Orthopedic Device-related Infections Research Articles

ANTIMICROBIAL NANOGELS TO PREVENT ORTHOPAEDIC DEVICE-RELATED INFECTIONS

Orthopedic Device-Related Infections (ODRIs) are a major medical challenge, particularly due to the involvement of biofilm-encased and multidrug-resistant bacteria. Current treatments, based on antibiotic administration, have proven to be ineffective. Consequently, there is a need for antibiotic-free alternatives. Antimicrobial peptides (AMPs) are a promising solution due to their broad-spectrum of activity, high efficacy at very low concentrations, and low propensity to induce resistance. We aim to develop a new AMP-based chitosan nanogel to be injected during orthopedic device implantation to prevent ODRIs. Chitosan was functionalized with norbornenes (NorChit) through the reaction with carbic anhydride and then, a cysteine-modified AMP, Dhvar5, a peptide with potent antibacterial activity, even against methicillin-resistant Staphylococcus aureus (MRSA), was covalently conjugated to NorChit (NorChit- Dhvar5), through a thiol-norbornene photoclick chemistry (UV= 365 nm). For NorChit-Dhvar5 nanogels production, the NorChit-Dhvar5 solution (0.15% w/v) and Milli-Q water were injected separately into microfluidic system. The nanogels were characterized regarding size, concentration, and shape, using Transmission Electron Microscopy (TEM), Nanoparticle Tracking Analysis (NTA) and Dynamic light scattering (DLS). The nanogels antibacterial properties were assessed in Phosphate Buffer (PBS) for 6 h, against four relevant microorganisms (Pseudomonas aeruginosa, S. aureus and MRSA, and in Muller- Hinton Broth (MHB), 50% (v/v) in PBS, supplemented with human plasma (1% (v/v)), for 6 and 24 h against MRSA. The obtained NorChit-Dhvar5 nanogels, presented a round-shaped and ∼100 nm. NorChit- Dhvar5 nanogels in a concentration of 1010 nanogels/mL in PBS were capable of reducing the initial inoculum of P. aeruginosa by 99%, S. aureus by 99%, and MRSA by 90%. These results were corroborated by a 99% MRSA reduction, after 24 h in medium. Furthermore, NorChit-Dhvar5 nanogels do not demonstrate signs of cytotoxicity against MC3T3-E1 cells (a pre-osteoblast cell line) after 14 days, having high potential to prevent antibiotic-resistant infection in the context of ODRIs.

SHORT-TERM CELECOXIB PROMOTES BONE FORMATION WITHOUT COMPROMISING ANTIBIOTIC EFFICACY IN EARLY ORTHOPAEDIC DEVICE-RELATED INFECTION: EVIDENCE FROM A RAT MODEL

We investigated the effects of non-steroidal anti-inflammatory drugs (NSAIDs) with different cyclooxygenase (COX) selectivity on orthopaedic device-related infections (ODRIs) in a rat model. We aimed to measure the impact of NSAID therapy on bone changes, bacterial load, and cytokine levels after treatment with antibiotics. We also compared the effects of long vs short-term celecoxib (a COX-2 inhibitor) treatment on the same outcomes.Skeletally mature female Wistar rats were implanted with Staphylococcus epidermidis- contaminated polyetheretherketone (PEEK) screws in the proximal right tibia and monitored for 7 days. All animals received subcutaneous antibiotics (rifampicin plus cefazolin) for two weeks from day 7 to 21. In phase I of the study, rats were randomly assigned to receive 28 days of oral treatment with acetylsalicylic acid, ibuprofen, celecoxib, or vehicle control. In phase II, an additional group received seven days of celecoxib treatment from day 0 to 7. Bone changes were monitored using in vivo micro-CT and histology. Quantitative bacteriology was performed at euthanasia. Plasma samples were collected to measure cytokine levels on days 0, 6, 20, and 28.Combination antibiotic therapy resulted in treatment success in 85.71% of cases, while the addition of long-term celecoxib treatment reduced it to 45.45%. Long-term celecoxib treatment significantly reduced bone loss (33.85% mean difference [95% CI 14.12–53.58], p=0.0004 on day 6 bone fraction) and periosteal reaction (0.2760 μm mean difference [95% CI 0.2073–0.3448], p<0.0001 on day 14 periosteal thickness) during early infection compared to the control group. Short- term celecoxib treatment showed similar radiological results without a reduction in treatment success (88.9%). No differences in the inflammatory markers were observed.Our findings highlight the potential benefits of short-term use of celecoxib in improving bone fraction during the early post-infection period without impairing the efficacy of antibiotic therapy

Biocomposites containing poly(lactic acid) and chitosan for 3D printing – Assessment of mechanical, antibacterial and in vitro biodegradability properties

New bone repair materials are needed for treatment of trauma- and disease-related skeletal defects as they still represent a major challenge in clinical practice. Additionally, new strategies are required to combat orthopedic device-related infections (ODRI), given the rising incidence of total joint replacement and fracture fixation surgeries in increasingly elderly populations. Recently, the convergence of additive manufacturing (AM) and bone tissue engineering (BTE) has facilitated the development of bone healthcare to achieve personalized three-dimensional (3D) scaffolds. This study focused on the development of a 3D printable bone repair material, based on the biopolymers poly(lactic acid) (PLA) and chitosan. Two different types of PLA and chitosan differing in their molecular weight (MW) were explored. The novel feature of this research was the successful 3D printing using biocomposite filaments composed of PLA and 10 wt% chitosan, with clear chitosan entrapment within the PLA matrix confirmed by Scanning Electron Microscopy (SEM) images. Tensile testing of injection molded samples indicated an increase in stiffness, compared to pure PLA scaffolds, suggesting potential for improved load-bearing characteristics in bone scaffolds. However, the potential benefit of chitosan on the biocomposite stiffness could not be reproduced in compression testing of 3D printed cylinders. The antibacterial assays confirmed antibacterial activity of chitosan when dissolved in acetic acid. The study also verified the biodegradability of the scaffolds, with a process producing an acidic environment that could potentially be neutralized by chitosan. In conclusion, the study indicated the feasibility of the proposed PLA/chitosan biocomposite for 3D printing, demonstrating adequate mechanical strength, antibacterial properties and biodegradability, which could serve as a new material for bone repair.

New developments in combating infection from biofilm forming bacteria of orthopedic implants

Orthopedic device related infections (ODRI’s) represent a difficult to treat situation owing to their biofilm based nature. Biofilm infections once established are difficult to eradicate even with an aggressive treatment regimen due to their recalcitrance towards antibiotics and immune attack. The definitive treatment to eradicate the infections once a biofilm has established is surgical excision of the implant and thorough local debridement, but this carries a significant socioeconomic cost, the outcomes for the patient are often poor, and there is a significant risk of recurrence. The aim of the study was to provide a comprehensive insight into the newer anti-biofilm interventions (non-antibiotic approaches) and a better understanding of their mechanism of action essential for improved management of orthopedic implant infections.

In Vivo Emergence of Dual Resistance to Rifampin and Levofloxacin in Osteoarticular Cutibacterium avidum.

Cutibacterium avidum is an emerging causative agent of orthopedic device-related infections (ODRIs). There are no guidelines for the antimicrobial treatment of C. avidum ODRI, but oral rifampin is frequently used in combination with a fluoroquinolone following intravenous antibiotics. We describe the in vivo emergence of combined resistance to rifampin and levofloxacin in a C. avidum strain isolated from a patient with early-onset ODRI treated with debridement, antibiotic treatment, and implant retention (DAIR) using rifampin combined with levofloxacin as the oral treatment. Whole-genome sequencing of C. avidum isolates before and after antibiotic exposure confirmed strain identity and identified new mutations in rpoB and gyrA, leading to amino acid substitutions previously reported to be associated with resistance to rifampin (S446P) and fluoroquinolones (S101L), respectively, in other microbial agents, in the posttherapy isolate. Aside from the molecular insights reported here, this study highlights potential limitations of the combination of oral rifampin and levofloxacin in patients undergoing a DAIR procedure for C. avidum ODRI and the potential need to evaluate specific optimal therapy for emerging ODRI pathogens. IMPORTANCE In this study, we report for the first time the in vivo emergence of dual resistance to levofloxacin and rifampin in C. avidum isolated from a patient who received both antibiotics orally in the setting of a salvage debridement and implant retention of an ODRI. Aside from the molecular insights reported here, this study highlights potential limitations of the combination of oral rifampin and levofloxacin in patients undergoing these surgical procedures and the potential need to evaluate specific optimal therapy for emerging ODRI pathogens.

Interest in the combination of antimicrobial therapy for orthopaedic device-related infections due to Enterococcus spp.

The objective of this study was to evaluate the management of orthopaedic device-related infections (ODRIs) due to Enterococcus spp. We performed a retrospective cohort study in a French tertiary university hospital. Patients with prosthetic joint- or osteosynthesis-associated infections caused by enterococci from 2013 to 2020 were included. Patients who died within 5days after surgery; who were in palliative care; or who had osteosynthesis of the hand, foot or vertebra were excluded. Thirty-six patients were included, with 24 in the arthroplasty group and 12 in the osteosynthesis material group. Most infections were polymicrobial (63.9%, n = 23). Debridement, antibiotics and implant retention (DAIR) was performed in 30.6% (n = 11), withdrawal of material in 16.7% (n = 6), one-stage exchange in 30.6% (n = 11) and two-stage exchange in 22.2% of cases (n = 8). The antibiotic regimen was amoxicillin in 41.6% (n = 15), rifampicin in 27.8% (n = 10), linezolid in 25% (n = 9) and/or fluoroquinolones in 30.6% (n = 11). Clinical success at 1year was 67% (18/27). The only variable statistically associated with a decreased risk of clinical failure was a duration of antibiotic therapy of 12weeks (p = 0.04). Patients with a lower body mass index and age tended to decrease the risk of clinical failure (p = 0.05 and 0.06 respectively). The management of enterococcal ODRIs is complex, and ODRI patients are at high risk for relapse. In our small study, a better outcome was not demonstrated for patients with combination therapy and rifampicin use. Further studies are needed to improve the medico-surgical strategy for treating these infections.

Fabrication and in vitro characterization of antibacterial magneto-luminescent core-shell bioactive glass nanoparticles

When nanomaterials with antibacterial properties were sent to the infected area, it was predicted that infection and related complications could be prevented. The nanoparticles can be designed to possess magnetic and luminescence (magneto-luminescent) properties to be effectively targeted and localized at the infection foci without dispersing into the body. Simultaneously, the magneto-luminescent characteristic of particles allows visualization and confirmation of localized particles at the desired area. In this regard, there are no studies on the use of antibacterial magneto-luminescent bioactive glass for orthopedic applications and the treatment of orthopedic device-related infections. In this study, antibacterial magneto-luminescent 58S bioactive glasses were synthesized by the modified Stöber using coupled with a layer-by-layer assembly approach to possess core/shell particle morphology. SPION/Bioactive glass nanoparticles had an average size of 50 nm and displayed superparamagnetic behavior. While the saturation magnetization value (σs) of the undoped 58S sample was 25.32 emu/g, that of the co-doped sample (2% Eu, 2% Zn) was 21.74 emu/g; this showed that the doping slightly reduced the magnetization value. Europium (Eu) doping of SPION/Bioactive glass nanoparticles induced characteristic red emission originating from Eu emissions belonging to 5D0–7FJ (J = 1–4) transitions and the strongest peak was at 612 nm (electric-dipole transition, 5D0–7F2). Color chromaticity coordinates confirmed emission in the red region. XPS spectrum revealed the existence of Eu and Zn dopant elements in 58S bioactive glass. After soaking characteristic peaks at 31.74° and 45.43° belonging to the hexagonal hydroxyapatite phase were detected in the XRD data, confirming the SEM images. 2% Eu doped SPION/Bioactive glass nanoparticles had the highest osteoblast viability up to 7 days in vitro, while doping the samples with 2% zinc did not yield bone cell viability as high as the Eu doped ones. Importantly, Eu doped SPION/Bioactive glass nanoparticles inhibited gram-positive Staphylococcus aureus (S. aureus) and gram-negative Escherichia coli (E. coli) growth up to 48 h in vitro. The results showed that Eu doping of SPION/Bioactive glass nanoparticles increased osteoblast viability and inhibited bacterial growth, while possessing superparamagnetic properties and exhibiting red luminescence.

Disrupting Biofilms From Titanium with a CHG Antimicrobial Irrigation System

Category: Other Introduction/Purpose: Orthopedic device-related infections can be difficult to treat and decrease the success of surgical interventions. The implant provides a surface for bacterial attachment and biofilm formation, which decreases antimicrobial efficacy. This study was conducted to assess the ability of the Chlorhexidine Gluconate (CHG) Antimicrobial Irrigation System to disrupt biofilms from titanium coupons using an adapted ASTM E2871-19 method, 'Standard Test Method for Determining Disinfectant Efficacy Against Biofilm Grown in the CDC Biofilm Reactor Using the Single Tube Method.' Methods: CDC Biofilm Reactor was inoculated with Staphylococcus epidermidis (ATCC 14990TM), methicillin-resistant Staphylococcus aureus (ATCC 43300TM), Pseudomonas aeruginosa (ATCC 15442TM), or Escherichia coli (ATCC 25922TM). The reactors were run in a batch phase for 24 h, followed by continuous flow phase for an additional 24 h to produce single-species biofilms on titanium coupons. After coupons were washed with PBS to remove planktonic bacteria, growth control coupons were placed into standard sampling solution with 1% Tamol (SST) (neutralizer) or treated with CHG Antimicrobial Irrigation System according to Instructions for Use (IFU) followed by a 60 sec dwell or no dwell. Coupons were rinsed with normal saline following treatment and placed in SST. Then coupons were sonicated and vortexed to release bacteria and plated for enumeration. A coupon from each group was fixed for SEM imaging. Results: The CHG Antimicrobial Irrigation System disrupted biofilms of all organisms from titanium coupons with the greatest log reduction per coupon in the 60 sec dwell treatment group (log10 reduction 2.02 to 4.56 CFU/coupon from controls) (Table). Overall, S. epidermidis and E. coli biofilms had the greatest reductions in bacterial densities. SEM images confirmed biofilm disruption from the titanium surface. Conclusion: his study determined that the CHG Antimicrobial Irrigation System disrupted biofilms from titanium coupons when used according to the instructions for use.

PROSPECTIVE STUDY OF MICROBIOLOGY OF BIOFILM IN ORTHOPAEDIC IMPLANT SURGERY

Background:Infection remains a major obstacle leading to implant failure, increased morbidity, and mortality. Implant-relatedinfections continue to pose a problem for orthopaedicians. In spite of the decreasing incidence of orthopaedic device-related infections to 1%, nowadays, device-related infections still remain a diagnostic, therapeutic, and cost-related problem. Aims And Objective: To isolate and identify the Bacteriological agent forming Biofilm in orthopaedic implant infection and their antibiotic sensitivity. Methods: In a prospective study, 100 patients who underwent orthopaedic implant removal surgery from Dec 2019 – to Sept 2021 were enrolled82 patients culture reports came out positive. Results: Of the 100 samples, 82(82%) were culture positive, and 18(18%) were culture negative. The femur was the most commonly affected bone in both males (median age–37.1yrs) and females (median age–41.3 yrs). Pseudomonas Aeruginosa was the organism that was most commonly isolated, followed by Staphylococcus Aureus and E.coli. No anaerobes were isolated. Aggressive antibiotic therapy was often found inadequate to eliminate the infections caused by the biofilm-forming organism. Conservative surgical treatment was associated with treatment failures. Conclusion: The most common bacteria which were isolated included Pseudomonas aeruginosa, followed by Staphylococcus aureus and E coli. A majority of them are resistant to the commonly used antibiotics, leading to treatment failures that necessitated implant removal.

Polycaprolactone-Coated Alginate/b-Tricalcium Phosphate Beads to Locally Deliver Vancomycin: A Pilot Study

Orthopedic device-related infections (ODRI) are difficult to control and the management of ODRI most frequently includes surgery and long-term antimicrobial therapy. Local application of vancomycin through a biodegradable carrier like alginate would provide a valuable tool, although it is hard to control the drug-release for a prolonged period of time due to its permeability. Coating with hydrophobic polymer such as polycaprolactone (PCL) may sustain the vancomycin release. We fabricated four types of vancomycin containing alginate/b-TCP beads (uncoated, coated with 1.25 w/v%, 2.5 w/v%, and 5.0 w/v% PCL). Scanning electron microscope (SEM) revealed that b-TCP particles were uniformly distributed on the surface of the uncoated beads and the most homogenous coating layer was observed using 2.5 w/v% PCL. Vancomycin release and its bioactivity were measured at the designated time points (1, 4, 12, 24 hours, then every day until disintegration). Burst release occured on the first hour, day 1, 2 and 6 respectively. The beads without coating dissolved at day 3, and those with different coatings dissolved at day 5, 6, and 9. The minimum concentration of the vancomycin in the elution was approximately 5 mg/L, higher than the vancomycin’s minimum inhibitory concentrations (MICs) for Methicillin-resistant Staphylococcus aureus (MRSA). PCL-coated alginate/b-TCP beads loaded with vancomycin may provide a potential local drug delivery device for the adjuvant antimicrobial therapy of the ODRI.

Rifampicin-loaded PLGA nanoparticles for local treatment of musculoskeletal infections: Formulation and characterization

Systemic treatment of orthopedic device-related infections requires potentially toxic doses to reach local therapeutic levels. A locally applied nanosized drug delivery system can provide a high drug dose at the target site. Branched PLGA of lower molar mass was used for rifampicin-loaded nanoparticles (RIF-NPs) formulation by the nanoprecipitation method. The formulation variables influenced the NPs size ranging from 200 to 380 nm. The missing peak of crystalline rifampicin on the DSC scan of the NPs indicates that the drug was molecularly dispersed. The negative charge of the NPs in the physiological buffer was masked by a nonionic surfactant or converted to a positive one by a cationic surfactant, which promotes bioadhesion, penetration, and antimicrobial effect of locally applied RIF-NPs without being toxic to proliferation. Low values of loading capacity showed that PLGA predominates in the NPs, which, however, perform their function as a drug carrier ensuring sustained RIF release. The ex vivo dissolution study of RIF-NPs impregnated into the cancellous allogeneic bone grafts showed a low initial burst followed by sustained release of RIF for 7 days. Rifampicin-loaded PLGA nanoparticles may contribute to the prevention of resistant biofilm formation in patients with implanted devices and the local treatment of infections in open musculoskeletal injuries.

Antimicrobial coating strategy to prevent orthopaedic device-related infections: recent advances and future perspectives.

The rapid development of multidrug-resistant (MDR) bacteria and biofilm-related infections (BRIs) has urgently called for new strategies to combat severe orthopaedic device-related infections (ODRIs). Antimicrobial coating has emerged as a promising strategy in halting the incidence of ODRIs and treating ODRIs in long term. With the advancement of material science and biotechnology, numerous antimicrobial coatings have been reported in literature, showing superior antimicrobial and osteogenic functions. This review has specifically discussed the currently developed antimicrobial coatings in the perspective of drug release from the coating system, focusing on their realization of controlled and on demand antimicrobial agents release, as well as multi-functionality. Acknowledging the multidisciplinary nature of antimicrobial coating, the conceptual design, the deposition method and the therapeutic effect of the antimicrobial coatings have been described in detail and discussed critically. Particularly, the challenges and opportunities on the way toward the clinical translation of antimicrobial coatings have been highlighted.

Antimicrobial peptides (AMP) in biofilm induced orthopaedic device-related infections

Orthopaedic device-related infection (ODRI) represent is one of the most challenging complications to manage in orthopaedic and trauma surgery. Biofilm formation is one of the crucial steps in the development of implant related orthopaedic infections due to the surface-adherent bacteria. Bacterial biofilms have several innate antimicrobial resistance mechanisms and hence difficult to eliminate with conventional antibiotics. Chronic, indolent, unresponsive infection can lead to clinical disability affecting quality of life with socio-economic consequences and compromised patient related health care outcomes. Although there is a basic understanding of the mechanism of biofilm associated antimicrobial resistance, enhanced knowledge, innovative treatment strategies and new therapeutic modalities is the need of the hour to manage biofilm associated Orthopaedic device-related infection (ODRI). Antimicrobial peptides (AMPs) represent an exciting opportunity to treat biofilm infections due to their diverse mechanisms of action. This article highlights the current role and mechanism of Antimicrobial peptides (AMPs) in preventing and eradicating Orthopaedic device-related infection (ODRI).

Cutibacterium acnes clonal complexes display various growth rates in blood culture vials used for diagnosing orthopedic device-related infections

ObjectivesBlood culture bottles (BCBs) are commonly used for the diagnosis of infections associated with orthopedic devices. Although Cutibacterium acnes is an important pathogen in orthopedics, relatively little is known about its growth characteristics in BCBs. This prompted us to analyze the influence of bacterial genotype and clinical significance on time-to-detection (TTD) in BCBs. MethodsWe reviewed 59 cases of orthopedic device-related infections in which at least one intraoperative specimen yielded a pure C. acnes culture from anaerobic BCBs (BD Bactec Lytic/10 Anaerobic/F; Lytic-Ana) and/or solid media. A strain was considered infectant if the same genotype was present in two or more intraoperative samples. From these cases, we isolated a total of 72 unique C. acnes strains belonging to four multilocus sequence type clonal complexes (CCs): CC18, CC28, CC36 and CC53. Growth rate and TTD in Lytic-Ana BCB were studied under experimental conditions (inoculation of standard inoculum) and in clinical samples (inoculation of periprosthetic tissue samples). ResultsMedian TTD values were shorter for CC53 compared to other CCs under experimental conditions (69 vs. 103 h; p < 0.001) and from clinical specimens (70 vs. 200 h; p = 0.02). Infectant strains had a shorter median TTD compared to contaminant strains in a clinical situation, while the difference was not observed under experimental conditions. ConclusionsThe detection dynamics of C. acnes in Lytic-Ana BCBs were associated with genotype. Thus, TTD not only reflects the bacterial load in clinical samples, but may also reflect the intrinsic properties of the clonal complex of C. acnes.

In vitro antibiotic activity against intraosteoblastic Staphylococcus aureus: a narrative review of the literature.

Staphylococcus aureus – a major aetiological agent of bone and joint infection (BJI) – is associated with a high risk of relapse and chronicity, in part due to its ability to invade and persist in non-professional phagocytic bone cells such as osteoblasts. This intracellular reservoir protects S. aureus from the action of the immune system and most antibiotics. To date, the choice of antimicrobial strategies for BJI treatment mostly relies on standard susceptibility testing, bone penetration of antibiotics and their ‘antibiofilm’ activity. Despite the role of intracellular persistent S. aureus in the development of chronic infection, the ability of antibiotics to target the S. aureus intraosteoblastic reservoir is not considered in therapeutic choices but might represent a key determinant of treatment outcome. This review provides an overview of the intracellular pharmacokinetics of antistaphylococcal drugs used in the treatment of BJI and of their ability to target intraosteoblastic S. aureus. Thirteen studies focusing on the intraosteoblastic activity of antibiotics against S. aureus were reviewed, all relying on in vitro models of osteoblast infection. Despite varying incubation times, multiplicities of infection, bacterial strains, and the types of infected cell lines, rifamycins and fluoroquinolones remain the two most potent antimicrobial classes for intraosteoblastic S. aureus eradication, consistent with clinical data showing a superiority of this combination therapy in S. aureus orthopaedic device-related infections.

Facilitating the Approval Process of Anti-Infective Technologies and Advancing Them to the Market: Insights from an FDA Workshop on Orthopaedic Device-Related Infections.

Orthopaedic device-related infection is one of the most devastating complications in orthopaedic and trauma surgery. With increasing life expectancies as well as the lifelong risk of bacterial seeding on an implant, the prevention and treatment of device-related infection remains an important area for research and development. To facilitate information exchange and enhance collaboration among various stakeholders in the orthopaedic community, the U.S. Food and Drug Administration (FDA) Center for Devices and Radiological Health (CDRH) organized an inaugural workshop on orthopaedic device-related infections, exploring the regulatory challenges that are faced when proceeding from the bench level to marketing and clinical implementation of new infection-control devices and products. This article summarizes the perspectives of scientists, clinicians, and industry partners on the current regulatory approval process for orthopaedic anti-infective technologies as well as the proposed strategies to overcome these regulatory challenges.

Cytotoxic effect of galvanically coupled magnesium-titanium particles on Escherichia coli.

Orthopedic device-related infections (ODRIs) are difficult to control due to microbial biofilm formation and associated with high-level resistance to conventional antibiotics. In many cases, the only treatment option for ODRI is explantation. Previous studies have shown that application of cathodic potentials at the metal surface can eradicate biofilms, and Mg and Mg-Ti particles have the same effect as cathodic potentials. This study investigated the effects of Mg and Mg-Ti particles on established biofilms and planktonic cells E. coli. Bacterial cultures with developed biofilms or planktonic cells were treated with Mg or Mg-Ti particles, and the viability were assessed using flow cytometry or visual assessment methods (i.e., observation from SEM images and opacity of the solution). It was found that viability of biofilms treated with 16.67 mg/ml of Mg was 2.8 ± 0.96% at the end of 6-hr killing compared to untreated controls. This extent of killing was more significant compared to 24-hr grown biofilms treated with ofloxacin, an antibiotic known to be effective against these bacteria. Biofilms treated with 50 and 100 μg/ml of ofloxacin had 62 ± 4.6% and 52 ± 19.3% survival, respectively, where ofloxacin at these concentrations is known to kill planktonic counterparts very effectively. Inhibition zone tests revealed that biofilms within 2 mm of Mg or Mg-Ti particle clusters were effectively killed. These results demonstrated the potential of Mg or Mg-Ti particles in killing microbial biofilms and potential for controlling ODRI.

An Improved 2-Aminoimidazole Based Anti-Biofilm Coating for Orthopedic Implants: Activity, Stability, and in vivo Biocompatibility.

Orthopedic device-related infections remain a serious challenge to treat. Central to these infections are bacterial biofilms that form on the orthopedic implant itself. These biofilms shield the bacteria from the host immune system and most common antibiotic drugs, which renders them essentially antibiotic-tolerant. There is an urgent clinical need for novel strategies to prevent these serious infections that do not involve conventional antibiotics. Recently, a novel antibiofilm coating for titanium surfaces was developed based on 5-(4-bromophenyl)-N-cyclopentyl-1-octyl-1H-imidazol-2-amine as an active biofilm inhibitor. In the current study we present an optimized coating protocol that allowed for a 5-fold higher load of this active compound, whilst shortening the manufacturing process. When applied to titanium disks, the newly optimized coating was resilient to the most common sterilization procedures and it induced a 1 log reduction in biofilm cells of a clinical Staphylococcus aureus isolate (JAR060131) in vitro, without affecting the planktonic phase. Moreover, the antibiofilm effect of the coating in combination with the antibiotic cefuroxime was higher than cefuroxime treatment alone. Furthermore, the coating was successfully applied to a human-scale fracture fixation device resulting in a loading that was comparable to the titanium disk model. Finally, an in vivo biocompatibility and healing study in a rabbit osteotomy model indicated that these coated implants did not negatively affect fracture healing or osteointegration. These findings put our technology one step closer to clinical trials, confirming its potential in fighting orthopedic infections without compromising healing.

In vitro polymicrobial inter-kingdom three-species biofilm model: influence of hyphae on biofilm formation and bacterial physiology

Biofilms are an important medical burden, notably for patients with orthopaedic device-related infections. When polymicrobial, these infections are more lethal and recalcitrant. Inter-kingdom biofilm infections are poorly understood and challenging to treat. Here, an in vitro three-species model including Staphylococcus aureus, Escherichia coli and Candida albicans was developed, to represent part of the diversity observed in orthopaedic infections or other clinical contexts. The importance of fungal hyphae for biofilm formation and virulence factor expression was explored. Two protocols were set up, allowing, or not, for hyphal formation. Culturable cells and biomass were characterised in both models, and biofilms were imaged in bright-field, confocal and electron microscopes. The expression of genes related to virulence, adhesion, exopolysaccharide synthesis and stress response was analysed in early-stage and mature biofilms. It was found that biofilms enriched in hyphae had larger biomass and showed higher expression levels of genes related to bacterial virulence or exopolysaccharides synthesis.

A Hyaluronic Acid Hydrogel Loaded with Gentamicin and Vancomycin Successfully Eradicates Chronic Methicillin-Resistant Staphylococcus aureus Orthopedic Infection in a Sheep Model.

Implantable orthopedic devices have had an enormously positive impact on human health; however, despite best practice, patients are prone to developing orthopedic device-related infections (ODRI) that have high treatment failure rates. One barrier to the development of improved treatment options is the lack of an animal model that may serve as a robust preclinical assessment of efficacy. We present a clinically relevant large animal model of chronic methicillin-resistant Staphylococcus aureus (MRSA) ODRI that persists despite current clinical practice in medical and surgical treatment at rates equivalent to clinical observations. Furthermore, we showed that an injectable, thermoresponsive, hyaluronic acid-based hydrogel loaded with gentamicin and vancomycin outperforms current clinical practice treatment in this model, eliminating bacteria from all animals. These results confirm that local antibiotic delivery with an injectable hydrogel can dramatically increase treatment success rates beyond current clinical practice, with efficacy proven in a robust animal model.