Gordon Christensen

The Efficacy of Various Irrigation Solutions in Removing Slime-Producing Staphylococcus

Summary: To determine which type of irrigation solution and which method of irrigation most effectively removes slime-producing Staphylococcus from implant surfaces, we performed experimental washings of bacteria-coated stainless steel screws with various solutions delivered by bulb syringe or by jet lavage. The quantity of bacteria remaining on the screw surface was determined after irrigation with 1 L of saline, 1 L of antibiotic solutions, or 1 L of saline containing a liquid soap. Antibiotic solutions tested included bacitracin, neomycin, and polymyxin/neomycin. We found that the use of power irrigation increased the removal of bacteria by a factor of at least 100 over bulb syringe irrigation of the same volume, no matter which solution was used. This effect ranged from a 100-fold improvement for neomycin, to a 285-fold effect for the polymyxin solution. The addition of antibiotic drugs to the irrigation solution had no significant effect on bacterial removal, and none of the antibiotic solutions were statistically different from saline alone in the amount of bacteria removed from the screws. The addition of a liquid soap solution dramatically increased the amount of bacteria removed by irrigation, reducing the residual bacteria per screw from a colony count of 3.5 x 104 for polymyxin (the best of the antibiotic solutions), to 4.38 x 103. This difference was statistically significant as judged by Students t test, with p=0.01. We have concluded that the use of power irrigation improves the ability to clean this pathogenic bacteria from metallic surfaces, and that the addition of antibiotic drugs to the irrigation solution does not. The use of liquid soap in the irrigation solution does improve the efficacy of irrigation in removing slime-producing bacteria.

Comparison of castile soap, benzalkonium chloride, and bacitracin as irrigation solutions for complex contaminated orthopaedic wounds.

OBJECTIVE The purpose of the present study was to determine the effects of cleaning a contaminated orthopaedic wound with different classes of wound irrigation solutions. STUDY DESIGN Rats with a contaminated orthopaedic wound were randomized into treatment groups: normal saline (NS), castile soap (CS), benzalkonium chloride (BzC), bacitracin (Abx), or sequential irrigation with BzC, CS, and NS. INTERVENTION Pseudomonas aeruginosa [P. aeruginosa; 1 x 10(6) colony-forming units (CFU)], or Staphylococcus aureus (S. aureus; 1 x 10(6) CFU) were placed into a paravertebral wound (containing a wire implant placed through a spinous process) and allowed to incubate for fifteen minutes. The wound was then irrigated with three liters of either NS, 0.05 percent CS, 0.03 percent BzC, Abx (33,000 units per liter) or underwent a sequential irrigation treatment (one liter each of BzC, CS, NS). MAIN OUTCOME MEASUREMENTS The animals were observed daily for wound complications for fourteen days and then killed, and cultures of the wound were obtained. RESULTS Pseudomonas aeruginosa: Both CS and the sequential irrigation treatment significantly lowered the rate of positive wound cultures when compared with NS (p < 0.05). Irrigation with BzC resulted in a higher rate of positive wound cultures and complications. The sequential irrigation treatment prevented the wound complications associated with irrigation with BzC alone. Staphylococcus aureus: Only BzC irrigation significantly lowered the rate of positive wound cultures when compared with NS (p < 0.05). CONCLUSION The rate of positive wound cultures due to P. aeruginosa is effectively reduced by irrigation with CS alone or by the sequential irrigation treatment. When used alone, the antiseptic BzC results in a higher rate of positive wound cultures and wound complications. The wound complications seen with irrigation with BzC alone are prevented by the sequential irrigation treatment (BzC followed by CS and NS). The rate of positive wound cultures in this model due to S. aureus is not decreased by irrigation with CS; however, the rate of positive wound cultures is safely and effectively decreased with the use of BzC.

Benzalkonium chloride. A potential disinfecting irrigation solution for orthopaedic wounds.

The efficacy of benzalkonium chloride was evaluated as an irrigating solution for the eradication of Staphylococcus aureus from a contaminated orthopaedic wound. Thirty Sprague Dawley rats were randomized into two groups. A stainless steel wire was placed in a lumbar spinous process, and the wound was inoculated with 107 or 106 colony forming units of Staphylococcus aureus. The wound was irrigated with 1 L of normal saline or 0.1% benzalkonium chloride solution. The animals were sacrificed, and cultures were obtained. Rats inoculated with 107 colony forming units of Staphylococcus aureus and irrigated with benzalkonium chloride had a significant decrease in the total number of positive cultures, deep wound cultures, and stainless steel wire cultures. Rats inoculated with 106 colony forming units of Staphylococcus aureus and irrigated with benzalkonium chloride also had a significant decrease in the total number of positive cultures, deep wound cultures, and stainless steel wire cultures. In a parallel noninoculation study, histologic evaluation of tissues did not show toxicity in the rats irrigated with benzalkonium chloride. This study shows that benzalkonium chloride is more effective than normal saline as an irrigating agent for eradicating Staphylococcus aureus from a contaminated orthopaedic wound.

Disinfecting agents for removing adherent bacteria from orthopaedic hardware.

This investigation seeks to determine whether surfactants or detergents can be used to clean and disinfect orthopaedic wounds with implanted hardware. Thus, a stepwise investigation of biocompatible surfactants and detergents was performed to identify an irrigation agent for disinfecting orthopaedic wounds. Bacterial adhesions assays, irrigation studies, and bactericidal assays determined that benzalkonium chloride showed the greatest efficacy. Testing involved stainless steel screws colonized with a preformed biofilm of Staphylococcus epidermidis, Staphylococcus aureus, or Pseudomonas aeruginosa, which were immersed in benzalkonium chloride solutions for various time intervals under static conditions. After 10 minutes, benzalkonium chloride achieved a minimum 4 log kill (10,000-fold) for all 3 strains of bacteria. Additional studies demonstrated that the high mechanical energy of jet irrigation improved the disinfecting properties of this agent. With jet lavage, both 1:1000 and 1:5000 concentrations of benzalkonium chloride achieved a minimum 2 log kill (100-fold) for all 3 bacteria. The results or this study suggest that at tissue compatible concentrations, benzalkonium chloride has significant disinfection properties for in vitro colonized orthopaedic devices, and these properties may be enhanced via jet lavage.

Synergy between Staphylococcus aureus and Pseudomonas aeruginosa in a rat model of complex orthopaedic wounds

Background: We observed an interaction in animals inoculated concomitantly with Staphylococcus aureus andPseudomonas aeruginosa during a study of the efficacy of surfactants for disinfection of orthopaedic wounds. This led us to investigate whether synergy could be demonstrated between Staphylococcus aureus and Pseudomonas aeruginosa in a rat model of complex orthopaedic wounds. Methods: A wire was implanted into the spinous process of a lumbar vertebra of Sprague-Dawley rats through a dorsal incision. Animals were divided into two groups: group one was inoculated with either Staphylococcus aureus or Pseudomonas aeruginosa, and group two received a polymicrobial inoculation with both test organisms in varying concentrations. After inoculation, the wounds were irrigated and closed. On postoperative day 14, all animals were killed and specimens from the wounds were cultured. The number of colony-forming units (CFU) of Staphylococcus aureus or Pseudomonas aeruginosa needed to cause infection in 50% of the animals (ID50) was determined with use of the Reed-Muench method. The infection rate associated with each inoculum combination was calculated, and the two groups were compared. Results: The ID50 was 2.8 ¥ 104 CFU for Staphylococcus aureus and 4.8 ¥ 105 CFU for Pseudomonas aeruginosa. The combination of 103 CFU of Staphylococcus aureus with low concentrations (102, 103, or 104 CFU) of Pseudomonas aeruginosa yielded infection rates that were higher than those found with either organism alone at the same concentrations. The combination of 103 CFU of Staphylococcus aureus and 103 CFU of Pseudomonas aeruginosa yielded a 75% infection rate, which was significantly higher (p = 0.004) than that associated with 103 CFU of either organism alone. As the Pseudomonas aeruginosa concentration was increased (to 105, 106, and 107 CFU), this trend reversed, and the infection rate decreased to 33% (p = 0.004). Low concentrations of Pseudomonas aeruginosa (0 to 105 CFU) combined with 106 CFU of Staphylococcus aureus yielded infection rates ranging from 83% to 100%. At the higher concentrations of Pseudomonas aeruginosa (106 and 107 CFU), however, the infection rate again decreased, to 33% (p = 0.005). Only Staphylococcus aureus was isolated from the cultures of the specimens from the animals that had received a polymicrobial inoculum. Conclusions: Synergy between Staphylococcus aureus and Pseudomonas aeruginosa was demonstrated when low levels of each organism were present in the wound. As the Pseudomonas aeruginosa concentration was increased, the infection rates fell well below what would be anticipated, suggesting that low concentrations of Pseudomonas aeruginosa enhance the ability of Staphylococcus aureus to cause infection in this orthopaedic wound model. At the same time, the presence of Staphylococcus aureus in the ratios tested decreased the rate of infection by Pseudomonas aeruginosa. Clinical Relevance: Staphylococcus aureus is a pathogen commonly seen in orthopaedic patients. The pathogenicity of Staphylococcus aureus was shown to be increased in the presence of anaerobic bacteria. This study is the first one that we are aware of that demonstrated synergy between Staphylococcus aureus and Pseudomonas aeruginosa, at low concentrations, in a wound model while at the same time showing that Staphylococcus aureus lowers the rate of Pseudomonas aeruginosa infection.

Benzalkonium chloride: a potential disinfecting irrigation solution.

OBJECTIVE To determine the disinfecting properties of benzalkonium chloride as an irrigation agent. DESIGN Comparison was made between irrigation of contaminated muscle strips with benzalkonium chloride and normal saline (control). SUMMARY OF BACKGROUND DATA Benzalkonium chloride is a cationic disinfectant, which has questionable efficacy in an organic environment. However, no previous study has attempted to use high volumes of this cationic solution to overcome the neutralizing effect of organic tissue and thus maintain this detergents germicidal properties. METHODS 2.5 cm x 0.5 cm x 0.5 cm pieces of bovine muscle were aseptically cut from the center of freshly harvested beef muscle and incubated with 1.0 x 10(7) colony forming units of bacteria for 15 minutes. The muscle strips were then irrigated with either 100 mL, 1 L, or 10 L of benzalkonium chloride at a 1:2000 concentration in normal saline. Normal saline was used as the control. The muscle strips were sonicated to remove adherent bacteria; the number of living organisms was determined by quantitatively culturing the sonicate. RESULTS In vitro, benzalkonium chloride was superior to normal saline at disinfecting bovine muscle (p < or = 0.001). When 10 L of benzalkonium chloride irrigation was used, no living bacteria could be recovered (p < or = 0.012). CONCLUSION In this experimental setting benzalkonium chloride was an effective disinfection agent, with enhanced activity at large volumes.

Methods for Evaluating Attached Bacteria and Biofilms

If you consider this text a cookbook and yourself—the investigator—the cook, how do you choose which recipe—or experimental procedure—to use? Or should you cook up something new? Like any good chef, the recipe you choose will reflect the meal you wish to prepare, the equipment in your kitchen, the supplies in your pantry, and your own past experience as a cook. But suppose you are not bound by past experience, materials, and equipment, then how do you choose an experimental approach? The answer lies in the experimental question. What hypothesis do you want to test? What meal do you wish to prepare?

Nanoscale Plasma Coating Inhibits Formation of Staphylococcus aureus Biofilm

ABSTRACT Staphylococcus aureus commonly infects medical implants or devices, with devastating consequences for the patient. The infection begins with bacterial attachment to the device, followed by bacterial multiplication over the surface of the device, generating an adherent sheet of bacteria known as a biofilm. Biofilms resist antimicrobial therapy and promote persistent infection, making management difficult to futile. Infections might be prevented by engineering the surface of the device to discourage bacterial attachment and multiplication; however, progress in this area has been limited. We have developed a novel nanoscale plasma coating technology to inhibit the formation of Staphylococcus aureus biofilms. We used monomeric trimethylsilane (TMS) and oxygen to coat the surfaces of silicone rubber, a material often used in the fabrication of implantable medical devices. By quantitative and qualitative analysis, the TMS/O2 coating significantly decreased the in vitro formation of S. aureus biofilms; it also significantly decreased in vivo biofilm formation in a mouse model of foreign-body infection. Further analysis demonstrated TMS/O2 coating significantly changed the protein adsorption, which could lead to reduced bacterial adhesion and biofilm formation. These results suggest that TMS/O2 coating can be used to effectively prevent medical implant-related infections.