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Seta JF, Pawlitz PR, Aboona F, Weaver MJ, Bou-Akl T, Ren W, Markel DC. Efficacy of Commercially Available Irrigation Solutions on Removal of Staphylococcus Aureus and Biofilm From Porous Titanium Implants: An In Vitro Study. J Arthroplasty 2024; 39:S292-S298. [PMID: 38889807 DOI: 10.1016/j.arth.2024.06.024] [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: 12/03/2023] [Revised: 06/10/2024] [Accepted: 06/10/2024] [Indexed: 06/20/2024] Open
Abstract
BACKGROUND Periprosthetic joint infection remains a major problem. The bactericidal efficacy of commercial irrigation solutions for the treatment of infection is not well established in the presence of porous titanium (Ti) implants. This study compared the in vitro efficacy of five irrigation solutions on infected three-dimensional-printed porous Ti discs. METHODS Titanium discs (2 × 4 mm, 400, 700, and 1,000 μm) were infected with S. aureus (1 × 106 colony-forming unit/mL) and incubated for 3 hours or 3 days to create acute or chronic infection with biofilm. Discs were irrigated with saline, antibiotic, or antiseptic solutions, then repeatedly sonicated. Sonicates were cultured for bacterial quantification. Statistical analyses were performed using one-way analysis of variance (ANOVA), followed by Tukey-Kramer post hoc testing (P < .05 significance). Biofilms were visualized by scanning electron microscopy. RESULTS Saline irrigation was ineffective in both groups. In acute infections with 400 μm pores, differences were found with saline versus solution #3 (P = .015) and #4 (P = .015). Solution #4 had the lowest bacterial counts for all pore sizes. For biofilm, irrigation with saline, solutions #1, #2, and #3 inadequately cleared bacteria in all pore sizes. Lower remaining concentrations were observed in #4 with 400μm pores compared to saline (P = .06) and #2 (P = .039). The scanning electron microscopy showed a reduction of biofilm in samples washed with #4. CONCLUSIONS Irrigation of infected porous Ti discs with saline, solutions #1 and #2 failed to reduce the bacterial load. The 400 μm discs consistently had more bacteria despite irrigation, highlighting the difficulty of removing bacteria from small pores. Solutions #3 and #4 reduced bacteria acutely, but only #4 demonstrated efficacy in clearing biofilm compared to saline. These results should be considered when treating periprosthetic joint infection in the presence of porous components and the potential presence of biofilm.
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Affiliation(s)
- Joseph F Seta
- Section of Orthopedic Surgery, Ascension Providence Hospital, Southfield, Michigan
| | - Paula R Pawlitz
- Section of Orthopedic Surgery, Ascension Providence Hospital, Southfield, Michigan
| | - Fadi Aboona
- Section of Orthopedic Surgery, Ascension Providence Hospital, Southfield, Michigan
| | - Martin J Weaver
- Section of Orthopedic Surgery, Ascension Providence Hospital, Southfield, Michigan
| | - Therese Bou-Akl
- Section of Orthopedic Surgery, Ascension Providence Hospital, Southfield, Michigan
| | - Weiping Ren
- Section of Orthopedic Surgery, Ascension Providence Hospital, Southfield, Michigan; Virotech Co, Inc, Troy, Michigan
| | - David C Markel
- Section of Orthopedic Surgery, Ascension Providence Hospital, Southfield, Michigan; The Core Institute, Novi, Michigan
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Wu X, Chen W, Rong R, Pan B, Hu X, Zheng L, Alimu A, Chu C, Tu Y, Zhang Z, Ye Y, Gu M, Sheng P. Application of the New Irrigation Protocol to Reduce Recurrence Rate in the Management Of Periprosthetic Joint Infection. Orthop Surg 2024; 16:577-584. [PMID: 38238252 PMCID: PMC10925507 DOI: 10.1111/os.13948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Revised: 10/24/2023] [Accepted: 10/24/2023] [Indexed: 02/15/2024] Open
Abstract
OBJECTIVE Irrigation is a conventional treatment for acute and chronic periprosthetic joint infections (PJI). However, there has been no unified standard for irrigation during surgery for PJI in the past, and the efficacy is uncertain. The purpose of this study is to create a new irrigation protocol to enhance the infection control rate and reduce the postoperative recurrence rate of PJI patients. METHODS We conducted a single-institution retrospective review with a total of 56 patients who underwent revision total hip or knee arthroplasties due to PJI from January 2011 to January 2022. Conventional irrigation (CI) was used in 32 cases, and standard operating procedure of irrigation (SOPI) was used in 24. The CI protocol carries out an empirical irrigation after debridement, which is quite random. Our SOPI protocol clearly stipulates the soaking concentration and time of hydrogen peroxide and povidone-iodine. The irrigation is carried out three times, and tissue samples are taken from multiple parts before and after irrigation, which are sent for microbial culture. The important statistical indicators were the rate of positive microbiological culture and postoperative recurrence rate with an average follow-up of 24 average months. RESULTS The drainage volume was lower in the SOPI group than in the CI group on postoperative day 3 (p < 0.01) and 7 (p = 0.016). In addition, the percentage of positive microbiological cultures after the third irrigation was less than that before (p < 0.01) and after (p < 0.01) the first irrigation. The most common causative organism was Staphylococcus aureus, which was detected in 25.0% and 12.5% of the SOPI and CI groups, respectively. The failure rate at the final follow-up was 8.3% and 31.3% (p = 0.039) for the SOPI and CI groups, respectively. CONCLUSION Compared with the traditional CI method, SOPI standardized the soaking time of hydrogen peroxide and povidone-iodine, increased the frequency of and irrigation, and proved that microorganisms were almost completely removed through the microbial culture of multiple tissues. SOPI has the potential to become a standardized irrigation process worthy of promotion, effectively reducing the postoperative recurrence rate of PJI patients.
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Affiliation(s)
- Xiaoyu Wu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Weishen Chen
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Rong Rong
- Department of Nosocomial InfectionThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
| | - Baiqi Pan
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Xuantao Hu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Linli Zheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Aerman Alimu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Chenghan Chu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yucheng Tu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Ziji Zhang
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yongyu Ye
- Department of Spinal SurgeryGuangdong Provincial People's HospitalGuangzhouChina
| | - Minghui Gu
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Puyi Sheng
- Department of Joint SurgeryThe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouChina
- Guangdong Provincial Key Laboratory of Orthopaedics and TraumatologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
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Wan J, He J, Chen L, Qiu L, Wang F, Chen XL. Retrospective Study from a Single Center on the Efficacy of Pulsed Lavage Following Excision of Burns ≥30% of the Total Body Surface Area in 63 Patients. Med Sci Monit 2022; 28:e937697. [PMID: 36348616 PMCID: PMC9661869 DOI: 10.12659/msm.937697] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Ensuring the take rate of skin grafting and reducing the mortality of patients with severe burns have remained big challenges worldwide. This retrospective study from a single center aimed to evaluate the efficacy of pulsed lavage following excision of burns ≥30% of the total body surface area (TBSA) in 63 patients. MATERIAL AND METHODS Among 63 patients, the types of burns sustained were severe burns and extremely severe burns (≥30% TBSA). The degrees of the burns were second degree and third degree, and the causes were thermal, chemical, and electric. Patients with early aggressive excision were divided into a pulsed lavage group and control group. The constituent of the lavage fluid was 0.9% physiological saline. The evaluation of wound healing and complications was based on the wound healing rate and time, clinical symptoms, and examination. We determined the take rate of skin grafting, positive rate of postoperative bacterial cultures, changes in perioperative serum C-reactive protein (CRP) and procalcitonin (PCT) levels, and incidence of secondary grafting. RESULTS The take rate of skin grafting and the decreased rates of perioperative serum CRP and PCT levels were significantly higher in the pulsed lavage group than in the control group (P<0.05). Moreover, the positive rate of wound postoperative bacterial cultures and mortality in the pulsed lavage group showed remarkably lower levels (P<0.05). CONCLUSIONS Pulsed lavage following excision of burns ≥30% TBSA increased the take rate of skin grafting, alleviated the positive rate of postoperative bacterial cultures, decreased serum CRP and PCT levels, and reduced mortality.
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Affiliation(s)
- Jia Wan
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Jia He
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Lu Chen
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Le Qiu
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Fei Wang
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China (mainland)
| | - Xu-Lin Chen
- Department of Burns, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China (mainland)
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Melin S, Haase I, Nilsson M, Claesson C, Östholm Balkhed Å, Tobieson L. Cryopreservation of autologous bone flaps following decompressive craniectomy: A new method reduced positive cultures without increase in post-cranioplasty infection rate. BRAIN AND SPINE 2022; 2:100919. [PMID: 36248144 PMCID: PMC9560573 DOI: 10.1016/j.bas.2022.100919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 07/11/2022] [Accepted: 07/19/2022] [Indexed: 11/18/2022]
Abstract
Introduction Cranioplasty (CP) after decompressive craniectomy (DC) is a common neurosurgical procedure. Implementation of European Union (EU) directives recommending bacterial cultures before cryopreservation, lead to increased number of autologous bone flaps being discarded due to positive cultures. A new method for handling bone flaps prior to cryopreservation, including the use of pulsed lavage, was developed. Research question The aim was to evaluate the effect of a new method on proportion of positive bacterial cultures and surgical site infection (SSI) following CP surgery. Material and methods Sixty-one bone flaps from 53 consecutive DC surgery patients were retrospectively included and the study period was divided into before and after method implementation. Patient demographics, laboratory and culture results, type of CP and occurrence of SSI were analyzed. Results Twenty-six and 18 bone flaps were available for analysis during the first and second period, respectively. The proportion of positive bacterial cultures was higher in the first period compared to the second (n = 9(35%) vs 0(0%); p = 0.001), and thus the use of custom made implants was considerably higher in the first study period (p = 0.001). There was no difference in the frequency of post-cranioplasty SSI between the first and second study period (n = 3 (11.5%) vs 1 (4.8%), p = 0.408). Discussion and conclusion The new method for handling bone flaps resulted in a lower frequency of positive bacterial cultures, without increased frequency of post-cranioplasty SSI, thus demonstrating it is safe to use, allows compliance with the EU-directives, and may reduce unnecessary discarding of bone flaps. New method of bone flap handling and preservation reduced positive bacterial cultures from 35% to 0%. The new method used pulsed lavage of bone flap with saline solution and subsequent swab culture. There was no increase in post-cranioplasty surgical site infection following introduction of the new method.
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Affiliation(s)
- Sofia Melin
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Ismene Haase
- Department of Anaesthesiology and Intensive Care in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Martin Nilsson
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Carina Claesson
- Department of Clinical Microbiology, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Åse Östholm Balkhed
- Department of Infectious Diseases in Östergötland, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
| | - Lovisa Tobieson
- Department of Neurosurgery in Linköping, and Department of Biomedical and Clinical Sciences, Linköping University, Linköping, Sweden
- Corresponding author. Department of Neurosurgery, University Hospital in Linköping, 581 85, Linköping, Sweden.
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Recent Strategies to Combat Infections from Biofilm-Forming Bacteria on Orthopaedic Implants. Int J Mol Sci 2021; 22:ijms221910243. [PMID: 34638591 PMCID: PMC8549706 DOI: 10.3390/ijms221910243] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2021] [Revised: 09/19/2021] [Accepted: 09/20/2021] [Indexed: 12/26/2022] Open
Abstract
Biofilm-related implant infections (BRII) are a disastrous complication of both elective and trauma orthopaedic surgery and occur when an implant becomes colonised by bacteria. The definitive treatment to eradicate the infections once a biofilm has established is surgical excision of the implant and thorough local debridement, but this carries a significant socioeconomic cost, the outcomes for the patient are often poor, and there is a significant risk of recurrence. Due to the large volumes of surgical procedures performed annually involving medical device implantation, both in orthopaedic surgery and healthcare in general, and with the incidence of implant-related infection being as high as 5%, interventions to prevent and treat BRII are a major focus of research. As such, innovation is progressing at a very fast pace; the aim of this study is to review the latest interventions for the prevention and treatment of BRII, with a particular focus on implant-related approaches.
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Direct-Contact Low-Frequency Ultrasound and Pulse Lavage Eradicates Biofilms on Implant Materials In Vitro. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2021:1562605. [PMID: 34504531 PMCID: PMC8423559 DOI: 10.1155/2021/1562605] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 07/25/2021] [Accepted: 08/12/2021] [Indexed: 02/02/2023]
Abstract
Pulse lavage (PL) debridement and ultrasound are both known to be the treatment of biofilm-related periprosthetic joint infection (PJI). However, the efficacy of these in combination is unknown in eradicating biofilm from the orthopaedic metal implant surface. This study was conducted to understand the efficacy of PL and ultrasound in combination in eradicating bacterial biofilms on titanium alloy in vitro. Biofilms of Staphylococcus aureus strains were grown on titanium alloy coupons for 24 h. Then, the coupons were taken to each treatment group: (i) debrided with PL, (ii) exposed to ultrasound, or (iii) exposed to both. An untreated biofilm was set as a control group. Viable plate count and confocal microscopy using live/dead staining was used to measure the amount of biofilm. Viable plate count showed an approximate two-log reduction in CFU/cm2 in PL alone, from an initial cell count on the mental surface of approximately 109 CFU/cm2. The ultrasound caused an approximate seven-log reduction, and the combination group eradicated viable biofilm bacteria completely. Confocal imaging corroborated the CFU data. Our results indicate that PL and ultrasound both are remarkably in eradicating biofilm, and the combination of PL and ultrasound is more effective than alone in reducing biofilm.
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Ruiz-Sorribas A, Poilvache H, Kamarudin NHN, Braem A, Van Bambeke F. In vitro polymicrobial inter-kingdom three-species biofilm model: influence of hyphae on biofilm formation and bacterial physiology. BIOFOULING 2021; 37:481-493. [PMID: 34225500 DOI: 10.1080/08927014.2021.1919301] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/18/2020] [Revised: 04/08/2021] [Accepted: 04/13/2021] [Indexed: 06/13/2023]
Abstract
Biofilms are an important medical burden, notably for patients with orthopaedic device-related infections. When polymicrobial, these infections are more lethal and recalcitrant. Inter-kingdom biofilm infections are poorly understood and challenging to treat. Here, an in vitro three-species model including Staphylococcus aureus, Escherichia coli and Candida albicans was developed, to represent part of the diversity observed in orthopaedic infections or other clinical contexts. The importance of fungal hyphae for biofilm formation and virulence factor expression was explored. Two protocols were set up, allowing, or not, for hyphal formation. Culturable cells and biomass were characterised in both models, and biofilms were imaged in bright-field, confocal and electron microscopes. The expression of genes related to virulence, adhesion, exopolysaccharide synthesis and stress response was analysed in early-stage and mature biofilms. It was found that biofilms enriched in hyphae had larger biomass and showed higher expression levels of genes related to bacterial virulence or exopolysaccharides synthesis.
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Affiliation(s)
- Albert Ruiz-Sorribas
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
| | - Hervé Poilvache
- Laboratoire de neuro musculo squelettique, Institut de Recherche Expérimentale et Clinique, Université catholique de Louvain, Brussels, Belgium
- Orthopaedic Surgery Department, Cliniques Universitaires Saint-Luc, Brussels, Belgium
| | - Nur Hidayatul Nazirah Kamarudin
- Biomaterials and Tissue Engineering Research Group, Department of Materials Engineering, KU Leuven, Leuven, Belgium
- Department of Chemical and Process Engineering, Faculty of Engineering and Built Environment, Universiti Kebangsaan Malaysia, Bangi, Malaysia
| | - Annabel Braem
- Biomaterials and Tissue Engineering Research Group, Department of Materials Engineering, KU Leuven, Leuven, Belgium
| | - Françoise Van Bambeke
- Pharmacologie cellulaire et moléculaire, Louvain Drug Research Institute, Université catholique de Louvain, Brussels, Belgium
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In Vitro Study of the Synergistic Effect of an Enzyme Cocktail and Antibiotics against Biofilms in a Prosthetic Joint Infection Model. Antimicrob Agents Chemother 2021; 65:AAC.01699-20. [PMID: 33468484 DOI: 10.1128/aac.01699-20] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Accepted: 12/29/2020] [Indexed: 11/20/2022] Open
Abstract
Prosthetic joint infections (PJI) are frequent complications of arthroplasties. Their treatment is made complex by the rapid formation of bacterial biofilms, limiting the effectiveness of antibiotic therapy. In this study, we explore the effect of a tri-enzymatic cocktail (TEC) consisting of an endo-1,4-β-d-glucanase, a β-1,6-hexosaminidase, and an RNA/DNA nonspecific endonuclease combined with antibiotics of different classes against biofilms of Staphylococcus aureus, Staphylococcus epidermidis, and Escherichia coli grown on Ti-6Al-4V substrates. Biofilms were grown in Trypticase soy broth (TSB) with 10 g/liter glucose and 20 g/liter NaCl (TGN). Mature biofilms were assigned to a control group or treated with the TEC for 30 min and then either analyzed or reincubated for 24 h in TGN or TGN with antibiotics. The cytotoxicity of the TEC was assayed against MG-63 osteoblasts, primary murine fibroblasts, and J-774 macrophages using the lactate dehydrogenase (LDH) release test. The TEC dispersed 80.3 to 95.2% of the biofilms' biomass after 30 min. The reincubation of the treated biofilms with antibiotics resulted in a synergistic reduction of the total culturable bacterial count (CFU) compared to that of biofilms treated with antibiotics alone in the three tested species (additional reduction from 2 to more than 3 log10 CFU). No toxicity of the TEC was observed against the tested cell lines after 24 h of incubation. The combination of pretreatment with TEC followed by 24 h of incubation with antibiotics had a synergistic effect against biofilms of S. aureus, S. epidermidis, and E. coli Further studies should assess the potential of the TEC as an adjuvant therapy in in vivo models of PJI.
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