A. Benini

Behavior of antibiotics during human necrotizing pancreatitis.

The aim of the study was to verify whether antibiotics excreted by the normal pancreas are also excreted in human necrotizing pancreatitis, reaching the tissue sites of the infection. Twelve patients suffering from acute necrotizing pancreatitis were treated with imipenem-cilastatin (0.5 g), mezlocillin (2 g), gentamicin (0.08 g), amikacin (0.5 g), pefloxacin (0.4 g), and metronidazole (0.5 g). Serum and necrotic samples were collected simultaneously at different time intervals after parenteral drug administration by computed tomography-guided needle aspiration, intraoperatively, and from surgical drainages placed during surgery. Drug concentrations were determined by microbiological and high-performance liquid chromatography assays. All antibiotics reached the necrotic tissues, but with varying degrees of penetration, this being low for aminoglycosides (13%) and high in the case of pefloxacin (89%) and metronidazole (99%). The concentrations of pefloxacin (13.0 to 23 micrograms/g) and metronidazole (8.4 micrograms/g) in the necrotic samples were distinctly higher than the MICs for the organisms most commonly isolated in this disease; the concentrations in tissue of imipenem (3.35 micrograms/g) and mezlocillin (8.0 and 15.0 micrograms/g) did not always exceed the MICs for 90% of strains tested, whereas the aminoglycoside concentrations in necrotic tissue (0.5 microgram/g) were inadequate. Repeated administration of drugs (for 3, 7, 17, and 20 days) seems to enhance penetration of pefloxacin, imipenem, and metronidazole into necrotic pancreatic tissue. The choice of antibiotics in preventing infected necrosis during necrotizing pancreatitis should be based on their antimicrobial activity, penetration rate, persistence, and therapeutic concentrations in the necrotic pancreatic area. These requisites are provided by pefloxacin and metronidazole and to a variable extent by imipenem and mezlocillin.

The intestinal ecosystem in chronic functional constipation

Chronic functional constipation is common in infants, and the bacterial composition of stools in this condition is not known. The study aims were to: (i) investigate the composition of the intestinal ecosystem in chronic functional constipation; (ii) establish whether the addition of the water‐holding agent calcium polycarbophil to the diet induces an improvement in constipation; and (iii) determine the composition of the intestinal ecosystem after the use of this agent. In total, 42 children (20F, 22M; mean age: 8.6 ± 2.9 y) were studied. Twenty‐eight children with functional chronic constipation without anatomical disorders were treated double‐blind in random sequence for 1 month with an oral preparation of calcium polycarbophil (0.62 g /twice daily) or placebo. Intestinal flora composition was evaluated by standard microbiological methods and biochemical assays on faecal samples collected before and after treatment. Fourteen healthy children were studied as controls. The results show that (i) the constipated children presented a significant increase in clostridia and bifidobacteria in faeces compared to healthy subjects–different species of clostridia and enterobacteriaceae were frequently isolated; no generalized overgrowth was observed; Clostridia outnumbered bacteroides and E. coli mean counts by 2–3log, while bacteroides and E. coli counts were similar (5‐6 log 10/g fresh faeces); these intestinal disturbances could be defined as a dysbiosis, i.e. a quantitative alteration in the relative proportions of certain intestinal bacterial species. (ii) Clinical resolution of constipation was achieved only in 43% of treated children and an improvement in 21% (one bowel movement every 2 d). (iii) Calcium polycarbophil treatment induced no significant changes in the composition of the intestinal ecosystem, nor in blood chemistry parameters.

Release of antibiotics from polymethylmethacrylate cement

Abstract The increase in resistance rates to antibiotics of bacteria isolated from infected hip joints, particularly staphylococci, prompted us to investigate the usefulness of antibiotic combinations such as gentamicin plus vancomycin. Cylinder test specimens of polymethylmethacrylate (PMMA) cement (Cemex®, Tecres) containing gentamicin alone, vancomycin alone and both drugs in combination, were studied. The antibiotic concentrations were determined using a microbiological method and fluorescence polarization immunoassay (FPIA). The release of gentamicin alone, vancomycin alone and in combination from PMMA cement was prompt. The combination revealed synergistic antimicrobial activity against Escherichia coli and Enterococcus faecalis. FPIA showed that gentamicin and vancomycin delivery rates from PMMA cement were different. Gentamicin alone and in combination with vancomycin presented similar release rates from PMMA cement (1.50%). Vancomycin release from PMMA cylinders impregnated with the combination was lower (0.51%) than that from cylinders with vancomycin alone (1.16%). Vancomycin showed a 34.1% loss of microbiological activity at 37°C after 10 days of incubation; the reduction corresponded to 15.0% when measured by FPIA. Results obtained with test specimens are indicative for the preparation of antibiotic-impregnated cements for different human prostheses.

Modulation of the Intestinal Ecosystem by Probiotics and Lactulose in Children During Treatment with Ceftriaxone

Abstract Background: The value of oral bacteriotherapy during antibiotic treatment is a much debated subject. Comparative studies on the effects of different probiotics on the intestinal ecosystem are lacking. Objective: Six different commercially available preparations of probiotics and 1 prebiotic (lactulose) were compared to establish whether their action prevented or corrected imbalances in the intestinal ecosystem (dysbiosis) during parenteral therapy with ceftriaxone. Methods: Fifty-one children (25 female, 26 male; mean age, 5.1 years) admitted to the hospital for febrile respiratory tract infections were treated. Ceftriaxone 50 mg/kg per day was administered parenterally alone (therapy 1) or with 1 of the following probiotic/prebiotic preparations: Saccharomyces boulardii (therapy 2); Enterococcus species (therapy 3); lactulose (therapy 4); Lactobacillus casei GG (therapy 5); Lactobacillus rhamnosus, Lactobacillus bifidus , and Lactobacillus acidophilus (therapy 6); Bifidobacterium bifidum and L acidophilus (therapy 7); or a mixture of various lactobacilli and bifidobacteria at high concentrations (therapy 8). Intestinal microflora were evaluated by standard microbiologic methods and by biochemical assays on fecal samples collected before and after treatment. Results: Ceftriaxone induced a decrease in Escherichia coli and lactobacilli counts and an increase in cocci and clostridia counts. Partial protection of the intestinal ecosystem (eubiosis) was achieved with therapies 6, 7, and 8, which contained different combinations of Lactobacillus and Bifidobacterium species. Probiotics containing lactobacilli were more active than the older Saccharomyces and Enterococcus preparations. The newer probiotics reduced β-galactosidase, β-glucosidase, and β-glucuronidase levels. Increased fecal β-lactamase activity was observed in 60% of patients treated with ceftriaxone alone and 75% of those treated with ceftriaxone and S boulardii . A lower incidence of beta-lactamase-positive samples (30%–40%) was observed with therapy 7 and therapy 8. Conclusions: In this preliminary study, probiotics containing multiple species of lactobacilli and bifidobacteria administered at high concentration (20 billion to 360 billion per day) were more effective in preventing dysbiosis induced by ceftriaxone treatment than were other preparations studied. Probiotic therapy may need to be maintained for several days after discontinuation of antibiotic treatment to adequately restore balance to the intestinal ecosystem.

Different microbial biofilm formation on polymethylmethacrylate (PMMA) bone cement loaded with gentamicin and vancomycin

We studied the in vitro effects of gentamicin and vancomycin alone and in combination added to polymethylmethacrylate (PMMA) cement specimens on the bacterial adhesion of multiresistant clinical isolates. The PMMA specimens (discs) loaded with gentamicin (1.9%) or vancomycin (1.9%) or with a combination of the two were placed in Mueller-Hinton Broth inoculated with bacterial strains. After incubation, bacterial growth was determined by optical density (OD(540)) and sub-cultures. The biofilm PMMA-associated dye (crystal violet) was measured. Antibiotic concentrations in broth were determined by fluorescence polarisation immunoassay. All antibiotic-loaded PMMA cement specimens released high, inhibitory concentrations of gentamicin and vancomycin. However, differences in strain growth and adhesion were recorded. The clinical isolates Met-R/Gent-R CoNS showed no adhesion to gentamicin-loaded specimens for 24 h; strains with Gent-Intermediate susceptibility exhibited growth after 48 h but reduced adhesion. Some Gent-R strains exhibited growth and adhesion to antibiotic-loaded specimens similar to controls (plain discs). Only the VRSA strain (Staphylococcus aureus 5/7) and Escherichia coli were able to grow and adhere to vancomycin-loaded specimens after 24 h of incubation. The specimens loaded with the gentamicin + vancomycin combination showed a synergistic inhibitory effect against all tested strains (no bacterial growth). The degree of bacterial adhesion to PMMA cement loaded with gentamicin or vancomycin may be reduced in spite of a normal growth rate and is different for the tested strains. The effect of gentamicin and vancomycin on bacterial growth and adhesion to PMMA bone cement depends on the antibiotic concentrations, on the characteristics of each specific strain and on its ability to produce biofilm and adhere to antibiotic-loaded PMMA bone cement.

Release of Gentamicin and Vancomycin from Preformed Spacers in Infected Total Hip Arthroplasties: Measurement of Concentrations and Inhibitory Activity in Patients’ Drainage Fluids and Serum

Gentamicin (G) and vancomycin (V) concentrations in drainage fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision of infected total hip arthroplasty were studied. The inhibitory activity of drainage fluids against different multiresistant clinical isolates was investigated as well. Seven hips were treated by implantation of industrial G-loaded spacers. Vancomycin was added by manually mixing with PMMA bone cement. Serum and drainage fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and drains bactericidal titer of combination were determined against multiresistant staphylococcal strains. The release of G and V from PMMA cement at the site of infection was prompt and effective. Serum levels were below the limit of detection. The local release kinetics of G and V from PMMA cement was similar, exerting a pronounced, combined inhibitory effect in the implant site. The inhibitory activity of drainage fluids showed substantial intersubject variability related to antibiotic concentrations and differed according to the pathogens tested. Gentamicin and vancomycin were released from temporary hip spacers at bactericidal concentrations, and their use in combination exerted strong inhibition against methicillin-resistant S. aureus and Coagulase Negative Staphylococci strains.

Antimicrobial activity of gentamicin and vancomycin combination in joint fluids after antibiotic-loaded cement spacer implantation in two-stage revision surgery

Abstract Gentamicin (G) and vancomycin (V) concentrations in joints fluids obtained from patients during the first 24 hours after implantation of antibiotic-loaded polymethylmethacrylate (PMMA) spacers in two-stage revision for infected arthroplasty, and the inhibitory activity of joint fluids against different multiresistant clinical isolates were studied. A total of 12 patients undergoing two-stage revision surgery with implantation of industrial G spacers added with different amounts of V was studied. Serum and joint fluid samples were collected 1, 4, and 24 hours after spacer implantation. Antibiotics concentrations and joint bactericidal titer (JBT) of combination were determined against multiresistant staphylococcal strains. The local release of G and V from PMMA cement seemed prompt and effective. Serum levels were below the limit of detection. The same joint fluid showed different activity according to the susceptibility of the pathogens tested. Gentamicin and V were released from spacers at bactericidal concentrations exerting a strong inhibition against methicillin-resistant Staphylococcus aureus (MRSA) and coagulase-negative staphylococci (CoNS) strains.

Microbiological and pharmacological tests on new antibiotic-loaded PMMA-based composites for the treatment of osteomyelitis

Local antibiotic diffusion in rabbit femurs from two new PMMA‐based and nail‐shaped composites, enriched with β‐tricalcium phosphate (P‐TCP) and BaSO4 or only with BaSO4 (P‐BaSO4), and soaked in a solution of gentamicin (G) and vancomycin (V) was studied. Nails were implanted into the intramedullary cavity of healthy and osteomyelitic femurs to study the resolution of infection and to quantify the antibiotic penetration into bone by microbiological, pharmacological, and histological tests. A significant progression of osteomyelitis was recorded 7 weeks after MRSA inoculation, whereas no bacteria were found in animals treated with antibiotic‐loaded nails as confirmed by microbiology and histology (Smeltzer score). The release of both antibiotics from composites was high and prompt both in healthy and infected bone; the amount of V was higher than that of G in all bone samples. Antibiotics of both composites were still present in bone 3 weeks after nail implantation. The P‐BaSO4 composite released a lower amount of antibiotics than did P‐TCP. The G–V combination in vivo exerted a synergistic bactericidal effect, which was confirmed by microbiological, histological, and clinical results (no infection). These new porous PMMA composites, soaked in G–V solution in the operating room, might be an effective and useful drug delivery system for osteomyelitis treatment.

New PMMA-based composites for preparing spacer devices in prosthetic infections

Even though the systemic antibiotic therapy is usually applied after prosthetic infections surgical treatments, it is unable to reach the infection site in sufficient concentrations to eradicate bacteria. Delivering antibiotics locally with the use of custom made device (spacer or nail coating) might eradicate or reduce the infection and the risk of recolonization, providing a very high concentration of antibiotic. PMMA-based (Mendec Spine®) composites with BaSO4 were enriched with β-tricalcium phosphate (Porosectan-TCP) or only a slightly higher BaSO4 concentration (Porosectan-BaSO4) to obtain higher porosity. The aim of the study was to evaluate: (i) drug absorption capability and drug release kinetics in vitro soaking them with a combined solution of gentamicin and vancomycin, (ii) their in vitro and in vivo biocompatibility, and finally, (iii) they were tested preliminarily in an experimental model of bone infection. The simultaneous presence of β-TCP and BaSO4 resulted in the formation of a texture of interconnecting channels with different diameters, from a few microns to several hundred microns, which totally filled the material. The porosity, determined by microcomputed tomography, was significantly higher in both tested plain composites (Porosectan-TCP: +17.3%; Porosectan-BaSO4: +7.5%) in comparison to control composite material (Mendec Spine®). The kinetics of antibiotic release from composites was rapid and complete, producing high drug concentrations for a short period of time. Both composites showed a good level of biocompatibility. The osteomyelitic model confirmed that both composites, soaked in antibiotic solution, were able to cure bone infection. These composites could be useful for preparing devices for prosthetic joint infections treatment also allowing the use of antibiotics solution at required concentrations.

PMMA as Drug Delivery System and in vivo Release from Spacers

Infection is the most serious complication following orthopaedic surgery. The frequency is low, but when present is difficult to treat. Systemic drug administration may not provide inhibitory concentration for a prolonged period, and this is further worsened by the decreased blood supply. The local delivery of antibiotics to the surgical area may may contribute to reduce the infection frequency and the risk of recolonization [16].