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Naoum S, Koutserimpas C, Pantekidis I, Giovanoulis V, Veizi E, Piagkou M, Ioannou P, Samonis G, Domouchtsidou A, Tsantes AG, Papadopoulos DV. Antimicrobial Regimens in Cement Spacers for Periprosthetic Joint Infections: A Critical Review. Antibiotics (Basel) 2024; 13:772. [PMID: 39200072 PMCID: PMC11351621 DOI: 10.3390/antibiotics13080772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Revised: 08/11/2024] [Accepted: 08/13/2024] [Indexed: 09/01/2024] Open
Abstract
Antibiotic-loaded cement spacers (ALCSs) are essential for treating periprosthetic joint infections (PJIs) by providing mechanical support and local antibiotic delivery. The purpose of this review is to comprehensively examine the various types of spacers utilised in the management of periprosthetic joint infections (PJIs), including both static and articulating variants and to analyse the fundamental principles underlying spacer use, their clinical benefits, the selection and administration of antimicrobial agents, appropriate dosages, and potential adverse effects. Articulating spacers, which allow joint mobility, often yield better outcomes than static ones. Spacer pharmacokinetics are vital for maintaining therapeutic antibiotic levels, influenced by cement porosity, mixing techniques, and the contact area. Antibiotic choice depends on heat stability, solubility, and impact on cement's mechanical properties. Mechanical properties are crucial, as spacers must withstand physical stresses, with antibiotics potentially affecting these properties. Complications, such as tissue damage and systemic toxicity, are discussed, along with mitigation strategies. Future advancements include surface modifications and novel carriers to enhance biofilm management and infection control.
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Affiliation(s)
- Symeon Naoum
- Department of Trauma and Orthopaedics, Royal Berkshire Hospital, Reading RG1 5AN, UK;
| | - Christos Koutserimpas
- Orthopaedic Surgery and Sports Medicine Department, Croix-Rousse Hospital, University Hospital, 69317 Lyon, France
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece;
| | - Ioannis Pantekidis
- Department of Trauma and Orthopaedics, Guy’s and St. Thomas’ NHS Foundation Trust, London SE1 7EH, UK
| | - Vasileios Giovanoulis
- Department of Orthopaedic Surgery, Hôpital Henri Mondor, AP-HP, Université Paris Est Créteil (UPEC), 94010 Creteil, France;
| | - Enejd Veizi
- Department of Orthopedics and Traumatology, Yıldırım Beyazıt University, Ankara City Hospital, Ankara 2367, Turkey;
| | - Maria Piagkou
- Department of Anatomy, School of Medicine, Faculty of Health Sciences, National and Kapodistrian University of Athens, 75 Mikras Asias Str., Goudi, 11527 Athens, Greece;
| | - Petros Ioannou
- School of Medicine, University of Crete, 71003 Heraklion, Greece (G.S.)
| | - George Samonis
- School of Medicine, University of Crete, 71003 Heraklion, Greece (G.S.)
- First Department of Medical Oncology, Metropolitan Hospital of Neon Faliron, 18547 Athens, Greece
| | - Aglaia Domouchtsidou
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece; (A.D.); (A.G.T.)
| | - Andreas G. Tsantes
- Microbiology Department, “Saint Savvas” Oncology Hospital, 11522 Athens, Greece; (A.D.); (A.G.T.)
- Laboratory of Hematology and Blood Bank Unit, “Attikon” University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462 Athens, Greece
| | - Dimitrios V. Papadopoulos
- 2nd Academic Department of Orthopaedics, School of Medicine, National and Kapodistrian University of Athens, 14233 Athens, Greece;
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Doub JB, Siddiqui H. Propensity of Candida spp. prosthetic joint infection clinical isolates to form aggregates in synovial fluid and the clinical ramifications. Mycoses 2024; 67:e13769. [PMID: 39039764 DOI: 10.1111/myc.13769] [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: 02/13/2024] [Revised: 07/12/2024] [Accepted: 07/13/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Bacterial aggregation has been shown to occur in synovial fluid which are resistant to high concentrations of antibiotics. Yet the propensity of Candida spp. to form aggregates is unknown. OBJECTIVE To assess the ability of numerous Candida spp. to form synovial fluid aggregates and the clinical ramifications of the aggregates. METHODS Nine different Candidal prosthetic joint infection clinical isolates were evaluated for their ability to form aggregates at static and dynamic conditions and their resistance to high concentrations of amphotericin. Furthermore, the ability of tissue plasminogen activator (TPA) to disrupt the aggregates and enhance amphotericin activity was assessed. RESULTS The results show that all species of Candida spp. evaluated formed aggregates in synovial fluid under dynamic conditions that were resistant to amphotericin. Yet no aggregates formed in tryptic soy broth under any conditions or in synovial fluid under static conditions. As well, when TPA was combined with amphotericin there was a statistically significant decrease (p < .005) in the amount of colony forming units per mL for all Candidal species evaluated. Interestingly, for Candida krusei there was no colony forming units observed after exposure to TPA and amphotericin. CONCLUSION Our findings suggest that Candidal species form synovial fluid aggregates that are resistant to high dose amphotericin similar to those that occur with bacteria. However, the varying ability of the different Candida spp. to form hyphae and pseudohyphae compared to yeast cells may have direct impacts on the hardiness of the aggregates and thereby have clinical ramifications with respect to treatment durations.
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Affiliation(s)
- James B Doub
- The Doub Laboratory of Translational Bacterial Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Hamda Siddiqui
- The Doub Laboratory of Translational Bacterial Research, University of Maryland School of Medicine, Baltimore, Maryland, USA
- Division of Clinical Care and Research, Institute of Human Virology, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Allison DC. CORR Insights®: High Rates of Treatment Failure and Amputation in Modular Endoprosthesis Prosthetic Joint Infections Caused by Fungal Infections With Candida. Clin Orthop Relat Res 2024; 482:1243-1245. [PMID: 38231012 PMCID: PMC11219143 DOI: 10.1097/corr.0000000000002967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 12/05/2023] [Indexed: 01/18/2024]
Affiliation(s)
- Daniel C Allison
- Department of Orthopaedic Surgery Cedars-Sinai Medical Center and Department of Pediatric Orthopaedics, Children's Hospital of Los Angeles, Los Angeles, CA, USA
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Prats-Peinado L, Fernández-Fernández T, Márquez-Gómez M, Matas-Diaz JA, Sánchez-Somolinos M, de la Villa-Martínez S, Vaquero-Martín J, Sanz-Ruiz P. Do High Doses of Multiple Antibiotics Loaded into Bone Cement Spacers Improve the Success Rate in Staphylococcal Periprosthetic Joint Infection When Rifampicin Cannot Be Employed? Antibiotics (Basel) 2024; 13:538. [PMID: 38927204 PMCID: PMC11200406 DOI: 10.3390/antibiotics13060538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 06/28/2024] Open
Abstract
Rifampicin is one of the mainstays in treating staphylococcal prosthetic joint infection (PJI). However, discontinuation due to intolerance, drug interactions, and adverse events is common. Two-stage revision surgery remains the gold standard, with the number of revision arthroplasties steadily increasing. This study aims to evaluate the effectiveness and safety of a novel two-stage revision protocol for staphylococcal prosthetic joint infection (PJI) utilizing bone cement spacers loaded with multiple high doses of antibiotics. Additionally, it seeks to analyze outcomes in patients ineligible for rifampicin treatment. A retrospective review of 43 cases of staphylococcal hip and knee prosthetic joint infections (PJIs) from 2012 to 2020 was conducted. In all instances, a commercial cement containing 1 g of gentamicin and 1 g of clindamycin, augmented with 4 g of vancomycin and 2 g of ceftazidime, was employed to cast a spacer manually after thorough surgical debridement. We report an eradication rate of 82%, with no significant differences observed (p = 0.673) between patients treated with (84%, n = 19) and without rifampicin (79%, n = 24). There were no disparities in positive culture rates (7%), spacer replacement (18%), or survival analysis (p = 0.514) after an average follow-up of 68 months (range 10-147) in the absence of systemic toxicity and surgical complications superimposable to those previously reported. In conclusion, two-stage revision with local high doses of ceftazidime, vancomycin, gentamicin, and clindamycin demonstrates high effectiveness in treating staphylococcal PJIs. Notably, systemic rifampicin does not influence the outcomes. This protocol, with multiple high doses of antibiotics loaded into the bone cement spacer, is presented as a viable and safe alternative for patients unsuitable for rifampicin treatment.
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Affiliation(s)
- Lourdes Prats-Peinado
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Tanya Fernández-Fernández
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Miguel Márquez-Gómez
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - José Antonio Matas-Diaz
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
| | - Mar Sánchez-Somolinos
- Department of Microbiology, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (S.d.l.V.-M.)
| | - Sofía de la Villa-Martínez
- Department of Microbiology, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (M.S.-S.); (S.d.l.V.-M.)
| | - Javier Vaquero-Martín
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
- Surgery Department, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
| | - Pablo Sanz-Ruiz
- Department of Orthopedic Surgery, General University Hospital Gregorio Marañón, 28007 Madrid, Spain; (L.P.-P.); (T.F.-F.); (M.M.-G.); (J.A.M.-D.); (J.V.-M.)
- Surgery Department, School of Medicine, Complutense University of Madrid, 28040 Madrid, Spain
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Rajme-López S, González-Lara MF, Rangel-Cordero A, Ponce-de-León A. Histoplasma capsulatum prosthetic joint infection. Med Mycol Case Rep 2023; 40:33-35. [PMID: 37063702 PMCID: PMC10090094 DOI: 10.1016/j.mmcr.2023.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 03/09/2023] [Accepted: 03/16/2023] [Indexed: 03/31/2023] Open
Abstract
Immunocompromised patients are at risk of opportunistic infections. This is a 67-year-old woman with systemic sclerosis and knee osteoarthritis who underwent left total knee arthroplasty in 2009. In 2018 she underwent surgery for presumed aseptic loosening. Inflammation and purulent fluid were found; implant was removed and replaced with a static spacer. Three weeks later, H. capsulatum was isolated. She was successfully treated with itraconazole for 18 months; cultures on revision spacer replacement surgery were negative.
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Krampitz B, Steiner J, Trampuz A, Kühn KD. Voriconazole Admixed with PMMA-Impact on Mechanical Properties and Efficacy. Antibiotics (Basel) 2023; 12:antibiotics12050848. [PMID: 37237751 DOI: 10.3390/antibiotics12050848] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/25/2023] [Accepted: 04/27/2023] [Indexed: 05/28/2023] Open
Abstract
BACKGROUND There are currently no recommendations to direct the optimal diagnosis and treatment of fungal osteoarticular infections, including prosthetic joint infections and osteomyelitis. Active agents (fluconazole; amphotericin B) are regularly applied per os or intravenously. Other drugs such as voriconazole are used less frequently, especially locally. Voriconazole is less toxic and has promising results. Local antifungal medication during primary surgical treatment has been investigated by implanting an impregnated PMMA cement spacer using intra-articular powder or by daily intra-articular lavage. The admixed dosages are rarely based on characteristic values and microbiological and mechanical data. The purpose of this in vitro study is to investigate the mechanical stability and efficacy of antifungal-admixed PMMA with admixed voriconazole at low and high concentrations. METHODS Mechanical properties (ISO 5833 and DIN 53435) as well as efficacy with inhibition zone tests with two Candida spp. were investigated. We tested three separate cement bodies at each measuring time (n = 3) Results: Mixing high dosages of voriconazole causes white specks on inhomogeneous cement surfaces. ISO compression, ISO bending, and DIN impact were significantly reduced, and ISO bending modulus increased. There was a high efficacy against C. albicans with low and high voriconazole concentrations. Against C. glabrata, a high concentration of voriconazole was significantly more efficient than a dose at a low concentration. CONCLUSIONS Mixing voriconazole powder with PMMA (Polymethylmethacrylate) powder homogeneously is not easy because of the high amount of dry voriconazole in the powder formulation. Adding voriconazole (a powder for infusion solutions) has a high impact on its mechanical properties. Efficacy is already good at low concentrations.
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Affiliation(s)
- Barbara Krampitz
- Medical Training and Science, Heraeus Medical GmhH, Hamburger Allee 50, 60486 Frankfurt, Germany
| | - Julia Steiner
- University Hospital for Orthopaedics and Traumatology, Medical University of Graz, 8036 Graz, Austria
| | - Andrej Trampuz
- Infectious Diseases, Center for Musculoskeletal Surgery, Charité, Universitätsmedizin Berlin, 10117 Berlin, Germany
| | - Klaus-Dieter Kühn
- University Hospital for Orthopaedics and Traumatology, Medical University of Graz, 8036 Graz, Austria
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Dapporto M, Tavoni M, Restivo E, Carella F, Bruni G, Mercatali L, Visai L, Tampieri A, Iafisco M, Sprio S. Strontium-doped apatitic bone cements with tunable antibacterial and antibiofilm ability. Front Bioeng Biotechnol 2022; 10:969641. [PMID: 36568303 PMCID: PMC9780487 DOI: 10.3389/fbioe.2022.969641] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 11/25/2022] [Indexed: 12/13/2022] Open
Abstract
Injectable calcium phosphate cements (CPCs) represent promising candidates for the regeneration of complex-shape bone defects, thanks to self-hardening ability, bioactive composition and nanostructure offering high specific surface area for cell attachment and conduction. Such features make CPCs also interesting for functionalization with various biomolecules, towards the generation of multifunctional devices with enhanced therapeutic ability. In particular, strontium-doped CPCs have been studied in the last years due to the intrinsic antiosteoporotic character of strontium. In this work, a SrCPC previously reported as osteointegrative and capable to modulate the fate of bone cells was enriched with hydroxyapatite nanoparticles (HA-NPs) functionalized with tetracycline (TC) to provide antibacterial activity. We found that HA-NPs functionalized with TC (NP-TC) can act as modulator of the drug release profile when embedded in SrCPCs, thus providing a sustained and tunable TC release. In vitro microbiological tests on Escherichia coli and Staphylococcus aureus strains proved effective bacteriostatic and bactericidal properties, especially for the NP-TC loaded SrCPC formulations. Overall, our results indicate that the addition of NP-TC on CPC acted as effective modulator towards a tunable drug release control in the treatment of bone infections or cancers.
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Affiliation(s)
- Massimiliano Dapporto
- Institute of Science, Technology and Sustainability for Ceramics (ISSMC) (Former ISTEC), National Research Council (CNR), Faenza, Italy
| | - Marta Tavoni
- Institute of Science, Technology and Sustainability for Ceramics (ISSMC) (Former ISTEC), National Research Council (CNR), Faenza, Italy
| | - Elisa Restivo
- Molecular Medicine Department, Center for Health Technologies, UdR INSTM, University of Pavia, Pavia, Italy
| | - Francesca Carella
- Institute of Science, Technology and Sustainability for Ceramics (ISSMC) (Former ISTEC), National Research Council (CNR), Faenza, Italy
| | - Giovanna Bruni
- Department of Chemistry, Physical Chemistry Section, Center for Colloid and Surfaces Science, University of Pavia, Pavia, Italy
| | - Laura Mercatali
- Osteoncology Unit, Bioscience Laboratory, IRCCS Istituto Romagnolo per lo Studio dei Tumori (IRST) “Dino Amadori”, Meldola, Italy
| | - Livia Visai
- Institute of Science, Technology and Sustainability for Ceramics (ISSMC) (Former ISTEC), National Research Council (CNR), Faenza, Italy
- Molecular Medicine Department, Center for Health Technologies, UdR INSTM, University of Pavia, Pavia, Italy
- Medicina Clinica-Specialistica, UOR5 Laboratorio di Nanotecnologie, ICS Maugeri. IRCCS, Pavia, Italy
| | - Anna Tampieri
- Institute of Science, Technology and Sustainability for Ceramics (ISSMC) (Former ISTEC), National Research Council (CNR), Faenza, Italy
| | - Michele Iafisco
- Institute of Science, Technology and Sustainability for Ceramics (ISSMC) (Former ISTEC), National Research Council (CNR), Faenza, Italy
| | - Simone Sprio
- Institute of Science, Technology and Sustainability for Ceramics (ISSMC) (Former ISTEC), National Research Council (CNR), Faenza, Italy
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Prosthetic Knee Joint Infection Due to Candida lusitaniae: A Diagnostic and Therapeutic Odyssey: A Case Study. Diagnostics (Basel) 2022; 12:diagnostics12112640. [DOI: 10.3390/diagnostics12112640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 10/17/2022] [Accepted: 10/27/2022] [Indexed: 11/16/2022] Open
Abstract
Prosthetic joint infections (PJIs) caused by fungi, although relatively rare, represent a major surgery-related complication. An extremely rare fungal PJI, following revised total knee replacement (TKR) caused by Candida lusitaniae, is reported, and a meticulous review of similar cases is provided. A 74-year-old female, who underwent primary total knee arthroplasty 10 years ago and a revision surgery three weeks ago, presented with signs and symptoms of PJI. C. lusitaniae was eventually isolated from the periprosthetic tissue using the MALDI-TOF VitekMS–bioMérieux technique. Multiple strategies for managing this fungal PJI were performed, and finally, the patient was treated successfully with an intramedullary arthrodesis system and proper antifungal treatment, including fluconazole. A multidisciplinary approach is essential for the diagnosis and treatment of such severe infections. In persistent cases and in cases where revision surgery is extremely difficult to perform, arthrodesis seems to be an effective solution for the elimination of the infection. The efficacy of the therapeutic management of fungal PJIs remains unclear. Therefore, more research should be reported, focusing on proper treatment so that the optimal strategy in treating these severe infections may be established.
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