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Hvistendahl MA, Bue M, Hanberg P, Kaspersen AE, Schmedes AV, Stilling M, Høy K. Cefuroxime concentrations in the anterior and posterior column of the lumbar spine - an experimental porcine study. Spine J 2022; 22:1434-1441. [PMID: 35671945 DOI: 10.1016/j.spinee.2022.05.010] [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: 11/23/2021] [Revised: 03/04/2022] [Accepted: 05/26/2022] [Indexed: 02/03/2023]
Abstract
BACKGROUND CONTEXT Surgical site infection following spine surgery is associated with increased morbidity and mortality. Perioperative antibiotic prophylaxis is a key factor in lowering the risk of acquiring an infection. Previous studies have assessed perioperative cefuroxime concentrations in the anterior column of the cervical spine with an anterior surgical approach. However, the majority of surgeries are performed in the posterior column and many surgeries involve the lumbar spine. PURPOSE The objective of this study was to compare the perioperative tissue concentrations of cefuroxime in the anterior and posterior column during lumbar spine surgery with a posterior surgical approach. STUDY DESIGN In vivo experimental pharmacokinetic study of cefuroxime concentrations in an acute preclinical porcine model. METHODS The lumbar vertebral column was exposed from L1 to L5 in 8 female pigs. Microdialysis catheters were placed for sampling in the anterior column (vertebral body) and posterior column (posterior arch) within the same vertebra (L5). Cefuroxime (1.5 g) was administered intravenously. Microdialysates and plasma samples were continuously obtained over 8 hours. Cefuroxime concentrations were quantified by Ultra High Performance Liquid Chromatography Tandem Mass Spectrometry. The primary endpoint was the time above the cefuroxime clinical breakpoint minimal inhibitory concentration (T>MIC) for Staphylococcus aureus of 4 µg/mL. The secondary endpoint was tissue penetration (AUCtissue/AUCplasma). RESULTS Mean T>MIC 4 µg/mL (95% confidence interval) was 123 min (105-141) in plasma, 97 min (79-115) in the anterior column and 93 min (75-111) in the posterior column. Tissue penetration (95% confidence interval) was incomplete for both the anterior column 0.48 (0.40-0.56) and posterior column 0.40 (0.33-0.48). CONCLUSIONS T>MIC was comparable between the anterior and posterior column. Mean cefuroxime concentrations decreased below the clinical breakpoint minimal inhibitory concentration for S. aureus of 4 µg/mL after 123 minutes (plasma), 97 minutes (anterior column) and 93 minutes (posterior column). This is shorter than the duration of most lumbar spine surgeries, and therefore alternative dosing regimens should be considered in posterior open lumbar spine surgeries lasting more than 1.5 hours. CLINICAL SIGNIFICANCE Open lumbar spine surgery often involves extensive soft tissue dissection, stripping and retraction of the paraspinal muscles which may impair the local blood flow exposing the lumbar vertebra to postoperative infections. A single intravenous administration of 1.5 g cefuroxime only provided sufficient prophylactic target tissue concentrations in the vertebra of the lumbar spine for up to 1.5 hours.
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Affiliation(s)
- Magnus A Hvistendahl
- Department of Clinical Medicine, Aarhus University, Aarhus N, Central Denmark Region, Denmark; Aarhus Denmark Microdialysis Research (ADMIRE), Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark.
| | - Mats Bue
- Department of Clinical Medicine, Aarhus University, Aarhus N, Central Denmark Region, Denmark; Aarhus Denmark Microdialysis Research (ADMIRE), Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark; Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark
| | - Pelle Hanberg
- Department of Clinical Medicine, Aarhus University, Aarhus N, Central Denmark Region, Denmark; Aarhus Denmark Microdialysis Research (ADMIRE), Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark
| | - Alexander Emil Kaspersen
- Department of Clinical Medicine, Aarhus University, Aarhus N, Central Denmark Region, Denmark; Aarhus Denmark Microdialysis Research (ADMIRE), Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark
| | - Anne Vibeke Schmedes
- Department of Clinical Biochemistry and Immunology, Hospital Lillebaelt, Vejle, Southern Denmark Region, Denmark
| | - Maiken Stilling
- Department of Clinical Medicine, Aarhus University, Aarhus N, Central Denmark Region, Denmark; Aarhus Denmark Microdialysis Research (ADMIRE), Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark; Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark
| | - Kristian Høy
- Department of Clinical Medicine, Aarhus University, Aarhus N, Central Denmark Region, Denmark; Aarhus Denmark Microdialysis Research (ADMIRE), Orthopedic Research Laboratory, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark; Department of Orthopedic Surgery, Aarhus University Hospital, Aarhus N, Central Denmark Region, Denmark
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Vittrup S, Stilling M, Hanberg P, Tøstesen SK, Knudsen MB, Kipp JO, Bue M. Concentrations of co-administered vancomycin and meropenem in the internal dead space of a cannulated screw and in cancellous bone adjacent to the screw - Evaluated by microdialysis in a porcine model. Injury 2022; 53:2734-2740. [PMID: 35710595 DOI: 10.1016/j.injury.2022.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 05/22/2022] [Accepted: 06/09/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Cannulated screws are often used in the management of open lower extremity fractures. These fractures exhibit broad contamination profiles, necessitating empirical Gram-positive and Gram-negative antibiotic coverage. To ensure full antibiotic protection of the cannulated screw and the bone tissue, it is generally accepted that target tissue antibiotic concentrations, as a minimum, reach and remain above relevant epidemiological cut-off minimal inhibitory concentrations (T>MIC) for a sufficient amount of time. METHODS 8 female pigs were included. Microdialysis catheters were placed in the internal dead space of a cannulated screw placed in tibial cancellous bone, in tibial cancellous bone adjacent to the screw (mean distance to the screw: 3 mm), and in cancellous bone on the contralateral tibia. Following single-dose simultaneous intravenous administrations of vancomycin (1000 mg) and meropenem (1000 mg), microdialysates and plasma were dynamically sampled over 8 h. The applied MIC targets ranged from 1 to 4 µg/mL for vancomycin and 0.125-2 µg/mL for meropenem RESULTS: For both drugs, and for all MIC targets investigated (except for the high vancomycin target: 4 µg/mL), the internal dead space of the cannulated screw had the shortest T>MIC. At the low MIC targets T>MIC ranged between 88 and 449 min across sampling sites for vancomycin (1 µg/mL), and 148-406 min for meropenem (0.125 µg/mL). For the high MIC targets, T>MIC ranged between 3 and 446 min for vancomycin (4 μg/mL) and 17-181 min for meropenem (2 μg/mL). Vancomycin displayed longer T>MIC (2 and 4 μg/mL), higher area under the concentration time curve (AUC0-last) and peak drug concentration in the proximal tibial cancellous bone without a screw nearby. For meropenem, only the cancellous bone AUC0-last was significantly higher on the side with no screw. CONCLUSION We found short T>MIC, particularly for the high MIC targets for vancomycin and meropenem, both inside the cannulated screw and in cancellous bone adjacent to the screw. The presence of a cannulated screw impaired the penetration of especially vancomycin into cancellous bone adjacent to the screw. More aggressive or different vancomycin and meropenem approaches may be considered to encompass contaminating differences and to ensure a theoretically more sufficient antibiotic protection of cannulated screws when used in the management of open lower extremity fractures.
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Affiliation(s)
- Sofus Vittrup
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark.
| | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark
| | - Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark
| | - Martin Bruun Knudsen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark
| | - Josephine Olsen Kipp
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, J112, Aarhus N 8200, Denmark; Department of Clinical Medicine, Aarhus University, Palle Juul-Jensens Boulevard 99, IN CUBA, Aarhus N 8200, Denmark; Department of Orthopaedic Surgery, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, Aarhus N 8200, Denmark
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Tøstesen SK, Stilling M, Hanberg P, Thillemann TM, Falstie-Jensen T, Tøttrup M, Knudsen M, Petersen ET, Bue M. High Cefuroxime Concentrations and Long Elimination in an Orthopaedic Surgical Deadspace—A Microdialysis Porcine Study. Antibiotics (Basel) 2022; 11:antibiotics11020208. [PMID: 35203810 PMCID: PMC8868149 DOI: 10.3390/antibiotics11020208] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Revised: 01/27/2022] [Accepted: 02/04/2022] [Indexed: 02/04/2023] Open
Abstract
Deadspace is the tissue and bony defect in a surgical wound after closure. This space is presumably poorly perfused favouring bacterial proliferation and biofilm formation. In arthroplasty surgery, an obligate deadspace surrounding the prosthesis is introduced and deadspace management, in combination with obtaining therapeutic prophylactic antibiotic concentrations, is important for limiting the risk of acquiring a periprosthetic joint infection (PJI). This study aimed to investigate cefuroxime distribution to an orthopaedic surgical deadspace in comparison with plasma and bone concentrations during two dosing intervals (8 h × 2). In a setup imitating shoulder arthroplasty surgery, but without insertion of a prosthesis, microdialysis catheters were placed for cefuroxime sampling in a deadspace in the glenohumeral joint and in cancellous bone of the scapular neck in eighteen pigs. Blood samples were collected as a reference. Cefuroxime was administered according to weight (20 mg/kg). The primary endpoint was time above the cefuroxime minimal inhibitory concentration of the free fraction of cefuroxime for Staphylococcus aureus (fT > MIC (4 μg/mL)). During the two dosing intervals, mean fT > MIC (4 μg/mL) was significantly longer in deadspace (605 min) compared with plasma (284 min) and bone (334 min). For deadspace, the mean time to reach 4 μg/mL was prolonged from the first dosing interval (8 min) to the second dosing interval (21 min), while the peak drug concentration was lower and half-life was longer in the second dosing interval. In conclusion, weight-adjusted cefuroxime fT > MIC (4 μg/mL) and elimination from the deadspace was longer in comparison to plasma and bone. Our results suggest a deadspace consolidation and a longer diffusions distance, resulting in a low cefuroxime turn-over. Based on theoretical targets, cefuroxime appears to be an appropriate prophylactic drug for the prevention of PJI.
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Affiliation(s)
- Sara Kousgaard Tøstesen
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- Correspondence:
| | - Maiken Stilling
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Pelle Hanberg
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
| | - Theis Muncholm Thillemann
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Thomas Falstie-Jensen
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
| | - Mikkel Tøttrup
- Department of Orthopaedic Surgery, Aalborg University Hospital, 9640 Farsoe, Denmark;
| | - Martin Knudsen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
| | - Emil Toft Petersen
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
- AutoRSA Research Group, Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark
| | - Mats Bue
- Aarhus Denmark Microdialysis Research (ADMIRE), Orthopaedic Research Laboratory, Aarhus University Hospital, 8200 Aarhus N, Denmark; (M.S.); (P.H.); (M.B.)
- Department of Orthopaedic Surgery, Aarhus University Hospital, 8200 Aarhus N, Denmark; (T.M.T.); (T.F.-J.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus N, Denmark; (M.K.); (E.T.P.)
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