Current review—The rise of bacteriophage as a unique therapeutic platform in treating peri‐prosthetic joint infections

Peri‐prosthetic joint infection (PJI) is one of the most serious and dreaded complications after total joint replacement (TJR). Due to an aging population and the constant rise in demand for TJR, the incidence of PJI is also increasing. Successful treatment of PJI is challenging and is associated with high failure rates. One of the main causes for treatment failure is bacterial biofilm formation on implant surfaces and the adherence of biofilm bacteria on tissue and bone next to the implant. Biofilms are protective shields to bacterial cells and possess many unique properties that leads to antibiotic resistance. New therapeutic platforms are currently being explored to breakdown biofilm matrix in order to enhance the efficacy of antibiotics. Bacteriophages (phages) is one of these unique therapeutic platforms that can degrade biofilms as well as target the killing of bacterial cells. Preclinical studies of biofilm‐mediated infections have demonstrated the ability of phage to eradicate biofilms and clear infections by working synergistically with antibiotics. There is strong preclinical evidence that phage can reduce the concentration of antibiotics required to treat an infection. These findings support a promising role for phages as a future clinical adjunct to antibiotics. In addition, phage therapy can be personalized to target a specific bacterial strain. Clinical studies using phage therapy are limited in Western literature; but phase I studies have established good safety profile with no adverse outcomes reported. In order to translate phage therapy to treat PJI in clinics, further preclinical testing is still required to study optimal delivery methods as well as the interaction between phage and the immune system in vivo. © 2017 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 36:1051–1060, 2018.

     

Biofilm theory can guide the treatment of device-related orthopaedic infections

Direct observations of the surfaces of orthopaedic prostheses that have failed and of bone affected by osteomyelitis with and without the presence of a prosthesis have shown that the bacteria that cause these infections live in well-developed biofilms. The cells within these matrix-enclosed surface-associated communities are protected from host defenses and antibiotics, and clinical experience has shown that they must be removed physically before the infection can be resolved. The biofilm etiology of these diseases demands new diagnostic methods because biofilm cells typically do not grow on agar plates when recovered by scraping or swabbing. I will recommend new molecular and immunologic diagnostic methods that have been useful in other biofilm infections. These diseases progress through quiescent periods that alternate with acute exacerbations, and clinicians must realize that antibiotic therapy can control the acute phases but cannot resolve the basic biofilm nidus of the infection. Now that it has been realized that these orthopaedic infections are caused by relatively common biofilm-forming bacterial pathogens, new technologies that deliver very high concentrations of antibiotics locally and "on demand" and novel molecular "mimics" that block the signals that control biofilm formation need to be examined.     

Movement of pseudomonas aeruginosa along catheter surfaces. A mechanism in pathogenesis of catheter-associated infection.

The etiologic mechanism involved in the establishment of catheter-associated bacteriuria is suggested in this in vitro study of the movement of Pseudomonas aeruginosa along a catheter surface against a flowing artificial urine milieu in the presence and absence of antibiotics. Following a lag phase, during which a bacterial biofilm becomes firmly established at a site of contamination, the bacteria ascend the surface of the Foley catheters in a rapidly expanding coherent biofilm. The speed of the bacterial ascent is increased as a result of turbulence-associated planktonic saltatory bacterial movement within the urine column. Bacteriocidal concentrations of antibiotics in the urine can slow down the bacterial ascent, but they do not preclude it.     

Engineering approaches for the detection and control of orthopaedic biofilm infections

Artificial joints are subject to chronic infections associated with bacterial biofilms, which only can be eradicated by the traumatic removal of the implant followed by sustained intravenous antibiotic therapy. We have adopted an engineering approach to develop electrical-current-based approaches to bacterial eradication and microelectromechanical systems that could be embedded within the implanted joint to detect the presence of bacteria and to provide in situ treatment of the infection before a biofilm can form. In the former case we will examine the combined bactericidal effects of direct and indirect electrical fields in combination with antibiotic therapy. In the latter case, bacterial detection will occur by developing a microelectromechanical-systems-based biosensor that can "eavesdrop" on bacterial quorum-sensing-based communication systems. Treatment will be effected by the release of a cocktail of pharmaceutical reagents contained within integral reservoirs associated with the implant, including a molecular jamming signal that competitively binds to the bacteria's quorum sensing receptors (which will "blind" the bacteria, preventing the production of toxins) and multiple high dose antibiotics to eradicate the planktonic bacteria. This approach is designed to take advantage of the relatively high susceptibility to antibiotics that planktonic bacteria display compared with biofilm envirovars. Here we report the development of a generic microelectromechanical systems biosensor that measures changes in internal viscosity in a base fluid triggered by a change in the external environment.     

Pathophysiology of infection on orthopedic biomaterials

Orthopedic biomaterials are foreign bodies and the molecular architecture of their surfaces provides a point of attachment for bacteria. This adherence is made possible through the interaction of the protein interface and the bacterial adhesins. Bacterial colonies use slime and biofilm as means of protection. The development of bacteria towards a reversible state of stationary growth or microcolony variants permits their survival. Microparticles released by biomaterials cause the chronic inflammation associated with the aseptic loosening of prostheses. Some bacterial sub-populations develop transitory resistance to bactericidal antibiotics in the presence of these materials.     

Wound biofilms: Lessons learned from oral biofilms

Biofilms play an important role in the development and pathogenesis of many chronic infections. Oral biofilms, more commonly known as dental plaque, are a primary cause of oral diseases including caries, gingivitis, and periodontitis. Oral biofilms are commonly studied as model biofilm systems as they are easily accessible; thus, biofilm research in oral diseases is advanced with details of biofilm formation and bacterial interactions being well elucidated. In contrast, wound research has relatively recently directed attention to the role biofilms have in chronic wounds. This review discusses the biofilms in periodontal disease and chronic wounds with comparisons focusing on biofilm detection, biofilm formation, the immune response to biofilms, bacterial interaction, and quorum sensing. Current treatment modalities used by both fields and future therapies are also discussed.     

A Wound-Isolated Pseudomonas aeruginosa Grows a Biofilm In Vitro Within 10 Hours and Is Visualized by Light Microscopy

BACKGROUND: In chronic wounds, biofilms probably play a vital role in protecting bacteria from host defenses and antimicrobial medications by creating a barrier of exopolysaccharide that is difficult for the immune system and antibiotics to penetrate. A biofilm consists of an exopolysaccharide matrix that is produced and secreted by certain species of bacteria. OBJECTIVE: The purpose of this study was to visualize and time the progressing growth of a biofilm by a wound-isolated Pseudomonas aeruginosa. METHODS: P. aeruginosa that was initially isolated from a human burn wound was allowed to grow a biofilm in vitro. We used a modified Congo red staining technique to demonstrate the sequential development of a mature biofilm as examined by light microscopy. RESULTS: We show that the exopolysaccharide of the developing biofilm is visible in just 5 hours after inoculation and has the characteristics of a mature biofilm by 10 hours. CONCLUSION: The rapidity of biofilm growth suggests that bacteria in wounds possess the capacity of producing this shield against antibiotics and immune effector cells early in the infection process. Therefore, efforts to prevent or slow the proliferation of bacteria and biofilms should occur soon after a wound is created. Additionally, this staining technique can be used to demonstrate the ability of agents to slow biofilm growth or to interrupt formed biofilm and may be useful in future studies of chronically infected wounds.     

Tolerant Small-colony Variants Form Prior to Resistance Within a Staphylococcus aureus Biofilm Based on Antibiotic Selective Pressure

BackgroundThe treatment of periprosthetic joint infection (PJI) is focused on the surgical or chemical removal of biofilm. Antibiotics in isolation are typically ineffective against PJI. Bacteria survive after antibiotic administration because of antibiotic tolerance, resistance, and persistence that arise in the resident bacteria of a biofilm. Small-colony variants are typically slow-growing bacterial subpopulations that arise after antibiotic exposure and are associated with persistent and chronic infections such as PJI. The role of biofilm-mediated antibiotic tolerance in the emergence of antibiotic resistance remains poorly defined experimentally.Questions/purposesWe asked: (1) Does prior antibiotic exposure affect how Staphylococcus aureus survives within a developing biofilm when exposed to an antibiotic that penetrates biofilm, like rifampicin? (2) Does exposure to an antibiotic with poor biofilm penetration, such as vancomycin, affect how S. aureus survives within a developing biofilm? (3) Do small-colony variants emerge from antibiotic-tolerant or -resistant bacteria in a S. aureus biofilm?MethodsWe used a porous membrane as an in vitro implant model to grow luminescent S. aureus biofilms and simultaneously track microcolony expansion. We evaluated the impact of tolerance on the development of resistance by comparing rifampicin (an antibiotic that penetrates S. aureus biofilm) with vancomycin (an antibiotic that penetrates biofilm poorly). We performed viability counting after membrane dissociation to discriminate among tolerant, resistant, and persistent bacteria. Biofilm quantification and small-colony morphologies were confirmed using scanning electron microscopy. Because of experimental variability induced by the starting bacterial inoculum, relative changes were compared since absolute values may not have been statistically comparable.ResultsAntibiotic-naïve S. aureus placed under the selective pressure of rifampicin initially survived within an emerging biofilm by using tolerance given that biofilm resident cell viability revealed 1.0 x 10⁸ CFU, of which 7.5 x 10⁶ CFU were attributed to the emergence of resistance and 9.3 x 10⁷ CFU of which were attributed to the development of tolerance. Previous exposure of S. aureus to rifampicin obviated tolerance-mediate survival when rifampicin resistance was present, since the number of viable biofilm resident cells (9.5 x 10⁹ CFU) nearly equaled the number of rifampicin-resistant bacteria (1.1 x 10¹⁰ CFU). Bacteria exposed to an antibiotic with poor biofilm penetration, like vancomycin, survive within an emerging biofilm by using tolerance as well because the biofilm resident cell viability for vancomycin-naïve (1.6 x 10¹⁰ CFU) and vancomycin-resistant (1.0 x 10¹⁰ CFU) S. aureus could not be accounted for by emergence of resistance. Adding rifampicin to vancomycin resulted in a nearly 500-fold reduction in vancomycin-tolerant bacteria from 1.5 x 10¹⁰ CFU to 3.3 x 10⁷ CFU. Small-colony variant S. aureus emerged within the tolerant bacterial population within 24 hours of biofilm-penetrating antibiotic administration. Scanning electron microscopy before membrane dissociation confirmed the presence of small, uniform cells with biofilm-related microstructures when unexposed to rifampicin as well as large, misshapen, lysed cells with a small-colony variant morphology [29, 41, 42, 63] and a lack of biofilm-related microstructures when exposed to rifampicin. This visually confirmed the rapid emergence of small-colony variants within the sessile niche of a developing biofilm when exposed to an antibiotic that exerted selective pressure.ConclusionTolerance explains why surgical and nonsurgical modalities that rely on antibiotics to “treat” residual microscopic biofilm may fail over time. The differential emergence of resistance based on biofilm penetration may explain why some suppressive antibiotic therapies that do not penetrate biofilm well may rely on bacterial control while limiting the emergence of resistance. However, this strategy fails to address the tolerant bacterial niche that harbors persistent bacteria with a small-colony variant morphology.Clinical RelevanceOur work establishes biofilm-mediated antibiotic tolerance as a neglected feature of bacterial communities that prevents the effective treatment of PJI.     

Disruption of the extracellular polymeric network of Pseudomonas aeruginosa biofilms by alginate lyase enhances pathogen eradication by antibiotics

BackgroundPseudomonas aeruginosa forms antibiotic-resistant biofilms that are responsible for the treatment failure or relapses of the bacterial infections in the lungs of patients with cystic fibrosis (CF). The alginate lyases that target extracellular polysaccharide alginate of P. aeruginosa biofilms are promising therapeutic candidates for treatment of P. aeruginosa biofilm infections.MethodsImmunofluorescent staining and thin layer chromatography were used to demonstrate the alginolytic activity of the alginate lyase enzyme (AlyP1400) purified from a marine Pseudoalteromonas bacterium. Anti-biofilm activities of AlyP1400 were tested alone or in combination with antibiotics on the biofilms of a mucoid Pseudomonas aeruginosa clinical isolate CF27 that were cultivated in 96-well plates and a flow cell.ResultsWe showed that AlyP1400 facilitated antibiotic activities to eliminate CF27 biofilms. The combination of AlyP1400 with antibiotics reduced the biofilm biomass and boosted bactericidal activity of antibiotics. Importantly, we demonstrated that the enzymatic activity of AlyP1400 was required for its biofilm disruption activity and its synergy with antibiotics to eradicate biofilm cells.ConclusionThis work shed new light on the potential mechanisms of the therapeutic activity for the combinational use of alginate lyase and antibiotics to treat P. aeruginosa infections in CF lungs or other P. aeruginosa biofilm-related infections.     

Ultrastructural microbial ecology of infection-induced urinary stones

With advanced techniques of scanning and transmission electron microscopy we studied the ultrastructural ecology of bacteria associated with struvite calculi on catheter surfaces, and in the bladder, ureter and renal pelvis. These detailed morphological data indicate that the interstices, core and external surface of such struvite aggregates contain large numbers of bacterial cells that grow as microcolonies and thick biofilms within extensive fibrous organic matrices. These bacterial cells and their secreted products (glycocalyx or biofilm matrix) appear to provide initial foci for crystal development and aggregation of crystals to form macroscopic struvite stones. The protective glycocalyx-enclosed microcolonial mode of bacterial growth also may explain the relative resistance to antibiotics observed in bacteria associated with infection stones.     

The role of biofilm infection in urology

In the process of endourological development a great variety of foreign bodies have been invented besides urinary catheters on which biofilm can be formed. Bacteria in the biofilm are less sensible to antibiotics. An additional problem of medical biomaterials in the urinary tract environment is the development of encrustation and consecutive obstruction. In this review, we tried to sum up the conditions where biofilm formation has a great impact on the development or maintenance of urological infections and on treatment success. Modification of the biomaterial surface seems to be the most promising prevention strategy for bacterial biofilms. Easier methods for diagnosing and quantifying biofilm infection, to develop more specific antimicrobial agents and ideal device surfaces would surely help the fight against biofilm formation.     

Microbial pathogenesis of bacterial biofilms: a causative factor of vascular surgical site infection

Vascular surgical site infection (SSI) is caused by pathogenic bacterial strains whose preferred mode of growth is within a surface biofilm. Bacterial biofilm formation can develop within hours to days in a wound and produces a recalcitrant infectious process especially in the presence of a prosthetic graft. The initial steps of biofilm formation are bacterial adhesion to biologic or inert surgical site structures followed by organism production of exopolysaccaride matrix which encases developing bacteria colonies to produce a protective microenvironment. As the biofilm matures, a dynamic process of organism cell-to-cell signaling occurs with varying growth modes of sessile bacteria within the biofilm and the release of planktonic bacteria with the potential to spread and expand the biofilm-mediated infection. The prevalence of staphyloccocal strains causing vascular SSI is best understood when viewed as a biofilm-mediated infection with virulence factors related to specific cell surface adhesion proteins and bacteria-derived matrix production. Nonhealing surgical sites following lower limb revascularization, the late appearance of prosthetic graft infection caused by Staphylococcus epidermidis, and the development of groin site tracts after aortofemoral bypass grafting are clinical examples of a biofilm-mediated SSI. A mature biofilm within a wound or coating a prosthetic device exhibits resistance to host defenses and selected antibiotics, impairs wound healing, and is a perpetual irritant to that host by inciting a chronic inflammatory process. By understanding the microbial pathogenesis of biofilm formation, strategies to treat and prevent biofilm-mediated infection can be developed and utilized to reduce vascular SSIs.     

细菌生物膜与慢性骨髓炎的关系

慢性骨髓炎作为常见的骨科感染性疾病,可导致内固定失败、死骨和窦道形成、长期排脓、甚至最终恶变等严重后果,影响患者的预后和生活质量,造成巨大的医疗和经济负担。骨髓炎的治疗手段由过去的清创术转为现在的清创+Masquelet骨重建术或截骨+Ilizarov骨搬运术,治疗效果显著提升,但缺点是手术次数多、疗程长、手术创伤和风险增加,暨需要新的治疗策略。慢性骨髓炎根治困难的原因包括自体免疫水平紊乱(炎症因子、氧化应激)、局部血供差、耐药细菌出现和细菌生物膜形成等因素,其中细菌生物膜作为细菌在体内的定植存在形式对慢性骨髓炎的影响显著,包括屏障抗生素、抵抗免疫清除、提高细菌耐受性、播散细菌和促进细菌间信号沟通,针对其中的关键因子和通路为靶点进行研究和干预是骨髓炎研究和治疗的热点和趋势。现对研究生物膜与慢性骨髓炎的关系的文献进行综述,便于了解生物膜对慢性骨髓炎的影响机制和相关靶点,为慢性骨髓炎的防治和药物开发提供理论基础。     

Delayed wound healing in diabetic (db/db) mice with Pseudomonas aeruginosa biofilm challenge: a model for the study of chronic wounds

Chronic wounds are a major clinical problem that lead to considerable morbidity and mortality. We hypothesized that an important factor in the failure of chronic wounds to heal was the presence of microbial biofilm resistant to antibiotics and protected from host defenses. A major difficulty in studying chronic wounds is the absence of suitable animal models. The goal of this study was to create a reproducible chronic wound model in diabetic mice by the application of bacterial biofilm. Six‐millimeter punch biopsy wounds were created on the dorsal surface of diabetic (db/db) mice, subsequently challenged with Pseudomonas aeruginosa (PAO1) biofilms 2 days postwounding, and covered with semiocclusive dressings for 2 weeks. Most of the control wounds were epithelialized by 28 days postwounding. In contrast, none of biofilm‐challenged wounds were closed. Histological analysis showed extensive inflammatory cell infiltration, tissue necrosis, and epidermal hyperplasia adjacent to challenged wounds—all indicators of an inflammatory nonhealing wound. Quantitative cultures and transmission electron microscopy demonstrated that the majority of bacteria were in the scab above the wound bed rather than in the wound tissue. The model was reproducible, allowed localized cutaneous wound infections without high mortality, and demonstrated delayed wound healing following a biofilm challenge. This model may provide an approach to study the role of microbial biofilms in chronic wounds as well as the effect of specific biofilm therapy on wound healing.     

Development of a novel,highly quantitative in vivo model for the study of biofilm‐impaired cutaneous wound healing

A growing body of evidence suggests that in addition to hypoxia, ischemia‐reperfusion injury, and intrinsic host factors, bacterial biofilms represent a fourth major pillar in chronic wound pathogenesis. Given that most studies to date rely on in vitro or observational clinical data, our aim was to develop a novel, quantitative animal model enabling further investigation of the biofilm hypothesis in vivo. Dermal punch wounds were created in New Zealand rabbit ears, and used as uninfected controls, or inoculated with green fluorescent protein‐labeled Staphylococcus aureus to form wounds with bacteria predominantly in the planktonic or biofilm phase. Epifluorescence and scanning electron microscopy revealed that S. aureus rapidly forms mature biofilm in wounds within 24 hours of inoculation, with persistence of biofilm viability over time seen through serial bacterial count measurement and laser scanning confocal imaging at different time points postwounding and inoculation. Inflammatory markers confirmed that the biofilm phenotype creates a characteristic, sustained, low‐grade inflammatory response, and that over time biofilm impairs epithelial migration and granulation tissue in‐growth, as shown histologically. We have established and validated a highly quantitative, reproducible in vivo biofilm model, while providing evidence that the biofilm phenotype specifically contributes to profound cutaneous wound healing impairment. Our model highlights the importance of bacterial biofilms in chronic wound pathogenesis, providing an in vivo platform for further inquiry into the basic biology of bacterial biofilm–host interaction and high‐throughput testing of antibiofilm therapeutics.     

An evaluation of the bacteriostatic effect of platelet‐rich plasma

Chronic wounds are a considerable health burden with high morbidity and poor rates of healing. Colonisation of chronic wounds by bacteria can be a significant factor in their poor healing rate. These bacteria can develop antibiotic resistance over time and can lead to wound infections, systemic illness, and occasionally amputation. When a large number of micro‐organisms colonise wounds, they can lead to biofilm formation, which are self‐perpetuating colonies of bacteria closed within an extracellular matrix, which are poorly penetrated by antibiotics. Platelet‐rich plasma (PRP) is an autologous blood product rich in growth factors and cytokines that are involved in an inflammatory response. PRP can be injected or applied to a wound as a topical gel, and there is some interest regarding its antimicrobial properties and whether this can improve wound healing. This study aimed to evaluate the in vitro bacteriostatic effect of PRP. PRP was collected from healthy volunteers and processed into two preparations: activated PRP—activated with calcium chloride and ethanol; inactivated PRP. The activity of each preparation against Staphylococcus aureus and Staphylococcus epidermis was evaluated against a control by three experiments: bacterial kill assay to assess planktonic bacterial growth; plate colony assay to assess bacterial colony growth; and colony biofilm assay to assess biofilm growth. Compared with control, both preparations of PRP significantly inhibited growth of planktonic S aureus and S epidermis. Activated PRP reduced planktonic bacterial concentration more than inactivated PRP in both bacteria. Both PRP preparations significantly reduced bacterial colony counts for both bacteria when compared with control; however, there was no difference between the two. There was no difference found between biofilm growth in either PRP against control or against the other preparation. This study demonstrates that PRP does have an inhibitory effect on the growth of common wound pathogens. Activation may be an important factor in increasing the antimicrobial effect of PRP. However, we did not find evidence of an effect against more complex bacterial colonies.     

Interplay of antibiotics and bacterial inoculum on suture-associated biofilms

BackgroundBiofilms are often antibiotic resistant, and it is unclear if prophylactic antibiotics can effectively prevent biofilm formation. Experiments were designed to test the ability of high (bactericidal) concentrations of ampicillin (AMP), vancomycin (VAN), and oxacillin (OXA) to prevent formation of suture-associated biofilms initiated with low (10⁴) and high (10⁷) numbers of Staphylococcus aureus.Materials and methodsS. aureus biofilms were cultivated overnight on silk suture incubated in biofilm growth medium supplemented with bactericidal concentrations of AMP, VAN, or OXA. Standard microbiological methods were used to quantify total numbers of viable suture-associated S. aureus. Crystal violet staining followed by spectroscopy was used to quantify biofilm biomass, which includes bacterial cells plus matrix components. To observe the effects of antibiotics on the microscopic appearance of biofilm formation, biofilms were cultivated on glass slides, then stained with fluorescent dyes, and observed by confocal microscopy.ResultsIn the presence of a relatively low inoculum (10⁴) of S. aureus cells, bactericidal concentrations of AMP, VAN, or OXA were effective in preventing development of suture-associated biofilms. However, similar concentrations of these antibiotics were typically ineffective in preventing biofilm development on sutures inoculated with 10⁷ S. aureus, a concentration relevant to contaminated skin. Confocal microscopy confirmed that bactericidal concentrations of AMP, VAN, or OXA inhibited, but did not prevent, development of S. aureus biofilms.ConclusionBactericidal concentrations of AMP, VAN, or OXA inhibited formation of suture-associated biofilms initiated with low numbers (10⁴), but not high numbers (10⁷), of S. aureus cells.     

Large variations in clinical antibiotic activity against Staphylococcus aureus biofilms of periprosthetic joint infection isolates

Staphylococcus aureus biofilms have a high tolerance to antibiotics, making the treatment of periprosthetic joint infection (PJI) challenging. From a clinical perspective, bacteria from surgical specimens are cultured in a planktonic state to determine antibiotic sensitivity. However, S. aureus exists primarily as established biofilms in PJI. To address this dichotomy, we developed a prospective registry of total knee and hip arthroplasty PJI S. aureus isolates to quantify the activity of clinically important antibiotics against isolates grown as biofilms. S. aureus planktonic minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) were assessed using clinical laboratory standard index assays for 10 antibiotics (cefazolin, clindamycin, vancomycin, rifampin, linezolid, nafcillin, gentamicin, trimethoprim/sulfamethoxazole, doxycycline, and daptomycin). Mature biofilms of each strain were grown in vitro, after which biofilm MIC (MBIC) and biofilm MBC (MBBC) were determined. Overall, isolates grown as biofilms displayed larger variations in antibiotic MICs as compared to planktonic MIC values. Only rifampin, doxycycline, and daptomycin had measurable biofilm MIC values across all S. aureus isolates tested. Biofilm MBC observations complemented biofilm MIC observations; rifampin, doxycycline, and daptomycin were the only antibiotics with measurable biofilm MBC values. 90% of S. aureus biofilms could be killed by rifampin, 50% by doxycycline, and only 15% by daptomycin. Biofilm formation increased bacterial antibiotic tolerance nonspecifically across all antibiotics, in both MSSA and MRSA samples. Rifampin and doxycycline were the most effective antibiotics at killing established S. aureus biofilms. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1604–1609, 2019.     

Prophylactic antibiotics prevent bacterial biofilm graft infection.

Bacterial biofilm graft infection is due to prostheses colonization by Staphylococcus epidermidis, a pathogen frequently recovered from perigraft tissues of man during vascular procedures despite the use of asepsis and prophylactic antibiotics. The effect of preoperative intraperitoneal cefazolin, administered at a standard (15 or 30 mg/kg) and high (120 mg/kg) dose, on the prevention of bacterial biofilm infection was studied in a rat model. Seventy-four Dacron grafts, colonized in vitro with S. epidermidis to produce an adherent biofilm (3.19 +/- 0.71 x 10(7) colony-forming units/cm2 graft), were implanted in the dorsal subcutaneous tissue at 0.5, 2, and 4 hr after antibiotic administration. The study strain was a slime-producing clinical isolate with minimum inhibitory concentration (MIC) of 15-30 micrograms/ml to cefazolin. Subcutaneous tissue antibiotic levels were determined at each time interval. One week after implantation, the concentration of bacteria in the surface biofilm by quantitative agar culture was significantly decreased (P less than 0.05) only for grafts implanted when antibiotic tissue levels were greater than or equal to the MIC of the study strain. The result of no growth by biofilm broth culture was significantly achieved (P less than 0.01) only for grafts implanted 0.5 hr after high dose cefazolin, in which the tissue antibiotic level was above the MIC of the study strain. Antibiotics can markedly reduce the bacteria concentration of a prosthetic surface biofilm. The effectiveness of prophylactic antibiotics on the prevention of graft infection is dependent upon maintaining an adequate antibiotic level in the perigraft tissues for the duration of the procedure.