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Bezstarosti H, Van Lieshout EMM, Van den Hurk MJB, Kortram K, Oprel P, Koch BCP, Croughs PD, Verhofstad MHJ. In Vitro Elution of Gentamicin from CERAMENT® G Has an Antimicrobial Effect on Bacteria With Various Levels of Gentamicin Resistance Found in Fracture-related Infection. Clin Orthop Relat Res 2024; 482:885-891. [PMID: 38289704 PMCID: PMC11008629 DOI: 10.1097/corr.0000000000002975] [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] [Received: 08/08/2023] [Accepted: 12/12/2023] [Indexed: 02/01/2024]
Abstract
BACKGROUND Fracture-related infection is a serious complication after trauma. CERAMENT® G combines dead-space management with local release of gentamicin in a single-stage procedure. Bacterial resistance against antibiotics is increasing. The local effect of CERAMENT® G on bacteria resistant to systemically administered gentamicin is unknown. QUESTIONS/PURPOSES (1) What is the in vitro elution pattern of gentamicin from CERAMENT® G using a full washout model? (2) What is the in vitro antimicrobial activity (zone of inhibition) of CERAMENT® G against bacterial isolates found in fracture-related infection with different susceptibility levels toward gentamicin? METHODS Elution of gentamicin from CERAMENT® G was determined in vitro over a period of 2 months. Elution experiments were performed in fivefold, with gentamicin being sampled in threefold at 19 different timepoints within 2 months. Antimicrobial activity was determined using the four most-frequently cultured bacterial species found in fracture-related infection: Staphylococcus aureus, Staphylococcus epidermidis, Pseudomonas aeruginosa, and Enterobacter cloacae . For each of the species, four different isolates with a different susceptibility to gentamicin were used. According to the European Committee on Antimicrobial Susceptibility Testing, the susceptibility of each isolate was classified into four different groups: fully susceptible (minimum inhibitory concentration 0.064 to 4 mg/L), minimally resistant (minimum inhibitory concentration 4 to 16 mg/L), moderately resistant (minimum inhibitory concentration 8 to 96 mg/L), and highly resistant (minimum inhibitory concentration 24 to 1024 mg/L), depending on each organism. The antimicrobial activity of CERAMENT® G was determined according to the European Committee on Antimicrobial Susceptibility Testing disk protocol. The experiment was performed in fivefold for each isolate. The zone of inhibition was compared between each bacterial isolate and within each of the four separate species. Nonlinear regression statistics were calculated between the zone of interest and logarithmic minimum inhibitory concentration for each bacterial species. RESULTS After 24 hours, 95% of all available gentamicin was eluted, and gentamicin was still detectable after 2 months. CERAMENT® G showed antimicrobial activity against all bacterial species; only S taphylococcus aureus (with a minimum inhibitory concentration > 1024 mg/L) was not susceptible. The zone of interest of the different bacterial isolates was correlated with the logarithmic minimum inhibitory concentration. CONCLUSION CERAMENT® G offers a bone substitute capable of releasing high levels of gentamicin within a short period of time. This study shows that CERAMENT® G has antimicrobial activity against bacterial isolates that are resistant to gentamicin when systemically administered. This finding raises the question of whether European Committee on Antimicrobial Susceptibility Testing cutoff points for systemic application are useful for the use of local CERAMENT® G. Standardized experiments to determine local antibiotic antimicrobial activity in fracture-related infection treatment are needed to form guidelines for the use of local antibiotics and ultimately improve fracture-related infection treatment. CLINICAL RELEVANCE Local concentrations of gentamicin with CERAMENT® G are much higher than when systemically administered. It seems effective against certain bacterial strains that are not affected by systemically reachable concentrations of gentamicin. CERAMENT® G might still be effective when bacteria that are resistant to systemically administered concentrations of gentamicin are occulated from patients with fracture-related infection.
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Affiliation(s)
- Hans Bezstarosti
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Esther M. M. Van Lieshout
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Maartje J. B. Van den Hurk
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Kirsten Kortram
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Pim Oprel
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Birgit C. P. Koch
- Department of Pharmacy, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Peter D. Croughs
- Department of Medical Microbiology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Michael H. J. Verhofstad
- Trauma Research Unit, Department of Surgery, Erasmus MC, University Medical Center Rotterdam, Rotterdam, the Netherlands
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Du B, Su Y, Li D, Ji S, Lu Y, Xu Y, Yang Y, Zhang K, Li Z, Ma T. Analysis of risk factors for serous exudation of biodegradable material calcium sulfate in the treatment of fracture-related infections. Front Bioeng Biotechnol 2023; 11:1189085. [PMID: 37346793 PMCID: PMC10279841 DOI: 10.3389/fbioe.2023.1189085] [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: 03/18/2023] [Accepted: 05/24/2023] [Indexed: 06/23/2023] Open
Abstract
Objective: To explore the related risk factors of serous exudation after antibiotic-loaded calcium sulfate treatment of fracture-related infections and to provide a theoretical basis for clinical treatment and prevention of serous exudation complications. Methods: The clinical data of 145 patients with limb fracture-related infection treated with antibiotic-loaded calcium sulfate in Xi'an Honghui Hospital from January 2019 to December 2022 were retrospectively analyzed. All patients were diagnosed with fracture-related infection by preoperative magnetic resonance examination, bacterial culture and gene detection and received antibiotic-loaded calcium sulfate implantation. The postoperative serous exudation was recorded through hospitalization observation, outpatient review or follow-up. The collected clinical data were sorted out, and the patient data were divided into serous exudation groups and non-exudation groups. Firstly, the clinical data of the two groups were compared by single-factor analysis to screen out the risk factors. Then multivariate binary Logistic regression analysis determined the independent risk factors and protective factors. Results: 1) According to the inclusion and exclusion criteria, there were 145 cases with complete clinical data, including 27 cases in the non-infectious exudation group and 118 cases in the non-exudative group; 2) Univariate analysis showed that the history of diabetes, smoking history, calcium sulfate implantation, drainage time, combined flap surgery, geometric shape of implanted calcium sulfate, and thickness of soft tissue covered by the surgical area were all associated with the occurrence of non-infectious exudation after antibiotic-loaded calcium sulfate implantation (p < 0.05); 3) The amount of implanted calcium sulfate was more [OR = 5.310, (1.302-21.657), p = 0.020], combined with flap surgery [OR = 3.565, (1.195-10.641), p = 0.023], and the thickness of soft tissue coverage in the operation area was thinner [OR = 5.305, (1.336-21.057), p = 0.018]. Longer drainage time [OR = 0.210, (0.045-0.967), p = 0.045] was a protective factor for non-infectious exudation after antibiotic-loaded calcium sulfate implantation. Conclusion: 1) The probability of serous exudation in patients with fracture-associated infection after antibiotic-loaded calcium sulfate surgery was 18.62%. This complication may cause a heavier economic and psychological burden on patients; 2) With the increase of bone infection area and the application of more calcium sulfate, the incidence of serous exudation after antibiotic-loaded calcium sulfate surgery in patients with the fracture-related infection will increase, so we should use the amount of calcium sulfate reasonably on the premise of sufficient control of infection in clinical work, and the incidence of serous exudation will also increase due to the recent skin flap surgery and the thinner soft tissue coverage of calcium sulfate implantation area; 3) Under the premise of being able to drain the drainage from the surgical area, the longer drainage time of the drainage tube has a positive effect on preventing the occurrence of serous exudation.
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Affiliation(s)
- Bing Du
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yu Su
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Dongchen Li
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Shuai Ji
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yao Lu
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yibo Xu
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Yanling Yang
- Medical College of Yan’an University, Yan’an, Shaanxi, China
| | - Kun Zhang
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Zhong Li
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
| | - Teng Ma
- Honghui Hospital, Xi’an Jiaotong University, Xi’an, Shaanxi, China
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Wang L, Lu S, Luo W, Wang G, Zhu Z, Liu Y, Gao H, Fu C, Ren J, Zhang Y, Zhang Y. Efficacy comparison of antibiotic bone cement-coated implants and external fixations for treating infected bone defects. INTERNATIONAL ORTHOPAEDICS 2023; 47:1171-1179. [PMID: 36862164 PMCID: PMC10079742 DOI: 10.1007/s00264-023-05727-8] [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] [Received: 11/15/2022] [Accepted: 01/30/2023] [Indexed: 03/03/2023]
Abstract
PURPOSE This study aimed to investigate the clinical efficacy of antibiotic bone cement-coated implants compared with external fixations for treating infected bone defects. METHODS We retrospectively enrolled 119 patients with infected bone defects in our hospital from January 2010 to June 2021, of which 56 were treated with antibiotic bone cement-coated implants and 63 were with external fixation. RESULTS The pre-operative and post-operative haematological indexes were tested to assess the infection control; the post-operative CRP level in the internal fixation group was lower than that in the external fixation group. No statistical significance was found in the rate of infection recurrence, loosening and rupture of the fixation, and amputation between the two groups. Twelve patients in the external fixation group had pin tract infection. In the evaluation of the Paley score scale, bone healing aspect revealed no significant difference between the two groups, while in the limb function aspect, antibiotic cement-coated implant group showed a much better score than the external fixation group (P = 0.002). The anxiety evaluation scale result also showed lower score in the antibiotic cement implant group (P < 0.001). CONCLUSIONS Compared with external fixation, antibiotic bone cement-coated implant had the same effect on controlling infection and was more effective in recovering limb function and mental health in the first-stage treatment of infected bone defects after debridement.
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Affiliation(s)
- Linhu Wang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Shuaikun Lu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Wen Luo
- Department of Ultrasound, Xijing Hospital, Air Force Medical University, 169 Changlexi Rd, Xi’an, 710032 Shaanxi China
| | - Guoliang Wang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Zhenfeng Zhu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Yunyan Liu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Hao Gao
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Congxiao Fu
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Jun Ren
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Yunfei Zhang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
| | - Yong Zhang
- Department of Orthopaedics, Second Affiliated Hospital, Air Force Medical University, 1 Xinsi Rd, Xi’an, 710038 Shaanxi China
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Shi X, Wu Y, Ni H, Li M, Zhang C, Qi B, Wei M, Wang T, Xu Y. Antibiotic-loaded calcium sulfate in clinical treatment of chronic osteomyelitis: a systematic review and meta-analysis. J Orthop Surg Res 2022; 17:104. [PMID: 35183215 PMCID: PMC8858512 DOI: 10.1186/s13018-022-02980-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 01/27/2022] [Indexed: 12/24/2022] Open
Abstract
Abstract
Background
Present work was aimed to gather accessible evidence on the eradication rates and related postoperative complications of antibiotic-loaded calcium sulfate (CS) as an implant in the treatment of chronic osteomyelitis (COM).
Methods
Databases including PubMed, EMBASE, Medline, Ovid and Cochrane library were searched from their dates of initiation until November 2021. Two independent authors scrutinized the relevant studies based on the effectiveness of radical debridement combined with antibiotic-loaded CS for COM; data extraction and quality assessment of the Methodological Index for Non-Randomized Studies (MINORS) criteria were also performed by the authors. In addition, clinical efficacy mainly depended on the evaluation of eradication rates and complications, and all the extracted data are pooled and analyzed by STATA 16.0.
Results
A total of 16 studies with 917 patients (920 locations) were recruited, with an overall eradication rate of 92%. Moreover, the overall reoperation rate, overall refracture rate, overall delayed wound healing rate, and the rate of aseptic wound leakage were 9.0%, 2.0%, 20.0%, and 12.0%, respectively. Moreover, the choice of tobramycin-loaded CS or vancomycin combined with gentamicin-loaded CS did not affect the eradication rate, and the incidence of postoperative complications in COM patients (all $$P>0.05$$
P
>
0.05
). The general quality of the included studies was fair.
Conclusions
Our meta-analysis indicated that the overall eradication rate of COM treated with antibiotic-loaded CS was 92%. Delayed healing is the most common postoperative complication. The choice of tobramycin-loaded CS or vancomycin combined with gentamicin-loaded CS did not affect the eradication rate and the incidence of postoperative complications in COM patients.
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Salamanca E, Pan YH, Sun YS, Hsueh HW, Dorj O, Yao WL, Lin JCY, Teng NC, Watanabe I, Abe S, Wu YF, Chang WJ. Magnesium Modified β-Tricalcium Phosphate Induces Cell Osteogenic Differentiation In Vitro and Bone Regeneration In Vivo. Int J Mol Sci 2022; 23:ijms23031717. [PMID: 35163639 PMCID: PMC8836187 DOI: 10.3390/ijms23031717] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 01/30/2022] [Accepted: 01/31/2022] [Indexed: 01/27/2023] Open
Abstract
In vitro, in vivo, and clinical studies have shown how the physicochemical and biological properties of β-tricalcium phosphate (β-TCP) work in bone regeneration. This study aimed to improve the properties of β-TCP by achieving optimum surface and bulk β-TCP chemical/physical properties through the hydrothermal addition of magnesium (Mg) and to later establish the biocompatibility of β-TCP/Mg for bone grafting and tissue engineering treatments. Multiple in vitro and in vivo analyses were used to complete β-TCP/Mg physicochemical and biological characterization. The addition of MgO brought about a modest rise in the number of β-TCP surface particles, indicating improvements in alkaline phosphatase (ALP) activity on day 21 (p < 0.05) and in the WST-1assay on all days (p < 0.05), with a corresponding increase in the upregulation of ALP and bone sialoprotein. SEM analyses stated that the surfaces of the β-TCP particles were not altered after the addition of Mg. Micro-CT and histomorphometric analysis from rabbit calvaria critical defects resulted in β-TCP/Mg managing to reform more new bone than the control defects and β-TCP control at 2, 6, and 8 weeks (* p ≤ 0.05, ** p ≤ 0.01, *** p ≤ 0.001, and **** p ≤ 0.0001). The hydrothermal addition of MgO to the β-TCP surfaces ameliorated its biocompatibility without altering its surface roughness resulting from the elemental composition while enhancing cell viability and proliferation, inducing more bone regeneration by osteoconduction in vivo and osteoblastic differentiation in vitro.
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Affiliation(s)
- Eisner Salamanca
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
| | - Yu-Hwa Pan
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
- Department of General Dentistry, Chang Gung Memorial Hospital, Taipei 10507, Taiwan
- Graduate Institute of Dental & Craniofacial Science, Chang Gung University, Taoyuan 33305, Taiwan
- School of Dentistry, College of Medicine, China Medical University, Taichung 40402, Taiwan
| | - Ying-Sui Sun
- School of Dental Technology, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan;
| | - Hao-Wen Hsueh
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
| | - Odontuya Dorj
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
- Department of Dental Technology and Hygiene, Mongolian National University of Medical Sciences, Ulaanbaatar 14210, Mongolia
| | - Wan-Ling Yao
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
| | - Jerry Chin-Yi Lin
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
- Department of Oral Medicine, Infection and Immunity, Harvard School of Dental, Medicine, Boston, MA 02115, USA
| | - Nai-Chia Teng
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
- Dental Department, Taipei Medical University Hospital, Taipei 11031, Taiwan
| | - Ikki Watanabe
- Department of Gerontology, Tokyo Medical and Dental University, Tokyo 113-8510, Japan;
| | - Shinichi Abe
- Department of Anatomy, Tokyo Dental College, Tokyo 101-0061, Japan;
| | - Yi-Fan Wu
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
- Correspondence: (Y.-F.W.); (W.-J.C.); Tel.: +886-2-2736-1661 (ext. 5148) (Y.-F.W.); +886-2-2736-1661 (ext. 5150) (W.-J.C.)
| | - Wei-Jen Chang
- School of Dentistry, College of Oral Medicine, Taipei Medical University, Taipei 11031, Taiwan; (E.S.); (Y.-H.P.); (H.-W.H.); (O.D.); (W.-L.Y.); (J.C.-Y.L.); (N.-C.T.)
- Dental Department, Shuang-ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan
- Correspondence: (Y.-F.W.); (W.-J.C.); Tel.: +886-2-2736-1661 (ext. 5148) (Y.-F.W.); +886-2-2736-1661 (ext. 5150) (W.-J.C.)
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Wassif RK, Elkayal M, Shamma RN, Elkheshen SA. Recent advances in the local antibiotics delivery systems for management of osteomyelitis. Drug Deliv 2021; 28:2392-2414. [PMID: 34755579 PMCID: PMC8583938 DOI: 10.1080/10717544.2021.1998246] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Chronic osteomyelitis is a challenging disease due to its serious rates of mortality and morbidity while the currently available treatment strategies are suboptimal. In contrast to the adopted systemic treatment approaches after surgical debridement in chronic osteomyelitis, local drug delivery systems are receiving great attention in the recent decades. Local drug delivery systems using special carriers have the pros of enhancing the feasibility of penetration of antimicrobial agents to bone tissues, providing sustained release and localized concentrations of the antimicrobial agents in the infected area while avoiding the systemic side effects and toxicity. Most important, the incorporation of osteoinductive and osteoconductive materials in these systems assists bones proliferation and differentiation, hence the generation of new bone materials is enhanced. Some of these systems can also provide mechanical support for the long bones during the healing process. Most important, if the local systems are designed to be injectable to the affected site and biodegradable, they will reduce the level of invasion required for implantation and can win the patients’ compliance and reduce the healing period. They will also allow multiple injections during the course of therapy to guard against the side effect of the long-term systemic therapy. The current review presents different available approaches for delivering antimicrobial agents for the treatment of osteomyelitis focusing on the recent advances in researches for local delivery of antibiotics.HIGHLIGHTS Chronic osteomyelitis is a challenging disease due to its serious mortality and morbidity rates and limited effective treatment options. Local drug delivery systems are receiving great attention in the recent decades. Osteoinductive and osteoconductive materials in the local systems assists bones proliferation and differentiation Local systems can be designed to provide mechanical support for the long bones during the healing process. Designing the local system to be injectable to the affected site and biodegradable will reduces the level of invasion and win the patients’ compliance.
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Affiliation(s)
- Reem Khaled Wassif
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Future University in Egypt, Cairo, Egypt
| | - Maha Elkayal
- Department of Pharmaceutics and Pharmaceutical Technology, Faculty of Pharmacy, Future University in Egypt, Cairo, Egypt
| | - Rehab Nabil Shamma
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
| | - Seham A Elkheshen
- Department of Pharmaceutics and Industrial Pharmacy, Faculty of Pharmacy, Cairo University, Cairo, Egypt
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Köse N, Asfuroğlu ZM, Köse A, Şahintürk V, Gürbüz M, Doğan A. Silver ion-doped calcium phosphate-based bone-graft substitute eliminates chronic osteomyelitis: An experimental study in animals. J Orthop Res 2021; 39:1390-1401. [PMID: 33295663 DOI: 10.1002/jor.24946] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 11/30/2020] [Accepted: 12/07/2020] [Indexed: 02/04/2023]
Abstract
Despite the latest technologies and advances in microbiology and orthopedic surgery, chronic osteomyelitis is still a challenging disorder. Antibiotic resistance and bacterially induced bone destruction can have very serious consequences. We hypothesized that calcium phosphate-based bone graft substitution with silver ion doping would simultaneously treat bone infection and the bony defect in the chronic osteomyelitis. An unicortical 10-mm-diameter bone was harvested in the proximal tibial metaphysis of 24 rabbits. After contaminating the wounds with an infective dose of methicillin-resistant Staphylococcus aureus (MRSA), osteomyelitis was proven radiographically and microbiologically in all rabbits. Animals were than divided into three groups. The first group received vancomycin-impregnated bone cement beads (comparative control group), the second/experimental group received silver ion-doped calcium phosphate beads and the third group received pure calcium phosphate beads (negative controls). Radiographs, intraosseous cultures, and histopathological examinations were performed on postoperative Week 10. The cultures showed no evidence of intramedullary infection in the silver ion-doped calcium phosphate beads group, but they were positive for MRSA in four of the six rabbits in the vancomycin- impregnated bone cement beads group and in all of the eight rabbits in the pure calcium phosphate beads group. Quantitative assessment of histopathological examination showed lowest total damage score in silver ion-doped calcium phosphate beads group (p < .001). Percentage of osteoid tissue + bony tissue was also higher in this group compared with other groups. In the final radiological examinations, it was observed that the changes caused by osteomyelitis in the bone tissue in the silver ion-doped calcium phosphate beads group were much improved compared with the vancomycin-impregnated bone cement beads group. Silver ion doped calcium phosphate-based bone-graft substitute offer the ability to stimulate bone growth, combat infection, and, ultimately, treat experimental chronic osteomyelitis in an animal model.
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Affiliation(s)
- Nusret Köse
- Department of Orthopedics and Traumatology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Zeynel M Asfuroğlu
- Division of Hand Surgery, Department of Orthopedics and Traumatology, Mersin University, Mersin, Turkey
| | - Aydan Köse
- Department of Plastic and Reconstructive Surgery, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Varol Şahintürk
- Department of Histology, Eskişehir Osmangazi University, Eskişehir, Turkey
| | - Mevlüt Gürbüz
- Department of Mechanical Engineering, Faculty of Engineering, Ondokuz Mayıs University, Samsun, Turkey
| | - Aydın Doğan
- Department of Materials Science and Engineering, Eskişehir Technical University, Eskişehir, Turkey
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Silver ion doped hydroxyapatite-coated titanium pins prevent bacterial colonization. Jt Dis Relat Surg 2020; 32:35-41. [PMID: 33463416 PMCID: PMC8073436 DOI: 10.5606/ehc.2021.79357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 12/08/2020] [Indexed: 01/05/2023] Open
Abstract
Objectives
This study aims to evaluate the effectiveness of silver ion doped calcium phosphate-based ceramic nano powder-coated titanium pins in preventing bacterial colonization. Materials and methods
A total of 66 titanium pins were divided into three groups of 22 implants. The first group was coated with silver ion doped calcium phosphate-based ceramic powder by using electrospray method. The second group was coated with pure hydroxyapatite (HA), and the remaining pins were used without any coating. The remaining 22 pins were used without any coating. Staphylococcus epidermidis clinical isolate was used for the study. Each pin was placed in 1¥104 CFU/mL bacterial suspension containing tube and at 24 h quantitative culture of bacteria on the broth and on the pins were performed. Free silver ions were determined by atomic absorption method. The antibacterial culture tests were repeated on Day 2 and Weeks 2, 4, 6, and 8. Results
Bacterial growth was statistically higher in broth containing uncoated pins, compared to broth media containing silver ion doped HA-coated, and pure HA-coated pins at 24 h (p=0.036 and p=0.009, respectively). The release of bacteria from silver doped HA-coated pins was statistically less, compared to pure HA-coated pins and uncoated pins (p=0.039 and p=0.002, respectively). No significant differences were observed between the HA-coated and uncoated pin groups. Minimum inhibitory concentration levels for silver ion doped powder was 8 μg/mL for coagulase-negative Staphylococcus. No free silver ions were detected in the broth media. Conclusion
Silver ion doped nano size calcium phosphate-based powder-coated titanium pins reduced the bacterial colonization significantly. Using silver ion doped materials in the body can be a good option to prevent from implant related infections.
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Roth KE, Maier GS, Schmidtmann I, Eigner U, Hübner WD, Peters F, Drees P, Maus U. Release of Antibiotics Out of a Moldable Collagen-β-Tricalciumphosphate-Composite Compared to Two Calcium Phosphate Granules. MATERIALS 2019; 12:ma12244056. [PMID: 31817409 PMCID: PMC6947585 DOI: 10.3390/ma12244056] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 11/15/2019] [Accepted: 11/25/2019] [Indexed: 02/07/2023]
Abstract
Bacterial bone infections after revision surgeries and diseases, like osteomyelitis, are still a challenge with regard to surgical treatments. Local bone infections were treated with antibiotics directly or by controlled drug-releasing scaffolds, like polymethylmethacrylate (PMMA) spheres, which have to be removed at a later stage, but there is a risk of a bacterial contamination during the removement. Therefore, biomaterials loaded with antibiotics for controlled release could be the method of choice: The biomaterials degrade during the drug release, therefore, there is no need for a second surgery to remove the drug eluting agent. Even non-resorbable bone materials are available (e.g., hydroxyapatite (HA)) or resorbable bone graft materials (e.g., beta-tricalcium phosphate (β-TCP)) that will be replaced by newly formed bone. Composite materials with organic additives (e.g., collagen) supports the handling during surgery and enhances the drug loading capacity, as well as the drug releasing time. The purpose of this study was to investigate the loading capacity and the release rate of Vancomycin and Gentamicin on TCP and HA granules in the shape of a degradable scaffold compared to composite materials from TCP mixed with porcine collagen. Its antibacterial efficacy to a more elementary drug with eluting in aqueous solution was examined. The loading capacity of the biomaterials was measured and compared according to the Minimum Inhibition Concentration (MIC) and the Minimum Biofilm Eradication Concentration (MBEC) of a bacterial biofilm after 24 h aging. Antibiotic elution and concentration of gentamycin and vancomycin, as well as inhibition zones, were measured by using the Quantitative Microparticle Systems (QMS) immunoassays. The antibiotic concentration was determined by the automated Beckman Coulter (BC) chemistry device. For examination of the antibacterial activity, inhibition zone diameters were measured. Generally, the antibiotic release is more pronounced during the first couple of days than later. Both TCP granules and HA granules experienced a significantly decline of antibiotics release during the first three days. After the fourth day and beyond, the antibiotic release was below the detection threshold. The antibiotic release of the composite material TCP and porcine collagen declined less drastically and was still in the frame of the specification during the first nine days. There was no significant evidence of interaction effect between antibiotic and material, i.e., the fitted lines for Gentamycin and Vancomycin are almost parallel. During this first in vitro study, β-TCP-Collagen composites shows a significantly higher loading capacity and a steadily release of the antibiotics Gentamycin and Vancomycin, compared to the also used TCP and HA Granules.
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Affiliation(s)
- Klaus Edgar Roth
- Zentrum für Orthopädie und Unfallchirurgie, Unimedizin, 55131 Mainz, Germany;
- Correspondence: ; Tel.: +49-6131-177302; Fax: +49-6131-17472552
| | - Gerrit Steffen Maier
- Pius Hospital, Universitätsklinik für Orthopädie und Unfallchirurgie, 26121 Oldenburg, Germany; (G.S.M.); (U.M.)
| | - Irene Schmidtmann
- Institut für Medizinische Biometrie, Epidemiologie und Informatik, Unimedizin Mainz, 55131 Mainz, Germany;
| | | | | | - Fabian Peters
- Curasan AG, 65933 Frankfurt am Main, Germany; (W.D.H.); (F.P.)
| | - Philipp Drees
- Zentrum für Orthopädie und Unfallchirurgie, Unimedizin, 55131 Mainz, Germany;
| | - Uwe Maus
- Pius Hospital, Universitätsklinik für Orthopädie und Unfallchirurgie, 26121 Oldenburg, Germany; (G.S.M.); (U.M.)
- Klinik für Orthopädie und Unfallchirurgie, Universitätsklinikum Düsseldorf, 40225 Düsseldorf, Germany
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Badie AA, Arafa MS. One-stage surgery for adult chronic osteomyelitis: concomitant use of antibiotic-loaded calcium sulphate and bone marrow aspirate. INTERNATIONAL ORTHOPAEDICS 2018; 43:1061-1070. [PMID: 30027354 DOI: 10.1007/s00264-018-4063-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 07/13/2018] [Indexed: 12/15/2022]
Abstract
PURPOSE To report our experience with one-stage treatment of chronic osteomyelitis using a prospective protocol involving the concomitant use of the antibiotic-loaded calcium sulphate pellets with addition of bone marrow aspirate after bony debridement. PATIENTS AND METHODS A total of 30 patients with the mean age of 26.2 years were treated according to a protocol that included (1) surgical debridement of bone and infected tissues, (2) local antibiotic therapy including vancomycin and garamycin loaded on calcium sulphate space filling biodegradable pellets, (3) bone marrow aspirate added to the biocomposite, (4) primary closure with external fixation (when needed) and (5) intravenous antibiotics according to culture and sensitivity results. RESULTS After a minimum of one year follow-up, infection was eradicated in 23 (76.7%) patients, the average rate of filling of the bony defect was 70.47%, complete filling of defect in 15 patients (50%) and pathological fracture in one patient. CONCLUSION The technique proved safety and efficacy in eradicating the infection and bony healing of the defects after debridement. Simple bone marrow aspiration is cheap, reproducible, safe and not exhausting the scanty autograft resources.
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Affiliation(s)
- Ahmed Abdel Badie
- Department of Orthopedic Surgery, Suez Canal University Hospital, Kilo 4.5 Ring Road, Ismailia, 41111, Egypt.
| | - Mohamed S Arafa
- Department of Orthopedic Surgery, Fayoum University Hospital, Al Fayoum, Egypt
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11
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Cao ZD, Jiang DM, Yan L, Wu J. Biosafety of the Novel Vancomycin-loaded Bone-like Hydroxyapatite/Poly-amino Acid Bony Scaffold. Chin Med J (Engl) 2017; 129:194-9. [PMID: 26830991 PMCID: PMC4799547 DOI: 10.4103/0366-6999.173489] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
BACKGROUND Recently, local sustained-release antibiotics systems have been developed because they can increase local foci of concentrated antibiotics without increasing the plasma concentration, and thereby effectively decrease any systemic toxicity and side effects. A vancomycin-loaded bone-like hydroxyapatite/poly-amino acid (V-BHA/PAA) bony scaffold was successfully fabricated with vancomycin-loaded poly lactic-co-glycolic acid microspheres and BHA/PAA, which was demonstrated to exhibit both porosity and perfect biodegradability. The aim of this study was to systematically evaluate the biosafety of this novel scaffold by conducting toxicity tests in vitro and in vivo. METHODS According to the ISO rules for medical implant biosafety, for in vitro tests, the scaffold was incubated with L929 fibroblasts or rabbit noncoagulant blood, with simultaneous creation of positive control and negative control groups. The growth condition of L929 cells and hemolytic ratio were respectively evaluated after various incubation periods. For in vivo tests, a chronic osteomyelitis model involving the right proximal tibia of New Zealand white rabbits was established. After bacterial identification, the drug-loaded scaffold, drug-unloaded BHA/PAA, and poly (methyl methacrylate) were implanted, and a blank control group was also set up. Subsequently, the in vivo blood drug concentrations were measured, and the kidney and liver functions were evaluated. RESULTS In the in vitro tests, the cytotoxicity grades of V-BHA/PAA and BHA/PAA-based on the relative growth rate were all below 1. The hemolysis ratios of V-BHA/PAA and BHA/PAA were 2.27% and 1.42%, respectively, both below 5%. In the in vivo tests, the blood concentration of vancomycin after implantation of V-BHA/PAA was measured at far below its toxic concentration (60 mg/L), and the function and histomorphology of the liver and kidney were all normal. CONCLUSION According to ISO standards, the V-BHA/PAA scaffold is considered to have sufficient safety for clinical utilization.
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Affiliation(s)
| | - Dian-Ming Jiang
- Department of Orthopedics, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
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Ferguson J, Diefenbeck M, McNally M. Ceramic Biocomposites as Biodegradable Antibiotic Carriers in the Treatment of Bone Infections. J Bone Jt Infect 2017; 2:38-51. [PMID: 28529863 PMCID: PMC5423569 DOI: 10.7150/jbji.17234] [Citation(s) in RCA: 79] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Local release of antibiotic has advantages in the treatment of chronic osteomyelitis and infected fractures. The adequacy of surgical debridement is still key to successful clearance of infection but local antibiotic carriers seem to afford greater success rates by targeting the residual organisms present after debridement and delivering much higher local antibiotic concentrations compared with systemic antibiotics alone. Biodegradable ceramic carriers can be used to fill osseous defects, which reduces the dead space and provides the potential for subsequent repair of the osseous defect as they dissolve away. A dissolving ceramic antibiotic carrier also raises the possibility of single stage surgery with definitive closure and avoids the need for subsequent surgery for spacer removal. In this article we provide an overview of the properties of various biodegradable ceramics, including calcium sulphate, the calcium orthophosphate ceramics, calcium phosphate cement and polyphasic carriers. We summarise the antibiotic elution properties as investigated in previous animal studies as well as the clinical outcomes from clinical research investigating their use in the surgical management of chronic osteomyelitis. Calcium sulphate pellets have been shown to be effective in treating local infection, although newer polyphasic carriers may support greater osseous repair and reduce the risk of further fracture or the need for secondary reconstructive surgery. The use of ceramic biocomposites to deliver antibiotics together with BMPs, bisphosphonates, growth factors or living cells is under investigation and merits further study. We propose a treatment protocol, based on the Cierny-Mader classification, to help guide the appropriate selection of a suitable ceramic antibiotic carrier in the surgical treatment of chronic osteomyelitis.
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Affiliation(s)
- Jamie Ferguson
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, United Kingdom
| | - Michael Diefenbeck
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, United Kingdom
| | - Martin McNally
- The Bone Infection Unit, Nuffield Orthopaedic Centre, Oxford University Hospitals Foundation NHS Trust, Oxford, United Kingdom
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Aiken SS, Cooper JJ, Florance H, Robinson MT, Michell S. Local release of antibiotics for surgical site infection management using high-purity calcium sulfate: an in vitro elution study. Surg Infect (Larchmt) 2015; 16:54-61. [PMID: 25148101 PMCID: PMC4363816 DOI: 10.1089/sur.2013.162] [Citation(s) in RCA: 66] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND The aim of this study was to characterize the elution of four antibiotics from pharmaceutical-grade calcium sulfate beads and show that the eluted antibiotics retained efficacy. METHODS Calcium sulfate was combined with gentamicin, tobramycin, vancomycin, or rifampicin (ratio: 20 g of calcium sulfate, to 240 mg, 500 mg, 900 mg, and 600 mg of antibiotic, respectively). Three grams of beads were immersed in 4 mL of sterile phosphate-buffered saline (PBS) at 37°C. At each time point (4, 8, 24 h; 2, 7, 14, 28, 42 d), eluates were removed for analysis by liquid chromatography-mass spectrometry. The antimicrobial efficacy of antibiotics combined with calcium sulfate beads after 42 d was tested by a modified Kirby-Bauer disc diffusion assay. RESULTS All samples showed a generally exponential decay in the eluted antibiotic concentration. At the first time point, both gentamicin and tobramycin had eluted to a peak concentration of approximately 10,000 mcg/mL. For rifampicin, the peak concentration occurred at 24 h, whereas for vancomycin, it occurred at 48 h. The eluted concentrations exceeded the minimum inhibitory concentration for common periprosthetic joint infection pathogens for the entire span of the 42 study days. Mass spectrometry confirmed all antibiotics were unchanged when eluted from the calcium sulfate carrier. Antimicrobial efficacy was unaltered after 42 d in combination with calcium sulfate at 37°C. CONCLUSIONS Pharmaceutical-grade calcium sulfate has the potential for targeted local release of tobramycin, gentamicin, vancomycin, and rifampicin over a clinically meaningful time period.
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Affiliation(s)
- Sean S. Aiken
- Biocomposites Ltd., Keele Science Park, Staffordshire, United Kingdom
| | - John J. Cooper
- Biocomposites Ltd., Keele Science Park, Staffordshire, United Kingdom
| | - Hannah Florance
- Biosciences, College of Life and Environmental Sciences, University of Exeter, Exeter, United Kingdom
| | - Matthew T. Robinson
- Biosciences, College of Life and Environmental Sciences, University of Exeter, Exeter, United Kingdom
| | - Stephen Michell
- Biosciences, College of Life and Environmental Sciences, University of Exeter, Exeter, United Kingdom
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Bozhkova SA, Novokshonova AA, Konev VA. Current trends in local antibacterial therapy of periprosthetic infection and osteomyelitis. ACTA ACUST UNITED AC 2015. [DOI: 10.21823/2311-2905-2015-0-3-92-107] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
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