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Hickok NJ, Li B, Oral E, Zaat SAJ, Armbruster DA, Atkins GJ, Chen AF, Coraça-Huber DC, Dai T, Greenfield EM, Kasinath R, Libera M, Marques CNH, Moriarty TF, Scott Phillips K, Raghuraman K, Ren D, Rimondini L, Saeed K, Schaer TP, Schwarz EM, Spiegel C, Stoodley P, Truong VK, Tsang STJ, Wildemann B, Zelmer AR, Zinkernagel AS. The 2023 Orthopedic Research Society's international consensus meeting on musculoskeletal infection: Summary from the in vitro section. J Orthop Res 2024; 42:512-517. [PMID: 38146070 DOI: 10.1002/jor.25774] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 12/21/2023] [Indexed: 12/27/2023]
Abstract
Antimicrobial strategies for musculoskeletal infections are typically first developed with in vitro models. The In Vitro Section of the 2023 Orthopedic Research Society Musculoskeletal Infection international consensus meeting (ICM) probed our state of knowledge of in vitro systems with respect to bacteria and biofilm phenotype, standards, in vitro activity, and the ability to predict in vivo efficacy. A subset of ICM delegates performed systematic reviews on 15 questions and made recommendations and assessment of the level of evidence that were then voted on by 72 ICM delegates. Here, we report recommendations and rationale from the reviews and the results of the internet vote. Only two questions received a ≥90% consensus vote, emphasizing the disparate approaches and lack of established consensus for in vitro modeling and interpretation of results. Comments on knowledge gaps and the need for further research on these critical MSKI questions are included.
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Affiliation(s)
- Noreen J Hickok
- Department of Orthopaedic Surgery, Department of Biochemistry & Molecular Biology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Bingyun Li
- Department of Orthopaedics, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Ebru Oral
- Harris Orthopaedic Laboratory, Department of Orthopaedic Surgery, Harvard Medical School, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sebastian A J Zaat
- Department of Medical Microbiology and Infection Prevention, Amsterdam Institute for Infection and Immunity, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Gerald J Atkins
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
| | - Antonia F Chen
- Department of Orthopaedics, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Débora C Coraça-Huber
- Research Laboratory for Implant Associated Infections (Biofilm Lab), University Hospital for Orthopedics and Traumatology, Experimental Orthopaedics, Medical University of Innsbruck, Innsbruck, Austria
| | - Tianhong Dai
- Harvard Medical School, Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Edward M Greenfield
- Department of Orthopaedic Surgery, Indiana University School of Medicine, Indiana Center for Musculoskeletal Health, Indianapolis, Indiana, USA
| | | | - Matthew Libera
- Department of Chemical Engineering and Materials Science, Stevens Institute of Technology, Hoboken, New Jersey, USA
| | - Cláudia N H Marques
- Department of Biological Sciences, Binghamton Biofilm Research Center, Binghamton University, Binghamton, New York, USA
| | | | - K Scott Phillips
- Laboratory of Analytical Chemistry, Division of Biological Standards and Quality Control, Office of Compliance and Biologics Quality, Center for Biologics Evaluation and Research, US Food and Drug Administration, Silver Spring, Maryland, USA
| | | | - Dacheng Ren
- Department of Biomedical and Chemical Engineering, Syracuse University, Syracuse, New York, USA
| | - Lia Rimondini
- Department of Health Sciences, Università del Piemonte Orientale, Novara, Italy
| | - Kordo Saeed
- University Hospital Southampton NHS Foundation Trust, Winchester and Basingstoke, UK
- University of Southampton, Southampton, UK
| | - Thomas P Schaer
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania, Kennett Square, Pennsylvania, USA
| | - Edward M Schwarz
- Center for Musculoskeletal Research, University of Rochester, Rochester, New York, USA
| | - Christopher Spiegel
- Research Laboratory for Biofilms and Implant Associated Infections (BIOFILM LAB), Experimental Orthopedics, University Hospital for Orthopedics and Traumatology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Stoodley
- Department Microbial Infection and Immunity and Department of Orthopaedics, The Ohio State University, Columbus, Ohio, USA
| | - Vi Khanh Truong
- Biomedical Nanoengineering Laboratory, College of Medicine and Public Health, Bedford Park, South Australia, Australia
| | - Shao-Ting Jerry Tsang
- Department of Trauma and Orthopaedic Surgery, University of Edinburgh, Edinburgh, Scotland, UK
| | - Britt Wildemann
- Experimental Trauma Surgery, Department of Trauma, Hand and Reconstructive Surgery, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Anja R Zelmer
- Centre for Orthopaedic and Trauma Research, University of Adelaide, Adelaide, South Australia, Australia
| | - Annelies S Zinkernagel
- Department of Infectious Diseases and Hospital Epidemiology, University Hospital of Zurich and University of Zurich, Zurich, Switzerland
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Moriarty TF, Hickok NJ, Saeed K, Schaer TP, Chen AF, Schwarz EM. The 2023 Orthopaedic Research Society International Consensus Meeting on musculoskeletal infection. J Orthop Res 2024; 42:497-499. [PMID: 37823833 DOI: 10.1002/jor.25714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Revised: 10/03/2023] [Accepted: 10/05/2023] [Indexed: 10/13/2023]
Abstract
The Orthopaedic Research Society's Research Interest Group completed its international consensus meeting (ICM) on musculoskeletal infections (MSKI) following the 2023 Annual Meeting. The work products from this ICM include the 65 questions with recommendation and rationale, and the voting results from the 72 delegates. There are also five Consensus Articles in this issue of the Journal of Orthopaedic Research from the ICM Sections: Host Immunity, Established Infection-Treatment, Clinical Questions not addressed by the prior MSKI ICMs, In Vitro, and Animal Models. This Introduction summarizes the 3-year Delphi process used by the ICM with timelines and critical milestones. It also highlights several challenges that had to be addressed, and a large body of work that remains.
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Affiliation(s)
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Kordo Saeed
- University Hospital Southampton, NHS Foundation Trust, University of Southampton, Southampton, UK
| | - Thomas P Schaer
- Department of Clinical Studies, University of Pennsylvania School of Veterinary Medicine, New Bolton Center, Kennett Square, Pennsylvania, USA
| | - Antonia F Chen
- Department of Orthpaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - Edward M Schwarz
- Department of Orthopaedics, Center for Musculoskeletal Research, University of Rochester, Rochester, New York, USA
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Maybin JA, Thompson TP, Flynn PB, Skvortsov T, Hickok NJ, Freeman TA, Gilmore BF. Cold atmospheric pressure plasma-antibiotic synergy in Pseudomonas aeruginosa biofilms is mediated via oxidative stress response. Biofilm 2023; 5:100122. [PMID: 37214348 PMCID: PMC10196807 DOI: 10.1016/j.bioflm.2023.100122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 04/06/2023] [Accepted: 04/06/2023] [Indexed: 05/24/2023] Open
Abstract
Cold atmospheric-pressure plasma (CAP) has emerged as a potential alternative or adjuvant to conventional antibiotics for the treatment of bacterial infections, including those caused by antibiotic-resistant pathogens. The potential of sub-lethal CAP exposures to synergise conventional antimicrobials for the eradication of Pseudomonas aeruginosa biofilms is investigated in this study. The efficacy of antimicrobials following or in the absence of sub-lethal CAP pre-treatment in P. aeruginosa biofilms was assessed. CAP pre-treatment resulted in an increase in both planktonic and biofilm antimicrobial sensitivity for all three strains tested (PAO1, PA14, and PA10548), with both minimum inhibitory concentrations (MICs) and minimum biofilm eradication concentrations (MBECs) of individual antimicrobials, being significantly reduced following CAP pre-treatment of the biofilm (512-fold reduction with ciprofloxacin/gentamicin; and a 256-fold reduction with tobramycin). At all concentrations of antimicrobial used, the combination of sub-lethal CAP exposure and antimicrobials was effective at increasing time-to-peak metabolism, as measured by isothermal microcalorimetry, again indicating enhanced susceptibility. CAP is known to damage bacterial cell membranes and DNA by causing oxidative stress through the in situ generation of reactive oxygen and nitrogen species (RONS). While the exact mechanism is not clear, oxidative stress on outer membrane proteins is thought to damage/perturb cell membranes, confirmed by ATP and LDH leakage, allowing antimicrobials to penetrate the bacterial cell more effectively, thus increasing bacterial susceptibility. Transcriptomic analysis, reveals that cold-plasma mediated oxidative stress caused upregulation of P. aeruginosa superoxide dismutase, cbb3 oxidases, catalases, and peroxidases, and upregulation in denitrification genes, suggesting that P. aeruginosa uses these enzymes to degrade RONS and mitigate the effects of cold plasma mediated oxidative stress. CAP treatment also led to an increased production of the signalling molecule ppGpp in P. aeruginosa, indicative of a stringent response being established. Although we did not directly measure persister cell formation, this stringent response may potentially be associated with the formation of persister cells in biofilm cultures. The production of ppGpp and polyphosphate may be associated with protein synthesis inhibition and increase efflux pump activity, factors which can result in antimicrobial tolerance. The transcriptomic analysis also showed that by 6 h post-treatment, there was downregulation in ribosome modulation factor, which is involved in the formation of persister cells, suggesting that the cells had begun to resuscitate/recover. In addition, CAP treatment at 4 h post-exposure caused downregulation of the virulence factors pyoverdine and pyocyanin; by 6 h post-exposure, virulence factor production was increasing. Transcriptomic analysis provides valuable insights into the mechanisms by which P. aeruginosa biofilms exhibits enhanced susceptibility to antimicrobials. Overall, these findings suggest, for the first time, that short CAP sub-lethal pre-treatment can be an effective strategy for enhancing the susceptibility of P. aeruginosa biofilms to antimicrobials and provides important mechanistic insights into cold plasma-antimicrobial synergy. Transcriptomic analysis of the response to, and recovery from, sub-lethal cold plasma exposures in P. aeruginosa biofilms improves our current understanding of cold plasma biofilm interactions.
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Affiliation(s)
- Jordanne-Amee Maybin
- Biofilm Research Group, School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Thomas P Thompson
- Biofilm Research Group, School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Padrig B Flynn
- Biofilm Research Group, School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Timofey Skvortsov
- Biofilm Research Group, School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
| | - Noreen J Hickok
- Department of Orthopaedic Surgery Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Theresa A Freeman
- Department of Orthopaedic Surgery Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, 19107, USA
| | - Brendan F Gilmore
- Biofilm Research Group, School of Pharmacy, Queen's University Belfast, Medical Biology Centre, 97 Lisburn Road, Belfast, BT9 7BL, UK
- Institute for Global Food Security, School of Biological Sciences, Queen's University Belfast, 19 Chlorine Gardens, Belfast, BT9 5DL, UK
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Zhao N, Isguven S, Evans R, Schaer TP, Hickok NJ. Berberine disrupts staphylococcal proton motive force to cause potent anti-staphylococcal effects in vitro. Biofilm 2023; 5:100117. [PMID: 37090161 PMCID: PMC10113750 DOI: 10.1016/j.bioflm.2023.100117] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 03/27/2023] [Accepted: 03/29/2023] [Indexed: 04/03/2023] Open
Abstract
The presence of antibiotic resistance has increased the urgency for more effective treatments of bacterial infections. Biofilm formation has complicated this issue as biofilm bacteria become tolerant to antibiotics due to environmental factors such as nutrient deprivation and adhesion. In septic arthritis, a disease with an 11% mortality rate, bacteria in synovial fluid organize into floating, protein-rich, bacterial aggregates (mm-cm) that display depressed metabolism and antibiotic tolerance. In this study, Staphylococcus aureus (S. aureus), which is the most common pathogen in septic arthritis, was tested against different inhibitors that modulate bacterial surface protein availability and that should decrease bacterial aggregation. One of these, berberine, a quaternary ammonium compound, was found to reduce bacterial counts by 3-7 logs in human synovial fluid (aggregating medium) with no effect in tryptic soy broth (TSB, non-aggregating). Unlike traditional antibiotics, the bactericidal activity of berberine appeared to be independent of bacterial metabolism. To elucidate the mechanism, we used synovial fluid fractionation, targeted MRSA transposon insertion mutants, dyes to assess changes in membrane potential (DiSC3(5)) and membrane permeability (propidium iodide (PI)), colony counting, and fluorescence spectroscopy. We showed that berberine's activity was dependent on an alkaline pH and berberine killed both methicillin-sensitive S. aureus and MRSA in alkaline media (pH 8.5-9.0; p < 0.0001 vs. same pH controls). Under these alkaline conditions, berberine localized to S. aureus where berberine was isolated in cytoplasmic (∼95%) and DNA (∼5%) fractions. Importantly, berberine increased bacterial cell membrane permeability, and disrupted the proton motive force, suggesting a mechanism whereby it may be able to synergize with other antibacterial compounds under less harsh conditions. We suggest that berberine, which is cheap and readily available, can be made into an effective treatment.
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Affiliation(s)
- Neil Zhao
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Selin Isguven
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
- Department of Radiology, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Rachel Evans
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Thomas P. Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, USA
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
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Delaney LJ, Isguven S, Hilliard R, Lacerda Q, Oeffinger BE, Machado P, Schaer TP, Hickok NJ, Kurtz SM, Forsberg F. In Vitro and In Vivo Evaluation of Ultrasound-Triggered Release From Novel Spinal Device. J Ultrasound Med 2023; 42:2357-2368. [PMID: 37249416 PMCID: PMC10524871 DOI: 10.1002/jum.16263] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 03/17/2023] [Accepted: 05/05/2023] [Indexed: 05/31/2023]
Abstract
OBJECTIVES Bacterial infection following spinal fusion is a major clinical concern with up to 20% incidence. An ultrasound-triggered bulk-release system to combat postsurgical bacterial survival was designed and evaluated. METHODS Polylactic acid (PLA) clips were loaded with vancomycin (VAN) and microbubbles (Sonazoid, GE HealthCare) in vitro. Stability was determined over 14 days. VAN-loaded clips were submerged in water and insonated using a Logiq E10 scanner (GE HealthCare) with a curvilinear C6 probe. Doppler-induced VAN release was quantified using spectrophotometry. For in vivo testing, clips were loaded with methylene blue (MeB) solution and Sonazoid. These clips were implanted into a rabbit along the spine at L2 and L5, as well as a pig at L1 and L3, then insonated in Doppler mode using the C6 probe. RESULTS Sonazoid microbubbles were better preserved when incubated in VAN compared with distilled water at 4°C, 25°C, and 37°C incubation temperatures (P = .0131). Contrast enhancement was observed from both solutions when incubated at 4°C storage conditions. Insonated clips achieved average cumulative VAN release of 101.8 ± 2.8% (81.4 ± 2.8 mg) after 72 hours. Uninsonated clips had only 0.3 ± 0.1% (0.3 ± 0.1 mg) average cumulative VAN release (P < .0001). Clips retrieved from the rabbit did not rupture with insonation nor produce MeB staining of surrounding tissues. In the pig, the PLA film was visibly ruptured and MeB tissue was observed following insonation, whereas the uninsonated clip was intact. CONCLUSION These results demonstrate ultrasound-triggered release of an encapsulated prophylactic solution and provide an important proof-of-concept for continuing large animal evaluations for translational merit.
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Affiliation(s)
- Lauren J. Delaney
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Selin Isguven
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Rachel Hilliard
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA, 19348
| | - Quezia Lacerda
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA, 19104
| | - Brian E. Oeffinger
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA, 19104
| | - Priscilla Machado
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Thomas P. Schaer
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, Kennett Square, PA, 19348
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, 19107
| | - Steven M. Kurtz
- School of Biomedical Engineering, Science & Health Systems, Drexel University, Philadelphia, PA, 19104
- Exponent, Inc., Philadelphia, PA, 19104
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, 19107
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Purtill C, Dhesi M, Haber D, D Antonio N, Hickok NJ, Simon JI. Multiple Sterile Withdrawals from Iohexol Bottles Does Not Increase Contamination Risk. Pain Physician 2023; 26:369-373. [PMID: 37535776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/05/2023]
Abstract
BACKGROUND There is a global shortage of iohexol contrast media, commonly used in epidural injections, as a result of lockdown and decreased production due to COVID-19. Iohexol bottles are designated for single use, which, depending on the vials available, often leads to wasting up to 95% of this limited resource. However, avoiding multiple withdrawals may be unnecessary if withdrawing multiple times using sterile technique does not increase the risk for contamination. OBJECTIVES The purpose of our study is to determine whether multiple withdrawals from iohexol injection bottles using a sterile technique poses a greater risk of introducing contaminants than a single withdrawal. Furthermore, we wish to determine the extent to which bacteria can survive and grow in the contrast media. STUDY DESIGN Experimental. SETTING Outpatient fluoroscopic suite and laboratory. METHODS Twenty-one 100 mL 300 mg(iodine)/mL iohexol injection bottles, after one clinical use, were tested after the first and last withdrawals (withdrawal one and withdrawal 9 or 10) for bacterial and fungal specimens using culture media and 3M™ Petrifilms™. To determine the ability of methicillin-susceptible Staphylococcus aureus (MSSA) to survive or grow in the media, MSSA was added to different concentrations (0, 25, 50, 75, and 100%) of iohexol contrast media. RESULTS There was no growth observed in cultures or on Petrifilms among the first and last draws of any of the samples. When bacteria were grown in different dilutions of the media, there was a significant, approximately one log decrease in counts from 0% contrast media to 100% contrast media (8.4 x 108 vs 5.6 x 107, P < 0.01). LIMITATIONS Our study is limited in the number of samples tested and would benefit from additional investigation before consideration of clinical application. CONCLUSIONS Our results suggest that single-use 300 iohexol bottles may be reusable and that the contrast media is mildly antimicrobial, but not enough to retard contamination. In setting of shortages, contrast media bottles can safely be reused. This is valuable for conserving resources and limiting unnecessary health care-associated costs.
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Affiliation(s)
- Caroline Purtill
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Manraj Dhesi
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedics, Philadelphia, PA
| | - Daniel Haber
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedics, Philadelphia, PA
| | - Nicholas D Antonio
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA
| | - Jeremy I Simon
- Department of Physical Medicine and Rehabilitation, Rothman Orthopaedics, Philadelphia, PA
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Zhao N, Curry D, Evans RE, Isguven S, Freeman T, Eisenbrey JR, Forsberg F, Gilbertie JM, Boorman S, Hilliard R, Dastgheyb SS, Machado P, Stanczak M, Harwood M, Chen AF, Parvizi J, Shapiro IM, Hickok NJ, Schaer TP. Microbubble cavitation restores Staphylococcus aureus antibiotic susceptibility in vitro and in a septic arthritis model. Commun Biol 2023; 6:425. [PMID: 37069337 PMCID: PMC10110534 DOI: 10.1038/s42003-023-04752-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Accepted: 03/24/2023] [Indexed: 04/19/2023] Open
Abstract
Treatment failure in joint infections is associated with fibrinous, antibiotic-resistant, floating and tissue-associated Staphylococcus aureus aggregates formed in synovial fluid (SynF). We explore whether antibiotic activity could be increased against Staphylococcus aureus aggregates using ultrasound-triggered microbubble destruction (UTMD), in vitro and in a porcine model of septic arthritis. In vitro, when bacterially laden SynF is diluted, akin to the dilution achieved clinically with lavage and local injection of antibiotics, amikacin and ultrasound application result in increased bacterial metabolism, aggregate permeabilization, and a 4-5 log decrease in colony forming units, independent of microbubble destruction. Without SynF dilution, amikacin + UTMD does not increase antibiotic activity. Importantly, in the porcine model of septic arthritis, no bacteria are recovered from the SynF after treatment with amikacin and UTMD-ultrasound without UTMD is insufficient. Our data suggest that UTMD + antibiotics may serve as an important adjunct for the treatment of septic arthritis.
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Affiliation(s)
- Neil Zhao
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Dylan Curry
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Rachel E Evans
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Selin Isguven
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Theresa Freeman
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
| | - John R Eisenbrey
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Jessica M Gilbertie
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, USA
| | - Sophie Boorman
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, USA
| | - Rachel Hilliard
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, USA
| | - Sana S Dastgheyb
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priscilla Machado
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maria Stanczak
- Department of Radiology, Thomas Jefferson University, Philadelphia, PA, USA
| | - Marc Harwood
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
- Rothman Orthopaedic Institute, Philadelphia, PA, USA
| | - Irving M Shapiro
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel College, Thomas Jefferson University, Philadelphia, PA, USA.
| | - Thomas P Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, USA.
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8
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Dewey MJ, Collins AJ, Tiffany A, Barnhouse VR, Lu C, Kolliopoulos V, Mutreja I, Hickok NJ, Harley BAC. Evaluation of bacterial attachment on mineralized collagen scaffolds and addition of manuka honey to increase mesenchymal stem cell osteogenesis. Biomaterials 2023; 294:122015. [PMID: 36701999 PMCID: PMC9928779 DOI: 10.1016/j.biomaterials.2023.122015] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Revised: 01/06/2023] [Accepted: 01/14/2023] [Indexed: 01/21/2023]
Abstract
The design of biomaterials to regenerate bone is likely to increasingly require modifications that reduce bacterial attachment and biofilm formation as infection during wound regeneration can significantly impede tissue repair and typically requires surgical intervention to restart the healing process. Further, much research on infection prevention in bone biomaterials has focused on modeling of non-resorbable metal alloy materials, whereas an expanding direction of bone regeneration has focused on development of bioresorbable materials. This represents a need for the prevention and understanding of infection in resorbable biomaterials. Here, we investigate the ability of a mineralized collagen biomaterial to natively resist infection and examine how the addition of manuka honey, previously identified as an antimicrobial agent, affects gram positive and negative bacterial colonization and mesenchymal stem cell osteogenesis and vasculature formation. We incorporate manuka honey into these scaffolds via either direct fabrication into the scaffold microarchitecture or via soaking the scaffold in a solution of manuka honey after fabrication. Direct incorporation results in a change in the surface characteristics and porosity of mineralized collagen scaffolds. Soaking scaffolds in honey concentrations higher than 10% had significant negative effects on mesenchymal stem cell metabolic activity. Soaking or incorporating 5% honey had no impact on endothelial cell tube formation. Although solutions of 5% honey reduced metabolic activity of mesenchymal stem cells, MSC-seeded scaffolds displayed increased calcium and phosphorous mineral formation, osteoprotegerin release, and alkaline phosphatase activity. Bacteria cultured on mineralized collagen scaffolds demonstrated surfaces covered in bacteria and no method of preventing infection, and using 10 times the minimal inhibitory concentration of antibiotics did not completely kill bacteria within the mineralized collagen scaffolds, indicating bioresorbable scaffold materials may act to shield bacteria from antibiotics. The addition of 5% manuka honey to scaffolds was not sufficient to prevent P. aeruginosa attachment or consistently reduce the activity of methicillin resistant staphylococcus aureus, and concentrations above 7% manuka honey are likely necessary to impact MRSA. Together, our results suggest bioresorbable scaffolds may create an environment conducive to bacterial growth, and potential trade-offs exist for the incorporation of low levels of honey in scaffolds to increase osteogenic potential of osteoprogenitors while high-levels of honey may be sufficient to reduce gram positive or negative bacteria activity but at the cost of reduced osteogenesis.
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Affiliation(s)
- Marley J Dewey
- Dept. of Materials Science and Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Alan J Collins
- Carl R. Woese Institute for Genomic Biology, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Aleczandria Tiffany
- Dept. of Chemical and Biomolecular Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Victoria R Barnhouse
- Dept. of Bioengineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Crislyn Lu
- School of Chemical Sciences, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Vasiliki Kolliopoulos
- Dept. of Bioengineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA
| | - Isha Mutreja
- Department of Restorative Science, Minnesota Dental Research Center for Biomaterials and Biomechanics, University of Minnesota, Minneapolis, MN, 55455, USA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Brendan A C Harley
- Dept. of Materials Science and Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Carl R. Woese Institute for Genomic Biology, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Dept. of Chemical and Biomolecular Engineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Dept. of Bioengineering, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA; Cancer Center at Illinois, University of Illinois Urbana-Champaign, Urbana, IL, 61801, USA.
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9
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Leong JY, Capella CE, D’Amico MJ, Isguven S, Purtill C, Machado P, Delaney LJ, Henry GD, Hickok NJ, Forsberg F, Chung PH. A scoping review of penile implant biofilms—what do we know and what remains unknown? Transl Androl Urol 2022; 11:1210-1221. [PMID: 36092843 PMCID: PMC9459550 DOI: 10.21037/tau-22-195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 07/22/2022] [Indexed: 11/06/2022] Open
Abstract
Background Penile prosthesis (PP) is a gold standard for treatment of erectile dysfunction given its reliability and efficacy. Infection remains the most feared complication of prosthetic surgery, which usually results in device removal, and places a significant economic burden on the healthcare system. While biofilms have shown to support the persistence of microorganisms, the degree by which this matrix is truly pathogenic remains unknown given its high prevalence even in asymptomatic patients. We aim to review and summarize the current literature pertaining to biofilm formation in the setting of PP surgeries in clinically infected and non-infected cases. Methods Searches were performed in the MEDLINE online database through PubMed using a combination of keywords “penile prosthetic” OR “penile prosthesis” OR “penile implant” AND “biofilm” OR “revision” OR “removal” OR “infection” OR “explant”. Eleven articles met inclusion criteria. There were only three studies that explicitly listed the number of biofilms identified in their cohort, but we also included eight articles that mentioned swabbing and culturing of any bacterial biofilm during revision procedures for both clinically infected and non-infected implants. Results Infected PP yielded a 11–100% rate of biofilm presence, while non-infected PP yielded a 3–70% rate of biofilm presence. Time to reoperation from initial PP placement were also largely variable, ranging from 2 weeks to over 2 years. Coagulase-negative staphylococcus (i.e., Staphylococcus epidermidis) were the most commonly reported organisms among non-infected implants, however, newer studies have identified a change towards more virulent organisms. Conclusions Since the advent of PP surgery, diabetes control, revision washout protocols and antibiotic-impregnated devices have led to an overall decrease in biofilm formation and infectious complications. There is an overall paradigm shift in microbial profiles with more virulent organisms, such as Escherichia coli, Pseudomonas aeruginosa, Enterococcus species, and even fungal species beginning to replace the more common coagulase-negative staphylococcal species, especially in clinically infected implants. Additional studies are necessary to define the significance of bacterial presence in biofilms using impactful technologies such as next-generation sequencing. Currently, preliminary and experimental biofilm-control strategies are also underway to further address this clinical issue.
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Affiliation(s)
- Joon Yau Leong
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Courtney E. Capella
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Maria J. D’Amico
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Selin Isguven
- Department of Orthopedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
- Department of Radiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Caroline Purtill
- Department of Orthopedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priscilla Machado
- Department of Radiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lauren J. Delaney
- Department of Radiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Noreen J. Hickok
- Department of Orthopedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Flemming Forsberg
- Department of Radiology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
| | - Paul H. Chung
- Department of Urology, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA
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10
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Gilbertie JM, Schaer TP, Engiles JB, Seiler GS, Deddens BL, Schubert AG, Jacob ME, Stefanovski D, Ruthel G, Hickok NJ, Stowe DM, Frink A, Schnabel LV. A Platelet-Rich Plasma-Derived Biologic Clears Staphylococcus aureus Biofilms While Mitigating Cartilage Degeneration and Joint Inflammation in a Clinically Relevant Large Animal Infectious Arthritis Model. Front Cell Infect Microbiol 2022; 12:895022. [PMID: 35711655 PMCID: PMC9195519 DOI: 10.3389/fcimb.2022.895022] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Accepted: 05/02/2022] [Indexed: 12/03/2022] Open
Abstract
The leading cause of treatment failure in Staphylococcus aureus infections is the development of biofilms. Biofilms are highly tolerant to conventional antibiotics which were developed against planktonic cells. Consequently, there is a lack of antibiofilm agents in the antibiotic development pipeline. To address this problem, we developed a platelet-rich plasma (PRP)-derived biologic, termed BIO-PLY (for the BIOactive fraction of Platelet-rich plasma LYsate) which has potent in vitro bactericidal activity against S. aureus synovial fluid free-floating biofilm aggregates. Additional in vitro studies using equine synoviocytes and chondrocytes showed that BIO-PLY protected these cells of the joint from inflammation. The goal of this study was to test BIO-PLY for in vivo efficacy using an equine model of infectious arthritis. We found that horses experimentally infected with S. aureus and subsequently treated with BIO-PLY combined with the antibiotic amikacin (AMK) had decreased bacterial concentrations within both synovial fluid and synovial tissue and exhibited lower systemic and local inflammatory scores compared to horses treated with AMK alone. Most importantly, AMK+BIO-PLY treatment reduced the loss of infection-associated cartilage proteoglycan content in articular cartilage and decreased synovial tissue fibrosis and inflammation. Our results demonstrate the in vivo efficacy of AMK+BIO-PLY and represents a new approach to restore and potentiate antimicrobial activity against synovial fluid biofilms.
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Affiliation(s)
- Jessica M. Gilbertie
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
| | - Thomas P. Schaer
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Julie B. Engiles
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
- Department of Pathobiology New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Gabriela S. Seiler
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Bennett L. Deddens
- Department of Molecular Biomedical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Alicia G. Schubert
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Megan E. Jacob
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Darko Stefanovski
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Gordon Ruthel
- Department of Pathobiology New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Noreen J. Hickok
- Department of Orthopedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Devorah M. Stowe
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Alexa Frink
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
| | - Lauren V. Schnabel
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States
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11
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Delaney LJ, Isguven S, Eisenbrey JR, Hickok NJ, Forsberg F. Making waves: how ultrasound-targeted drug delivery is changing pharmaceutical approaches. Mater Adv 2022; 3:3023-3040. [PMID: 35445198 PMCID: PMC8978185 DOI: 10.1039/d1ma01197a] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Accepted: 02/23/2022] [Indexed: 05/06/2023]
Abstract
Administration of drugs through oral and intravenous routes is a mainstay of modern medicine, but this approach suffers from limitations associated with off-target side effects and narrow therapeutic windows. It is often apparent that a controlled delivery of drugs, either localized to a specific site or during a specific time, can increase efficacy and bypass problems with systemic toxicity and insufficient local availability. To overcome some of these issues, local delivery systems have been devised, but most are still restricted in terms of elution kinetics, duration, and temporal control. Ultrasound-targeted drug delivery offers a powerful approach to increase delivery, therapeutic efficacy, and temporal release of drugs ranging from chemotherapeutics to antibiotics. The use of ultrasound can focus on increasing tissue sensitivity to the drug or actually be a critical component of the drug delivery. The high spatial and temporal resolution of ultrasound enables precise location, targeting, and timing of drug delivery and tissue sensitization. Thus, this noninvasive, non-ionizing, and relatively inexpensive modality makes the implementation of ultrasound-mediated drug delivery a powerful method that can be readily translated into the clinical arena. This review covers key concepts and areas applied in the design of different ultrasound-mediated drug delivery systems across a variety of clinical applications.
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Affiliation(s)
- Lauren J Delaney
- Department of Radiology, Thomas Jefferson University 132 S. 10th Street, Main 763 Philadelphia PA 19107 USA +1 (215) 955-4870
| | - Selin Isguven
- Department of Radiology, Thomas Jefferson University 132 S. 10th Street, Main 763 Philadelphia PA 19107 USA +1 (215) 955-4870
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street Philadelphia PA 19107 USA
| | - John R Eisenbrey
- Department of Radiology, Thomas Jefferson University 132 S. 10th Street, Main 763 Philadelphia PA 19107 USA +1 (215) 955-4870
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street Philadelphia PA 19107 USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University 132 S. 10th Street, Main 763 Philadelphia PA 19107 USA +1 (215) 955-4870
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12
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Isguven S, Fitzgerald K, Delaney LJ, Harwood M, Schaer TP, Hickok NJ. In vitro investigations of Staphylococcus aureus biofilms in physiological fluids suggest that current antibiotic delivery systems may be limited. Eur Cell Mater 2022; 43:6-21. [PMID: 35106744 PMCID: PMC10043781 DOI: 10.22203/ecm.v043a03] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023] Open
Abstract
Orthopaedic surgical site infections, especially when a hardware is involved, are associated with biofilm formation. Clinical strategies for biofilm eradication still fall short. The present study used a novel animal model of long-bone fixation with vancomycin- or gentamicin-controlled release and measured the levels of antibiotic achieved at the site of release and in the surrounding tissue. Then, using fluids that contain serum proteins (synovial fluid or diluted serum), the levels of vancomycin or gentamicin required to substantially reduce colonising bacteria were measured in a model representative of either prophylaxis or established biofilms. In the in vivo model, while the levels immediately adjacent to the antibiotic release system were up to 50× the minimal inhibitory concentration in the first 24 h, they rapidly dropped. At peripheral sites, values never reached these levels. In the in vitro experiments, Staphylococcus aureus biofilms formed in serum or in synovial fluid showed a 5-10 fold increase in antibiotic tolerance. Importantly, concentrations required were much higher than those achieved in the local delivery systems. Finally, the study determined that the staged addition of vancomycin and gentamicin was not more efficacious than simultaneous vancomycin and gentamicin administration when using planktonic bacteria. On the other hand, for biofilms, the staged addition seemed more efficacious than adding the antibiotics simultaneously. Overall, data showed that the antibiotics' concentrations near the implant in the animal model fall short of the concentrations required to eradicate biofilms formed in either synovial fluid or serum.
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Affiliation(s)
| | | | | | | | - T P Schaer
- Department of Clinical Studies, New Bolton Center, University of Pennsylvania School of Veterinary Medicine, 382 West Street Road, Kennett Square, PA 19348, Philadelphia,
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13
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Massaglia JE, Lebowitz C, Fitzgerald K, Hickok NJ, Beredjiklian P, Rivlin M. An Evaluation of the Bacterial Adherence to Casting Materials. Cureus 2021; 13:e16724. [PMID: 34513359 PMCID: PMC8405175 DOI: 10.7759/cureus.16724] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/28/2021] [Indexed: 11/30/2022] Open
Abstract
Introduction: The purpose of this study was to evaluate bacterial adherence to common casting materials including plaster of Paris (plaster), fiberglass, three-dimensional (3D) printed plastic, and silicone-coated 3D printed plastic. Methods: The minimal inhibitory concentration of a phosphate-free detergent (Palmolive) needed to achieve total bacterial kill off was determined. 3D printed polylactic acid plastic samples were coated with silicone. Plaster, fiberglass, plastic, and silicone-coated plastic samples were inoculated with Staphylococcus aureus. After bacterial inoculation, scanning electron microscopy of the samples was performed to visualize bacterial adherence to the materials' surface. Using either sterile water or a 5% detergent solution, the materials were subjected to washings. Each material was run in 30 replicates: 6 without washing, 6 with sterile water for 1 minute, 6 with detergent for 1 minute, 6 with sterile water for 3 minutes, and 6 with detergent for 3 minutes. The replicates that did not undergo a washing trial represented the initial bacterial inoculation. Samples were then rinsed and sonicated in polysorbate to isolate the remaining adherent bacteria on the materials’ surface. The sonicated solutions were plated, incubated, and counted for quantification of colony forming units (CFU) of bacteria. This protocol was repeated for a total of four trials. Results: During inoculation, there were significantly less bacteria that adhered to silicone-coated 3D printed plastic (58879 CFU) compared to plastic (217479 CFU), plaster (140063 CFU), and fiberglass (550546 CFU). Silicone coating showed further superiority. Silicone-coated 3D printed plastic was able to be decontaminated as demonstrated by significantly fewer remaining bacteria (9.3%) on its surface after being washed with a 5% detergent solution (1797 CFU) compared to sterile water (19321 CFU). The mean remaining bacteria on silicone-coated 3D printed plastic was significantly less than that remaining on all other materials when washed with either sterile water or a detergent solution for both durations of 1 minute and 3 minutes. Conclusions: The current study demonstrates that significantly less bacteria adhere to the surface of 3D printed plastic with silicone coating showing added protection and that this material can be decontaminated to a greater degree with washing than conventional casting materials. These results provide evidence that 3D printed casts can be washed and successfully decontaminated during a patient’s period of immobilization, which is advantageous especially during an infectious crisis such as the coronavirus disease 2019 (COVID-19) pandemic.
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Affiliation(s)
- Joseph E Massaglia
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, USA
| | - Cory Lebowitz
- Department of Orthopaedic Surgery, Rowan University School of Osteopathic Medicine, Stratford, USA
| | - Keith Fitzgerald
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, USA
| | - Pedro Beredjiklian
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
| | - Michael Rivlin
- Division of Hand Surgery, Rothman Orthopaedic Institute, Philadelphia, USA
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14
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Knott S, Curry D, Zhao N, Metgud P, Dastgheyb SS, Purtill C, Harwood M, Chen AF, Schaer TP, Otto M, Hickok NJ. Staphylococcus aureus Floating Biofilm Formation and Phenotype in Synovial Fluid Depends on Albumin, Fibrinogen, and Hyaluronic Acid. Front Microbiol 2021; 12:655873. [PMID: 33995317 PMCID: PMC8117011 DOI: 10.3389/fmicb.2021.655873] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Accepted: 03/19/2021] [Indexed: 11/13/2022] Open
Abstract
Biofilms are typically studied in bacterial media that allow the study of important properties such as bacterial growth. However, the results obtained in such media cannot take into account the bacterial localization/clustering caused by bacteria-protein interactions in vivo and the accompanying alterations in phenotype, virulence factor production, and ultimately antibiotic tolerance. We and others have reported that methicillin-resistant or methicillin-susceptible Staphylococcus aureus (MRSA or MSSA, respectively) and other pathogens assemble a proteinaceous matrix in synovial fluid. This proteinaceous bacterial aggregate is coated by a polysaccharide matrix as is characteristic of biofilms. In this study, we identify proteins important for this aggregation and determine the concentration ranges of these proteins that can reproduce bacterial aggregation. We then test this protein combination for its ability to cause marked aggregation, antibacterial tolerance, preservation of morphology, and expression of the phenol-soluble modulin (PSM) virulence factors. In the process, we create a viscous fluid that models bacterial behavior in synovial fluid. We suggest that our findings and, by extension, use of this fluid can help to better model bacterial behavior of new antimicrobial therapies, as well as serve as a starting point to study host protein-bacteria interactions characteristic of physiological fluids.
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Affiliation(s)
- Samantha Knott
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Dylan Curry
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Neil Zhao
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Pallavi Metgud
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Sana S Dastgheyb
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Caroline Purtill
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
| | - Marc Harwood
- Rothman Orthopaedic Institute, Philadelphia, PA, United States
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham and Women's Hospital, Boston, PA, United States
| | - Thomas P Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States
| | - Michael Otto
- Pathogen Molecular Genetics Section, Laboratory of Human Bacterial Pathogenesis, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, MD, United States
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, United States
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15
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Saeed K, Sendi P, Arnold WV, Bauer TW, Coraça-Huber DC, Chen AF, Choe H, Daiss JL, Ghert M, Hickok NJ, Nishitani K, Springer BD, Stoodley P, Sculco TP, Brause BD, Parvizi J, McLaren AC, Schwarz EM. Bacterial toxins in musculoskeletal infections. J Orthop Res 2021; 39:240-250. [PMID: 32255540 PMCID: PMC7541548 DOI: 10.1002/jor.24683] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 02/27/2020] [Accepted: 04/01/2020] [Indexed: 02/04/2023]
Abstract
Musculoskeletal infections (MSKIs) remain a major health burden in orthopaedics. Bacterial toxins are foundational to pathogenesis in MSKI, but poorly understood by the community of providers that care for patients with MSKI, inducing an international group of microbiologists, infectious diseases specialists, orthopaedic surgeons and biofilm scientists to review the literature in this field to identify key topics and compile the current knowledge on the role of toxins in MSKI, with the goal of illuminating potential impact on biofilm formation and dispersal as well as therapeutic strategies. The group concluded that further research is needed to maximize our understanding of the effect of toxins on MSKIs, including: (i) further research to identify the roles of bacterial toxins in MSKIs, (ii) establish the understanding of the importance of environmental and host factors and in vivo expression of toxins throughout the course of an infection, (iii) establish the principles of drug-ability of antitoxins as antimicrobial agents in MSKIs, (iv) have well-defined metrics of success for antitoxins as antiinfective drugs, (v) design a cocktail of antitoxins against specific pathogens to (a) inhibit biofilm formation and (b) inhibit toxin release. The applicability of antitoxins as potential antimicrobials in the era of rising antibiotic resistance could meet the needs of day-to-day clinicians.
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Affiliation(s)
- Kordo Saeed
- University Hospital Southampton NHS Foundation Trust, Department of Microbiology, Microbiology Innovation and Research Unit (MIRU), Southampton, UK; and University of Southampton, School of Medicine, Southampton UK,To whom correspondence should be addressed. Dr Kordo Saeed, Consultant Microbiologist/ University Hospital Southampton NHS Foundation Trust, Honorary Senior Lecturer/ University of Southampton, Tremona Road, SOUTHAMPTON, SO16 6YD.
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland.,Department of Infectious Diseases and Hospital Epidemiology/ Department of Orthopaedics and Traumatology, University Hospital Basel, University Basel, Basel, Switzerland
| | - William V. Arnold
- Department of Orthopaedic Surgery, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Thomas W. Bauer
- Department of Pathology and Laboratory Medicine, Weill Cornell Medical College, Hospital for Special Surgery, New York, NY, USA
| | - Débora C. Coraça-Huber
- Research Laboratory for Implant Associated Infections (Biofilm Lab), Experimental Orthopaedics, Department of Orthopaedic Surgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Antonia F. Chen
- Department of Orthopaedic Surgery, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
| | - Hyonmin Choe
- Department of Orthopaedic Surgery, Yokohama City University, Yokohama, Kanagawa, Japan
| | - John L. Daiss
- Center for Musculoskeletal Research, School of Medicine and Dentistry University of Rochester, Rochester, NY, USA
| | - Michelle Ghert
- Department of Surgery, Division of Orthopaedic Surgery, McMaster University, Hamilton, ON, Canada
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - Kohei Nishitani
- Department of Orthopaedic Surgery, Kyoto University, Kyoto, Japan
| | - Bryan D. Springer
- OrthoCarolina Hip and Knee Center, Atrium Musculoskeletal Institute, Charlotte, NC, USA
| | - Paul Stoodley
- Departments of Microbial Infection and Immunity and OrthopedicsInfectious Diseases Institute, The Ohio State University, 716 Biomedical Research Tower, 460 West 12th Avenue, Columbus OH, Canada.,National Centre for Microbial Tribology at Southampton (nCATS), National Biofilm Innovation Centre (NBIC), Mechanical Engineering, University of Southampton, Southampton, UK.
| | - Thomas P. Sculco
- Department of Orthopaedic Surgery, Weill Cornell Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Barry D. Brause
- Department of Infectious Diseases, Weill Cornell Medicine, Hospital for Special Surgery, New York, NY, USA
| | - Javad Parvizi
- Department of Orthopaedics, Rothman Institute at Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Alex C. McLaren
- Department of Orthopaedic Surgery, University of Arizona, College of Medicine-Phoenix, Phoenix, AZ, USA
| | - Edward M. Schwarz
- Center for Musculoskeletal Research, Department of Orthopaedics, University of Rochester, Rochester, NY, USA
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16
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Heslin C, Boehm D, Gilmore BF, Megaw J, Freeman TA, Hickok NJ, Cullen PJ, Bourke P. Biomolecules as Model Indicators of In Vitro and In Vivo Cold Plasma Safety. Front Phys 2021; 8:613046. [PMID: 37124146 PMCID: PMC10136044 DOI: 10.3389/fphy.2020.613046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Indexed: 05/03/2023]
Abstract
The potential applications for cold plasma in medicine are extensive, from microbial inactivation and induction of apoptosis in cancer cells to stimulating wound healing and enhancing the blood coagulation cascade. The safe bio-medical application of cold plasma and subsequent effect on complex biological pathways requires precision and a distinct understanding of how physiological redox chemistry is manipulated. Chemical modification of biomolecules such as carbohydrates, proteins, and lipids treated with cold plasma have been characterized, however, the context of how alterations of these molecules affect cell behavior or in vivo functionality has not been determined. Thus, this study examines the cytotoxic and mutagenic effects of plasma-treated molecules in vitro using CHO-K1 cells and in vivo in Galleria mellonella larvae. Specifically, albumin, glucose, cholesterol, and arachidonic acid were chosen as representative biomolecules, with established involvement in diverse bioprocesses including; cellular respiration, intracellular transport, cell signaling or membrane structure. Long- and short-term effects depended strongly on the molecule type and the treatment milieu indicating the impact of chemical and physical modifications on downstream biological pathways. Importantly, absence of short-term toxicity did not always correlate with absence of longer-term effects, indicating the need to comprehensively assess ongoing effects for diverse biological applications.
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Affiliation(s)
- Caitlin Heslin
- School of Food Science and Environmental Health, Technological University Dublin, Dublin, Ireland
| | - Daniela Boehm
- School of Food Science and Environmental Health, Technological University Dublin, Dublin, Ireland
| | | | - Julianne Megaw
- School of Pharmacy, Queens University Belfast, Belfast, United Kingdom
| | - Theresa A. Freeman
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Jefferson University, Philadelphia, PA, United States
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Jefferson University, Philadelphia, PA, United States
| | - P. J. Cullen
- School of Food Science and Environmental Health, Technological University Dublin, Dublin, Ireland
- School of Chemical and Biomolecular Engineering, University of Sydney, Sydney, NSW, Australia
| | - Paula Bourke
- School of Food Science and Environmental Health, Technological University Dublin, Dublin, Ireland
- School of Biological Sciences, Queens University Belfast, Belfast, United Kingdom
- Plasma Research Group, School of Biosystems and Food Engineering, University College Dublin, Dublin, Ireland
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17
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Isguven S, Chung PH, Machado P, Delaney LJ, Chen AF, Forsberg F, Hickok NJ. AUTHOR REPLY. Urology 2020; 146:14. [PMID: 33272418 DOI: 10.1016/j.urology.2020.08.062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Selin Isguven
- Department of Orthopaedic Surgery, Thomas Jefferson University Philadelphia, Philadelphia, PA; Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Paul H Chung
- Department of Urology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Priscilla Machado
- Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Lauren J Delaney
- Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, MA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University Philadelphia, Philadelphia, PA
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Isguven S, Chung PH, Machado P, Delaney LJ, Chen AF, Forsberg F, Hickok NJ. Minimizing Penile Prosthesis Implant Infection: What Can We Learn From Orthopedic Surgery? Urology 2020; 146:6-14. [PMID: 32991908 DOI: 10.1016/j.urology.2020.08.060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Revised: 08/15/2020] [Accepted: 08/17/2020] [Indexed: 11/18/2022]
Abstract
The implantation of penile protheses for the surgical treatment of erectile dysfunction has risen in popularity over the past several decades. Considerable advances have been made in surgical protocol and device design, specifically targeting infection prevention. Despite these efforts, device infection remains a critical problem, which causes significant physical and emotional burden to the patient. The aim of this review is to broaden the discussion of best practices by not only examining practices in urology, but additionally delving into the field of orthopedic surgery to identify techniques and approaches that may be applied to penile prothesis surgery.
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Affiliation(s)
- Selin Isguven
- Department of Orthopaedic Surgery, Thomas Jefferson University Philadelphia, Philadelphia, PA; Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Paul H Chung
- Department of Urology, Thomas Jefferson University Philadelphia, Philadelphia, PA.
| | - Priscilla Machado
- Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Lauren J Delaney
- Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Antonia F Chen
- Department of Orthopaedic Surgery, Brigham & Women's Hospital, Boston, MA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University Philadelphia, Philadelphia, PA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University Philadelphia, Philadelphia, PA
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Delaney LJ, Basgul C, MacDonald DW, Fitzgerald K, Hickok NJ, Kurtz SM, Forsberg F. Acoustic Parameters for Optimal Ultrasound-Triggered Release from Novel Spinal Hardware Devices. Ultrasound Med Biol 2020; 46:350-358. [PMID: 31732196 PMCID: PMC7139856 DOI: 10.1016/j.ultrasmedbio.2019.10.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 09/28/2019] [Accepted: 10/01/2019] [Indexed: 05/06/2023]
Abstract
Post-operative infection is a catastrophic complication of spinal fusion surgery, with rates as high as 10%, and existing preventative measures (i.e., peri-operative antibiotics) are only partially successful. To combat this clinical problem, we have designed a drug delivery system around polyether ether ketone clips to be used for prophylactic post-surgical release of antibiotics upon application of ultrasound. The overall hypothesis is that antimicrobial release from this system will aggressively combat post-surgical bacterial survival. This study investigated a set of acoustic parameters optimized for in vitro ultrasound-triggered coating rupture and subsequent release of encapsulated prophylactic antibiotics. We determined that a transducer frequency of 1.7 MHz produced the most consistent burst release and that, at this frequency, a pulse repetition frequency of 6.4 kHz and acoustic output power of 100% (3.41 MPa) produced the greatest release, representing an important proof of principle and the basis for continued development of this novel drug delivery system.
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Affiliation(s)
- Lauren J Delaney
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Cemile Basgul
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Daniel W MacDonald
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA
| | - Keith Fitzgerald
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Steven M Kurtz
- School of Biomedical Engineering, Science and Health Systems, Drexel University, Philadelphia, Pennsylvania, USA; Exponent, Inc., Philadelphia, Pennsylvania, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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20
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Nguyen L, Lu P, Boehm D, Bourke P, Gilmore BF, Hickok NJ, Freeman TA. Cold atmospheric plasma is a viable solution for treating orthopedic infection: a review. Biol Chem 2019; 400:77-86. [PMID: 30138104 DOI: 10.1515/hsz-2018-0235] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Accepted: 08/06/2018] [Indexed: 12/15/2022]
Abstract
Bacterial infection and antibiotic resistance are major threats to human health and very few solutions are available to combat this eventuality. A growing number of studies indicate that cold (non-thermal) plasma treatment can be used to prevent or eliminate infection from bacteria, bacterial biofilms, fungi and viruses. Mechanistically, a cold plasma discharge is composed of high-energy electrons that generate short-lived reactive oxygen and nitrogen species which further react to form more stable compounds (NO2, H2O2, NH2Cl and others) depending on the gas mixture and plasma parameters. Cold plasma devices are being developed for medical applications including infection, cancer, plastic surgery applications and more. Thus, in this review we explore the potential utility of cold plasma as a non-antibiotic approach for treating post-surgical orthopedic infections.
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Affiliation(s)
- Ly Nguyen
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107-5099, USA
| | - Peng Lu
- College of Science and Health, Dublin Institute of Technology, Dublin, Ireland
| | - Daniela Boehm
- College of Science and Health, Dublin Institute of Technology, Dublin, Ireland
| | - Paula Bourke
- College of Science and Health, Dublin Institute of Technology, Dublin, Ireland
| | - Brendan F Gilmore
- School of Pharmacy, Queen's University Belfast, 97 Lisburn Road, Belfast BT9 7BL, UK
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107-5099, USA
| | - Theresa A Freeman
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107-5099, USA
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21
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Gilbertie JM, Schnabel LV, Hickok NJ, Jacob ME, Conlon BP, Shapiro IM, Parvizi J, Schaer TP. Equine or porcine synovial fluid as a novel ex vivo model for the study of bacterial free-floating biofilms that form in human joint infections. PLoS One 2019; 14:e0221012. [PMID: 31415623 PMCID: PMC6695105 DOI: 10.1371/journal.pone.0221012] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2019] [Accepted: 07/30/2019] [Indexed: 12/14/2022] Open
Abstract
Bacterial invasion of synovial joints, as in infectious or septic arthritis, can be difficult to treat in both veterinary and human clinical practice. Biofilms, in the form of free-floating clumps or aggregates, are involved with the pathogenesis of infectious arthritis and periprosthetic joint infection (PJI). Infection of a joint containing an orthopedic implant can additionally complicate these infections due to the presence of adherent biofilms. Because of these biofilm phenotypes, bacteria within these infected joints show increased antimicrobial tolerance even at high antibiotic concentrations. To date, animal models of PJI or infectious arthritis have been limited to small animals such as rodents or rabbits. Small animal models, however, yield limited quantities of synovial fluid making them impractical for in vitro research. Herein, we describe the use of ex vivo equine and porcine models for the study of synovial fluid induced biofilm aggregate formation and antimicrobial tolerance. We observed Staphylococcus aureus and other bacterial pathogens adapt the same biofilm aggregate phenotype with significant antimicrobial tolerance in both equine and porcine synovial fluid, analogous to human synovial fluid. We also demonstrate that enzymatic dispersal of synovial fluid aggregates restores the activity of antimicrobials. Future studies investigating the interaction of bacterial cell surface proteins with host synovial fluid proteins can be readily carried out in equine or porcine ex vivo models to identify novel drug targets for treatment of prevention of these difficult to treat infectious diseases.
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Affiliation(s)
- Jessica M. Gilbertie
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States of America
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States of America
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States of America
| | - Lauren V. Schnabel
- Department of Clinical Sciences, College of Veterinary Medicine, North Carolina State University, Raleigh, NC, United States of America
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States of America
| | - Noreen J. Hickok
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Megan E. Jacob
- Comparative Medicine Institute, North Carolina State University, Raleigh, NC, United States of America
- Department of Population Health and Pathobiology, College of Veterinary Medicine, North Carolina State University, Raleigh, North Carolina, United States of America
| | - Brian P. Conlon
- Department of Microbiology and Immunology, University of North Carolina-Chapel Hill, Chapel Hill, NC, United States of America
| | - Irving M. Shapiro
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Javad Parvizi
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA, United States of America
| | - Thomas P. Schaer
- Department of Clinical Studies New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, Kennett Square, PA, United States of America
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Delaney LJ, MacDonald D, Leung J, Fitzgerald K, Sevit AM, Eisenbrey JR, Patel N, Forsberg F, Kepler CK, Fang T, Kurtz SM, Hickok NJ. Ultrasound-triggered antibiotic release from PEEK clips to prevent spinal fusion infection: Initial evaluations. Acta Biomater 2019; 93:12-24. [PMID: 30826477 PMCID: PMC6764442 DOI: 10.1016/j.actbio.2019.02.041] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Revised: 02/21/2019] [Accepted: 02/26/2019] [Indexed: 01/01/2023]
Abstract
Despite aggressive peri-operative antibiotic treatments, up to 10% of patients undergoing instrumented spinal surgery develop an infection. Like most implant-associated infections, spinal infections persist through colonization and biofilm formation on spinal instrumentation, which can include metal screws and rods for fixation and an intervertebral cage commonly comprised of polyether ether ketone (PEEK). We have designed a PEEK antibiotic reservoir that would clip to the metal fixation rod and that would achieve slow antibiotic release over several days, followed by a bolus release of antibiotics triggered by ultrasound (US) rupture of a reservoir membrane. We have found using human physiological fluid (synovial fluid), that higher levels (100–500 μg) of vancomycin are required to achieve a marked reduction in adherent bacteria vs. that seen in the common bacterial medium, trypticase soy broth. To achieve these levels of release, we applied a polylactic acid coating to a porous PEEK puck, which exhibited both slow and US-triggered release. This design was further refined to a one-hole or two-hole cylindrical PEEK reservoir that can clip onto a spinal rod for clinical use. Short-term release of high levels of antibiotic (340 ± 168 μg), followed by US-triggered release was measured (7420 ± 2992 μg at 48 h). These levels are sufficient to prevent adhesion of Staphylococcus aureus to implant materials. This study demonstrates the feasibility of an US-mediated antibiotic delivery device, which could be a potent weapon against spinal surgical site infection.
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Affiliation(s)
- Lauren J Delaney
- Department of Radiology, Thomas Jefferson University, 132 S. 10th Street, Philadelphia, PA 19107, USA
| | - Daniel MacDonald
- School of Biomedical Engineering, Science and Health Systems, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104, USA
| | - Jay Leung
- School of Biomedical Engineering, Science and Health Systems, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104, USA
| | - Keith Fitzgerald
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA
| | - Alex M Sevit
- School of Biomedical Engineering, Science and Health Systems, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104, USA
| | - John R Eisenbrey
- Department of Radiology, Thomas Jefferson University, 132 S. 10th Street, Philadelphia, PA 19107, USA
| | - Neil Patel
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA
| | - Flemming Forsberg
- Department of Radiology, Thomas Jefferson University, 132 S. 10th Street, Philadelphia, PA 19107, USA
| | - Christopher K Kepler
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA; The Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Taolin Fang
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA; The Rothman Institute, Thomas Jefferson University, 925 Chestnut Street, Philadelphia, PA 19107, USA
| | - Steven M Kurtz
- School of Biomedical Engineering, Science and Health Systems, Drexel University, 3141 Chestnut Street, Philadelphia, PA 19104, USA; Exponent, Inc., 3440 Market Street Suite 600, Philadelphia, PA 19104, USA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Philadelphia, PA 19107, USA.
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23
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Abstract
With the increase in numbers of joint replacements, spinal surgeries, and dental implantations, there is an urgent need to combat implant-associated infection. In addition to stringent sterile techniques, an efficacious way to prevent this destructive complication is to create new implants with antimicrobial properties. Specifically, these implants must be active in the dental implant environment where the implant is bathed in the glycoprotein-rich salivary fluids that enhance bacterial adhesion, and propagation, and biofilm formation. However, in designing an antimicrobial surface, a balance must be struck between antimicrobial activity and the need for the implant to interact with the bone environment. Three types of surfaces have been designed to combat biofilm formation, while attempting to maintain osseous interactions: 1) structured surfaces where topography, usually at the nanoscale, decreases bacterial adhesion sufficiently to retard establishment of infection; 2) surfaces that actively elute antimicrobials to avert bacterial adhesion and promote killing; and 3) surfaces containing permanently bonded agents that generate antimicrobial surfaces that prevent long-term bacterial adhesion. Both topographical and elution surfaces exhibit varying, albeit limited, antimicrobial activity in vitro. With respect to covalent coupling, we present studies on the ability of the permanent antimicrobial surfaces to kill organisms while fostering osseointegration. All approaches have significant drawbacks with respect to stability and efficacy, but the permanent surfaces may have an edge in creating a long-term antibacterial environment.
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Affiliation(s)
- N J Hickok
- 1 Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - I M Shapiro
- 1 Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA
| | - A F Chen
- 1 Department of Orthopaedic Surgery, Sidney Kimmel Medical College of Thomas Jefferson University, Philadelphia, PA, USA.,2 The Rothman Institute, Philadelphia, PA, USA
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Abstract
BACKGROUND Allograft bone is commonly used to augment bone stock. Unfortunately, allograft is prone to bacterial contamination and current antimicrobial therapies are inadequate. Photoactivated porphyrins combat bacterial growth by production of reactive oxygen species (ROS); however, to our knowledge, they have not been tested in the setting of allograft bone. QUESTIONS/PURPOSES We asked: (1) Does 5,10,15,20-tetrakis-(4-aminophenyl)-porphyrin (TAPP) stably adsorb to morselized, mineralized allograft? (2) Does Staphylococcus aureus acquire TAPP from TAPP-allograft? (3) Is TAPP-allograft antibacterial to S. aureus? (4) Is ROS production critical for antimicrobial activity? (5) Does illuminated TAPP-allograft dislodge biofilm? (6) Could other photoactive dyes (TAPP, TMPyP, TSP, THP, and methylene blue) confer antimicrobial properties to allograft? METHODS TAPP adsorption to allograft (TAPP-allograft), its localization in S. aureus, and TAPP-allograft long-term stability were determined spectrophotometrically. Antimicrobial activity was measured while activated with light or in the dark during incubation with S. aureus or after allograft biofilm formation. Glutathione was added to illuminated TAPP-allograft to quench ROS and antimicrobial activity was determined. Light-dependent antimicrobial activity of other photoactive dyes (TMPyP, TSP, THP, and methylene blue) adsorbed to allograft was also tested. RESULTS We found (1) porphyrins strongly adhere to bone allograft; and (2) the bacteria are not able to sequester TAPP from the TAPP-allograft; (3) when illuminated, TAPP-allograft is resistant to bacterial adherence; (4) the effects of TAPP are inhibited by the radical scavenger glutathione, indicating ROS-dependent antimicrobial activity; (5) illumination of TAPP-allograft disrupts biofilms; and, (6) other photoactive dyes impede biofilm formation on allograft bone in the presence of light. CONCLUSIONS Porphyrins stably associate with allograft and are inactive until illuminated. Illuminated TAPP-allograft markedly reduces bacterial colonization, which is restored in the presence of radical scavengers. Finally, illuminated TAPP-allograft disrupts biofilms. CLINICAL RELEVANCE The findings of this in vitro study suggest that loading bone allograft with biocompatible porphyrins before surgery might allow increased sterility of the allograft during implantation. Future testing in an animal model will determine if these in vitro activities can be used to prevent allograft-based infection in an establishing osteomyelitis.
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Affiliation(s)
- Sana S. Dastgheyb
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Suite 501, Philadelphia, PA 19107 USA
| | - Cyrus B. Toorkey
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Suite 501, Philadelphia, PA 19107 USA
| | - Irving M. Shapiro
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Suite 501, Philadelphia, PA 19107 USA
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Suite 501, Philadelphia, PA 19107 USA
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25
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Dastgheyb S, Hickok NJ, Otto M. Reply to Perez and Patel. J Infect Dis 2015; 212:336-7. [PMID: 25712972 DOI: 10.1093/infdis/jiv097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2015] [Accepted: 02/10/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- Sana Dastgheyb
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noreen J Hickok
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Michael Otto
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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26
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Dastgheyb SS, Hammoud S, Ketonis C, Liu AY, Fitzgerald K, Parvizi J, Purtill J, Ciccotti M, Shapiro IM, Otto M, Hickok NJ. Staphylococcal persistence due to biofilm formation in synovial fluid containing prophylactic cefazolin. Antimicrob Agents Chemother 2015; 59:2122-8. [PMID: 25624333 PMCID: PMC4356782 DOI: 10.1128/aac.04579-14] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 01/21/2015] [Indexed: 11/20/2022] Open
Abstract
Antibiotic prophylaxis is standard for patients undergoing surgical procedures, yet despite the wide use of antibiotics, breakthrough infections still occur. In the setting of total joint arthroplasty, such infections can be devastating. Recent findings have shown that synovial fluid causes marked staphylococcal aggregation, which can confer antibiotic insensitivity. We therefore asked in this study whether clinical samples of synovial fluid that contain preoperative prophylactic antibiotics can successfully eradicate a bacterial challenge by pertinent bacterial species. This study demonstrates that preoperative prophylaxis with cefazolin results in high antibiotic levels. Furthermore, we show that even with antibiotic concentrations that far exceed the expected bactericidal levels, Staphylococcus aureus bacteria added to the synovial fluid samples are not eradicated and are able to colonize model implant surfaces, i.e., titanium pins. Based on these studies, we suggest that current prophylactic antibiotic choices, despite high penetration into the synovial fluid, may need to be reexamined.
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Affiliation(s)
- Sana S Dastgheyb
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA National Institute of Allergy and Infectious Diseases, The National Institutes of Health, Bethesda, Maryland, USA
| | | | - Constantinos Ketonis
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA The Rothman Institute, Philadelphia, Pennsylvania, USA
| | - Andrew Yongkun Liu
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Keith Fitzgerald
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Javad Parvizi
- The Rothman Institute, Philadelphia, Pennsylvania, USA
| | - James Purtill
- The Rothman Institute, Philadelphia, Pennsylvania, USA
| | | | - Irving M Shapiro
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Michael Otto
- National Institute of Allergy and Infectious Diseases, The National Institutes of Health, Bethesda, Maryland, USA
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
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27
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Lee HS, Dastgheyb SS, Hickok NJ, Eckmann DM, Composto RJ. Targeted release of tobramycin from a pH-responsive grafted bilayer challenged with S. aureus. Biomacromolecules 2015; 16:650-9. [PMID: 25585173 DOI: 10.1021/bm501751v] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
A stimuli-responsive, controlled release bilayer for the prevention of bacterial infection on biomaterials is presented. Drug release is locally controlled by the pH-responsiveness of the bilayer, comprised of an inner poly(acrylic acid) (PAA) monolayer grafted to a biomaterial and cross-linked with an outer chitosan (CH) brush. Tobramycin (TOB) is loaded in the inner PAA in part to minimize bacteria resistance. Because biofilm formation causes a decrease in local pH, TOB is released from PAA and permeates through the CH, which is in contact with the biofilm. Antibiotic capacity is controlled by the PAA thickness, which depends on PAA brush length and the extent of cross-linking between CH and PAA at the bilayer interface. This TOB-loaded, pH-responsive bilayer exhibits significantly enhanced antibacterial activity relative to controls.
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Affiliation(s)
- Hyun-Su Lee
- Department of Materials Science and Engineering and ‡Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
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28
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Davidson H, Poon M, Saunders R, Shapiro IM, Hickok NJ, Adams CS. Tetracycline tethered to titanium inhibits colonization by Gram-negative bacteria. J Biomed Mater Res B Appl Biomater 2014; 103:1381-9. [PMID: 25389082 DOI: 10.1002/jbm.b.33310] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2014] [Revised: 08/14/2014] [Accepted: 10/18/2014] [Indexed: 11/07/2022]
Abstract
As peri-prosthetic infection is one of the most devastating complications associated with implant placement, we have reasoned that such infection can be largely subverted by development of antibacterial implants. Our previous work demonstrated that covalent coupling of vancomycin to titanium alloy prevented colonization by the Gram-positive pathogens, Staphylococcus aureus and Staphylococcus epidermidis. Some orthopedic devices, including permanent prosthesis anchors, and most dental implants are transcutaneous or transmucosal and can be prone to colonization by Gram-negative pathogens. We report here the successful covalent coupling of the broad-spectrum antibiotic, tetracycline (TET), to titanium surfaces (Ti-TET) to retard Gram-negative colonization. Synthetic progress was followed by changes in water contact angle, while the presence of TET was confirmed by immunofluorescence. Ti-TET actively prevented colonization in the presence of bathing Escherichia coli, both by fluorescence microscopy and direct counting. Finally, the Ti-TET surface supported osteoblastic cell adhesion and proliferation over a 72-h period. Thus, this new surface offers a powerful means to protect transcutaneous implants from adhesion of Gram-negative pathogens, decreasing the need for replacement of this hardware.
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Affiliation(s)
- Helen Davidson
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Martin Poon
- Department of Orthodontics, School of Dental Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Ray Saunders
- Department of Biological Science, University of the Sciences, Philadelphia, Pennsylvania
| | - Irving M Shapiro
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noreen J Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher S Adams
- Department of Bio-Medical Sciences, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
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29
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Dastgheyb S, Parvizi J, Shapiro IM, Hickok NJ, Otto M. Effect of biofilms on recalcitrance of staphylococcal joint infection to antibiotic treatment. J Infect Dis 2014; 211:641-50. [PMID: 25214518 DOI: 10.1093/infdis/jiu514] [Citation(s) in RCA: 116] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The pathogenesis of joint infections is not well understood. In particular, we do not know why these infections respond poorly to antibiotic treatment. Here we show that methicillin-resistant Staphylococcus aureus, a major cause of joint infections, forms exceptionally strong biofilmlike aggregates in human synovial fluid (SF), to an extent significantly exceeding biofilm formation observed in growth medium or serum. Screening a transposon bank identified bacterial fibronectin- and fibrinogen-binding proteins as important for the formation of macroscopic clumps in SF, suggesting an important role of fibrin-containing clots in the formation of bacterial aggregates during joint infection. Pretreatment of SF with plasmin led to a strongly reduced formation of aggregates and increased susceptibility to antibiotics. These results give important insight into the pathogenesis of staphylococcal joint infection and the mechanisms underlying resistance to treatment. Furthermore, they point toward a potential novel approach for treating joint infections.
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Affiliation(s)
- Sana Dastgheyb
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland Department of Orthopedic Surgery, Thomas Jefferson University
| | | | | | - Noreen J Hickok
- Department of Orthopedic Surgery, Thomas Jefferson University
| | - Michael Otto
- National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland
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30
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Coll Ferrer MC, Dastgheyb S, Hickok NJ, Eckmann DM, Composto RJ. Designing nanogel carriers for antibacterial applications. Acta Biomater 2014; 10:2105-11. [PMID: 24434534 DOI: 10.1016/j.actbio.2014.01.009] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2013] [Revised: 12/06/2013] [Accepted: 01/07/2014] [Indexed: 12/20/2022]
Abstract
We have developed a novel and simple synthesis route to create nanosized (∼5nm) silver nanoparticles (Ag NPs) embedded in a biocompatible nanogel (NG) comprising degradable, natural polymers, namely dextran and lysozyme. In this study, we prepared hybrid nanogels with varying lysozyme content, evaluated their potential to reduce Ag NPs in situ (using ultraviolet-visible spectroscopy, cryo-transmission electronic microscopy, thermogravimetric analysis and Fourier transform infrared spectroscopy) and determined their antibacterial properties against Escherichia coli and Staphylococcus aureus. Lysozyme was found to enhance nucleation and stabilization of Ag NPs while limiting their growth. As lysozyme concentration increased, larger nanogels with greater loading of smaller Ag NPs were obtained. The antibacterial properties of hybrid NGs were found to depend upon nanogel type and bacterial conditions. Hybrid nanogels with the largest Ag NPs showed the lowest minimum inhibition concentration. However, the greatest bacterial killing efficiency (up to 100%) occurred within 1h if the bacteria were exposed to hybrid nanogels with smaller Ag NPs while agitating the medium. These results suggest that nanogel properties as well as antibacterial activity can be tuned by varying the lysozyme content. By targeting drug delivery (e.g. ligand grafted surface), these nanogels can be used to prevent biofilm formation and control infection without the complications (i.e. overexposure) associated with classical antibiotic delivery platforms.
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31
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Abstract
In this work, we present a novel method to prepare a hybrid coating based on dextran grafted to a substrate and embedded with silver nanoparticles (Ag NPs). First, the Ag NPs are synthesized in situ in the presence of oxidized dextran in solution. Second, the oxidized dextran is exposed to an amine functionalized surface resulting in the simultaneous grafting of dextran and the trapping of Ag NPs within the layer. The NP loading is controlled by the concentration of silver nitrate, which is 2 mM (DEX-Ag2) and 5 mM (DEX-Ag5). The dried film thickness increases with silver nitrate concentration from 2 nm for dextran to 7 nm and 12 nm for DEX-Ag2 and DEX-Ag5, respectively. The grafted dextran film displays features with a diameter and height of ~ 50 nm and 2 nm, respectively. For the DEX-Ag2 and DEX-Ag5, the dextran features as well as individual Ag NPs (~ 5 nm) and aggregates of Ag NPs are observed. Larger and more irregular aggregates are observed for DEX-Ag5. Overall, the Ag NPs are embedded in the dextran film as suggested by AFM and UVO studies. In terms of its antimicrobial activity, DEX-Ag2 resists bacterial adhesion to a greater extent than DEX-Ag5, which in turn is better than dextran and silicon. Because these antibacterial hybrid coatings can be grafted to a variety of surfaces, many biomedical applications can be envisioned, ranging from coating implants to catheters.
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Affiliation(s)
- M. Carme Coll Ferrer
- The Institute for Medicine and Engineering, University of Pennsylvania, Philadelphia, PA 19104, US
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, PA 19104, US
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, US
| | - David M. Eckmann
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104, US
- Russell J. Composto Phone: (215)-898-4451; Fax: (215)-573-2128; ; David M. Eckmann Phone: (215)-349-5348; Fax: (215)-349-5078;
| | - Russell J. Composto
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, PA 19104, US
- Russell J. Composto Phone: (215)-898-4451; Fax: (215)-573-2128; ; David M. Eckmann Phone: (215)-349-5348; Fax: (215)-349-5078;
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Lee HS, Yee MQ, Eckmann YY, Hickok NJ, Eckmann DM, Composto RJ. Reversible Swelling of Chitosan and Quaternary Ammonium Modified Chitosan Brush Layers: Effect of pH and Counter Anion Size and Functionality. J Mater Chem 2012; 22:19605-19616. [PMID: 23209343 PMCID: PMC3510778 DOI: 10.1039/c2jm34316a] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
This study investigates the swelling of grafted polycationic brushes as a function of pH and anion type. The brushes are chitosan (CH) and chitosans with 27% and 51% degree of substitution (DS) of quaternary ammonium salt, denoted as CH-Q(25) and CH-Q(50), respectively. The water content and swelling behaviors are monitored using in situ quartz-crystal microbalance with dissipation (QCM-D). The pH varies from ~3.5 to 8.5, and the counter anion types include chloride, acetate, and citrate. At fixed pH, the water content and brush swelling increase as the DS increases. Whereas the CH-Q(50) brush layer shows symmetric swelling with a minimum near pH = 4.5, the swelling of CH and CH-Q(25) is relatively constant as pH decreases from 8.2 to 5.5, and then begins to increase near pH 4. These studies indicate that the symmetric swelling of CH-Q(50) is likely attributed to increasing protonation of primary amines for pH values below pH 6.5 and the quaternary ammonium salts above pH 6.5. At pH 4, the swelling of the CH brush increases upon exchanging the smaller chloridewith a bulkier acetate anion, which is less effective at screening intra/inter molecular repulsion. In contrast, upon exchanging the acetate with trifunctional citrate, CH and CH-Q(25) brushes collapse by 53 and 42%, respectively, because the citrate forms ionic cross-links. To test antibacterial properties, silicon oxide, CH and CH-Q(50) brush layers are exposed to 10(7)-10(8) cfu/ml of S. aureus for two days at 37 °C and exposed to stepped shear stresses in 2 min intervals. Whereas an S. aureus biofilm adheres strongly to silicon oxide and CH for stresses up to 12 dyne/cm(2), biofilms on CH-Q(50) detach at a relatively low shear stress, 1.5 dyne/cm(2). Due to their high degree of swelling that can be tuned via pH, counterion size and type, chitosan and quaternary modified chitosans have potential as responsive coatings for applications including MEMS/NEMS devices and drug eluting implants.
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Affiliation(s)
- Hyun-Su Lee
- Institute of Medicine and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Michael Q. Yee
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Yonaton Y. Eckmann
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery and Biochemistry & Molecular Biology, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, United States
| | - David M. Eckmann
- Institute of Medicine and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
| | - Russell J. Composto
- Institute of Medicine and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, Pennsylvania 19104, United States
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Hickok NJ, Shapiro IM. Immobilized antibiotics to prevent orthopaedic implant infections. Adv Drug Deliv Rev 2012; 64:1165-76. [PMID: 22512927 DOI: 10.1016/j.addr.2012.03.015] [Citation(s) in RCA: 179] [Impact Index Per Article: 14.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2011] [Revised: 03/08/2012] [Accepted: 03/20/2012] [Indexed: 12/17/2022]
Abstract
Many surgical procedures require the placement of an inert or tissue-derived implant deep within the body cavity. While the majority of these implants do not become colonized by bacteria, a small percentage develops a biofilm layer that harbors invasive microorganisms. In orthopaedic surgery, unresolved periprosthetic infections can lead to implant loosening, arthrodeses, amputations and sometimes death. The focus of this review is to describe development of an implant in which an antibiotic tethered to the metal surface is used to prevent bacterial colonization and biofilm formation. Building on well-established chemical syntheses, studies show that antibiotics can be linked to titanium through a self-assembled monolayer of siloxy amines. The stable metal-antibiotic construct resists bacterial colonization and biofilm formation while remaining amenable to osteoblastic cell adhesion and maturation. In an animal model, the antibiotic modified implant resists challenges by bacteria that are commonly present in periprosthetic infections. While the long-term efficacy and stability is still to be established, ongoing studies support the view that this novel type of bioactive surface has a real potential to mitigate or prevent the devastating consequences of orthopaedic infection.
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Stewart S, Barr S, Engiles J, Hickok NJ, Shapiro IM, Richardson DW, Parvizi J, Schaer TP. Vancomycin-modified implant surface inhibits biofilm formation and supports bone-healing in an infected osteotomy model in sheep: a proof-of-concept study. J Bone Joint Surg Am 2012; 94:1406-15. [PMID: 22854994 PMCID: PMC3401139 DOI: 10.2106/jbjs.k.00886] [Citation(s) in RCA: 79] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND Implant-associated infections contribute to patient morbidity and health care costs. We hypothesized that surface modification of titanium fracture hardware with vancomycin would support bone-healing and prevent bacterial colonization of the implant in a large-animal model. METHODS A unilateral transverse mid-diaphyseal tibial osteotomy was performed and repaired with a titanium locking compression plate in nine sheep. Four control animals were treated with an unmodified plate and five experimental animals were treated with a vancomycin-modified plate. The osteotomy was inoculated with 2.5 × 106 colony-forming units of Staphylococcus aureus. The animals were killed at three months postoperatively, and implants were retrieved aseptically. Microbiologic and histologic analyses, scanning electron and confocal microscopy, and microcomputed tomography were performed. RESULTS All animals completed the study. Compared with the treatment cohort, control animals exhibited protracted lameness in the operatively treated leg. Gross findings during necropsy were consistent with an infected osteotomy accompanied by a florid and lytic callus. Microcomputed tomography and histologic analysis of the tibiae further supported the presence of septic osteomyelitis in the control cohort. Thick biofilms were also evident, and bacterial cultures were positive for Staphylococcus aureus in three of four control animals. In contrast, animals treated with vancomycin-treated plates exhibited a healed osteotomy site with homogenous remodeling, there was no evidence of biofilm formation on the retrieved plate, and bacterial cultures from only one of five animals were positive for Staphylococcus aureus. CONCLUSIONS Vancomycin-derivatized plate surfaces inhibited implant colonization with Staphylococcus aureus and supported bone-healing in an infected large-animal model.
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Affiliation(s)
- Suzanne Stewart
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, 382 West Street Road, Kennett Square, PA 19348. E-mail address for T.P. Schaer:
| | - Stephanie Barr
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 501, Philadelphia, PA 19107
| | - Julie Engiles
- Department of Pathobiology, School of Veterinary Medicine, University of Pennsylvania, 382 West Street Road, Kennett Square, PA 19348
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 501, Philadelphia, PA 19107
| | - Irving M. Shapiro
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Curtis Building, Suite 501, Philadelphia, PA 19107
| | - Dean W. Richardson
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, 382 West Street Road, Kennett Square, PA 19348. E-mail address for T.P. Schaer:
| | - Javad Parvizi
- The Rothman Institute, 925 Chestnut Street, Philadelphia, PA 19107
| | - Thomas P. Schaer
- Department of Clinical Studies, New Bolton Center, School of Veterinary Medicine, University of Pennsylvania, 382 West Street Road, Kennett Square, PA 19348. E-mail address for T.P. Schaer:
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Abstract
The use of metallic implants has revolutionised the practice of orthopaedic surgery. While the safety and biocompatibility of these devices are excellent, a small percentage becomes infected. These infections are due to the formation of a biofilm that harbours bacteria encased in a complex extracellular matrix. The matrix serves as a barrier to immune surveillance as well as limiting the biocidal effects of systemic and local antibiotics. The objective of the review is to describe a novel approach to controlling implant infection using an antibiotic that is linked to titanium through a self-assembled monolayer of siloxy amines. We show that the hybrid-engineered surface is stable, biocompatible and resists colonisation by bacterial species most commonly associated with implant-related infections. Studies with rodent bone infection models suggest that the engineered titanium surface prevents bone infection. Results of a very recent investigation utilising a sheep model of infection indicate that the titanium-tethered antibiotic controls infection without compromising bone formation and remodelling. From all of these perspectives, the tethered antibiotic holds promise of providing a novel and practical approach to reducing implant-associated infections.
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Affiliation(s)
- I M Shapiro
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA.
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Abstract
Charged polymer brushes grafted to surfaces are of great interest for antibacterial, biosensor, nanofluidic, and drug delivery applications. In this paper, chitosans with quaternary ammonium salts, CH-Q, were immobilized on silicon oxide and characterized by in situ quartz-crystal microbalance with dissipation, QCM-D, and in situ spectroscopic ellipsometry, SE. Both methods showed that the hydrated film exhibited a minimum thickness of ~40 nm near pH 5 that increased strongly (up to ~80 nm) at lower and higher pH. This symmetric swelling is surprising because CH-Q is a cationic polymer. The CH-Q grafted layer was stable for pH values from 3 to 8 and exhibited rapid, reversible swelling and contraction upon varying pH. The CH-Q layer also reduced S. aureus colonization by a factor of ~30× compared to bare silicon oxide and an amine terminated silane grafted to silicon oxide. This antibacterial characteristic of CH-Q is attributed to the quaternary ammonium salts and the flexible polymer brush.
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Affiliation(s)
- Hyun-Su Lee
- Institute of Medicine and Engineering, University of Pennsylvania, Philadelphia, PA 19104
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, PA 19104
| | - David M. Eckmann
- Institute of Medicine and Engineering, University of Pennsylvania, Philadelphia, PA 19104
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA 19104
| | - Daeyeon Lee
- Department of Chemical and Biomolecular Engineering, University of Pennsylvania, Philadelphia, PA 19104
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery and Biochemistry & Molecular Biology, Thomas Jefferson University, Philadelphia, PA 19107
| | - Russell J. Composto
- Institute of Medicine and Engineering, University of Pennsylvania, Philadelphia, PA 19104
- Department of Materials Science and Engineering, University of Pennsylvania, Philadelphia, PA 19104
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Ketonis C, Barr S, Shapiro IM, Parvizi J, Adams CS, Hickok NJ. Antibacterial activity of bone allografts: comparison of a new vancomycin-tethered allograft with allograft loaded with adsorbed vancomycin. Bone 2011; 48:631-8. [PMID: 21035576 PMCID: PMC3039041 DOI: 10.1016/j.bone.2010.10.171] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Revised: 10/19/2010] [Accepted: 10/20/2010] [Indexed: 11/18/2022]
Abstract
Bacterial contamination of bone allograft is a significant complication of orthopedic surgery. To address this issue, we have engineered a method for covalently modifying bone allograft tissue with the antibiotic vancomycin. The goal of this investigation was to compare the biocidal properties of this new allograft material with those of vancomycin physisorbed onto graft material. The duration of antibiotic release from the vancomycin-modified allograft matrix was determined, and no elution was observed. In contrast, the adsorbed antibiotic showed a peak elution at 24h that then decreased over several days. We next used an Staphylococcus aureus disk diffusion assay to measure the activity of the eluted vancomycin. Again we found that no active antibiotic was eluted from the covalently modified allograft. Similarly, when the vancomycin-modified allograft morsel was used in the assay, no measurable elution was observed; amounts of antibiotic released from the adsorbed samples inhibited S. aureus growth for 4-7 days. Probably the most telling property of the allograft was that after 2 weeks, the tethered allograft was able to resist bacterial colonization. Unlike the elution system in which vancomycin was depleted over the course of days-weeks, the antibiotic on the allograft was stably bound even after 300 days, while its biocidal activity remained undiminished for 60 days. This finding was in stark contrast to the antibiotic impregnated allograft, which was readily colonized by bacteria. Finally we chose to evaluate three indicators of cell function: expression of a key transcription factor, expression of selected transcripts, and assessment of cell morphology. Since the tethered antibiotic appeared to have little or no effect on any of these activities, it was concluded that the stable, tethered antibiotic prevented bacterial infection while not modifying bone cell function.
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Affiliation(s)
- Constantinos Ketonis
- Department of Orthopaedic Surgery; Thomas Jefferson University; Philadelphia, PA
| | - Stephanie Barr
- Department of Orthopaedic Surgery; Thomas Jefferson University; Philadelphia, PA
| | - Irving M. Shapiro
- Department of Orthopaedic Surgery; Thomas Jefferson University; Philadelphia, PA
- Department of Biochemistry & Molecular Biology, Thomas Jefferson University; Philadelphia, PA
| | - Javad Parvizi
- Department of Orthopaedic Surgery; Thomas Jefferson University; Philadelphia, PA
- The Rothman Institute, Philadelphia, PA
| | - Christopher S. Adams
- Department of Orthopaedic Surgery; Thomas Jefferson University; Philadelphia, PA
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery; Thomas Jefferson University; Philadelphia, PA
- Department of Biochemistry & Molecular Biology, Thomas Jefferson University; Philadelphia, PA
- Corresponding author: Noreen J. Hickok Associate Professor Department of Orthopaedic Surgery Thomas Jefferson University 1015 Walnut St., Suite 501 Philadelphia, PA 19107 Tel: 215-955-6979 Fax: 215-955-9159
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Ketonis C, Adams CS, Barr S, Aiyer A, Shapiro IM, Parvizi J, Hickok NJ. Antibiotic modification of native grafts: improving upon nature's scaffolds. Tissue Eng Part A 2010; 16:2041-9. [PMID: 20109017 DOI: 10.1089/ten.tea.2009.0610] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Infection associated with inert implants is complicated by bacterial biofilm formation that renders the infection antibiotic insensitive. The goal of this investigation was to synthesize and characterize a vancomycin (VAN)-modified bone allograft that could render the tissue inhospitable to bacterial colonization and the establishment of infection. We found that the numbers of primary amines, which could serve as anchors for chemical synthesis, increased with limited demineralization. Using these amines, we coupled two linkers and VAN to bone using Fmoc chemistry. By immunohistochemistry, VAN was abundant on the surface of the allograft; based on elution and measurement of bound antibody, this coupling yielded at least approximately 26 ng VAN/mg bone. The coupled VAN appeared to be permanently bound to the allograft, as it showed no elution in a disk diffusion assay, and, importantly, resisted colonization by Staphylococcus aureus challenges. We suggest that this chimeric construct represents a new generation of antibiotic-modified allografts that provide antibacterial properties.
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Affiliation(s)
- Constantinos Ketonis
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Abstract
BACKGROUND Bone grafts are frequently used to supplement bone stock and to establish structural stability. However, graft-associated infection represents a challenging complication leading to increased patient morbidity and healthcare costs. QUESTIONS/PURPOSES We therefore designed this study to (1) determine if increasing initial S. aureus inoculation of bone allograft results in a proportionate increase in colonization; (2) assess if antibiotics decrease colonization and if antibiotic tethering to allograft alters its ability to prevent bacterial colonization; and (3) determine if covalent modification alters the allograft topography or its biological properties. METHODS Allograft bone and vancomycin-modified bone (VAN-bone) was challenged with different doses of S. aureus for times out to 24 hours in the presence or absence of solution vancomycin. Bacterial colonization was assessed by fluorescence, scanning electron microscopy (SEM), and by direct colony counting. Cell density and distribution of osteoblast-like cells on control and modified allograft were then compared. RESULTS Bacterial attachment was apparent within 6 hours with colonization and biofilm formation increasing with time and dose. Solution vancomycin failed to prevent bacterial attachment whereas VAN-bone successfully resisted colonization. The allograft modification did not affect the attachment and distribution of osteoblast-like cells. CONCLUSIONS Allograft bone was readily colonized by S. aureus and covered by a biofilm with especially florid growth in natural topographic niches. Using a novel covalent modification, allograft bone was able to resist colonization by organisms while retaining the ability to allow adhesion of osteoblastic cells. CLINICAL RELEVANCE Generation of allograft bone that can resist infection in vivo would be important in addressing one of the most challenging problems associated with the use of allograft, namely infection.
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Affiliation(s)
- Constantinos Ketonis
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA USA
| | - Stephanie Barr
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA USA
| | - Christopher S. Adams
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA USA
| | - Noreen J. Hickok
- Department of Orthopedic Surgery, Thomas Jefferson University, Philadelphia, PA USA ,Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, PA USA
| | - Javad Parvizi
- Department of Orthopaedic Surgery, Rothman Institute, Thomas Jefferson University, Philadelphia, PA 19107 USA
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Adams CS, Antoci V, Harrison G, Patal P, Freeman TA, Shapiro IM, Parvizi J, Hickok NJ, Radin S, Ducheyne P. Controlled release of vancomycin from thin sol-gel films on implant surfaces successfully controls osteomyelitis. J Orthop Res 2009; 27:701-9. [PMID: 19051247 DOI: 10.1002/jor.20815] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Peri-prosthetic infection remains a serious complication of joint replacement surgery. Herein, we demonstrate that a vancomycin-containing sol-gel film on Ti alloy rods can successfully treat bacterial infections in an animal model. The vancomycin-containing sol-gel films exhibited predictable release kinetics, while significantly inhibiting S. aureus adhesion. When evaluated in a rat osteomyelitis model, microbiological analysis indicated that the vancomycin-containing sol-gel film caused a profound decrease in S. aureus number. Radiologically, while the control side showed extensive bone degradation, including abscesses and an extensive periosteal reaction, rods coated with the vancomycin-containing sol-gel film resulted in minimal signs of infection. MicroCT analysis confirmed the radiological results, while demonstrating that the vancomycin-containing sol-gel film significantly protected dense bone from resorption and minimized remodeling. These results clearly demonstrate that this novel thin sol-gel technology can be used for the targeted delivery of antibiotics for the treatment of periprosthetic as well as other bone infections.
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Affiliation(s)
- Christopher S Adams
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA.
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41
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Abstract
Antibiotic concentrations associated with antibiotic bone cements may cause skeletal cell toxicity and prevent fracture healing. We investigated toxicity effects of dose and treatment time after exposure to three antibiotics commonly used in orthopaedic local drug delivery systems. We hypothesized a threshold exists for toxicity of osteoblasts and chondrocytes after treatment with ciprofloxacin, vancomycin, or tobramycin. To test this hypothesis, we first determined whether treatment with antibiotics caused differences in cellular morphology. Cells exposed to ciprofloxacin showed considerable changes in spread, cell membrane, and extensions. We next asked what dosage of antibiotic would cause reductions in osteoblast and chondrocyte cell numbers. Ciprofloxacin at a dose greater than 100 microg/mL and vancomycin and tobramycin at doses greater than 2000 microg/mL severely decreased cellular proliferation. Finally, we questioned whether observed decreases in cell numbers were the result of increased cellular toxicity or senescence. Released lactate dehydrogenase ratios were severely increased in osteoblasts. These data suggest the balance between the targeted microbicidal effects and host cellular toxicity is critical for skeletal cell survival and function.
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Affiliation(s)
- Valentin Antoci
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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42
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Abstract
Despite improved strategies for treating periprosthetic infection, current antibiotic delivery approaches are imperfect and can result in bacterial resistance and recalcitrant bio-films. To address the issues, we developed a covalently linked vancomycin-titanium implant interface that prevents and possibly eliminates bacterial colonization. We determined the amount of vancomycin immobilized on the titanium surface and assessed vancomycin stability and activity over time. When incubated with Staphylococcus aureus, the vancomycin-titanium surface showed an almost complete absence of adherent bacteria. To determine if continual exposure to vancomycin-titanium would cause decreased susceptibility to the antibiotic, S. aureus was incubated with vancomycin-titanium for 1 week or 4 weeks; these bacteria did not show an increased minimum inhibitory concentration for vancomycin. We tested the long-term stability of the vancomycin-titanium surface by incubation in phosphate-buffered saline for 11 months and then challenging the surface with S. aureus. Fluorescent staining for bacteria indicated the vancomycin-titanium retained its bactericidal activity. Finally, osteoblasts seeded on the vancomycin-titanium surface exhibited no change in viability, indicating the surface supports bone cell adhesion. Based on these observations, covalent modification of the titanium surface with an antibiotic may be viewed as a potential new tool in preventing or eliminating periprosthetic infection.
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Affiliation(s)
- Valentin Antoci
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA 19107, USA
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43
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Abstract
A major challenge in treating periprosthetic infection is the predilection of certain bacteria to colonize implants, form biofilms, and resist treatment. We engineered an innovative self-protective implant with covalently bound antibiotics that prevents bacterial colonization and remains stable for extended periods of time. To test this surface in vivo, we developed a rat periprosthetic infection model with an intramedullary implant in S. aureus-infected femora. Using the model, we then evaluated the effect of vancomycin-modified titanium rods on the clinical presentation of bone infection. Finally, assuming delayed and chronic periprosthetic infections originate from biofilms atop contaminated implants, the numbers of surface adherent bacteria were measured to assess the capability of the implant to prevent biofilms. S. aureus (1.5 x 10(3) colony forming units) with no known resistance were injected into the femoral canal of Wistar rats, followed by the implant. Signs of infection were assessed weekly by direct clinical observation of the animals, radiograph, and microCT, and counts of bacteria adherent to the implant. Vancomycin-modified implants showed superior inhibition of bacterial attachment and proliferation compared to control titanium surfaces.
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Affiliation(s)
- Valentin Antoci
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, PA, USA
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44
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Antoci V, King SB, Jose B, Parvizi J, Zeiger AR, Wickstrom E, Freeman TA, Composto RJ, Ducheyne P, Shapiro IM, Hickok NJ, Adams CS. Vancomycin covalently bonded to titanium alloy prevents bacterial colonization. J Orthop Res 2007; 25:858-66. [PMID: 17415753 DOI: 10.1002/jor.20348] [Citation(s) in RCA: 109] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Periprosthetic infection is a devastating consequence of implant insertion and can arise from hematogenous sources or surgical contamination. Microbes can preferentially colonize the implant surface and, by forming a biofilm, escape immune surveillance. We hypothesized that if an antibiotic can be tethered to a titanium alloy (Ti) surface, it will inhibit bacterial colonization, prevent biofilm formation, and avert late-stage infection. To test this hypothesis, a Ti rod was covalently derivatized with vancomycin. Reaction efficiencies were evaluated by colorimetric and spectrophotometric measurements. The vancomycin-modified surface was stable in aqueous solutions over extended time periods and maintained antibiotic coverage, even after press-fit insertion into a cadaverous rat femora. When evaluated using fluorescently labeled bacteria, or by direct colony counts, the surface-bound antibiotic prevented bacterial colonization in vitro after: (1) exposure to high levels of S. aureus; (2) extended incubation in physiological buffers; and (3) repeated bacterial challenges. Importantly, whereas the vancomycin-derivitized pins prevented bacterial colonization, S. aureus adhered to control pins, even in the presence of concentrations of vancomycin that exceeded the strain MIC. These results demonstrate that we have effectively engineered a stable, bactericidal Ti surface. This new surface holds great promise in terms of mitigating or preventing periprosthetic infection.
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Affiliation(s)
- Valentin Antoci
- Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut Street, Suite 501, Philadelphia, Pennsylvania 19107, USA
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45
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Edupuganti OP, Antoci V, King SB, Jose B, Adams CS, Parvizi J, Shapiro IM, Zeiger AR, Hickok NJ, Wickstrom E. Covalent bonding of vancomycin to Ti6Al4V alloy pins provides long-term inhibition of Staphylococcus aureus colonization. Bioorg Med Chem Lett 2007; 17:2692-6. [PMID: 17369042 DOI: 10.1016/j.bmcl.2007.03.005] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2007] [Revised: 03/01/2007] [Accepted: 03/02/2007] [Indexed: 11/24/2022]
Abstract
Self-protecting Ti6Al4V alloy pins were prepared by covalent bonding of bis(ethylene glycol) linkers, then vancomycin to the oxidized, aminopropylated Ti6Al4V alloy surface. Fluorescence modification-enabled estimation of yields of free amines on the metallic surface monolayer at each reaction step. The vancomycin-protected Ti6Al4V pins were not colonized by Staphylococcus aureus, even after 44days storage in physiological buffer. These results provide a basis for testing self-protection against S. aureus colonization in animal models.
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Affiliation(s)
- Om P Edupuganti
- Department of Biochemistry & Molecular Biology, Thomas Jefferson University, Philadelphia, PA 19107, USA
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46
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Abstract
In this review, we discuss current advances leading to an exciting change in implant design for orthopedic surgery. The initial biomaterial approaches in implant design are being replaced by cellular-molecular interactions and nanoscale chemistry. New designs address implant complications, particularly loosening and infection. For infection, local delivery systems are an important first step in the process. Selfprotective 'smart' devices are an example of the next generation of orthopedic implants. If proven to be effective, antibiotics or other active molecules that are tethered to the implant surface through a permanent covalent bond and tethering of antibiotics or other biofactors are likely to transform the practice of orthopedic surgery and other medical specialties. This new technology has the potential to eliminate periprosthetic infection, a major and growing problem in orthopedic practice.
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Affiliation(s)
- Javad Parvizi
- Thomas Jefferson University, Rothman Institute of Orthopedics, 925 Chestnut Street, Philadelphia, PA 19107, USA.
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Han F, Gilbert JR, Harrison G, Adams CS, Freeman T, Tao Z, Zaka R, Liang H, Williams C, Tuan RS, Norton PA, Hickok NJ. Transforming growth factor-beta1 regulates fibronectin isoform expression and splicing factor SRp40 expression during ATDC5 chondrogenic maturation. Exp Cell Res 2007; 313:1518-32. [PMID: 17391668 PMCID: PMC1920702 DOI: 10.1016/j.yexcr.2007.01.028] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2005] [Revised: 01/09/2007] [Accepted: 01/17/2007] [Indexed: 11/28/2022]
Abstract
Fibronectin (FN) isoform expression is altered during chondrocyte commitment and maturation, with cartilage favoring expression of FN isoforms that includes the type II repeat extra domain B (EDB) but excludes extra domain A (EDA). We and others have hypothesized that the regulated splicing of FN mRNAs is necessary for the progression of chondrogenesis. To test this, we treated the pre-chondrogenic cell line ATDC5 with transforming growth factor-beta1, which has been shown to modulate expression of the EDA and EDB exons, as well as the late markers of chondrocyte maturation; it also slightly accelerates the early acquisition of a sulfated proteoglycan matrix without affecting cell proliferation. When chondrocytes are treated with TGF-beta1, the EDA exon is preferentially excluded at all times whereas the EDB exon is relatively depleted at early times. This regulated alternative splicing of FN correlates with the regulation of alternative splicing of SRp40, a splicing factor facilitating inclusion of the EDA exon. To determine if overexpression of the SRp40 isoforms altered FN and FN EDA organization, cDNAs encoding these isoforms were overexpressed in ATDC5 cells. Overexpression of the long-form of SRp40 yielded an FN organization similar to TGF-beta1 treatment; whereas overexpression of the short form of SRp40 (which facilitates EDA inclusion) increased formation of long-thick FN fibrils. Therefore, we conclude that the effects of TGF-beta1 on FN splicing during chondrogenesis may be largely dependent on its effect on SRp40 isoform expression.
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Affiliation(s)
- Fei Han
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - James R. Gilbert
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Gerald Harrison
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Christopher S. Adams
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Theresa Freeman
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Zhuliang Tao
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Raihana Zaka
- Division of Rheumatology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Hongyan Liang
- Department of Biochemistry & Molecular Pharmacology, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Charlene Williams
- Department of Biochemistry & Molecular Pharmacology, Thomas Jefferson University, Philadelphia, Pennsylvania
- Division of Rheumatology, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Rocky S. Tuan
- Cartilage Biology and Orthopaedics Branch, NIAMS, NIH, Bethesda, MD
| | - Pamela A. Norton
- Department of Biochemistry & Molecular Pharmacology, Thomas Jefferson University, Philadelphia, Pennsylvania
- Jefferson Center for Biomedical Research, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Noreen J. Hickok
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania
- ‡ To Whom Correspondence Should be Addressed: Noreen J. Hickok, Ph.D., Department of Orthopaedic Surgery, Thomas Jefferson University, 1015 Walnut St., Suite 501, Philadelphia, PA 19107, Tel: 215-955-6979, Fax: 215-955-4317, e-mail:
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Jose B, Antoci V, Zeiger AR, Wickstrom E, Hickok NJ. Vancomycin covalently bonded to titanium beads kills Staphylococcus aureus. ACTA ACUST UNITED AC 2006; 12:1041-8. [PMID: 16183028 DOI: 10.1016/j.chembiol.2005.06.013] [Citation(s) in RCA: 101] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2005] [Revised: 06/28/2005] [Accepted: 06/30/2005] [Indexed: 11/22/2022]
Abstract
Periprosthetic infections are life-threatening complications that occur in about 6% of medical device insertions. Stringent sterile techniques have reduced the incidence of infections, but many implant patients are at high risk for infection, especially the elderly, diabetic, and immune compromised. Moreover, because of low vascularity at the site of the new implant, antibiotic prophylaxis is often not effective. To address this problem, we designed a covalent modification to titanium implant surfaces to render them bactericidal. Specifically, we aminopropylated titanium, a widely used implant material and extended a tether by solid phase coupling of ethylene glycol linkers, followed by solid phase coupling of vancomycin. Vancomycin covalently attached to titanium still bound soluble bacterial peptidoglycan, reduced Staphylococcus aureus colony-forming units by 88% +/- 16% over 2 hr, and retained antibacterial activity upon a repeated challenge.
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Affiliation(s)
- Binoy Jose
- Department of Biochemistry and Molecular Biology, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Han F, Adams CS, Tao Z, Williams CJ, Zaka R, Tuan RS, Norton PA, Hickok NJ. Transforming growth factor-β1 (TGF-β1) regulates ATDC5 chondrogenic differentiation and fibronectin isoform expression. J Cell Biochem 2005; 95:750-62. [PMID: 15832361 DOI: 10.1002/jcb.20427] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Regulated splicing of fibronectin (FN) occurs during the mesenchymal to chondrocyte transition and ultimately results in the relative enrichment of an extra domain B (EDB) exon-containing FN isoform with the suggestion that FN isoforms may play a functional role in chondrogenesis. Promotion of chondrogenesis can also be achieved by treatment with transforming growth factor-beta (TGF-beta), which also regulates FN isoform expression. We have examined the effects of TGF-beta treatment on the assumption of the chondrogenic phenotype in the teratoma-derived cell line ATDC5 and tested whether these effects on chondrogenesis are paralleled by appropriate changes in FN isoform expression. ATDC5 cells were maintained in a pre-chondrogenic state and, in this state, treated with 10 ng/ml TGF-beta. The cells started to elaborate a matrix rich in sulfated proteoglycans, such that within the first 12 days of culture, TGF-beta1 treatment appeared to slightly accelerate early acquisition of an Alcian blue-stained matrix, and caused a dose- and time-dependent decrease in collagen type I expression; changes in collagen type II expression were variable. At later times, cells treated with TGF-beta became indistinguishable from those of the controls. Interestingly, TGF-beta treatment caused a significant dose- and time-dependent decrease in the proportion of FN containing the extra domain A (EDA) and the EDB exons. These data suggest that TGF-beta induces the early stages of chondrogenic maturation in this pre-chondrogenic line and that TGF-beta treatment increases expression of FN isoforms that lack the EDA and EDB exons.
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Affiliation(s)
- Fei Han
- Department of Orthopaedic Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania 19107, USA
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Parvizi J, Wickstrom E, Zeiger AR, Adams CS, Shapiro IM, Purtill JJ, Sharkey PF, Hozack WJ, Rothman RH, Hickok NJ. Frank Stinchfield Award. Titanium surface with biologic activity against infection. Clin Orthop Relat Res 2004:33-8. [PMID: 15577462 DOI: 10.1097/01.blo.0000150116.65231.45] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Despite immense improvements, periprosthetic infection continues to compromise the result of otherwise successful joint arthroplasty. There are various limitations in the treatment of periprosthetic infection, the most important of which is the inability to deliver antibiotics to the local tissue without the need for intravenous administration. We have developed a novel route to covalently tether vancomycin to a metal (titanium) surface, which showed effective bactericidal activity because of a vancomycin coupling. The chemistry of tethering does not affect the biological activity of the biofactors that are attached to the metal surface. This technology holds great promise for the manufacturing of "smart" implants that can be self protective against periprosthetic infection, or can be used for the treatment of periprosthetic infections when they occur.
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Affiliation(s)
- Javad Parvizi
- Department of Orthopaedic Surgery, WORK, Thomas Jefferson University, Philadelphia, PA 19107, USA.
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