Antimicrobial effect of combinations of EDTA-Tris and amikacin or neomycin on the microorganisms associated with otitis externa in dogs

Pseudomonas spp. in Canine Otitis Externa

Canine otitis externa (OE) is a commonly diagnosed condition seen in veterinary practice worldwide. In this review, we discuss the mechanisms of the disease, with a particular focus on the biological characteristics of Pseudomonas aeruginosa and the impact that antibiotic resistance has on successful recovery from OE. We also consider potential alternatives to antimicrobial chemotherapy for the treatment of recalcitrant infections. P. aeruginosa is not a typical constituent of the canine ear microbiota, but is frequently isolated from cases of chronic OE, and the nature of this pathogen often makes treatment difficult. Biofilm formation is identified in 40-95% of P. aeruginosa from cases of OE and intrinsic and acquired antibiotic resistance, especially resistance to clinically important antibiotics, highlights the need for alternative treatments. The role of other virulence factors in OE remains relatively unexplored and further work is needed. The studies described in this work highlight several potential alternative treatments, including the use of bacteriophages. This review provides a summary of the aetiology of OE with particular reference to the dysbiosis that leads to colonisation by P. aeruginosa and highlights the need for novel treatments for the future management of P. aeruginosa otitis.

Determination of amikacin stability at 1% and 3% concentrations in four topical solutions over a 56 day period

BACKGROUND

Anecdotally, amikacin has been added to compounded topical preparations for the management of canine bacterial otitis externa. However, the stability of amikacin within these solutions is unknown.

HYPOTHESIS/OBJECTIVES

The purpose of this study was to determine the stability of amikacin at 10 and 30 mg/mL concentrations in four topical solutions over a 56 day period. We hypothesised that amikacin would maintain chemical stability within the various solutions.

METHODS AND MATERIALS

Amikacin was formulated to 10 and 30 mg/mL (1% and 3%) concentrations within four topical solutions: tris-EDTA (TrizEDTA Aqueous Flush) (TE); 0.15% chlorhexidine gluconate and tris-EDTA (TrizCHLOR Flush) (TC); 0.9% NaCl (NA); and 0.9% NaCl + 2 mg/mL dexamethasone (ND). Samples were made in duplicate and stored at room temperature (25°C) for 0, 7,14, 21, 28 and 56 days. Amikacin content was quantified, in triplicate, by ultrahigh-performance liquid chromatography tandem mass spectrometry.

RESULTS

The recovered amikacin concentrations for the 10 mg/mL solutions ranged from 10 to 13.5 mg/mL (mean 11.5 mg/mL) with the exception of NA sample 2 at Day (D)0 (9.4 mg/mL) and D7 (9.2 mg/mL). The recovered amikacin concentrations for the 30 mg/mL solutions ranged from 30 to 40.2 mg/mL (mean 35.7 mg/mL). No significant difference was seen between the amikacin concentrations at D0 compared to D56 for all solutions except 10 mg/mL TE (P < 0.001).

CONCLUSIONS AND CLINICAL RELEVANCE

Amikacin maintained stability within TE, TC, NA and ND over 56 days except when formulated at 10 mg/mL within TE.

Chemical and microbiological stability of diluted ceftazidime in three different solutions under three storage temperatures over a 28 day period

BACKGROUND

Ceftazidime (CAZ) solutions are being used based on anecdotal reports for otitis externa complicated by multidrug-resistant Pseudomonas aeruginosa (MDR PA). The chemical and microbiological stability of these proposed compounded solutions have not been evaluated, and likely are affected by the diluent and storage duration or temperature.

HYPOTHESIS/OBJECTIVES

Compounded CAZ solutions would show variable degradation dependent on diluent, time and temperature. The antimicrobial activity of the solutions would reflect changes in concentration and not alterations to the chemical compound.

METHODS AND MATERIALS

Ceftazidime was compounded with 100 mL 0.9% sodium chloride (NA+CAZ), 118 mL Triz-EDTA Aqueous flush (TE+CAZ) and 125 mL Douxo Micellar Solution (MI+CAZ). Aliquots of the solutions were stored at 25ºC, 4ºC and -20ºC for 28 days. High-performance liquid chromatography was used to analyse CAZ recovery from compounded solutions at weekly intervals. A modified broth dilution technique was utilised to assess minimum inhibitory concentration (MIC) to monitor antimicrobial activity against a reference PA strain.

RESULTS

Temperature, duration of storage and diluent each had independent effects on the chemical stability of CAZ. CAZ concentrations decreased over time as well as with increased temperature. NA+CAZ solutions exhibited the least degradation compared to the other solutions. The MIC for PA was most consistent for NA+CAZ solutions regardless of storage temperature and duration of storage.

CONCLUSIONS AND CLINICAL IMPORTANCE

Chemical and microbiological stability of compounded CAZ solutions varied by diluent, storage temperature and duration of storage. Dilution in NA resulted in the lowest variation in stability over 28 days when stored at refrigerated or frozen temperatures compared to other diluents.

The effect of EDTA in combination with some antibiotics against clinical isolates of gram negative bacteria in Mansoura, Egypt

Extensive use of antibiotics in clinical practice has been associated with increasing frequency of resistant microorganisms. So new strategy is needed to treat the resistant pathogens. Hence this study was conducted to determine the effect of Ethylenediaminetetraacetic acid (EDTA) in increasing the inhibition effect of some antibiotics on multi-drug resistant (MDR) gram-negative bacteria. For this purpose, 40 E. coli isolates, 40 K. pneumoniae isolates and 50 P. aeruginosa isolates were collected from different University's hospitals in Mansoura, Egypt. Antibacterial susceptibility pattern against 9 different antimicrobials were studied by disc diffusion method. Also the effect of two sub-inhibitory concentrations of EDTA (1 and 2 mM) on the inhibition zones of antibiotic discs against the highly multidrug resistant (MDR) isolates was determined. Checkerboard method was used for testing the activity of gentamicin/EDTA and cefotaxime/EDTA combinations on the highly MDR isolates. Additionally, the effect of EDTA on the expression of efflux pump genes was tested by real time-PCR. Most of the clinical isolates were found to be resistant to the tested antibiotics except imipenem and high prevalence of MDR isolates was recorded. 34 isolates were selected as those showed the highest multi-drug resistance and were tested to specify their MIC for EDTA as EDTA showed strong antibacterial activity with MIC ranging 4-8 mM. The addition of sub-MIC of EDTA (1or 2 mM) to the agar plate resulted in changing the 11 tested E. coli isolates from resistant to sensitive to ceftazidime, gentamicin, rifampin, ampicillin, erythromycin and vancomycin, the tested K. pneumoniae isolates were turned also from resistant to sensitive to gentamicin and ceftazidime, additionally the tested P. aeruginosa isolates became sensitive to gentamicin, ceftazidime and ciprofloxacin. Indifference to additive activity was observed for tested combinations and MIC value of cefotaxime or gentamicin in combination with EDTA was less than antibiotic alone in the most tested isolates. Moreover, significant reduction (P < 0.01) in the expression of all tested efflux pump genes in treated E. coli, K. pneumoniae and P. aeruginosa isolates with EDTA compared to untreated isolates was observed. In conclusion, these results suggest that the combination of antibiotic especially gentamicin with EDTA may be fruitful for management of resistant gram negative infections.

Role of Tris-CaEDTA as an adjuvant with nebulised tobramycin in cystic fibrosis patients with Pseudomonas aeruginosa lung infections: A randomised controlled trial

BACKGROUND

We tested if disrupting iron utilisation by P. aeruginosa by adding the Tris-buffered chelating agent CaEDTA to nebulised tobramycin would enhance bacterial clearance and improve lung function in CF patients.

METHODS

In this double-blind, randomised controlled trial, 26 episodes (25 patients) with P. aeruginosa infection admitted to two CF centres for treatment of an acute pulmonary exacerbation were randomly assigned to receive either 75 mg CaEDTA in Tris-buffered saline or placebo (Tris-buffered saline) nebulised in combination with 250 mg tobramycin twice daily for six weeks followed with four week safety follow-up. Primary endpoints were safety, tolerability, and bacterial density of P. aeruginosa. A secondary endpoint was lung function.

RESULTS

The study drug was well tolerated with adverse events comparable in both groups. The mean (SD) reduction in sputum P. aeruginosa count (log₁₀ CFU/g) in the CaEDTA vs placebo group was 2·05 (2·57) vs 0·82 (2·71) at two weeks relative to admission (p = 0·39). The mean improvement in ppFEV₁ was 16 vs 5 (p = 0·16); 11 vs 2 (p = 0·28); and 6 vs 2 percentage points (p = 0·47) at two, six, and ten weeks in CaEDTA and placebo groups, respectively.

CONCLUSIONS

In this pilot study in CF patients, an increase in the reduction of sputum density of P. aeruginosa and an increase in ppFEV₁ was observed in the group of patients who received Tris-CaEDTA added to inhaled tobramycin compared to the group who received inhaled tobramycin alone, although these differences were not statistically significant. The treatment was also shown to be safe.

Exploration of Antibiotic Activity of Aminoglycosides, in Particular Ribostamycin Alone and in Combination With Ethylenediaminetetraacetic Acid Against Pathogenic Bacteria

The emergence of infections caused by bacterial pathogens that are resistant to current antibiotic therapy is a critical healthcare challenge. Aminoglycosides are natural antibiotics with broad spectrum of activity; however, their clinical use is limited due to considerable nephrotoxicity. Moreover, drug-resistant bacteria that cause infections in human as well as livestock are less responsive to conventional antibiotics. Herein, we report the in vitro antibacterial evaluation of five different aminoglycosides, including ribostamycin, against a panel of Gram-positive and Gram-negative pathogens. Eight of the tested bacterial strains are linked to gastrointestinal (GI) infections. The minimum inhibitory concentration (MIC) of ribostamycin against three different Escherichia coli strains is in the range of 0.9–7.2 μM and against a strain of Haemophilus influenzae is 0.5 μM. We also found that the MIC of ribostamycin was considerably enhanced from 57.2 to 7.2 μM, an 8-fold improvement, when bacteria were treated with a combination of ribostamycin and ethylenediaminetetraacetic acid (EDTA). These findings demonstrate a promising approach to enhance the clinical potential of ribostamycin and provide a rational for its antibiotic reclassification from special level to non-restricted level.

In vitro antibacterial activity of the manuka essential oil from Leptospermum scoparium combined with Tris-EDTA against Gram-negative bacterial isolates from dogs with otitis externa

BACKGROUND

The increasing prevalence of antimicrobial resistance among bacteria in dogs with otitis externa has led to a need for novel therapeutic agents.

HYPOTHESIS/OBJECTIVE

To examine the antibacterial effects of manuka oil combined with ethylenediaminetetraacetic acid-tromethamine (Tris-EDTA) against Gram-negative bacteria isolates from dogs with otitis externa.

METHODS AND MATERIALS

A total of 53 clinical isolates including Pseudomonas aeruginosa, Escherichia coli, Klebsiella pneumoniae ssp. pneumoniae and Proteus mirabilis. Antimicrobial susceptibility was determined using disk diffusion; the minimum inhibitory concentrations (MICs) and minimum bactericidal concentrations (MBCs) of manuka essential oil, with or without Tris-EDTA, were investigated.

RESULTS

A total of 44 isolates were resistant to at least one antibiotic and 19 strains were multidrug-resistant, with resistance to at least one agent in three or more antimicrobial classes. The MICs and MBCs of manuka oil alone were ≥1% (v/v) and ≥2% (v/v), respectively. There was no antimicrobial effect of Tris-EDTA (1.125:0.3 mg/mL) without manuka oil. However, the combination of manuka oil with Tris-EDTA significantly decreased the MICs (ranging from 0.06% to 0.5%, v/v; P < 0.001) and MBCs (ranging from 0.06% to 1%, v/v; P < 0.001). There also was no significant difference between multidrug-resistant and nonresistant bacterial isolates in terms of the antimicrobial activity of manuka oil with Tris-EDTA.

CONCLUSIONS AND CLINICAL IMPORTANCE

The study findings suggest that manuka oil, especially when combined with Tris-EDTA, may be a promising alternative therapeutic option for Gram-negative otic pathogens. Clinical studies are needed to assess potential for in vivo ototoxic effects and efficacy.

Antibiofilm activity of an EDTA-containing nanoemulsion on multidrug-resistant Acinetobacter baumannii

Acinetobacter baumannii have evolved as an exceedingly troublesome pathogenic microorganisms and prevention and controlling this pathogen is considered to be a public health problem. Nanoemulsions (NE) are a distinctive type of decontaminator produced by integration of immiscible oil phase with aqueous phase under extreme shear forces. The effectiveness of NEs and their components was determined against four stains of A. baumannii by MBC, adherence assay, biofilm assay and SEM studies. NE dilutions ranging from 125 to 225 reduced adhesion by from 61.8 to 99.9% in NE-treated groups (p<.05) as determined by MBC. Four-day-old A. baumannii biofilms were treated with NE; LIVE/DEAD staining showed dead cell intensity of 56.2-92.0% in NE-treated groups. After NE treatment and observation by SEM, cell surfaces appeared to be remarkably disintegrated. Irregular boundaries were observed and margins of cell walls were unclear. The anti-adherence, anti-biofilm and morphological disruption effects of NE suggest that this material could be useful for the development of promising antimicrobial agents.

Topical ear treatment - options, indications and limitations of current therapy

Topical otic products form an integral part of the overall management of otitis externa. With an ever increasing array of ear drops and cleaners to choose from, appropriate selection of therapy can be difficult. The investigation of all cases of otitis externa should consider primary and secondary causes and predisposing and perpetuating factors. This article considers topical therapy under these same broad headings and discusses, through literature review, the various properties of the components of the ear cleaning solutions and drops.

Advances in the diagnosis and treatment of chronic infectious and post-mating-induced endometritis in the mare

CONTENTS

Rapid physical uterine clearance is paramount for fertility. Mares that are unable to clear the by-products of insemination or foaling quickly may develop post-mating-induced or acute endometritis. If endometritis is not promptly resolved, the infection can become chronic. Endometritis can be difficult to identify because clinical signs, ultrasonographic and laboratory findings can vary between uterine pathogens. Some micro-organisms are associated with an influx of neutrophils and fluid into the uterine lumen while others are associated with only heavy debris on cytological specimens. Identifying the inciting cause may require more than swabbing the endometrium. Culturing endometrial biopsy tissue or uterine fluids are more sensitive methods for identifying Escherichia coli than culture swab while endometrial cytology identifies twice as many mares with acute inflammation than uterine culture swab. While post-mating-induced endometritis is classically treated with uterine irrigation and ecbolics and acute endometritis is treated with either systemic or intra-uterine antibiotics, these therapies are not always effective in resolving chronic uterine inflammation or infections. Mucolytics can be used to break up mucus produced by an irritated endometrium, steroids can modulate the inflammatory response associated with insemination and buffered chelating agents can remove biofilm, a protective mechanism used primarily by gram-negative organisms and yeast to evade the host immune response.

In vitro and in vivo evaluation of a potentiated miconazole aural solution in chronic Malassezia otitis externa in dogs

This study assessed the in vitro and in vivo activity of an ear solution containing a third-generation chelating agent (Tricide) as an antimicrobial potentiator for miconazole in chronic Malassezia otitis. Thirty-one ears from 20 dogs were enrolled in the study. Fungal culture, minimum inhibitory concentration (MIC), and minimum fungicidal concentration (MFC) testing of miconazole with and without Tricide were performed on all ears. In a randomized, controlled, and blinded treatment trial the ears were treated either with 0.9% saline solution containing 0.01% miconazole, 0.03% dexamethasone and 540 microg/mL Tricide or the same solution without Tricide. Cytologic and auroscopic examinations were conducted on day 0, 14 and 28 and evaluated for number of yeast organisms, degree of erythema, hyperplasia and amount of discharge. The in vitro data was compared with Wilcoxon signed-rank test. The cytologic and auroscopic scores were compared between the visits and treatment groups at day 0, 14 and 28 using a Wilcoxon-Mann-Whitney test and repeated measures analysis. MIC and MFC were significantly (P < 0.0001) reduced when miconazole was combined with the chelating agent versus miconazole alone. The cytologic scores were significantly lower on days 14 (P = 0.0156) and 28 (P = 0.0280) for the group treated with Tricide. The auroscopic scores decreased significantly by the end of the trial compared to day 0, but the difference between the two groups was not significant. This study suggests that Tricide enhances in vitro activity and in vivo efficacy against Malassezia sp. in dogs with yeast otitis.

Chronic monolateral otomycosis in a dog caused by Aspergillus ochraceus

Aspergillus ochraceus, a widely distributed filamentous fungus, was isolated and identified by cytology and culture as the cause of unilateral ceruminous purulent otitis in a 4-year-old male mixed-breed dog. The pathogenic role of the fungal isolate was confirmed by a good response to antifungal therapy and the absence of other pathogens. No underlying diseases were identified and the dog recovered after 3 weeks of therapy with oral itraconazole and topical miconazole.

In vitro activity of an ear rinse containing tromethamine, EDTA, benzyl alcohol and 0.1% ketoconazole on Malassezia organisms from dogs with otitis externa

The purpose of this study was to evaluate the in vitro activity of an ear rinse containing tromethamine, EDTA, benzyl alcohol and 0.1% ketoconazole in purified water on Malassezia organisms from dogs with otitis externa. Malassezia organisms were collected from ear swab samples from the external ear canal of 19 dogs with otitis externa plus one control strain of Malassezia pachydermatis. Three test solutions were evaluated: ER (EDTA, tromethamine, benzyl alcohol), ER + keto (EDTA, tromethamine, benzyl alcohol, ketoconazole), and H2O (purified water). Ten-millilitre aliquots of each test solution was transferred into 20 tubes and inoculated with one of the isolates (1 tube per isolate: 19 clinical and 1 control strain). Samples were retrieved from each tube at five time points (0, 15, 30, 45 and 60 min), transferred to Petri dishes, mixed with Sabouraud dextrose agar supplemented with 0.5% Tween 80 and incubated. Following incubation, the plates were examined for growth and colonies counted as colony-forming units per millilitre. The data were analysed using a repeated measures analysis, with pair-wise comparisons of solution-time combinations. There was a significant reduction in Malassezia growth in ER + keto at all time points (P < 0.0001) compared to time zero. Neither ER nor H2O had any effect on the growth of Malassezia. ER + keto was significantly more effective in reducing Malassezia growth (P < 0.0001) at all time points compared to both ER and H2O. ER + keto may be useful in the treatment of Malassezia otitis externa. Future studies should be performed to evaluate the in vivo efficacy of ER + keto as treatment for otic infections caused by Malassezia.

In vitro activity of an ear rinse containing tromethamine, EDTA, and benzyl alcohol on bacterial pathogens from dogs with otitis

OBJECTIVE

To evaluate the in vitro activity of an ear rinse (ER) containing tromethamine, EDTA, and benzyl alcohol on bacterial pathogens from dogs with otitis.

SAMPLE POPULATION

Organisms were collected from ear swab specimens from the external and middle ear and included Staphylococcus spp (n = 11; Staphylococcus intermedius [7] and Staphylococcus spp [4]), Pseudomonas aeruginosa (5), Proteus spp (5), beta-hemolytic streptococcus (11), and 1 control strain of each organism.

PROCEDURES

3 test solutions were evaluated including EDTA, tromethamine, and benzyl alcohol (ER); EDTA and tromethamine (ER without benzyl alcohol [ER - BA]); and purified water. Ten-milliliter aliquots of each test solution were transferred into 36 tubes and inoculated with one of the organisms. Samples were retrieved from each tube at 0, 15, 30, 45, and 60 minutes, transferred to Petri dishes, mixed with soybean-casein digest agar, and incubated. After incubation, plates were examined for growth, and the number of colonies was expressed as CFU per milliliter.

RESULTS

ER significantly decreased bacterial growth in vitro of P aeruginosa and beta-hemolytic streptococcal organisms within 15 minutes, Proteus spp within 30 minutes, and Staphylococcus spp within 60 minutes. Comparatively, the presence of benzyl alcohol in ER significantly decreased bacterial growth of beta-hemolytic streptococcus and Proteus spp.

CONCLUSIONS AND CLINICAL RELEVANCE

On the basis of results of this study, future studies should be performed to evaluate the in vivo efficacy of ER alone as a treatment for otic infections caused by beta-hemolytic streptococcus, P aeruginosa, and Proteus spp and of ER combined with an antimicrobial agent for otic infections caused by Staphylococcus spp.

In vitro efficacy of a buffered chelating solution as an antimicrobial potentiator for antifungal drugs against fungal pathogens obtained from horses with mycotic keratitis

OBJECTIVE

To determine whether a novel third-generation chelating agent (8 mM disodium EDTA dehydrate and 20 mM 2-amino-2-hydroxymethyl-1, 3-propanediol) would act as an antimicrobial potentiator to enhance in vitro activity of antifungal medications against fungal isolates obtained from horses with mycotic keratitis.

SAMPLE POPULATION

Fungal isolates (3 Aspergillus isolates, 5 Fusarium isolates, 1 Penicillium isolate, 1 Cladosporium isolate, and 1 Curvularia isolate) obtained from horses with mycotic keratitis and 2 quality-control strains obtained from the American Type Culture Collection (ATCC; Candida albicans ATCC 90028 and Paecilomyces variotii ATCC 36257).

PROCEDURE

Minimum inhibitory concentrations (MICs) against fungal isolates for 4 antifungal drugs (miconazole, ketoconazole, itraconazole, and natamycin) were compared with MICs against fungal isolates for the combinations of each of the 4 antifungal drugs and the chelating agent. The Clinical and Laboratory Standards Institute microdilution assay method was performed by use of reference-grade antifungal powders against the fungal isolates and quality-control strains of fungi.

RESULTS

Values for the MIC at which the antifungal drugs decreased the growth of an organism by 50% (MIC50) and 90% (MIC90) were decreased for the control strains and ophthalmic fungal isolates by 50% to 100% when the drugs were used in combination with the chelating agent at a concentration of up to 540 microg/mL.

CONCLUSIONS AND CLINICAL RELEVANCE

The chelating agent increased in vitro activity of antifungal drugs against common fungal pathogens isolated from eyes of horses with mycotic keratitis.

Use of potentiated antibiotics in wound management

Prevention or resolution of microbial colonization of wounds is critical to rapid and uneventful healing. The use and misuse of antimicrobial agents continues to support the evolution of multidrug resistant organisms that can cause severe or life-threatening infections. Chelating agents have been shown to potentiate the effects of antimicrobial compounds. The third generation chelating agent. Tricide has been shown to be effective against many multidrug resistant pathogens, prevents pathogens from development resistance to the antimicrobials with which it is mixed and substantially reduces the amount of antimicrobials needed to kill bacteria and fungi.

Potentiating effect of EDTA-Tris on the activity of antibiotics against resistant bacteria associated with otitis, dermatitis and cystitis

Possible synergistic effects of the combination of EDTA-tromethamine (EDTA-Tris) and three antimicrobial agents (cephaloridine, kanendomycin and enrofloxacin) against resistant Gram-positive and Gram-negative bacteria are reported. Bacteria were isolated from eight cases of chronic otitis externa, five cases of chronic dermatitis and four cases of recurrent cystitis in dogs which had previously been treated with one of the three antibiotics without success. Animals exposed to EDTA-tromethamine plus the antibiotic recovered completely within 10 days, and were controlled clinically and bacteriologically for 180 days. Local irrigation with EDTA-tromethamine solution was well tolerated and no side effects were recorded.