patients were stratified based on the peri-operative antibiotic prophylaxis they received: cefazolin with addition of gentamicin (case group) or cefazolin (control group). Our primary study endpoints were rates of PJI and SSI, which were compared between groups using the chi-square test. Statistical significance was set as p < 0.05. RESULTS The final study population consisted of 1590 patients, 1008 (63.4%) in the control group and 582 (36.6%) patients in the case group. The total infection rate for patients that received gentamicin dropped by 34%; however, this finding did not reach statistical significance (1.3% (control) vs. 0.86% (case), p = 0.43). The same drop was seen after subdivision of infections to PJI (0.5% vs. 0.34%, 32% drop, p = 0.66) and SSI (0.8% vs. 0.52%, 35% drop, p = 0.52). CONCLUSIONS A single dose of gentamicin administered pre-operatively to a standard antibiotic prophylaxis was not associated with a statistically significant lower rate of PJI. Although the difference in infection rate did not reach statistical significance, the current study noted a drop in the rate of infection by 1/3 in the gentamicin cohort. Further investigation to evaluate the potential benefit of adding gentamicin to a peri-operative antibiotic regimen is warranted.
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Goyal T, Dhamija P, Vardhan G, Gupta P, Trikha V. In vitro study of elution kinetics and biological activity of piperacillin/tazobactam and gentamicin in acrylic bone cement. Orthop Traumatol Surg Res 2022; 108:103230. [PMID: 35123032 DOI: 10.1016/j.otsr.2022.103230] [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: 08/21/2020] [Revised: 03/28/2021] [Accepted: 04/02/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Antibiotics differ in their elution characteristics from bone cement. But no such data is available on piperacillin and tazobactam. Therefore, we performed an in vitro observational study to examine (1) in vitro elution characteristics of piperacillin and tazobactam from bone cement, (2) their biological activity using minimum inhibitory concentration and (3) elution characteristics and biological activity when combined with gentamicin in bone cement. HYPOTHESIS The null hypothesis was that piperacillin and tazobactam after elution from bone cement can achieve concentrations higher than minimum inhibitory concentration. MATERIAL AND METHODS Forty milligrams bone cement was mixed with the following combination of antibiotics: without any antibiotic (sample A, control), 4g/0.50g piperacillin/tazobactam (sample B), 6g/0.75g piperacillin/tazobactam (sample C), 8g/1.0g piperacillin/tazobactam (sample D) and 4g/0.50g piperacillin/tazobactam and 400mg gentamicin (sample E). Samples were analysed on reverse-phase ultra-high-performance liquid chromatography. Antibacterial activity in the elute were tested against standard American Type Culture Collection (ATCC) strains. RESULTS Detectable drug elution for piperacillin and tazobactam was seen till 21days. Peak drug levels for all formulations were seen at 48hours (140.8 & 297.5μg/mL for samples B of piperacillin and tazobactam respectively). About 0.83-1.24% of piperacillin and 23.17-29.17% of tazobactam were released from the samples. Gentamicin improved elution of piperacillin and tazobactam: 140.8 vs. 919.9μg/mL (p=0.000) for samples B & E of piperacillin respectively and 297.5 & 1138.4μg/mL (p=0.001) for samples B & E of tazobactam respectively at 2days. Sample E showed complete inhibition of tested microorganisms, while B sample was microbiologically less active compared to E on day 5. CONCLUSIONS Piperacillin and tazobactam eluted successfully from bone cement and also retained antimicrobial activity after elution. Maximum elution was seen up to day 2 after which it reduced drastically. Antimicrobial action was seen up to 7days. LEVEL OF EVIDENCE III; comparative study.
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Affiliation(s)
- Tarun Goyal
- Department of Orthopaedics, All India Institute of Medical Sciences, Dabwali Road, Bathinda, Punjab 151001, India.
| | - Puneet Dhamija
- Pharmacology Department, All India Institute of Medical Sciences, Virbhadra Marg, Pashulok, Rishikesh, Uttarakhand 249203, India
| | - Gyan Vardhan
- Pharmacology Department, All India Institute of Medical Sciences, Virbhadra Marg, Pashulok, Rishikesh, Uttarakhand 249203, India
| | - Pratima Gupta
- Department of Microbiology All India Institute of Medical Sciences, Virbhadra Marg, Pashulok, Rishikesh, Uttarakhand 249203, India
| | - Vivek Trikha
- Department of Orthopaedics, All India Institute of Medical Sciences, Virbhadra Marg, Pashulok, Rishikesh, Uttarakhand 249203, India
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Tut TA, Cesur S, Ilhan E, Sahin A, Yildirim OS, Gunduz O. Gentamicin-loaded polyvinyl alcohol/whey protein isolate/hydroxyapatite 3D composite scaffolds with drug delivery capability for bone tissue engineering applications. Eur Polym J 2022. [DOI: 10.1016/j.eurpolymj.2022.111580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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15
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Balcioglu S, Noma SAA, Ulu A, Karaaslan-Tunc MG, Ozhan O, Koytepe S, Parlakpinar H, Vardi N, Colak MC, Ates B. Fast Curing Multifunctional Tissue Adhesives of Sericin-Based Polyurethane-Acrylates for Sternal Closure. ACS APPLIED MATERIALS & INTERFACES 2022; 14:41819-41833. [PMID: 36066351 PMCID: PMC9501797 DOI: 10.1021/acsami.2c14078] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 08/22/2022] [Indexed: 06/09/2023]
Abstract
The use of wire cerclage after sternal closure is the standard method because of its rigidity and strength. Despite this, they have many disadvantages such as tissue trauma, operator-induced failures, and the risk of infection. To avoid complications during sternotomy and promote tissue regeneration, tissue adhesives should be used in post-surgical treatment. Here, we report a highly biocompatible, biomimetic, biodegradable, antibacterial, and UV-curable polyurethane-acrylate (PU-A) tissue adhesive for sternal closure as a supportive to wire cerclage. In the study, PU-As were synthesized with variable biocompatible monomers, such as silk sericin, polyethylene glycol, dopamine, and an aliphatic isocyanate 4,4'-methylenebis(cyclohexyl isocyanate). The highest adhesion strength was found to be 4322 kPa, and the ex vivo compressive test result was determined as 715 kPa. The adhesive was determined to be highly biocompatible (on L-929 cells), biodegradable, and antibacterial (on Escherichia coli, Pseudomonas aeruginosa, and Staphylococcus aureus bacteria). Finally, after opening the sternum of rats, the adhesive was applied to bond the bones and cured with UV for 5 min. According to the results, there was no visible inflammation in the adhesive groups, while some animals had high inflammation in the cyanoacrylate and wire cerclage groups. These results indicate that the adhesive may be suitable for sternal fixation by preventing the disadvantages of the steel wires and promoting tissue healing.
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Affiliation(s)
- Sevgi Balcioglu
- Department
of Medicinal Laboratory, Sakarya University
of Applied Sciences, 54000 Sakarya, Turkey
| | - Samir Abbas Ali Noma
- Faculty
of Arts and Sciences, Department of Chemistry, Bursa Uludaǧ University, 16059 Bursa, Turkey
| | - Ahmet Ulu
- Faculty
of Arts and Sciences, Department of Chemistry, İnönü University, 44210 Malatya, Turkey
| | | | - Onural Ozhan
- Medical
Faculty, Department of Medicinal Pharmacology, İnönü University, 44210 Malatya, Turkey
| | - Suleyman Koytepe
- Faculty
of Arts and Sciences, Department of Chemistry, İnönü University, 44210 Malatya, Turkey
| | - Hakan Parlakpinar
- Medical
Faculty, Department of Medicinal Pharmacology, İnönü University, 44210 Malatya, Turkey
| | - Nigar Vardi
- Medical
Faculty, Department of Histology and Embryology, İnönü University, 44210 Malatya, Turkey
| | - Mehmet Cengiz Colak
- Medical Faculty,
Department of Cardiovascular Surgery, İnönü
University, 44210 Malatya, Turkey
| | - Burhan Ates
- Faculty
of Arts and Sciences, Department of Chemistry, İnönü University, 44210 Malatya, Turkey
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Al Thaher Y, Khalil R, Abdelghany S, Salem MS. Antimicrobial PMMA Bone Cement Containing Long Releasing Multi-Walled Carbon Nanotubes. NANOMATERIALS 2022; 12:nano12081381. [PMID: 35458089 PMCID: PMC9026701 DOI: 10.3390/nano12081381] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/26/2022] [Revised: 04/09/2022] [Accepted: 04/13/2022] [Indexed: 02/07/2023]
Abstract
Prosthetic joint infections (PJIs) ensued from total joint replacement (TJR) pose a severe threat to patients that involve poor health outcomes, severe pain, death (in severe cases), and negative influence patients' quality of life. Antibiotic-loaded bone cement (ALBC) is frequently used for the prevention and treatment of PJI. This work aims to study gentamicin release from carbon nanotubes (CNTs) incorporated in polymethyl methacrylate (PMMA) bone cement to prolong release over several weeks to provide prophylaxis from PJIs after surgery. Different CNT concentrations were tested with the presence of gentamicin as a powder or preloaded onto carboxyl functionalized CNTs. The different types of bone cement were tested for drug release, mechanical properties, water uptake, antimicrobial properties, and cytocompatibility with human osteoblast cells (MTT, LDH, alizarin red, and morphology). Results showed prolonged release of gentamicin from CNT-loaded bone cements over several weeks compared to gentamicin-containing bone cement. Additionally, the presence of CNT enhanced the percentage of gentamicin released without adversely affecting the nanocomposite mechanical and antimicrobial properties needed for performance. Cytotoxicity testing showed non-inferior performance of the CNT-containing bone cement to the equivalent powder containing cement. Therefore, the developed nanocomposites may serve as a novel PMMA bone cement to prevent PJIs.
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Affiliation(s)
- Yazan Al Thaher
- Faculty of Pharmacy, Philadelphia University, Amman 19392, Jordan;
- Correspondence:
| | - Raida Khalil
- Department of Biotechnology and Genetic Engineering, Faculty of Science, Philadelphia University, Amman 19392, Jordan;
| | | | - Mutaz S. Salem
- Faculty of Pharmacy, Philadelphia University, Amman 19392, Jordan;
- Faculty of Pharmacy, Jordan University of Science and Technology, Irbid 22110, Jordan
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A comparison of low-dose teicoplanin-loaded spacer application vs. high-dose vancomycin-and-gentamicin-loaded spacer application in the treatment of periprosthetic knee infection. JOURNAL OF ORTHOPAEDICS, TRAUMA AND REHABILITATION 2022. [DOI: 10.1177/22104917221082312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Background/purpose In the current study, our aim was to compare the efficacy and biocompatibility of teicoplanin-loaded and vancomycin-and-gentamicin-loaded articulating spacers used in two-stage revision arthroplasty for eradication of periprosthetic knee joint infection. Methods In the current retrospective cohort study, there were 24 patients who were given 2 g or less antibiotics per 40 g of cement in the low-dose teicoplanin group, and 20 patients who were given a total of 3.6 g or more antibiotics per 40 g of cement in the high-dose vancomycin and gentamicin group. Two groups were compared statistically. Results There was no statistically significant difference in the treatment failure between the two groups (p = 0.488). No statistically significant differences were found in spacer fracture rates between the two groups (p = 0.802). Conclusion The current study has demonstrated that low-dose teicoplanin protocol is as effective and safe as high-dose vancomycin and gentamycin protocol.
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18
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Lex JR, Koucheki R, Stavropoulos NA, Michele JD, Toor JS, Tsoi K, Ferguson PC, Turcotte RE, Papagelopoulos PJ. Megaprosthesis anti-bacterial coatings: A comprehensive translational review. Acta Biomater 2022; 140:136-148. [PMID: 34879295 DOI: 10.1016/j.actbio.2021.11.045] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Revised: 11/29/2021] [Accepted: 11/30/2021] [Indexed: 12/15/2022]
Abstract
Periprosthetic joint infections (PJI) are catastrophic complications for patients with implanted megaprostheses and pose significant challenges in the management of orthopaedic oncology patients. Despite various preventative strategies, with the increasing rate of implanted orthopaedic prostheses, the number of PJIs may be increasing. PJIs are associated with a high rate of amputation. Therefore, novel strategies to combat bacterial colonization and biofilm formation are required. A promising strategy is the utilization of anti-bacterial coatings on megaprosthetic implants. In this translational review, a brief overview of the mechanism of bacterial colonization of implants and biofilm formation will be provided, followed by a discussion and classification of major anti-bacterial coatings currently in use and development. In addition, current in vitro outcomes, clinical significance, economic importance, evolutionary perspectives, and future directions of anti-bacterial coatings will also be discussed. Megaprosthetic anti-bacterial coating strategies will help reduce infection rates following the implantation of megaprostheses and would positively impact sarcoma care. STATEMENT OF SIGNIFICANCE: This review highlights the clinical challenges and a multitude of potential solutions to combating peri-prosthetic join infections in megaprotheses using anti-bacterial coatings. Reducing infection rates following the implantation of megaprostheses would have a major impact on sarcoma care and major trauma surgeries that require reconstruction of large skeletal defects.
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Affiliation(s)
- Johnathan R Lex
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Robert Koucheki
- Temerty Faculty of Medicine, University of Toronto, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Canada
| | | | - Joseph Di Michele
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Jay S Toor
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada
| | - Kim Tsoi
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada; Institute of Biomedical Engineering, University of Toronto, Toronto, Canada; University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Peter C Ferguson
- Division of Orthopaedic Surgery, Department of Surgery, University of Toronto, Toronto, Canada; University Musculoskeletal Oncology Unit, Mount Sinai Hospital, Toronto, Canada
| | - Robert E Turcotte
- Division of Orthopedic Surgery, McGill University Health Centre, Montreal, Canada
| | - Panayiotis J Papagelopoulos
- 1st Department of Orthopaedic Surgery, School of Medicine, National and Kapodistrian University of Athens, Greece
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Prophylactic Antibiofilm Activity of Antibiotic-Loaded Bone Cements against Gram-Negative Bacteria. Antibiotics (Basel) 2022; 11:antibiotics11020137. [PMID: 35203740 PMCID: PMC8868455 DOI: 10.3390/antibiotics11020137] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 01/13/2022] [Accepted: 01/19/2022] [Indexed: 02/01/2023] Open
Abstract
Gram-negative bacilli can be responsible for prosthetic joint infection (PJI) even if staphylococci are the main involved pathogens. Gram-negative PJIs (GN-PJI) are considered difficult-to-treat infections due to the increase in antimicrobial resistance and biofilm formation. To minimize the risk of infection in cases of arthroplasties with cemented prosthesis, bone cement can be loaded with antibiotics, especially gentamicin. In this study, we aimed to compare the prophylactic antibiofilm activity of ready-to-use antibiotic-loaded bone cements (ALBC), already commercialized or new prototypes. We compared ALBCs containing gentamicin alone, gentamicin plus vancomycin, gentamicin plus clindamycin, gentamicin plus Fosfomycin, and fosfomycin alone, to plain cement (no antibiotic); these comparisons were conducted to investigate the biofilm formation of three strains of Escherichia coli, three strains of Pseudomonas aeruginosa and two strains of Klebsiella pneumoniae, with or without specific resistance to gentamicin or fosfomycin. We reported that ALBC containing gentamicin and clindamycin (COPAL G+C) seems to be the most interesting ALBC of our tested panel for the prevention of biofilm formation by gentamicin-susceptible strains, even if clindamycin is not effective against Gram-negative bacteria. However, gentamicin-resistant strains are still a problem, and further studies are needed to identify an antibiotic to associate with gentamicin for an efficient dual ALBC against Gram-negative bacteria.
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BIDOLEGUI FERNANDO, CODESIDO MARIANO, PEREIRA SEBASTIÁN, ABRAHAM AGUSTÍN, PIRES ROBINSONESTEVES, GIORDANO VINCENZO. O uso de placas revestidas de cimentado com antibiótico é uma técnica viável e eficiente para o tratamento da pseudoartrose infectada da metáfise do fêmur e da tíbia. Rev Col Bras Cir 2022. [DOI: 10.1590/0100-6991e-20223060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
RESUMO Introdução: implantes revestidos de cimento com antibiótico vêm demonstrando bons resultados no tratamento da pseudoartrose infectada da diáfise, no entanto seu uso na metáfise dos ossos longos ainda é pouco explorado. Neste estudo relatamos uma série de casos de pseudoartrose infectada da metáfise do fêmur e da tíbia tratados com o uso de placas revestidas de cimento com antibiótico. Métodos: Os antibióticos usados foram gentamicina e/ou vancomicina. Os desfechos analisados na última visita ambulatorial foram controle de infecção, consolidação óssea, retorno às atividades diárias e qualidade de vida. Regressão linear bivariada foi usada para avaliar fatores individuais que afetaram a qualidade de vida dos pacientes. Um valor p<5% foi considerado estatisticamente significativo. Resultados: quinze pacientes adultos foram incluídos no estudo. S. aureus suscetível à meticilina foi isolado em 53,3% dos casos. O tempo médio de acompanhamento pós-operatório foi de 18 meses. Controle local da infecção e consolidação óssea radiográfica foram alcançados em 93,3% dos pacientes. Nenhum paciente apresentou sintomas recorrentes de infecção de sítio cirúrgico. Quatorze pacientes relataram ser capazes, mas não no nível pré-lesional ou no mesmo nível de antes da lesão, com 73,3% relatando nenhum problema em todas as cinco dimensões do EQ-5D-3L. Infecção persistente foi a única variável associada à redução da qualidade de vida a longo prazo. Conclusão: A placa revestida de cimento com antibiótico mostrou-se uma técnica cirúrgica viável e eficiente para o tratamento da pseudoartrose infectada da metáfise do fêmur e da tíbia.
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Affiliation(s)
| | - MARIANO CODESIDO
- Hospital Universitario Austral, Servicio de Ortopedia y Traumatología, Argentina
| | | | - AGUSTÍN ABRAHAM
- Hospital Universitario Austral, Servicio de Ortopedia y Traumatología, Argentina
| | | | - VINCENZO GIORDANO
- Hospital Municipal Miguel Couto, Brasil; Clínica São Vicente, Brazil
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Balcioglu S, Gurses C, Ozcan I, Yildiz A, Koytepe S, Parlakpinar H, Vardi N, Ates B. Photocrosslinkable gelatin/collagen based bioinspired polyurethane-acrylate bone adhesives with biocompatibility and biodegradability. Int J Biol Macromol 2021; 192:1344-1356. [PMID: 34536477 DOI: 10.1016/j.ijbiomac.2021.09.043] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2021] [Revised: 08/30/2021] [Accepted: 09/08/2021] [Indexed: 01/11/2023]
Abstract
Hard or soft tissue adhesives have been presented as a promising candidate to replace traditional wound closure methods. However, there are mechanical strength problems in biological adhesives and biocompatibility problems in synthetic-based adhesives. At this point, we aimed to remove all these disadvantages and produce a single adhesive that contains all the necessary features and acrylate functionalized UV-curable polyurethane formulations were produced with high crosslink density, high adhesion strength, biocompatibility and injectable property for easy application as potential biomedical adhesives. Aliphatic isophorone diisocyanate (IPDI) was used as the isocyanate source and β-cyclodextrin was used for host-guest relationship with gentamicin by crosslinking. Proteins (gelatin (GEL), collagen (COL)) and PEGs of various molecular weight ranges (P200, P400, P600) were selected as the polyol backbone for polyurethane synthesis due to their multiple biological activities such as biocompatibility, biodegradability, biomimetic property. Several techniques have been used to characterize the structural, thermal, morphological, and various other physicochemical properties of the adhesive formulations. Besides, the possibility of its use as a hard tissue adhesive was investigated by evaluating the tissue adhesion strength in vitro and ex vivo via a universal testing analyzer in tensile mode. Corresponding adhesive formulations were evaluated by in vitro and in vivo techniques for biocompatibility. The best adhesion strength results were obtained as 3821.0 ± 214.9, and 3722.2 ± 486.8 kPa, for IPDI-COL-P200 and IPDI-GEL-P200, respectively. Good antibacterial activity capability toward Escherichia coli Pseudomonas aeruginosa, and Staphylococcus aureus were confirmed using disc diffusion method. Moreover, cell viability assay demonstrated that the formulations have no significant cytotoxicity on the L929 fibroblast cells. Most importantly, we finally performed the in vivo biodegradability and in vivo biocompatibility evaluations of the adhesive formulations on rat model. Considering their excellent cell/tissue viability, fast curable, strong adhesion, high antibacterial character, and injectability, these adhesive formulations have significant potential for tissue engineering applications.
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Affiliation(s)
- Sevgi Balcioglu
- Sakarya University of Applied Sciences, Department of Medicinal Laboratory, Sakarya, Turkey.
| | - Canbolat Gurses
- İnönü University, Science Faculty, Department of Molecular Biology and Genetics, Malatya, Turkey
| | - Imren Ozcan
- İnönü University, Science Faculty, Department of Chemistry, Malatya, Turkey
| | - Azibe Yildiz
- İnönü University, Medical Faculty, Department of Histology and Embryology, Malatya, Turkey
| | - Suleyman Koytepe
- İnönü University, Science Faculty, Department of Chemistry, Malatya, Turkey
| | - Hakan Parlakpinar
- İnönü University, Medical Faculty, Department of Medicinal Pharmacology, Malatya, Turkey
| | - Nigar Vardi
- İnönü University, Medical Faculty, Department of Histology and Embryology, Malatya, Turkey
| | - Burhan Ates
- İnönü University, Science Faculty, Department of Chemistry, Malatya, Turkey.
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22
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Jiang X, Bu F, Xu Y, Jing Z, Jiao G, Li M, Rong X. Antibiotic-loaded bone cement combined with vacuum sealing drainage to treat deep sternal wound infection following cardiac surgery: the first case report. J Cardiothorac Surg 2021; 16:292. [PMID: 34629078 PMCID: PMC8504067 DOI: 10.1186/s13019-021-01673-x] [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: 07/04/2021] [Accepted: 09/25/2021] [Indexed: 11/18/2022] Open
Abstract
Background Deep sternal wound infection (DSWI) is a rare but serious complication after median sternotomy, and treatment success depends mainly on surgical experience. Here we first present a case of a patient successfully treated for antibiotic-loaded bone cement (ALBC) combined with vacuum sealing drainage (VSD) of DSWI. Case presentation This case report presented a patient who underwent open heart surgery, and suffered postoperatively from a DSWI associated with enterococcus cloacae. Focus debridement combined with ALBC filling and VSD was conducted in stage I. Appropriate antibiotics were started according to sensitivity to be continued for 2 weeks until the inflammatory markers decreased to normal. One month after the surgery, patient’s wound was almost healed and was discharged from hospital with a drainage tube. Two months after the stage I surgery procedure, the major step was removing the previous ALBC, and extensive debridement in stage II. The patient fully recovered without further surgical treatment. Conclusions The results of this case suggest that ALBC combined with VSD may be a viable and safe option for deep sternal wound reconstruction.
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Affiliation(s)
- Xia Jiang
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Fanyu Bu
- Department of Chronic Wound, Wuxi Ninth People's Hospital Affiliated to Soochow University, Wuxi, 214062, China
| | - Yong Xu
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Zhaohui Jing
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Guoqing Jiao
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China
| | - Mingqiu Li
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China.
| | - Xiaosong Rong
- Department of Cardiovascular Surgery, Wuxi People's Hospital/Wuxi Affiliated Hospital of Nanjing Medical University, Wuxi, 214203, China.
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23
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Shahid A, Aslam B, Muzammil S, Aslam N, Shahid M, Almatroudi A, Allemailem KS, Saqalein M, Nisar MA, Rasool MH, Khurshid M. The prospects of antimicrobial coated medical implants. J Appl Biomater Funct Mater 2021; 19:22808000211040304. [PMID: 34409896 DOI: 10.1177/22808000211040304] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
The implants are increasingly being a part of modern medicine in various surgical procedures for functional or cosmetic purposes. The progressive use of implants is associated with increased infectious complications and prevention of such infections always remains precedence in the clinical settings. The preventive approaches include the systemic administration of antimicrobial agents before and after the surgical procedures as well as the local application of antibiotics. The relevant literature and existing clinical practices have highlighted the role of antimicrobial coating approaches in the prevention of implants associated infections, although the applications of these strategies are not yet standardized, and the clinical efficacy is not much clear. The adequate data from the randomized control trials is challenging because of the unavailability of a large sample size although it is compulsory in this context to assess the clinical efficacy of preemptive practices. This review compares the efficacy of preventive approaches and the prospects of antimicrobial-coated implants in preventing implant-related infections.
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Affiliation(s)
- Aqsa Shahid
- Department of Microbiology, Government College University, Faisalabad, Pakistan
| | - Bilal Aslam
- Department of Microbiology, Government College University, Faisalabad, Pakistan
| | - Saima Muzammil
- Department of Microbiology, Government College University, Faisalabad, Pakistan
| | - Nosheen Aslam
- Department of Biochemistry, Government College University, Faisalabad, Pakistan
| | - Muhammad Shahid
- Department of Bioinformatics and Biotechnology, Government College University, Faisalabad, Pakistan
| | - Ahmad Almatroudi
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia
| | - Khaled S Allemailem
- Department of Medical Laboratories, College of Applied Medical Sciences, Qassim University, Buraydah, Saudi Arabia
| | - Muhammad Saqalein
- Department of Microbiology, Government College University, Faisalabad, Pakistan
| | - Muhammad Atif Nisar
- Department of Microbiology, Government College University, Faisalabad, Pakistan.,College of Science and Engineering, Flinders University, Bedford Park, SA, Australia
| | | | - Mohsin Khurshid
- Department of Microbiology, Government College University, Faisalabad, Pakistan
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24
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Hu S, Xue Y, He J, Chen C, Sun J, Jin Y, Zhang Y, Shi Q, Rui Y. Irisin recouples osteogenesis and osteoclastogenesis to protect wear-particle-induced osteolysis by suppressing oxidative stress and RANKL production. Biomater Sci 2021; 9:5791-5801. [PMID: 34323888 DOI: 10.1039/d1bm00563d] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The disruption of bone homeostasis with the decrease in osteoblastic bone formation and facilitated osteoclastic bone resorption is the leading cause of periprosthetic osteolysis. Accumulative studies have indicated that irisin has the function of maintaining and rebalancing bone homeostasis. In this study, we explored the protective effect of irisin on wear-particle-induced osteolysis in mice. The results showed that irisin effectively inhibited titanium (Ti) particle-induced calvarial osteolysis, supported by a lower bone loss and existence of more collagen, compared with the ones stressed by Ti particles. Further analysis demonstrated that irisin not only rescued Ti-particle-impaired osteogenesis derived from bone mesenchymal stem cells (BMSCs) but also alleviated the increase in wear-particle-induced nuclear factor-κB ligand (RANKL) secreted by BMSCs-derived osteoblasts, which consequently restrained the activation of osteoclasts. Meanwhile, irisin inhibited osteoclastogenesis by the direct inactivation of reactive oxygen species (ROS) signaling. These results revealed that irisin functions to fight against osteolysis caused by wear particles through rebalancing the periprosthetic bone homeostasis microenvironment, which may provide a potential therapeutic strategy for the management of osteolysis and induced prosthetic loosening.
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Affiliation(s)
- Sihan Hu
- Department of Orthopedics, the First Affiliated Hospital of Soochow University, Orthopedics Institute of Soochow University, Medical College of Soochow University, Suzhou, Jiangsu 215006, P. R. China.
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25
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Budiatin AS, Gani MA, Ardianto C, Pattah SYD, Mubarokah F, Khotib J. The impact of glutaraldehyde on the characteristics of bovine hydroxyapatite-gelatin based bone scaffold as gentamicin delivery system. J Basic Clin Physiol Pharmacol 2021; 32:687-691. [PMID: 34214365 DOI: 10.1515/jbcpp-2020-0405] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2020] [Accepted: 02/03/2021] [Indexed: 12/30/2022]
Abstract
OBJECTIVES Biomaterials are widely used as drug delivery systems targeting bone tissue, such as to treat bone infectious disease. However, the addition of drugs to biomaterials weakens their mechanical properties. Crosslinkers are compounds that improve the mechanical properties of biomaterials. This study aims to determine the effect of glutaraldehyde (GTA) as a crosslinker on the characteristics of bovine hydroxyapatite-gelatin-based bone scaffold with gentamicin as antibiotics (BHA-GEL-GEN-GTA). METHODS BHA-GEL-GEN-GTA scaffold with GTA solid content ranging from 0.1 to 1.4 wt% was made by direct compression. The compressive strength test was carried out using autograph. Scaffold degradation test was carried out by dissolving the scaffolds in PBS. Scaffold toxicity was performed by MTT assay using BHK-21 fibroblast cells. RESULTS There was a significant difference in the scaffolds' compressive strength due to differences in GTA volume. Scaffold crosslinked using GTA with solid content 0.1 and 0.2 wt% in 2 mL solution had higher compressive strength than those in 1 mL solution. Furthermore, GTA with solid content 0.6, 1, 1.2, and 1.4 wt% showed higher compressive strength than those without GTA. Degradation test results showed that GTA increased the percentage of weight loss and swelling of the scaffold. The scaffold exhibited a nontoxic profile in MTT assay. CONCLUSIONS GTA with optimum solid content shows great compressive strength, stable swelling profile with low percentage of scaffold's weight loss, and is considered as nontoxic.
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Affiliation(s)
- Aniek Setiya Budiatin
- Department of Clinical Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
| | - Maria Apriliani Gani
- Department of Clinical Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
| | - Chrismawan Ardianto
- Department of Clinical Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
| | | | - Fitroh Mubarokah
- Department of Clinical Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
| | - Junaidi Khotib
- Department of Clinical Pharmacy, Faculty of Pharmacy, Airlangga University, Surabaya, Indonesia
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26
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Ge SM, Harvey EJ. Collagen fleece in orthopaedic infections. OTA Int 2021; 4:e111(1-5). [PMID: 37609481 PMCID: PMC10441674 DOI: 10.1097/oi9.0000000000000111] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Revised: 11/05/2020] [Accepted: 12/11/2020] [Indexed: 08/24/2023]
Abstract
Collagen fleece is a relatively new development. It represents another option in the battle against infection. It is a cheap, biocompatible, and resorbable local antibiotic delivery mechanism with favorable drug release kinetics and low risk of adverse effects or toxicity. Benefit may be conferred when used in contaminated cases. Significantly more research is still needed before the adoption of collagen fleece as the standard of care. However, we can likely conclude that there are no major adverse effects and it can be safely used as an adjunct in addition to conventional therapies for the prophylaxis and treatment of infections.
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27
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Huchital MJ, Saleh A, Patel R, Subik M. Cancelloplasty for Treatment of Osteomyelitis of the Calcaneus: A Novel Technique and Case Report. Foot Ankle Spec 2021; 14:255-265. [PMID: 33272060 DOI: 10.1177/1938640020975885] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Calcaneal osteomyelitis has the potential to cause limb- and life-threatening complications. The anatomic and biomechanical attributes of the heel make limb salvage in the setting of bone infection complex. Current treatment options include surgical resection of part or all of the calcaneus, lower extremity amputation, or prolonged intravenous antibiotic usage. Each modality has its own inherent disadvantages. We present a novel surgical technique using antibiotic-impregnated calcium phosphate as an alternative treatment option coupled with ultrasonic bone dissection as a method for enhancing delivery of antibiotics, while mitigating tissue damage and maintaining osseous integrity. The details of the surgical technique are discussed along with a single case example.
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Affiliation(s)
- Michael J Huchital
- North Jersey Reconstructive Foot and Ankle Fellowship, Lyndhurst, New Jersey
| | - Ali Saleh
- Department of Podiatry, Saint Mary's General Hospital, Passaic, New Jersey
| | - Rajan Patel
- North Jersey Reconstructive Foot and Ankle Fellowship, Lyndhurst, New Jersey
| | - Michael Subik
- North Jersey Reconstructive Foot and Ankle Fellowship, Lyndhurst, New Jersey.,Department of Podiatry, Saint Mary's General Hospital, Passaic, New Jersey
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28
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Bovine Hydroxyapatite-Based Bone Scaffold with Gentamicin Accelerates Vascularization and Remodeling of Bone Defect. Int J Biomater 2021; 2021:5560891. [PMID: 34104195 PMCID: PMC8159631 DOI: 10.1155/2021/5560891] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/28/2021] [Indexed: 12/21/2022] Open
Abstract
Osteomyelitis is an infectious disease which is also a major complication of bone defects. This study aims to determine the effect of bovine hydroxyapatite-gelatin-based bone implants with gentamicin as an antibiotic (BHA-GEL-GEN implant) on the regeneration of bone defects in vivo. The BHA-GEL-GEN and BHA-GEL implants were made by direct compression. In vivo study was carried out with Wistar rats. The rats were divided into three groups: negative control, BHA-GEL implant, and BHA-GEL-GEN implants. The defect model used was the burr hole defect model with diameter 2.2 mm and 2 mm deep. After 2, 7, 14, and 28 days, the rats were sacrificed. Bone integrity was carried out using X-ray radiography. Radiological examination was performed using haematoxylin and eosin (HE) staining and immunohistochemical techniques with anti-vascular endothelial growth factor (VEGF) and anti-alkaline phosphatase (ALP) antibodies. Based on the radiograph, the implanted group had accelerated bone growth in the defect area. Semiquantitative data from HE staining showed that the implanted group had accelerated migration of osteoclasts, osteoblasts, and osteocytes in the defect area. The immunoreactive score showed that the BHA-GEL-GEN group had higher VEGF expression compared to two other groups. The three groups did not provide a significant difference in ALP expression. In conclusion, the BHA-GEL-GEN implant causes accelerated bone defects repair by accelerating tissue vascularity and does not interfere with the bone remodeling process. Therefore, the BHA-GEL-GEN implant is potentially a biomedical material for osteomyelitis therapy.
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29
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Berberich CE, Josse J, Laurent F, Ferry T. Dual antibiotic loaded bone cement in patients at high infection risks in arthroplasty: Rationale of use for prophylaxis and scientific evidence. World J Orthop 2021; 12:119-128. [PMID: 33816139 PMCID: PMC7995342 DOI: 10.5312/wjo.v12.i3.119] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 01/20/2021] [Accepted: 03/08/2021] [Indexed: 02/06/2023] Open
Abstract
In view of the demographic changes and projected increase of arthroplasty procedures worldwide, the number of prosthetic joint infection cases will naturally grow. Therefore, in order to counteract this trend more rigid rules and a stricter implementation of effective preventive strategies is of highest importance. In the absence of a “miracle weapon” priorities should lie in evidence-based measures including preoperative optimization of patients at higher infection risks, the fulfilment of strict hygiene rules in the operating theatre and an effective antibiotic prophylaxis regimen. Instead of a “one size fits all” philosophy, it has been proposed to adjust the antibiotic prophylaxis protocol to major infection risks taking into account important patient- and procedure-related risk factors. A stronger focus on the local application mode via use of high dose dual antibiotic-loaded bone cement in such risk situations may have its advantages and is easy to apply in the theatre. The more potent antimicrobial growth inhibition in vitro and the strong reduction of the prosthetic joint infection rate in risk for infection patients with aid of dual antibiotic-loaded bone cement in clinical studies align with this hypothesis.
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Affiliation(s)
| | - Jérôme Josse
- Institut des Sciences Pharmaceutiques et Biologiques de Lyon (ISPB), International Center for Research in Infectiology, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon 69008, France
- Interregional Reference Center for the Management of Complex Osteo-Articular Infections, Hospices Civils de Lyon, Lyon 69008, France
| | - Frédéric Laurent
- Institut des Sciences Pharmaceutiques et Biologiques de Lyon (ISPB), International Center for Research in Infectiology, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon 69008, France
- Interregional Reference Center for the Management of Complex Osteo-Articular Infections, Hospices Civils de Lyon, Lyon 69008, France
- Bacteriology Laboratory, Institute of Infectious Agents, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon 69008, France
| | - Tristan Ferry
- Institut des Sciences Pharmaceutiques et Biologiques de Lyon (ISPB), International Center for Research in Infectiology, Inserm U1111, CNRS UMR5308, ENS de Lyon, UCBL1, Lyon 69008, France
- Interregional Reference Center for the Management of Complex Osteo-Articular Infections, Hospices Civils de Lyon, Lyon 69008, France
- Infectious and Tropical Diseases Department, Croix-Rousse Hospital, Hospices Civils de Lyon, Lyon 69008, France
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30
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Mosselhy DA, Assad M, Sironen T, Elbahri M. Nanotheranostics: A Possible Solution for Drug-Resistant Staphylococcus aureus and their Biofilms? NANOMATERIALS (BASEL, SWITZERLAND) 2021; 11:E82. [PMID: 33401760 PMCID: PMC7824312 DOI: 10.3390/nano11010082] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/20/2020] [Revised: 12/24/2020] [Accepted: 12/30/2020] [Indexed: 12/14/2022]
Abstract
Staphylococcus aureus is a notorious pathogen that colonizes implants (orthopedic and breast implants) and wounds with a vicious resistance to antibiotic therapy. Methicillin-resistant S. aureus (MRSA) is a catastrophe mainly restricted to hospitals and emerged to community reservoirs, acquiring resistance and forming biofilms. Treating biofilms is problematic except via implant removal or wound debridement. Nanoparticles (NPs) and nanofibers could combat superbugs and biofilms and rapidly diagnose MRSA. Nanotheranostics combine diagnostics and therapeutics into a single agent. This comprehensive review is interpretative, utilizing mainly recent literature (since 2016) besides the older remarkable studies sourced via Google Scholar and PubMed. We unravel the molecular S. aureus resistance and complex biofilm. The diagnostic properties and detailed antibacterial and antibiofilm NP mechanisms are elucidated in exciting stories. We highlight the challenges of bacterial infections nanotheranostics. Finally, we discuss the literature and provide "three action appraisals". (i) The first appraisal consists of preventive actions (two wings), avoiding unnecessary hospital visits, hand hygiene, and legislations against over-the-counter antibiotics as the general preventive wing. Our second recommended preventive wing includes preventing the adverse side effects of the NPs from resistance and toxicity by establishing standard testing procedures. These standard procedures should provide breakpoints of bacteria's susceptibility to NPs and a thorough toxicological examination of every single batch of synthesized NPs. (ii) The second appraisal includes theranostic actions, using nanotheranostics to diagnose and treat MRSA, such as what we call "multifunctional theranostic nanofibers. (iii) The third action appraisal consists of collaborative actions.
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Affiliation(s)
- Dina A. Mosselhy
- Nanochemistry and Nanoengineering, Department of Chemistry and Materials Science, School of Chemical Engineering, Aalto University, 02150 Espoo, Finland;
- Microbiological Unit, Fish Diseases Department, Animal Health Research Institute, Dokki, Giza 12618, Egypt
- Department of Virology, Faculty of Medicine, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland;
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 66, 00014 Helsinki, Finland
| | - Mhd Assad
- Nanochemistry and Nanoengineering, Department of Chemistry and Materials Science, School of Chemical Engineering, Aalto University, 02150 Espoo, Finland;
| | - Tarja Sironen
- Department of Virology, Faculty of Medicine, University of Helsinki, P.O. Box 21, 00014 Helsinki, Finland;
- Department of Veterinary Biosciences, Faculty of Veterinary Medicine, University of Helsinki, P.O. Box 66, 00014 Helsinki, Finland
| | - Mady Elbahri
- Nanochemistry and Nanoengineering, Department of Chemistry and Materials Science, School of Chemical Engineering, Aalto University, 02150 Espoo, Finland;
- Nanochemistry and Nanoengineering, Institute for Materials Science, Faculty of Engineering, Kiel University, 24143 Kiel, Germany
- Center for Nanotechnology, Zewail City of Science and Technology, Sheikh Zayed District, Giza 12588, Egypt
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31
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Liang ZC, Yang C, Ding X, Hedrick JL, Wang W, Yang YY. Carboxylic acid-functionalized polycarbonates as bone cement additives for enhanced and sustained release of antibiotics. J Control Release 2021; 329:871-881. [DOI: 10.1016/j.jconrel.2020.10.018] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 10/01/2020] [Accepted: 10/09/2020] [Indexed: 01/22/2023]
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32
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Quinn J, McFadden R, Chan CW, Carson L. Titanium for Orthopedic Applications: An Overview of Surface Modification to Improve Biocompatibility and Prevent Bacterial Biofilm Formation. iScience 2020; 23:101745. [PMID: 33235984 PMCID: PMC7670191 DOI: 10.1016/j.isci.2020.101745] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Titanium and its alloys have emerged as excellent candidates for use as orthopedic biomaterials. Nevertheless, there are often complications arising after implantation of orthopedic devices, most notably prosthetic joint infection and aseptic loosening. To ensure that implanted devices remain functional in situ, innovation in surface modification has attracted much attention in the effort to develop orthopedic materials with optimal characteristics at the biomaterial-tissue interface. This review will draw together metallurgy, surface engineering, biofilm microbiology, and biomaterial science. It will serve to appreciate why titanium and its alloys are frequently used orthopedic biomaterials and address some of the challenges facing these biomaterials currently, including the significant problem of device-associated infection. Finally, the authors shall consolidate and evaluate surface modification techniques employed to overcome some of these issues by offering a unique perspective as to the direction in which research is headed from a broad, interdisciplinary point of view.
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Affiliation(s)
- James Quinn
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Ryan McFadden
- School of Mechanical and Aerospace Engineering, Queen's University Belfast, Ashby Building, Stranmillis Road, Belfast BT9 5AH, UK
| | - Chi-Wai Chan
- School of Mechanical and Aerospace Engineering, Queen's University Belfast, Ashby Building, Stranmillis Road, Belfast BT9 5AH, UK
| | - Louise Carson
- School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast BT9 7BL, UK
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33
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Biphasic composite of calcium phosphate-based mesoporous silica as a novel bone drug delivery system. Drug Deliv Transl Res 2020; 10:455-470. [PMID: 31820299 PMCID: PMC7066108 DOI: 10.1007/s13346-019-00686-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
We reported the new biphasic composites of calcium phosphate and mesoporous silica material (CaP@MSi) in the form of powders and pellets as a potential bone drug delivery system for doxycycline hydrochloride (DOX). The CaP@MSi powders were synthesized by cationic surfactant-templating method. The effects of 10, 20, and 30% CaP content in the CaP@MSi powders on the molecular surface structure, the cytotoxicity against osteoblast cells in vitro, and the mineralization potential in simulated body fluid were investigated. The CaP@MSi characterized by the highest mineralization potential (30% CaP content) were used for DOX adsorption and pelletization process. The CaP which precipitated in the CaP@MSi composites was characterized as calcium-deficient with the Ca:P molar ratio between 1.0 and 1.2. The cytotoxicity assays demonstrated that the CaP content in MSi increases osteoblasts viability indicating the CaP@MSi (30% CaP content) as the most biocompatible. The combination of CaP and MSi was an effective strategy to improve the mineralization potential of parent material. Upon immersion in simulated body fluid, the CaP of composite converted into the bone-like apatite. The obtained pellets preserved the mineralization potential of CaP@MSi and provided the prolonged 5-day DOX release. The obtained biphasic CaP@MSi composites seem to have an application potential as bone-specific drug delivery system.
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34
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Polyethylene-Based Knee Spacer for Infection Control: Design Concept and Pre-Clinical In Vitro Validations. Polymers (Basel) 2020; 12:polym12102334. [PMID: 33066104 PMCID: PMC7601983 DOI: 10.3390/polym12102334] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2020] [Revised: 10/05/2020] [Accepted: 10/09/2020] [Indexed: 12/30/2022] Open
Abstract
Antibiotic-loaded polymethyl methacrylate (PMMA) has been widely applied in the treatment of knee periprosthetic joint infections. However, problems with antibiotic-loaded PMMA-based spacers, such as structural fracture and implant dislocation, remain unresolved. A novel polyethylene-based spacer, designed with an ultra-congruent articulating surface and multiple fenestrations, was introduced in the current study. Validation tests for biomechanical safety, wear performance, and efficacy of antibiotic cement were reported. During cycle fatigue testing, no tibial spacer failures were observed, and less wear debris generation was reported compared to commercial PMMA-based spacers. The volumetric wear of the novel spacer was within the safety threshold for osteolysis-free volumetric wear. An effective infection control was demonstrated despite the application of lesser antibiotic cement in the 30-day antibiotic elution test. The tube dilution test confirmed adequate inhibitory capabilities against pathogens with the loaded antibiotic option utilized in the current study. The novel polyethylene-based knee spacer may offer sufficient biomechanical safety and serve as an adequate carrier of antibiotic-loaded cement for infection control. Further clinical trials shall be conducted for more comprehensive validation of the novel spacer for practical application.
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35
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Kang J, Dietz MJ, Hughes K, Xing M, Li B. Silver nanoparticles present high intracellular and extracellular killing against Staphylococcus aureus. J Antimicrob Chemother 2020; 74:1578-1585. [PMID: 30778552 DOI: 10.1093/jac/dkz053] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2018] [Revised: 11/20/2018] [Accepted: 01/15/2019] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVES Bone and joint infections caused by Staphylococcus aureus are becoming increasingly difficult to treat due to rising antibiotic resistance, resilient biofilms and intracellular survival of S. aureus. It has been challenging to identify and develop antimicrobial agents that can be used to kill extracellular and intracellular bacteria while having limited toxicity towards host cells. In addressing this challenge, this study investigates the antimicrobial efficacy and toxicity of silver nanoparticles (AgNPs). METHODS Intracellular bacteria were generated using a co-culture model of human osteoblast cells and S. aureus. Extracellular and intracellular S. aureus were treated with AgNPs, antibiotics and their combinations, and numbers of colonies were quantified. Toxicity of AgNPs against human osteoblast cells was determined by quantifying the number of viable cells after treatment. RESULTS AgNPs demonstrated excellent antimicrobial activity against extracellular S. aureus with a 100% killing efficacy at concentrations as low as 56 μM, along with a high intracellular killing efficacy of 76% at 371 μM. AgNPs were non-toxic or slightly toxic towards human osteoblasts at the concentrations studied (up to 927 μM). Moreover, smaller-sized (40 nm) AgNPs were more efficacious in killing bacteria compared with their larger-sized (100 nm) counterparts and synergistic antimicrobial effects against extracellular bacteria were observed when AgNPs were combined with gentamicin. CONCLUSIONS AgNPs and their combination with antibiotics have demonstrated high extracellular and intracellular bacterial killing and presented unique aspects for potential clinical applications, especially for chronic and recurrent infections where intracellular bacteria may be the cause.
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Affiliation(s)
- Jason Kang
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Matthew J Dietz
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Krystal Hughes
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, WV, USA
| | - Malcolm Xing
- Department of Mechanical Engineering, University of Manitoba, Winnipeg, Canada
- The Children's Hospital Research Institute of Manitoba, Winnipeg, Canada
| | - Bingyun Li
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, WV, USA
- Mary Babb Randolph Cancer Center, Morgantown, WV, USA
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36
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Gentamycin elution from polymethylmethacrylate and bone graft substitute: Comparison between commercially available and home-made preparations. J Orthop 2020; 19:9-13. [DOI: 10.1016/j.jor.2019.11.034] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2019] [Accepted: 11/24/2019] [Indexed: 11/21/2022] Open
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Tricard J, Chermat A, El Balkhi S, Denes E, Bertin F. An antibiotic loaded ceramic sternum to treat destroyed infected sternum: 4 cases. J Thorac Dis 2020; 12:209-216. [PMID: 32274086 PMCID: PMC7138964 DOI: 10.21037/jtd.2020.01.70] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background After its destruction during refractory deep sternal wound infection (DSWI), current sternum reconstructions mainly rely on muscle flaps technique, but such technique have pitfalls and limits. To tackle the limited possibilities to use device implantation because of the risk of infection, we developed a self-protected device allowing its implantation in an infected area. Methods We used gentamicin alone or in combination with vancomycin loaded in a porous ceramic sternum to replace sternums destroyed during DSWI. The aim was to mechanically replace the sternum and to secure the implantation by killing the remaining bacteria in the wound thanks to the loaded antibiotic. Results This device was implanted in four infected patients during DWSI with sternal dehiscence. No complication occurred during surgeries, and wound healing was obtained quickly. Local antibiotic concentrations largely exceeded the ones needed for their efficacy while no antibiotic was found in the blood. All patients are well-being. However previously unknown gentamicin resistant bacteria, present in the surgical wound at the time of positioning, required sternal implant removal for one patient after 19 months. For all patients, pulmonary function tests (PFT) improved after implantation. Conclusions The ceramic sternum played its role consolidating the thoracic cage without stiffening. The antibiotic loaded in the sternum allowed a secure implantation, killing bacteria before the colonization of the implant even in this infected area. These four implantations are promising for patients with sternal destruction after DSWI.
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Affiliation(s)
- Jeremy Tricard
- Thoracic and Cardiovascular Surgery Department, Limoges Teaching Hospital, Limoges, France
| | - Anaëlle Chermat
- Thoracic and Cardiovascular Surgery Department, Limoges Teaching Hospital, Limoges, France
| | | | - Eric Denes
- R&D Department, I.Ceram, Limoges, France.,Infectious Diseases Department, Polyclinique de Limoges, Limoges, France
| | - François Bertin
- Thoracic and Cardiovascular Surgery Department, Limoges Teaching Hospital, Limoges, France
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Lee J, Zilm PS, Kidd SP. Novel Research Models for Staphylococcus aureus Small Colony Variants (SCV) Development: Co-pathogenesis and Growth Rate. Front Microbiol 2020; 11:321. [PMID: 32184775 PMCID: PMC7058586 DOI: 10.3389/fmicb.2020.00321] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2019] [Accepted: 02/13/2020] [Indexed: 01/08/2023] Open
Abstract
Staphylococcus aureus remains a great burden on the healthcare system. Despite prescribed treatments often seemingly to be successful, S. aureus can survive and cause a relapsing infection which cannot be cleared. These infections are in part due to quasi-dormant sub-population which is tolerant to antibiotics and able to evade the host immune response. These include Small Colony Variants (SCVs). Because SCVs readily revert to non-SCV cell types under laboratory conditions, the characterization of SCVs has been problematic. This mini-review covers the phenotypic and genetic changes in stable SCVs including the selection of SCVs by and interactions with other bacterial species.
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Affiliation(s)
- James Lee
- Department of Molecular and Biomedical Science, The University of Adelaide, Adelaide, SA, Australia.,Research Centre for Infectious Diseases, Adelaide, SA, Australia.,Australian Centre for Antimicrobial Resistance Ecology, Adelaide, SA, Australia
| | - Peter S Zilm
- Faculty of Health and Medical Sciences, The University of Adelaide, Adelaide, SA, Australia
| | - Stephen P Kidd
- Department of Molecular and Biomedical Science, The University of Adelaide, Adelaide, SA, Australia.,Research Centre for Infectious Diseases, Adelaide, SA, Australia.,Australian Centre for Antimicrobial Resistance Ecology, Adelaide, SA, Australia
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39
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Li T, Fu L, Wang J, Shi Z. High dose of vancomycin plus gentamicin incorporated acrylic bone cement decreased the elution of vancomycin. Infect Drug Resist 2019; 12:2191-2199. [PMID: 31410038 PMCID: PMC6645360 DOI: 10.2147/idr.s203740] [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] [Subscribe] [Scholar Register] [Received: 01/31/2019] [Accepted: 07/03/2019] [Indexed: 12/23/2022] Open
Abstract
Purpose Low doses of vancomycin and gentamicin were commonly incorporated into acrylic bone cement (antibiotic-impregnated bone cement, AIBC) during revision arthroplasty. Previous studies showed that only a very small amount of antibiotics could be eluted from AIBC. Given the fact that a high dose of antibiotic would elute high concentration of antibiotic, this study investigated the influence of a high dose of dual-antibiotic loading on the properties of cement. Methods A total of 8 groups of AIBC containing either gentamicin or vancomycin or both with different amounts of antibiotics (1 g, 2 g and 4 g) were tested on material properties, elution profiles, antibacterial activity and cytological toxicity. Results A high dose of gentamicin and vancomycin AIBC (with 2 g gentamicin and 2 g vancomycin loaded) regiment showed acceptable compressive strength of 74.25±0.72 MPa. No cytotoxicity or antibacterial activity reduction was observed in any group tested in this study. The elution profiles indicated that incorporating 2 g vancomycin resulted in 4.77% (1049.57±3.74 μg) released after 28 days. However, after 2 g gentamicin was added, the vancomycin released was significantly reduced to 2.42% (532.24±1.77 μg) (p<0.001), approximately 50% reduction. No significant influence of vancomycin on gentamicin was observed. Conclusion These findings suggest that the addition of 2 g vancomycin and 2 g gentamicin into acrylic bone cement was preferred while considering this dual-antibiotic AIBC regiment with acceptably material properties and effective antibacterial activity. However, special attention should be drawn to the reduction of vancomycin elution when incorporated with gentamicin.
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Affiliation(s)
- Tao Li
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Lilan Fu
- Nanfang PET Center, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Jian Wang
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
| | - Zhanjun Shi
- Department of Orthopedics, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, People's Republic of China
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40
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Haseeb A, Ajit Singh V, Teh CSJ, Loke MF. Addition of ceftaroline fosamil or vancomycin to PMMA: An in vitro comparison of biomechanical properties and anti-MRSA efficacy. J Orthop Surg (Hong Kong) 2019; 27:2309499019850324. [PMID: 31138005 DOI: 10.1177/2309499019850324] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Ceftaroline is a cephalosporin that is effective against methicillin-resistant Staphylococcus aureus (MRSA) infections. The objective of this study was to determine the feasibility of using ceftaroline-loaded Polymethyl methacrylate (PMMA) as antibiotic cement against MRSA versus vancomycin-loaded PMMA in an in vitro setting. METHODS PMMA pellets were prepared with three separate concentrations of each of the two antibiotics tested. They were tested to determine the effect of increasing concentration of antibiotics on the biomechanical properties of PMMA and antibiotic activity by measuring the zone of inhibition and broth elution assay. RESULTS Ceftaroline PMMA at 3 wt%, three-point bending was 37.17 ± 0.51 N ( p < 0.001) and axial loading was 41.95 N ± 0.51 ( p < 0.001). At 5-wt% vancomycin-PMMA, three-point bending was 41.65 ± 0.79 N ( p = 0.02) and axial loading was 49.49 ± 2.21 N ( p = 0.01). Stiffness of ceftroline-loaded PMMA in low and medium concentration was significantly higher than the vancomycin. The zone of inhibition for ceftaroline was higher than vancomycin. Ceftaroline at 3 wt% eluted up to 6 weeks (0.3 ± 0.1 μg/ml) above the minimum inhibitory concentration (MIC) and vancomycin at 2.5 wt% eluted up to 3 weeks, same as MIC, that is, 0.5 ± 0.0 μg/ml. CONCLUSIONS Ceftaroline, loaded at similar concentrations as vancomycin into PMMA, is a more potent alternative based on its more favourable bioactivity and elution properties, while having a lesser effect on the mechanical properties of the cement. The use of 3-wt% ceftaroline as antibiotic laden PMMA against MRSA is recommended. It should be noted that this was an in vitro study and to determine the clinical efficacy would need prospective, controlled and randomized studies.
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Affiliation(s)
- Amber Haseeb
- 1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Vivek Ajit Singh
- 1 Department of Orthopaedic Surgery, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Cindy Shuan Ju Teh
- 2 Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | - Mun Fai Loke
- 2 Department of Medical Microbiology, Faculty of Medicine, University of Malaya, Kuala Lumpur, Malaysia
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41
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Hip and Knee Section, Prevention, Local Antimicrobials: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S289-S292. [PMID: 30343975 DOI: 10.1016/j.arth.2018.09.013] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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42
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Abdel MP, Barreira P, Battenberg A, Berry DJ, Blevins K, Font-Vizcarra L, Frommelt L, Goswami K, Greiner J, Janz V, Kendoff DO, Limberg AK, Manrique J, Moretti B, Murylev V, O'Byrne J, Petrie MJ, Porteous A, Saleri S, Sandiford NA, Sharma V, Shubnyakov I, Sporer S, Squire MW, Stockley I, Tibbo ME, Turgeon T, Varshneya A, Wellman S, Zahar A. Hip and Knee Section, Treatment, Two-Stage Exchange Spacer-Related: Proceedings of International Consensus on Orthopedic Infections. J Arthroplasty 2019; 34:S427-S438. [PMID: 30348562 DOI: 10.1016/j.arth.2018.09.027] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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43
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Al Thaher Y, Yang L, Jones SA, Perni S, Prokopovich P. LbL-assembled gentamicin delivery system for PMMA bone cements to prolong antimicrobial activity. PLoS One 2018; 13:e0207753. [PMID: 30543660 PMCID: PMC6292632 DOI: 10.1371/journal.pone.0207753] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Accepted: 11/06/2018] [Indexed: 01/06/2023] Open
Abstract
INTRODUCTION Antibiotic-loaded poly(methyl methacrylate) bone cements (ALBCs) are widely used in total joint replacement (TJR), for local delivery of antibiotics to provide prophylaxis against prosthetic joint infections (PJI). One of the shortcomings of the current generation of ALBCs is that the antibiotic release profile is characterized by a burst over the first few hours followed by a sharp decrease in rate for the following several days (often below minimum inhibitory concentration (MIC)), and, finally, exhaustion (after, typically, ~ 20 d). This profile means that the ALBCs provide only short-term antimicrobial action against bacterial strains involved PJI. RATIONALE The purpose of the present study was to develop an improved antibiotic delivery system for an ALBC. This system involved using a layer-by-layer technique to load the antibiotic (gentamicin sulphate) (GEN) on silica nanoparticles, which are then blended with the powder of the cement. Then, the powder was mixed with the liquid of the cement (NP-GEN cement). For controls, two GEN-loaded brands were used (Cemex Genta and Palacos R+G). Gentamicin release and a host of other relevant properties were determined for all the cements studied. RESULTS Compared to control cement specimens, improved GEN release, longer antimicrobial activity (against clinically-relevant bacterial strains), and comparable setting time, cytocompatibility, compressive strength (both prior to and after aging in PBS at 37 oC for 30 d), 4-point bend strength and modulus, fracture toughness, and PBS uptake. CONCLUSIONS NP-GEN cement may have a role in preventing or treating PJI.
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Affiliation(s)
- Yazan Al Thaher
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, United Kingdom
| | - Lirong Yang
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, United Kingdom
| | - Steve A. Jones
- University Hospital Llandough, Cardiff & Vale University Health Board, Vale of Glamorgan, Wales, United Kingdom
| | - Stefano Perni
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, United Kingdom
| | - Polina Prokopovich
- School of Pharmacy and Pharmaceutical Science, Cardiff University, Cardiff, United Kingdom
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Keser N, Is M, Ceman D, Somay A. Locally Used Antibiotics for Spinal Infection Prophylaxis and Their Effects on Epidural Fibrosis: an Experimental Laminectomy Study in Rats Using Rifamycin and Gentamycin. Inflammation 2018; 42:714-720. [PMID: 30413905 DOI: 10.1007/s10753-018-0929-x] [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: 11/27/2022]
Abstract
The study aims to assess the effects of antibiotics (ABs), which are typically used in spinal infection prophylaxis, on the formation of epidural fibrosis (EF). Specifically, we investigated the effect of rifamycin and gentamycin on EF formation in laminectomized rats. Thirty-two rats were randomly and equally divided into four groups as follows: laminectomy and physiological saline (0.9% NaCl) solution (control); laminectomy and rifamycin; laminectomy and gentamicin; and laminectomy and a mixture of rifamycin and gentamicin. Laminectomy was performed on L1 and L2 vertebrae in all rats. One month after spinal surgery, spinal tissue samples surrounding the laminectomy were cut with a microtome and stained with hematoxylin-eosin and Masson's trichrome. The histopathological analysis included examining the extent of EF, fibroblast cell density, and cartilage and bone regeneration. Statistical analysis was performed using the IBM SPSS Statistics 22 program (SPSS IBM, Turkey). A value of p < 0.05 was considered statistically significant. EF value differences between the AB treatment groups and the control group were statistically significant (p = 0.030). Specifically, binary comparisons indicated that the EF value was significantly higher in the rifamycin group than that in the control group (p = 0.003; p < 0.05). Our study suggests that locally applied ABs, especially rifamycin, should be diluted before administration to the epidural space.
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Affiliation(s)
- Nese Keser
- Department of Neurological Surgery, Istanbul Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, E-5 Karayolu Uzeri, 34752, İcerenkoy-Atasehir, Istanbul, Turkey.
| | - Merih Is
- Department of Neurological Surgery, Istanbul Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, E-5 Karayolu Uzeri, 34752, İcerenkoy-Atasehir, Istanbul, Turkey
| | - Duygu Ceman
- Department of Neurological Surgery, Haydarpasa Numune Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
| | - Adnan Somay
- Department of Pathology, Istanbul Fatih Sultan Mehmet Education and Research Hospital, University of Health Sciences, Istanbul, Turkey
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45
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Antibiotic-loaded Porous Alumina Ceramic for One-stage Surgery for Chronic Osteomyelitis. JOURNAL OF THE AMERICAN ACADEMY OF ORTHOPAEDIC SURGEONS GLOBAL RESEARCH AND REVIEWS 2018; 2:e079. [PMID: 30656266 PMCID: PMC6324901 DOI: 10.5435/jaaosglobal-d-18-00079] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The classic treatment of chronic osteomyelitis is usually a two-stage surgery combined with systemic antibiotic therapy for several months. We report the case of a patient presenting a chronic osteomyelitis caused by methicillin-resistant Staphylococcus aureus who was treated with a one-stage surgery using an antibiotic-loaded ceramic. We used a porous alumina ceramic loaded with gentamicin to reconstruct the bone removed during débridement and to avoid its colonization. All bacteriological samples performed before and during the surgery revealed the presence of a methicillin-resistant S aureus. Because of the local release of the antibiotic, very high concentrations (more than 50 times the concentration needed) were administered in the surgical wound, thus helping to cure the infection. Owing to the strength of the ceramic, the patient was allowed to walk 10 days after the surgery. After a follow-up at 14 months, the patient is well-being, without any relapse of the infection. The CT-scan follow-up shows an osseointegration of the ceramic. Even, if it is too early to tell that infection is completely cured, these first results are encouraging for the use, in the future, of this antibiotic-loaded ceramic for complex bone infection.
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46
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Tyas B, Marsh M, Oswald T, Refaie R, Molyneux C, Reed M. Antibiotic resistance profiles of deep surgical site infections in hip hemiarthroplasty; comparing low dose single antibiotic versus high dose dual antibiotic impregnated cement. J Bone Jt Infect 2018; 3:123-129. [PMID: 30013893 PMCID: PMC6043471 DOI: 10.7150/jbji.22192] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2017] [Accepted: 02/04/2018] [Indexed: 12/27/2022] Open
Abstract
Objectives: The incidence of fractured neck of femur (FNOF) is increasing yearly. Many of these patients undergo hip hemiarthroplasty. High dose dual-antibiotic cement (HDDAC) has been shown to reduce rates of deep surgical site infection (SSI) when compared to the current standard low dose single-antibiotic cement (LDSAC) in a quasi-randomised controlled trial. Some concerns exist regarding the use of HDDAC and the development of antibiotic resistance. We reviewed cases of infection in LDSAC and HDDAC bone cement with regard to causative organism and resistance profile. Methods: A retrospective analysis was undertaken of all hemiarthroplasties within our trust from April 2008 to December 2014. We identified all patients in this time period who acquired a deep SSI. The infecting organisms and susceptibility patterns were collated for each cement. Results: We identified 1941 hemiarthroplasties. There were 38 deep surgical site infections representing an infection rate of 3.4% in LDSAC patients and 1.2% in HDDAC patients. The majority of infections were polymicrobial. Staphylococcus epidermidis was the most commonly isolated organism. It accounted for a larger proportion of HDDAC than LDSAC infections (p<0.05). Infection with Corynebacterium species and S. aureus, including MRSA, was eradicated completely with the use of HDDAC. There was no significant change in the proportion of Gram negative and Gram positive infections between the two cements. In Gram positive organisms, there was no significant change in resistance to most antibiotics. Although fewer resistant infections overall, there were significant increases in the proportion of resistance to ciprofloxacin and clindamycin with HDDAC. We observed no resistance to daptomycin or linezolid in either cement and levels of resistance remained low to rifampicin and teicoplanin. In Gram negative organisms, no significant change in resistance was observed. Conclusions: We observed a significantly lower infection rate with the use of HDDAC compared to LDSAC. Such was this reduced infection rate that there was a trend to a lower rate of resistance with the use of HDDAC. However, there were increases in the proportion of resistant cases, most notably to clindamycin and ciprofloxacin in Gram positive organisms, possibly reflecting the higher number of S. epidermidis in the HDDAC group. Whilst the differences in our study were not found to be statistically significant, it is reassuring for teams using HDDAC to prevent SSI in hip hemiarthroplasty.
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Affiliation(s)
- Ben Tyas
- Foundation Doctor, University Hospital North Durham, North Road, Durham, DH1 5TW, United Kingdom
| | - Martin Marsh
- Clinical Research Fellow, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
| | - Tamsin Oswald
- Consultant Microbiologist, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
| | - Ramsay Refaie
- Clinical Research Fellow, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
| | - Catherine Molyneux
- Consultant Microbiologist, Royal Victoria Infirmary, Queen Victoria Road, NE1 4LP, United Kingdom
| | - Mike Reed
- Consultant Trauma and Orthopaedic Surgeon, Northumbria Specialist Emergency Healthcare Centre, Northumbrian Road, Cramlington, NE23 6NZ, United Kingdom
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Helbig L, Bechberger M, Aldeeri R, Ivanova A, Haubruck P, Miska M, Schmidmaier G, Omlor GW. Initial peri- and postoperative antibiotic treatment of infected nonunions: results from 212 consecutive patients after mean follow-up of 34 months. Ther Clin Risk Manag 2018; 14:59-67. [PMID: 29379296 PMCID: PMC5757496 DOI: 10.2147/tcrm.s152008] [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] [Indexed: 12/14/2022] Open
Abstract
PURPOSE Infected nonunions of the long bones belong to the most feared complications in the field of orthopedic and trauma surgery. Optimal antibiotic therapy should start early with the first revision surgery. Therefore, the aim of this study was to evaluate our peri- and postoperative antibiotic regime in context with the microbial spectrum and antibiotic resistances of patients with infected nonunions and to assess the possible impact on healing rates. METHODS We included all patients with first revision surgery during 2010-2015 due to nonunion of long bones with a clinical history of infection treated with radical debridement, local application of a gentamicin-impregnated bone cement, and systemic cefuroxime. Mean follow-up was 34.2 months. Data collection was performed retrospectively using a computerized databank with information about microbial species from intraoperatively acquired tissue samples and respective antibiograms. Bone fusion rates were evaluated based on findings of the latest X-rays and computed tomography scans. RESULTS Two hundred and twelve patients with nonunion and history of infection were selected; 171 patients had positive intraoperative microbial evidence of infection. Bacterial testing was mostly positive in fractures of the tibia (47.4%) and the femur (27.5%). Coagulase-negative Staphylococcus spp. were the most frequently detected (44.4%) followed by mixed infections (18.7%) and Staphylococcus aureus (10.5%). Antibiograms revealed that 62.6% of our cases were cefuroxime sensitive; 87.7% were gentamicin sensitive. Only 10.5% showed resistance to both cefuroxime and gentamicin. There was no statistically significant difference of fusion rates between patients with different microbial species or different antibiograms. CONCLUSION Our data suggest that besides the high variety of different detected species, initial antibiotic treatment with a combination of systemic cefuroxime and local gentamicin-loaded bone cement is effective and in almost 90% the later determined microbial infection was sensitive to this treatment. Therefore, we recommend initial treatment according to this algorithm until specific antibiograms are available from intraoperatively acquired tissue samples.
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Affiliation(s)
- Lars Helbig
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | - Maren Bechberger
- Pharmacy Department, Heidelberg University Hospital, Heidelberg, Germany
| | - Riyadh Aldeeri
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | - Adriana Ivanova
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | | | - Matthias Miska
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
| | | | - Georg W Omlor
- Department of Orthopaedics, Trauma Surgery and Paraplegiology
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Dietz MJ. CORR Insights®: The John N. Insall Award: Higher Tissue Concentrations of Vancomycin Achieved With Intraosseous Regional Prophylaxis in Revision TKA: A Randomized Controlled Trial. Clin Orthop Relat Res 2018. [PMID: 29529619 PMCID: PMC5919234 DOI: 10.1007/s11999.0000000000000084] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Affiliation(s)
- Matthew J Dietz
- M. J. Dietz, Department of Orthopaedics, West Virginia University School of Medicine, Morgantown, WV, USA
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49
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Dorati R, DeTrizio A, Modena T, Conti B, Benazzo F, Gastaldi G, Genta I. Biodegradable Scaffolds for Bone Regeneration Combined with Drug-Delivery Systems in Osteomyelitis Therapy. Pharmaceuticals (Basel) 2017; 10:E96. [PMID: 29231857 PMCID: PMC5748651 DOI: 10.3390/ph10040096] [Citation(s) in RCA: 76] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2017] [Revised: 11/27/2017] [Accepted: 11/29/2017] [Indexed: 12/31/2022] Open
Abstract
A great deal of research is ongoing in the area of tissue engineering (TE) for bone regeneration. A possible improvement in restoring damaged tissues involves the loading of drugs such as proteins, genes, growth factors, antibiotics, and anti-inflammatory drugs into scaffolds for tissue regeneration. This mini-review is focused on the combination of the local delivery of antibiotic agents with bone regenerative therapy for the treatment of a severe bone infection such as osteomyelitis. The review includes a brief explanation of scaffolds for bone regeneration including scaffolds characteristics and types, a focus on severe bone infections (especially osteomyelitis and its treatment), and a literature review of local antibiotic delivery by the combination of scaffolds and drug-delivery systems. Some examples related to published studies on gentamicin sulfate-loaded drug-delivery systems combined with scaffolds are discussed, and future perspectives are highlighted.
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Affiliation(s)
- Rossella Dorati
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
| | - Antonella DeTrizio
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
| | - Tiziana Modena
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
| | - Bice Conti
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
| | - Francesco Benazzo
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
- Centre oh Health Technology (CHT), Via Ferrata 1, University of Pavia, 27100 Pavia, Italy.
| | - Giulia Gastaldi
- Centre oh Health Technology (CHT), Via Ferrata 1, University of Pavia, 27100 Pavia, Italy.
- Department of Molecular Medicine, University of Pavia, Viale Taramelli 2, 27100 Pavia, Italy.
| | - Ida Genta
- Department of Drug Sciences, University of Pavia, Viale Taramelli 12, 27100 Pavia, Italy.
- Center of Health Technology, University of Pavia, Via Ferrata 1, 27100 Pavia, Italy.
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50
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Athans V, Veve MP, Davis SL. Trowels and Tribulations: Review of Antimicrobial-Impregnated Bone Cements in Prosthetic Joint Surgery. Pharmacotherapy 2017; 37:1565-1577. [DOI: 10.1002/phar.2040] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Affiliation(s)
- Vasilios Athans
- Department of Pharmacy Services; Cleveland Clinic; Cleveland Ohio
| | - Michael P. Veve
- Eugene Applebaum College of Pharmacy and Health Sciences; Wayne State University; Detroit Michigan
- Department of Pharmacy Services; Henry Ford Hospital; Detroit Michigan
| | - Susan L. Davis
- Eugene Applebaum College of Pharmacy and Health Sciences; Wayne State University; Detroit Michigan
- Department of Pharmacy Services; Henry Ford Hospital; Detroit Michigan
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