Ozone therapy in conjunction with oral antibiotics as a successful primary and sole treatment for chronic septic prosthetic joint: review and case report

Use of oxygen-ozone therapy to improve the effectiveness of antibiotic treatment on infected arthroplasty: protocol for a superiority, open-label, multicentre, randomised, parallel trial

INTRODUCTION

Surgical site infections still remain a major public health challenge and have become an increasing universal risk, especially for the implantation of orthopaedic devices.Unfortunately, the discovery and increasingly widespread use (especially the misuse) of antibiotics have led to the rapid appearance of antibiotic-resistant strains today; more and more infections are caused by microorganisms that fail to respond to conventional treatments.Oxygen-ozone therapy has been extensively used and studied for decades across various potential medical applications and has provided consistent effects with minimal side effects.This study aims to determine the superiority of oxygen-ozone therapy in combination with oral antibiotic therapy in patients with wound infections after an orthopaedic device implantation when compared with antibiotic therapy alone.

METHODS AND ANALYSIS

This is an open-label, multicentre, randomised, parallel-group study that aims to assess the efficacy and safety of oxygen-ozone therapy in combination with oral antibiotic therapy to treat infections in patients (male or female aged ≥18 years) having undergone surgery for the implant of an orthopaedic device. Patients must have at least one (but no more than three) postoperative wounds in the site of surgery (ulcers, eschars and sores) and at least one symptom (pain, burning, redness and malodour) and at least one sign (erythema, local warmth, swelling and purulent secretion) of infection of at least moderate intensity (score ≥2) in the target lesion at the screening visit (patients with wounds without signs of localised infection or with undermining wounds will be excluded).Patients (n=186) will be recruited from five Italian hospitals and studied for 7 weeks. All will be assigned to one of the two treatment groups according to a web-based, centralised randomisation procedure and placed into either the (1) intervention: oxygen-ozone therapy 2-3 times a week for 6 weeks (for a maximum of 15 sessions) simultaneously with an appropriate oral antibiotic therapy prescribed at baseline or (2) control: oral antibiotic therapy prescribed at baseline.The primary outcome is the efficacy and superiority of the treatment (ozone and oral antibiotic therapies); secondary outcomes include the resolution of signs and symptoms, modifications in lesion size and the treatment's safety and tolerability.

ETHICS AND DISSEMINATION

This study has been reviewed and approved by the responsible Independent Ethics Committee (IEC) of COMITATO ETICO CAMPANIA NORD, located at 'Azienda Ospedaliera San Giuseppe Moscati di Avellino'.After completion of the study, the project coordinator will prepare a draft manuscript containing the final results of the study on the basis of the statistical analysis. The manuscript will be derived by the co-authors for comments, and after revision, it will be sent to a major scientific journal. Findings will be disseminated via online and print media, events and peer-reviewed journals.

TRIAL REGISTRATION NUMBER

NCT04787575.

The Oxygen-Ozone Adjunct Medical Treatment According to the Protocols from the Italian Scientific Society of Oxygen-Ozone Therapy: How Ozone Applications in the Blood Can Influence Clinical Therapy Success via the Modulation of Cell Biology and Immunity

BACKGROUND

Ozone is an allotrope of oxygen whose use in medicine has rapidly grown in recent years. Ozonated blood allows for the use of ozone in a safe modality, as plasma and blood cells are endowed with an antioxidant system able to quench ozone's pro-oxidant property and to elicit the Nrf2/Kwap1/ARE pathway.

METHODS

We present two clinical studies, a case-series (six patients) observational study adopting ozone as a major autohemotherapy and topical ozone to address infected post-surgical wounds with multi-drug resistant bacteria and an observational study (250 patients) using ozonated blood for treating knee osteoarthritis.

RESULTS

Ozonated blood via major autohemotherapy reduced the extent of infections in wounds, reduced the inflammatory biomarkers by more than 75% and improved patients' QoL, whereas ozonated blood via minor autohemotherapy improved significantly (p < 0.001) WOMAC and Lequesne's parameters in knee osteoarthritis.

CONCLUSIONS

The models described, i.e., ozone autohemotherapy in wound antimicrobial treatment and ozonated blood in knee osteoarthrosis, following our protocols, share the outstanding ability of ozone to modulate the innate immune response and address bacterial clearance as well as inflammation and pain.

The Role of Ozone as an Nrf2-Keap1-ARE Activator in the Anti-Microbial Activity and Immunity Modulation of Infected Wounds

Ozone is an allotrope of oxygen, widely known to exert an anti-oxidant potential. The ability of low, controlled and standardized doses of ozone in the ozone adjunct treatment of bacterial infections, which occur in wounds, is engaging clinical research to deepen the role of ozone in eradicating even multidrug-resistant bacteria. Ozone activates the nuclear factor erythroid 2-related factor 2 (Nrf2), and this activation triggers a complex cascade of events, which ultimately leads to macrophage training and an improvement in their ability to operate a clearance of bacteria in the patient's anatomical districts. In this review, we try to elucidate the recent evidence about the mechanisms with which ozone can actually remove bacteria and even multi-drug-resistant (MDR) bacteria, accounting on its complex ability in modulating immunity.

Oxidation and “Unconventional” Approaches to Infection

Nonpharmacological approaches can be useful to control infectious diseases. Historically infection has been successfully managed with oxidation therapy methods that support the body's own innate defenses. Several modalities include ozone and hyperbaric oxygen therapy, ultraviolet blood irradiation (UBI), intravenous hydrogen peroxide, and ascorbate therapies. Oxidation therapies are virtually 100% safe, and repeatedly reported as highly and quickly effective in quelling infection (bacterial and viral) either as stand-alone therapies or adjunctive with drugs. They are directly and indirectly germicidal, and modulate the immune system via pro-oxidant signaling molecules. Oxidation therapies especially enhance oxygen delivery and metabolism, critical for all infection defenses. Ozone has remitted Ebola, COVID-19, and bacterial infections. UBI defeated most preantibiotic era infections in hospitals. Not being drug therapy, the effects of oxidation defenses, used by planetary animal life for millions of years, are not diminished by antibiotic-resistant organisms. Oxidation, depending on delivery method, can be very inexpensive and third world adaptable. This chapter summarizes the use of these key modalities, by exploring known published literature.

Ozone and oxidation therapies as a solution to the emerging crisis in infectious disease management: a review of current knowledge and experience

Medicine faces crisis with emerging “super bugs,” lethal viruses (Ebola), and stealth pathogens such as tick-borne infections. Thousands are dying worldwide of once easily treatable diseases. Ozone therapy, extensively studied, may be a valuable adjunctive or stand-alone therapy. Ebola again ravages Africa with over 2000 already dead, carrying a 65% mortality rate. The world desperately needs safe, inexpensive and effective anti-infective therapy to which microbes will not develop resistance. Oxidation therapies have shown an extremely high safety profile, lacking credible reports of significant injury beyond vein irritation. Ozone therapy, the most studied and least expensive to perform, is in itself a germicide, not an antibiotic, and improves several physiological parameters essential for infection defense. Recent reports indicate very favorable responses to both bacterial and viral disease, inclusive of Ebola. Despite lack of commercial profitability (not patentable), medicine would do well to revisit its pre-antibiotic era oxidation therapy roots, especially ozone in the current crisis.

Multilayering as a solution to medical device failure

There are three main problems associated with medical device implants: biofilm, wear and corrosion, and bio rejection. A potential solution to these problems is multilayering. Polyelectrolyte multilayered films composed of polyallylamine hydrochloride and poly(4-vinylphenol) have been demonstrated to inhibit Staphylococcus epidermidis growth. Another study examined the wear behavior of polyelectrolyte multilayer coated orthopedic surfaces composed of poly(acrylic acid) and poly(allylamine hydrochloride) and found coated systems resulted in 33 % less wear than uncoated systems. Additionally, a heparin/collagen anti-CD34 antibody ((HEP/COL)₅-CD34) multilayer system provided accelerated adhesion of endothelial cells with a significant number of endothelial cells attaching in the first 5 min. This allowed for re-endothelialization to occur possibly reducing cardiac stent bio rejection. This review explores various ways multilayering has been utilized to prolong medical device use and decrease the number of complications associated with them.

High 2-year mortality and recurrent infection rates after surgical treatment for primary septic arthritis of the hip in adult patients: An observational study

Primary septic arthritis of the hip is rare and potentially devastating in adults. Its optimal surgical treatment and clinical outcomes remain unclear.In this retrospective cohort study, we investigated mortality and reinfection rates after surgery of patients with septic hip arthritis. We reviewed patients treated for primary septic hip joints from October 2005 to December 2016. A total of 51 adult patients were identified, and 38 among them had destructive hip joints. A poor postoperative outcome was defined as mortality or recurrent infection within 2 years of surgery.After surgery, 7 (13.7%) patients died within 1 year and 5 (9.8%) patients developed a recurrent hip infection within 2 years. Therefore, poor outcomes occurred in 22% (n = 11) of the study cohort. Among the 38 patients with a destructive hip joint, 7 (18.4%) died within 1 year after surgery and 4 (10.5%) developed a recurrent hip infection within 2 years of surgery. Correlative infections other than infected hip joint and liver cirrhosis were identified as risk factors for poor outcomes.In conclusion, clinical physicians treating adult primary septic hip joints should be cognizant of the high failure rate of surgical treatment. In addition, the high mortality rate should be considered during the discussion of surgical treatment with these patients and their families.

Ozone therapy as a primary and sole treatment for acute bacterial infection: case report

The world is facing a crisis of antibiotic resistance, which impacts every treating physician on the planet. Thousands of patients die yearly in the USA from infections that have failed to respond to anti-infectives. Alarms have been ringing about bacterial infection fatality resurgence, the end of the antibiotic era, a calamity in progress. Ozone therapy has been used in medicine since World War I. However, it is not patentable and has suffered from lack of private source funding for research sufficient to have it accepted by the mainstream. Basic science, both in vivo and in vitro, research has found it to have several effects including modulating the immune system, enhancing circulation, destroying microorganisms including bacteria and viruses, and enhancing oxygen delivery and consumption by the body. This report presents background basic ozone science and a case report of acute bacterial infection - tick bite cellulitis, which immediately responded to ozone therapy as the sole treatment, and which fully resolved within 24-48 hours. Ozone therapy could be considered as an adjunctive or alternative therapy for bacterial infection.