Cathodic voltage-controlled electrical stimulation of titanium implants as treatment for methicillin-resistant Staphylococcus aureus periprosthetic infections

Cathodic voltage-controlled electrical stimulation and betadine decontaminate nosocomial pathogens from implant surfaces

Periprosthetic joint infection (PJI) after total joint arthroplasty is a major concern requiring multiple surgeries and antibiotic interventions. Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli are the predominant causes of these infections. Due to biofilm formation, antibiotic treatment for patients with PJI can prolong resistance, further complicating the use of current treatments. Previous research has shown that cathodic voltage-controlled electrical stimulation (CVCES) is an effective technique to prevent/treat implant-associated biofilm infections on titanium (Ti) surfaces. This study thus evaluated the efficacy of CVCES via the use of 10% betadine alone and in combination with CVCES to eradicate lab-grown biofilms on cemented and cementless cobalt-chromium (CoCr) and Ti surfaces. CVCES treatment alone for 24 hours demonstrated no detectable CFU for E. coli and P. aeruginosa biofilms on cementless CoCr implants. In the presence of cement, E. coli biofilms had 106 CFUs/implant remaining after CVCES treatment alone; however, P. aeruginosa biofilms on cemented implants were reduced to below detectable limits. The use of 10% betadine treatment for 3 minutes followed by 24-hour CVCES treatment brought CFU levels to below detectable limits in E. coli and P. aeruginosa. The same was true for S. aureus biofilms on cementless patellofemoral implants as well as femoral and tibial implants. These treatment methods were not sufficient for eradication of S. aureus biofilms on cemented implants. These results suggest that CVCES alone and CVCES with 10% betadine are effective approaches to treating biofilms formed by certain bacterial species potentially leading to the treatment of PJI.IMPORTANCEPeriprosthetic joint infections (PJIs) are problematic due to requiring multiple surgeries and antibiotic therapies that are responsible for increased patient morbidity and healthcare costs. These infections become resistant to antibiotic treatment due to the formation of biofilms on the orthopedic surfaces. Cathodic voltage-controlled electrical stimulation (CVCES) has previously been shown to be an effective technique to prevent and treat biofilm infections on different surfaces. This study shows that CVCES can increase the efficacy of 10% betadine irrigation used in debridement, antibiotics, and implant retention by 99.9% and clear infection to below detection limits. PJI treatments are at times limited, and CVCES could be a promising technology to improve patient outcomes.

In vitro and in vivo assessment of extended duration cathodic voltage-controlled electrical stimulation for treatment of orthopedic implant-associated infections

Effective treatment of orthopedic implant-associated infections (IAIs) remains a clinical challenge. The in vitro and in vivo studies presented herein evaluated the antimicrobial effects of applying cathodic voltage-controlled electrical stimulation (CVCES) to titanium implants inoculated with preformed bacterial biofilms of methicillin-resistant Staphylococcus aureus (MRSA). The in vitro studies showed that combining vancomycin therapy (500 µg/mL) with application of CVCES at -1.75 V (all voltages are with respect to Ag/AgCl unless otherwise stated) for 24 h resulted in 99.98% reduction in the coupon-associated MRSA colony-forming units (CFUs) (3.38 × 103 vs. 2.14 × 107 CFU/mL, p < 0.001) and a 99.97% reduction in the planktonic CFU (4.04 × 104 vs. 1.26 × 108 CFU/mL, p < 0.001) as compared with the no treatment control samples. The in vivo studies utilized a rodent model of MRSA IAIs and showed a combination of vancomycin therapy (150 mg/kg twice daily) with CVCES of -1.75 V for 24 h had significant reductions in the implant associated CFU (1.42 × 101 vs. 1.2 × 106 CFU/mL, p < 0.003) and bone CFU (5.29 × 101 vs. 4.48 × 106 CFU/mL, p < 0.003) as compared with the untreated control animals. Importantly, the combined 24 h CVCES and antibiotic treatments resulted in no implant-associated MRSA CFU enumerated in 83% of the animals (five out of six animals) and no bone-associated MRSA CFU enumerated in 50% of the animals (three out of six animals). Overall, the outcomes of this study have shown that extended duration CVCES therapy is an effective adjunctive therapy to eradicate IAIs.

Titanium alloys with varying surface micro-area potential differences have antibacterial abilities and a favorable cellular response

OBJECTIVES

Surface micro-area potential difference (MAPD) can achieve bacteriostatic performance independent of metal ion dissolution. To study the influence of MAPD on antibacterial properties and the cellular response, Ti-Ag alloys with different surface potentials were designed and prepared by changing the preparation and heat treatment processes.

MATERIALS AND METHODS

Ti-Ag alloys (T4, T6, and S) were prepared by vacuum arc smelting, water quenching, and sintering. Cp-Ti was set as a control group in this work. The microstructures and surface potential distributions of the Ti-Ag alloys were analyzed by SEM and energy dispersive spectrometry. Plate counting and live/dead staining methods were used to evaluate the antibacterial properties of the alloys, and the mitochondrial function, ATP levels, and apoptosis were assessed in MC3T3-E1 cells to analyze the cellular response.

RESULTS

Due to the formation of the Ti-Ag intermetallic phase in the Ti-Ag alloys, Ti-Ag (T4) without the Ti-Ag phase had the lowest MAPD, Ti-Ag (T6) with a fine Ti2Ag phase had a moderate MAPD, and Ti-Ag (S) with a Ti-Ag intermetallic phase had the highest MAPD. The primary results demonstrated that the Ti-Ag samples with different MAPDs exhibited different bacteriostatic effects, ROS expression levels, and apoptosis-related protein expression levels in cells. The alloy with a high MAPD exhibited a strong antibacterial effect. A moderate MAPD stimulated cellular antioxidant regulation (GSH/GSSG) and downregulated the expression of intracellular ROS. MAPD could also promote the transformation of the inactive mitochondria to biologically active mitochondria by increasing the ΔΨm and reducing apoptosis.

CONCLUSION

The results here indicated that moderate MAPD not only had bacteriostatic effects but also promoted mitochondrial function and inhibited cell apoptosis, which provides a new strategy to improve the surface bioactivity of titanium alloys and a new idea for titanium alloy design.

CLINICAL RELEVANCE

There are some limitations of the mechanism of MAPD. However, researchers will become increasingly aware of the advantages and disadvantages of MAPD and MAPD might provide an affordable solution of peri-implantitis.

Sensor Technology in Fracture Healing

Introduction

SMART sensor technology may provide the solution to bridge the gap between the current radiographic determination of fracture healing and clinical assessment. The displacement and rigidity between the fracture ends can be accurately measured using strain gauges. Progressively increasing stiffness is a sign of fracture consolidation which can be monitored using sensors. The design of standard orthopaedic implants can remain the same and needs no major modifications as the sensor can be mounted onto the implant without occupying much space. Data regarding various fracture morphologies and their strain levels throughout the fracture healing process may help develop AI algorithms that can subsequently be used to optimise implant design/materials.

Materials and Methods

The literature search was performed in PubMed, PubMed Central, Scopus, and Web of Science databases for reviewing and evaluating the published scientific data regarding sensor technology in fracture healing.

Results and Interpretation

SMART sensor technology comes with a variety of uses such as determining fracture healing progress, predicting early implant failure, and determining fractures liable for non-union to exemplify a few. The main limitations are that it is still in its inception and needs extensive refinement before it becomes widely and routinely used in clinical practice. Nevertheless, with continuous advances in microprocessor technology, research designs, and additive manufacturing, the utilisation and application of SMART implants in the field of trauma and orthopaedic surgery are constantly growing.

Conclusion

Mass production of such SMART implants will reduce overall production costs and see its use in routine clinical practice in the future and is likely to make a significant contribution in the next industrial revolution termed 'Industry 5.0' which aims at personalised patient-specific implants and devices. SMART sensor technology may, therefore, herald a new era in the field of orthopaedic trauma.

Physical Approaches to Prevent and Treat Bacterial Biofilm

Prosthetic joint infection (PJI) presents several clinical challenges. This is in large part due to the formation of biofilm which can make infection eradication exceedingly difficult. Following an extensive literature search, this review surveys a variety of non-pharmacological methods of preventing and/or treating biofilm within the body and how they could be utilized in the treatment of PJI. Special attention has been paid to physical strategies such as heat, light, sound, and electromagnetic energy, and their uses in biofilm treatment. Though these methods are still under study, they offer a potential means to reduce the morbidity and financial burden related to multiple stage revisions and prolonged systemic antibiotic courses that make up the current gold standard in PJI treatment. Given that these options are still in the early stages of development and offer their own strengths and weaknesses, this review offers an assessment of each method, the progress made on each, and allows for comparison of methods with discussion of future challenges to their implementation in a clinical setting.

Biofilms: Formation, Research Models, Potential Targets, and Methods for Prevention and Treatment

Due to the continuous rise in biofilm-related infections, biofilms seriously threaten human health. The formation of biofilms makes conventional antibiotics ineffective and dampens immune clearance. Therefore, it is important to understand the mechanisms of biofilm formation and develop novel strategies to treat biofilms more effectively. This review article begins with an introduction to biofilm formation in various clinical scenarios and their corresponding therapy. Established biofilm models used in research are then summarized. The potential targets which may assist in the development of new strategies for combating biofilms are further discussed. The novel technologies developed recently for the prevention and treatment of biofilms including antimicrobial surface coatings, physical removal of biofilms, development of new antimicrobial molecules, and delivery of antimicrobial agents are subsequently presented. Finally, directions for future studies are pointed out.

Bioelectronic multifunctional bone implants: recent trends

The concept of Instrumented Smart Implant emerged as a leading research topic that aims to revolutionize the field of orthopaedic implantology. These implants have been designed incorporating biophysical therapeutic actuation, bone-implant interface sensing, implant-clinician communication and self-powering ability. The ultimate goal is to implement revist interface, controlled by clinicians/surgeons without troubling the quotidian activities of patients. Developing such high-performance technologies is of utmost importance, as bone replacements are among the most performed surgeries worldwide and implant failure rates can still exceed 10%. In this review paper, an overview to the major breakthroughs carried out in the scope of multifunctional smart bone implants is provided. One can conclude that many challenges must be overcome to successfully develop them as revision-free implants, but their many strengths highlight a huge potential to effectively establish a new generation of high-sophisticated biodevices.

Current treatments for biofilm-associated periprosthetic joint infection and new potential strategies

Periprosthetic joint infection (PJI) remains a devastating complication after total joint arthroplasty. Bacteria involved in these infections are notorious for adhering to foreign implanted surfaces and generating a biofilm matrix. These biofilms protect the bacteria from antibiotic treatment and the immune system making eradication difficult. Current treatment strategies including debridement, antibiotics, and implant retention, and one- and two-stage revisions still present a relatively high overall failure rate. One of the main shortcomings that has been associated with this high failure rate is the lack of a robust approach to treating bacterial biofilm. Therefore, in this review, we will highlight new strategies that have the potential to combat PJI by targeting biofilm integrity, therefore giving antibiotics and the immune system access to the internal network of the biofilm structure. This combination antibiofilm/antibiotic therapy may be a new strategy for PJI treatment while promoting implant retention.

Multifunctional Smart Bone Implants: Fiction or Future?-A New Perspective

Implantable medical devices have been developed to provide multifunctional ability to numerous bioapplications. In the scope of orthopaedics, four methodologies were already proposed to design implant technologies: non-instrumented passive implants, non-instrumented active implants, instrumented passive implants and instrumented active implants. Even though bone replacements are among the most performed surgeries worldwide, implant failure rates can still exceed 10%. Controversial positions multiply in the scientific community about the potential of each methodology to minimize the burden related to implant failures. In this perspective paper, we argue that the next technological revolution in the field of implantable bone devices will most likely emerge with instrumented active implants as multifunctional smart devices extracorporeally controlled by clinicians/surgeons. Moreover, we provide a new perspective about implant technology: the essence of instrumented implants is to enclose a hybrid architecture in which optimal implant performances require both smart instrumentation and smart coatings, although the implant controllability must be ensured by extracorporeal systems.

Magnetoelectric Polymer Membrane-Based Electrical Microenvironment with Magnetically Controlled Antibacterial Activity

The "hard to clean" parts of food processing devices (e.g., the corners of pipes) are difficult to disinfect. This challenge might be overcome through the application of a positive electrical environment. However, the chemical modification of a material surface is complex and difficult. In this work, we developed a smart electroactive Tb_xDy_1-xFe alloy/poly(vinylidene fluoride-trifluoroethylene) (TD/P(VDF-TrFE)) magnetoelectric coating to endow stainless steel with the function of a smart adjustable electrical environment, which was realized by the introduction of a magnetic field of various intensities (0-1800 Oe). An antibacterial assay showed that the polarized coating@stainless steel (P-CS) exhibited antibacterial effects, with the highest antibacterial effect observed at 1800 Oe. Furthermore, in this study, we have, for the first time, explored the antibacterial mechanism of TD/P(VDF-TrFE)-assisted electrical stimulation based on the bacterial intracellular reactive oxygen species (ROS) level, cell respiratory chain, and membrane potential. The results showed that a microelectric field was formed on the P-CS sample in an aqueous solution, which not only generated ROS on the cathode surface but also caused H⁺ consumption in the electrochemical gradient of the bacterial membrane, leading to OH^- production and inhibition of adenosine triphosphate (ATP) synthesis. In addition, the electric field also induced hyperpolarization of the membrane potential in Escherichia coli cells via a K⁺ efflux, thus inducing rearrangement of the outer membrane. In conclusion, an adjustable surface potential was established through the introduction of magnetoelectric polymer coatings, which endowed stainless steel with magnetically controlled antibacterial effects.

A healing promoting wound dressing with tailor-made antibacterial potency employing piezocatalytic processes in multi-functional nanocomposites

Developing a novel antibiotics-free antibacterial strategy is essential for minimizing bacterial resistance. Materials that not only kill bacteria but also promote tissue healing are especially challenging to achieve. Inspired by chemical conversion processes in living organisms, we develop a piezoelectrically active antibacterial device that converts ambient O₂ and H₂O to ROS by piezocatalytic processes. The device is achieved by mounting nanoscopic polypyrrole/carbon nanotube catalyst multilayers onto piezoelectric-dielectric films. Under stimuli by a hand-held massage device, the sterilizing rates for S. aureus and E. coli reach 84.11% and 94.85% after 10 minutes of operation, respectively. The antibacterial substrate at the same time preserves and releases drugs and presents negligible cytotoxicity. Animal experiments demonstrate that daily treatment for 10 minutes using the device effectively accelerates the healing of infected wounds on the backs of mice, promoting hair follicle generation and collagen deposition. We believe that this report provides a novel design approach for antibacterial strategies in medical treatment.

Ionic Silver and Electrical Treatment for Susceptibility and Disinfection of Escherichia coli Biofilm-Contaminated Titanium Surface

In this work, surface disinfection and biofilm susceptibility were investigated by applying ionic silver of 0.4–1.6 µg/mL and cathodic voltage-controlled electrical treatment of 1.8 V and a current of 30 mA to Escherichia coli (E. coli) ATCC 25922 biofilm-contaminated titanium substrates. Herein, it is evident that the treatment exhibited the potential use to enhance the susceptibility of bacterial biofilms for surface disinfection. In vitro studies have demonstrated that the ionic silver treatment of 60 min significantly increased the logarithmic reduction (LR) of bacterial populations on disinfectant-treated substrates and the electrical treatment enhanced the silver susceptibility of E. coli biofilms. The LR values after the ionic silver treatments and the electric-enhanced silver treatments were in the ranges of 1.94–2.25 and 2.10–2.73, respectively. The treatment was also associated with morphological changes in silver-treated E. coli cells and biofilm-contaminated titanium surfaces. Nevertheless, the treatments showed no cytotoxic effects on the L929 mouse skin fibroblast cell line and only a slight decrease in pH was observed during the electrical polarization of titanium substrate.

Recent Advances in the Evaluation of Antimicrobial Materials for Resolution of Orthopedic Implant-Associated Infections In Vivo

While orthopedic implant-associated infections are rare, revision surgeries resulting from infections incur considerable healthcare costs and represent a substantial research area clinically, in academia, and in industry. In recent years, there have been numerous advances in the development of antimicrobial strategies for the prevention and treatment of orthopedic implant-associated infections which offer promise to improve the limitations of existing delivery systems through local and controlled release of antimicrobial agents. Prior to translation to in vivo orthopedic implant-associated infection models, the properties (e.g., degradation, antimicrobial activity, biocompatibility) of the antimicrobial materials can be evaluated in subcutaneous implant in vivo models. The antimicrobial materials are then incorporated into in vivo implant models to evaluate the efficacy of using the material to prevent or treat implant-associated infections. Recent technological advances such as 3D-printing, bacterial genomic sequencing, and real-time in vivo imaging of infection and inflammation have contributed to the development of preclinical implant-associated infection models that more effectively recapitulate the clinical presentation of infections and improve the evaluation of antimicrobial materials. This Review highlights the advantages and limitations of antimicrobial materials used in conjunction with orthopedic implants for the prevention and treatment of orthopedic implant-associated infections and discusses how these materials are evaluated in preclinical in vivo models. This analysis serves as a resource for biomaterial researchers in the selection of an appropriate orthopedic implant-associated infection preclinical model to evaluate novel antimicrobial materials.

In Situ Investigation of the Cytotoxic and Interfacial Characteristics of Titanium When Galvanically Coupled with Magnesium Using Scanning Electrochemical Microscopy

Recently, the cytotoxic properties of galvanically coupled Ti-Mg particles have been shown in different cells. This cytotoxic effect has been attributed mainly to Mg due to its tendency to undergo activation when coupled with Ti, forming a galvanic cell consisting of an anode (Mg) and a cathode (Ti). However, the role of the Ti cathode has been ignored in explaining the cytotoxic effect of Ti-Mg particles due to its high resistance to corrosion. In this work, the role of titanium (Ti) in the cytotoxic mechanism of galvanically coupled Ti-Mg particles was examined. A model galvanic cell (MGC) was prepared to simulate the Mg-Ti particles. The electrochemical reactivity of the Ti sample and the pH change in it due to galvanic coupling with Mg were investigated using scanning electrochemical microscopy (SECM). It was observed that the Ti surface changed from passive to electrochemically active when coupled with Mg. Furthermore, after only 15 min of galvanic coupling with Mg, the pH in the electrolyte volume adjacent to the Ti surface increased to an alkaline pH value. The effects of the galvanic coupling of Ti and Mg, as well as those of the alkaline pH environment, on the viability of Hs27 fibroblast cells were investigated. It was shown that the viability of Hs27 cells significantly diminished when Mg and Ti were galvanically coupled compared to when the two metals were electrically disconnected. Thus, although Ti usually exhibited high corrosion resistance when exposed to physiological environments, an electrochemically active surface was observed when galvanically coupled with Mg, and this surface may participate in electron transfer reactions with chemical species in the neighboring environment; this participation resulted in the increased pH values above its surface and enhanced generation of reactive oxygen species. These features contributed to the development of cytotoxic effects by galvanically coupled Ti-Mg particles.

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.

Improved antibacterial and cellular response of electrets and piezobioceramics

The bacterial contamination in implants has been recognized as one of the key issues in orthopedics. In this article, a new technique of electrical polarization of various non-piezoelectric and piezoelectric biocompatible ceramics has been explored to develop antibacterial implants. Optimally processed hydroxyapatite (HA), BaTiO₃ (BT), CaTiO₃ (CT), Na_0.5K_0.5NbO₃ (NKN) and their composites have been used as model biomaterials to verify the concept. The phase evolution analyses and microstructural characterizations were performed for sintered samples. The samples were polarized at polarizing voltage and temperature of 20 kV and 500°C, respectively, for 30 min. The hydrophilicity of polarized surfaces was examined using deionized water and culture media. The polarization induced in-vitro antibacterial study was performed for both, gram positive and gram negative bacteria. The viability of Staphylococcus aureus (S. aureus) and Escherichia coli (E. coli) bacteria reduces significantly on the polarized surfaces. In addition, the influence of polarization on antibacterial response has been explored via various mechanisms such as development of reactive oxygen species (ROS), catalase activity and lipoperoxidation. Furthermore, the cellular response of polarized surfaces was also examined using SaOS2 and MG-63 cells. The viability of SaOS2 and MG-63 cells was observed to increase significantly on negatively polarized surfaces. Overall, the surface treatment enhances the antibacterial response of HA, NKN, BT, CT and their composites surfaces with positive influence on cellular response.

Future directions of postoperative spinal implant infections

This article outlines some promising future concepts against postoperative spinal implant infections on the basis of today available literature. The ever-adapting bacteria causing this common complication compel a corresponding continuous research about best effective treatment. The aim is to give a perspective on several future attack-points: surgical infection prevention strategies such as technical optimization of implants and surgical technique; faster diagnostic tools to detect infection, especially in the context of late infections with low-virulent germs and with regard to decision-making in the course of the surgical workflow; and combined surgical and medical treatment options against implant infections. The surgical treatment section will also state open issues concerning implant removal, and the medical treatment section will give an outlook to promising medical alternatives in a post-antibiotic era. To keep up in this field will be important to retain spine surgery in the future as the state-of-the-art treatment option for mandatory spinal interventions in the presence of tumor or trauma and even more so as an attractive option for patients with degenerative spinal disorder for improvement of their life quality.

Novel in vivo mouse model of shoulder implant infection

BACKGROUND

Animal models are used to guide management of periprosthetic implant infections. No adequate model exists for periprosthetic shoulder infections, and clinicians thus have no preclinical tools to assess potential therapeutics. We hypothesize that it is possible to establish a mouse model of shoulder implant infection (SII) that allows noninvasive, longitudinal tracking of biofilm and host response through in vivo optical imaging. The model may then be employed to validate a targeting probe (1D9-680) with clinical translation potential for diagnosing infection and image-guided débridement.

METHODS

A surgical implant was press-fit into the proximal humerus of c57BL/6J mice and inoculated with 2 μL of 1 × 103 (e3), or 1 × 104 (e4), colony-forming units (CFUs) of bioluminescent Staphylococcus aureus Xen-36. The control group received 2 μL sterile saline. Bacterial activity was monitored in vivo over 42 days, directly (bioluminescence) and indirectly (targeting probe). Weekly radiographs assessed implant loosening. CFU harvests, confocal microscopy, and histology were performed.

RESULTS

Both inoculated groups established chronic infections. CFUs on postoperative day (POD) 42 were increased in the infected groups compared with the sterile group (P < .001). By POD 14, osteolysis was visualized in both infected groups. The e4 group developed catastrophic bone destruction by POD 42. The e3 group maintained a congruent shoulder joint. Targeting probes helped to visualize low-grade infections via fluorescence.

DISCUSSION

Given bone destruction in the e4 group, a longitudinal, noninvasive mouse model of SII and chronic osteolysis was produced using e3 of S aureus Xen-36, mimicking clinical presentations of chronic SII.

CONCLUSION

The development of this model provides a foundation to study new therapeutics, interventions, and host modifications.

The Impact of Engineered Silver Nanomaterials on the Immune System

Over the last decades there has been a tremendous volume of research efforts focused on engineering silver-based (nano)materials. The interest in silver has been mostly driven by the element capacity to kill pathogenic bacteria. In this context, the main area of application has been medical devices that are at significant risk of becoming colonized by bacteria and subsequently infected. However, silver nanomaterials have been incorporated in a number of other commercial products which may or may not benefit from antibacterial protection. The rapid expansion of such products raises important questions about a possible adverse influence on human health. This review focuses on examining currently available literature and summarizing the current state of knowledge of the impact of silver (nano)materials on the immune system. The review also looks at various surface modification strategies used to generate silver-based nanomaterials and the immunomodulatory potential of these materials. It also highlights the immune response triggered by various silver-coated implantable devices and provides guidance and perspective towards engineering silver nanomaterials for modulating immunological consequences.

The state of the art of osseointegration for limb prosthesis

Osseointegration (OI) is the direct attachment of bone onto a titanium implant. Recently, the term is used to describe "transdermal" implants that allow an external prosthesis to be connected directly to the skeleton. This technology eliminates the challenges of conventional socket-based prostheses, such as skin breakdown and poor fit, which are common in patients with major extremity amputations. Osseointegration patients demonstrate encouraging improvements in quality of life and function. Patients report improvement in prosthetic use, prosthetic mobility, global health, and pain reduction on a variety of clinical assessment tools. Various implants have been developed for osseointegration for amputees. These implants use a variety of fixation strategies and surface augments to allow for successful integration into the host bone. Regardless of design, all OI implants face similar challenges, particularly infections. Other challenges include the inability to determine when integration has occurred and the inability to detect loss of integration. These challenges may be met by incorporating sensing systems into the implants. The percutaneous nature of the metal devices can be leveraged so that internal sensors need not be wireless, and can be interrogated by external monitoring systems, thus providing crucial, real-time information about the state of the implant. The purpose of this review is to (1) review the basic science behind osseointegration, (2) provide an overview of current implants, practice patterns, and clinical outcomes, and (3) preview sensor technologies which may prove useful in future generations of transdermal orthopaedic implants.

Electrochemical methods to enhance osseointegrated prostheses

Osseointegrated (OI) prosthetic limbs have been shown to provide an advantageous treatment option for amputees. In order for the OI prosthesis to be successful, the titanium implant must rapidly achieve and maintain proper integration with the bone tissue and remain free of infection. Electrochemical methods can be utilized to control and/or monitor the interfacial microenvironment where the titanium implant interacts with the biological system (host bone tissue or bacteria). This review will summarize the current understanding of how electrochemical modalities can influence bone tissue and bacteria with specific emphasis on applications where the metallic prosthesis itself can be utilized directly as a stimulating electrode for enhanced osseointegration and infection control. In addition, a summary of electrochemical impedance sensing techniques that could be used to potentially assess osseointegration and infection status of the metallic prosthesis is presented.

Electrochemical Strategy for Eradicating Fluconazole-Tolerant Candida albicans Using Implantable Titanium

A persistent problem in modern health care derives from the overwhelming presence of antibiotic-resistant microbes on biomaterials, more specifically, fungal growth on metal-based implants. This study seeks to investigate the antifungal properties of low-level electrochemical treatments delivered using titanium electrodes against Candida albicans. We show that C. albicans can be readily controlled with electrical currents/potentials, reducing the number of viable planktonic cells by 99.7% and biofilm cells by 96.0-99.99%. Additionally, this study explores the ability of the electrochemical treatments to potentiate fluconazole, a clinically used antifungal drug. We have found that electrochemical treatment substantially enhances fluconazole killing activity. While fluconazole alone exhibits a low efficiency against the stationary phase and biofilm cells of C. albicans, complete eradication corresponding to 7-log killing is achieved when the antifungal drug is provided subsequently to the electrochemical treatment. Further mechanistic analyses have revealed that the sequential treatment shows a complex multimodal action, including the disruption of cell wall integrity and permeability, impaired metabolic functions, and enhanced susceptibility to fluconazole, while altering the biofilm structure. Altogether, we have developed and optimized a new therapeutic strategy to sensitize and facilitate the eradication of fluconazole-tolerant microbes from implantable materials. This work is expected to help advance the use of electrochemical approaches in the treatment of infections caused by C. albicans in both nosocomial and clinical cases.

The Effect of In Vitro Electrolytic Cleaning on Biofilm-Contaminated Implant Surfaces

Purpose: Bacterial biofilms are a major problem in the treatment of infected dental and orthopedic implants. The purpose of this study is to investigate the cleaning effect of an electrolytic approach (EC) compared to a powder-spray system (PSS) on titanium surfaces. Materials and Methods: The tested implants (different surfaces and alloys) were collated into six groups and treated ether with EC or PSS. After a mature biofilm was established, the implants were treated, immersed in a nutritional solution, and streaked on Columbia agar. Colony-forming units (CFUs) were counted after breeding and testing (EC), and control (PSS) groups were compared using a paired sample t-test. Results: No bacterial growth was observed in the EC groups. After thinning to 1:1,000,000, 258.1 ± 19.9 (group 2), 264.4 ± 36.5 (group 4), and 245.3 ± 40.7 (group 6) CFUs could be counted in the PSS groups. The difference between the electrolytic approach (test groups 1, 3, and 5) and PSS (control groups 2, 4, and 6) was statistically extremely significant (p-value < 2.2 × 10⁻¹⁶). Conclusion: Only EC inactivated the bacterial biofilm, and PSS left reproducible bacteria behind. Within the limits of this in vitro test, clinical relevance could be demonstrated.

Antibiotics Enhance Prevention and Eradication Efficacy of Cathodic-Voltage-Controlled Electrical Stimulation against Titanium-Associated Methicillin-Resistant Staphylococcus aureus and Pseudomonas aeruginosa Biofilms

Periprosthetic joint infections (PJIs) develop clinically in the presence of antibiotic therapies and are responsible for increased patient morbidity and rising health care costs. Many of these infections involve bacterial biofilm formation on orthopedic hardware, and it has been well established that these biofilms are refractory to most antibiotic treatments. Recent studies have focused on novel methods to prevent and eradicate infection. Cathodic-voltage-controlled electrical stimulation (CVCES) has previously been shown to be effective as a method for prevention and eradication of Gram-positive and Gram-negative infections. The present study revealed that the utility of CVCES for prevention and eradication of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa is enhanced in the presence of clinically relevant antibiotics. The synergistic effects of CVCES and antibiotics are effective in a magnitude-dependent manner. The results of this study indicate a promising alternative method to current PJI mitigation techniques.

Periprosthetic joint infection (PJI) develops clinically, even with antibiotic treatment, and methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa are predominant causes of these infections. Due to biofilm formation, antibiotic treatment for patients with PJI can perpetuate resistance, further complicating the use of noninvasive treatments. This study evaluated cathodic-voltage-controlled electrical stimulation (CVCES) of titanium, in combination with a clinically relevant antibiotic, to synergistically prevent MRSA and P. aeruginosa PJIs by inhibiting bacterial adherence or as a treatment for eradicating established biofilms. CVCES of −1.0 V, −1.5 V, or −1.8 V (versus Ag/AgCl), with or without vancomycin for MRSA or gentamicin for P. aeruginosa, was applied to sterile titanium incubated with cultures to evaluate prevention of attachment or eradication of preestablished biofilms. Treatments were 24 h long and included open-circuit potential controls, antibiotic alone, CVCES, and CVCES plus antibiotic. Biofilm-associated and planktonic CFU were enumerated. In general, CVCES at −1.8 V alone or with antibiotic completely eradicated biofilm-associated CFU for both strains, and these parameters were also highly effective against planktonic bacteria, resulting in a >6-log reduction in MRSA and no detectable planktonic P. aeruginosa. All CFU were reduced ∼3 to 5 logs from controls for prevention CVCES plus antibiotics at −1.0 V and −1.5 V against MRSA. Remarkably, there were no detectable P. aeruginosa CFU following prevention CVCES at −1.0 V or −1.5 V with gentamicin. Our results suggest that CVCES in combination with antibiotics may be an effective approach for prevention and treatment of PJI.

IMPORTANCE Periprosthetic joint infections (PJIs) develop clinically in the presence of antibiotic therapies and are responsible for increased patient morbidity and rising health care costs. Many of these infections involve bacterial biofilm formation on orthopedic hardware, and it has been well established that these biofilms are refractory to most antibiotic treatments. Recent studies have focused on novel methods to prevent and eradicate infection. Cathodic-voltage-controlled electrical stimulation (CVCES) has previously been shown to be effective as a method for prevention and eradication of Gram-positive and Gram-negative infections. The present study revealed that the utility of CVCES for prevention and eradication of methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa is enhanced in the presence of clinically relevant antibiotics. The synergistic effects of CVCES and antibiotics are effective in a magnitude-dependent manner. The results of this study indicate a promising alternative method to current PJI mitigation techniques.

The antibacterial effect of potassium-sodium niobate ceramics based on controlling piezoelectric properties

The implant infection is one of the most serious postsurgical complications of medical device implantation. Therefore, the development of biocompatible materials with improved antibacterial properties is of great importance. It might be a new insight to apply the intrinsic electrical properties of biomaterials to solve this problem. Here, potassium-sodium niobate piezoceramics (K_0.5Na_0.5NbO₃, KNN) with different piezoelectric constants were prepared, and the microstructures and piezoelectric properties of these piezoceramics were evaluated. Moreover, the antibacterial effect and biocompatibility of these piezoceramics were assayed. Results showed that these piezoceramics were able to decrease the colonies of bacteria staphylococcus aureus (S. aureus), favor the rat bone marrow mesenchymal stem cells (rBMSCs) proliferation and promote the cell adhesion and spreading. The above effects were found closely related to the surface positive charges of the piezoceramics, and the sample bearing the most positive charges on its surface (sample 80KNN) had the best performance in both antibacterial effect and biocompatibility. Based on our work, it is feasible to develop biocompatible antibacterial materials by controlling piezoelectric properties.

New Innovations in the Treatment of PJI and Biofilms-Clinical and Preclinical Topics

PURPOSE OF REVIEW

Periprosthetic joint infection (PJI) is a devastating complication after total joint replacement. A main source for antibiotic tolerance and treatment failure is bacterial production of biofilm-a resilient barrier against antibiotics, immune system, and mechanical debridement. The purpose of this review is to explore some novel approaches to treat PJI and biofilm-related infections.

RECENT FINDINGS

Innovative treatment strategies of bacterial and biofilm infections revolve around (a) augmenting current therapies, such as improving the delivery and efficiency of conventional antibiotics and enhancing the efficacy of antiseptics and (b) administrating completely new therapeutic modalities, such as using immunotherapy, nanoparticles, lytic bacteriophages, photodynamic therapy, novel antibiotics, and antimicrobial peptides. Several promising treatment strategies for PJI are available to be tested further. The next requirement for most of the novel treatments is reproducing their effects in clinically representative animal models of PJI against clinical isolates of relevant bacteria.

Staphylococcus aureus Evasion of Host Immunity in the Setting of Prosthetic Joint Infection: Biofilm and Beyond

PURPOSE OF REVIEW

The incidence of complications from prosthetic joint infection (PJI) is increasing, and treatment failure remains high. We review the current literature with a focus on Staphylococcus aureus pathogenesis and biofilm, as well as treatment challenges, and novel therapeutic strategies.

RECENT FINDINGS

S. aureus biofilm creates a favorable environment that increases antibiotic resistance, impairs host immunity, and increases tolerance to nutritional deprivation. Secreted proteins from bacterial cells within the biofilm and the quorum-sensing agr system contribute to immune evasion. Additional immunoevasive properties of S. aureus include the formation of staphylococcal abscess communities (SACs) and canalicular invasion. Novel approaches to target biofilm and increase resistance to implant colonization include novel antibiotic therapy, immunotherapy, and local implant treatments. Challenges remain given the diverse mechanisms developed by S. aureus to alter the host immune responses. Further understanding of these processes should provide novel therapeutic mechanisms to enhance eradication after PJI.

Electroactive biomaterials: Vehicles for controlled delivery of therapeutic agents for drug delivery and tissue regeneration

Electrical stimulation for delivery of biochemical agents such as genes, proteins and RNA molecules amongst others, holds great potential for controlled therapeutic delivery and in promoting tissue regeneration. Electroactive biomaterials have the capability of delivering these agents in a localized, controlled, responsive and efficient manner. These systems have also been combined for the delivery of both physical and biochemical cues and can be programmed to achieve enhanced effects on healing by establishing control over the microenvironment. This review focuses on current state-of-the-art research in electroactive-based materials towards the delivery of drugs and other therapeutic signalling agents for wound care treatment. Future directions and current challenges for developing effective electroactive approach based therapies for wound care are discussed.

Electrochemical removal of biofilms from titanium dental implant surfaces

The infection of dental implants may cause severe inflammation of tissue and even bone degradation if not treated. For titanium implants, a new, minimally invasive approach is the electrochemical removal of the biofilms including the disinfection of the metal surface. In this project, several parameters, such as electrode potentials and electrolyte compositions, were varied to understand the underlying mechanisms. Optimal electrolytes contained iodide as well as lactic acid. Electrochemical experiments, such as cyclic voltammetry or measurements of open circuit potentials, were performed in different cell set-ups to distinguish between different possible reactions. At the applied potentials of E < -1.4 V, the hydrogen evolution reaction dominated at the implant surface, effectively lifting off the bacterial films. In addition, several disinfecting species are formed at the anode, such as triiodide and hydrogen peroxide. Ex situ tests with model biofilms of E. coli clearly demonstrated the effectiveness of the respective anolytes in killing the bacteria, as determined by the LIVE/DEAD™ assay. Using optimized electrolysis parameters of 30 s at 7.0 V and 300 mA, a 14-day old wildtype biofilm could be completely removed from dental implants in vitro.

Eradication of Pseudomonas aeruginosa cells by cathodic electrochemical currents delivered with graphite electrodes

Antibiotic resistance is a major challenge to the treatment of bacterial infections associated with medical devices and biomaterials. One important intrinsic mechanism of such resistance is the formation of persister cells that are phenotypic variants of microorganisms and highly tolerant to antibiotics. Recently, we reported a new approach to eradicating persister cells of Pseudomonas aeruginosa using low-level direct electrochemical current (DC) and synergy with the antibiotic tobramycin. To further understand the underlying mechanism and develop this technology toward possible medical applications, we investigated the electricidal activities of non-metallic biomaterial on persister and biofilm cells of P. aeruginosa using graphite-based TGON™ 805 electrodes. We employed both single and dual chamber systems to compare electrochemical factors of TGON and stainless steel 304 electrodes. The results revealed that TGON-based treatments were highly effective against P. aeruginosa persister cells. In the single chamber system, complete eradication of planktonic persister cells (corresponding to a 7-log killing) was achieved with 70μA/cm² DC using TGON electrodes within 40min of treatment, while the cell viability in biofilms was reduced by 2 logs within 1h. The killing effects were dose and time dependent with higher current densities requiring less time. Moreover, reduction reactions were found more effective than oxidation reactions, confirming that metal cations are not indispensable, although they may facilitate cell killing. The findings of this study can help develop electrochemical technologies to eradicate persister and biofilm cells for more effective treatment of medical device and biomaterial associated infections.

STATEMENT OF SIGNIFICANCE

Infections associated with medical devices and biomaterials present a major challenge due to high-level tolerance of microbes to conventional antibiotics. It is well established that such tolerance is due to the formation of dormant persister cells and multicellular structures known as biofilms. Recent studies have demonstrated electrochemical treatment as a promising alternative to eradicate bacterial infections, since the killing mechanism is independent of the growth phase of bacterial cells, but relies on various electrochemical species interplaying during the treatment. The current study investigated major bactericidal properties of the electrochemical currents mediated via TGON, a carbon-based electrode material. Up to total eradication of Pseudomonas aeruginosa persister cells was achieved. The new knowledge of electrochemical properties and the bioactivity of TGON may help develop new methods/devices to eradicate bacterial infections by delivering safe levels of electrochemical currents.

Wireless electrostimulation: a new approach in combating infection?

Electrostimulation (ES), hitherto successfully employed in wound treatment, has shown potential in antimicrobial applications, suggesting its use as synergistic to or replacement of antibiotics. The differential susceptibility of pathogens and host tissue and organs to various ES modalities might allow selective use against specific infections. The use of ES is cheaper in terms of development/testing, routine application and environmental footprint. If extensive substitution of chemical compounds is achieved, the development of resistance might be reversed through negative selection. A promising setup of ES seems to be the noncontact current transfer, due to low amperage similar to innate bioelectricity, painlessness, simple logistics and low risk for treatment-caused infection.

Cutaneous wound biofilm and the potential for electrical stimulation in management of the microbiome

Infection contributes significantly to delayed cutaneous wound healing, which impacts patient care. External application of electrical stimulation (ES) has beneficial effects on wound repair and regeneration. The majority of studies to date have explored ES in relation to planktonic microorganisms, yet evidence indicates that bacteria in chronic wounds reside as antibiotic-resistant polymicrobial biofilms, which contribute to impairing wound healing. Culture-independent sequencing techniques have revolutionized our understanding of the skin microbiome and allowed a more accurate determination of microbial taxa and their relative abundance in wounds allowing a greater understanding of the host–microbial interface. Future studies combining the fields of ES, biofilm and microbiome research are necessary to fully elucidate the use of ES in the management of wound infection.

Magnesium alloy AZ91 exhibits antimicrobial properties in vitro but not in vivo

Magnesium alloys hold great promise for developing orthopedic implants that are biocompatible, biodegradable, and mechanically similar to bone tissue. This study evaluated the in vitro and in vivo antimicrobial properties of magnesium-9%aluminum-1%zinc (AZ91) and commercially pure titanium (cpTi) against Acinetobacter baumannii (Ab307). The in vitro results showed that as compared to cpTi, incubation with AZ91 significantly reduced both the planktonic (cpTi = 3.45e8, AZ91 = 8.97e7, p < 0.001) colony forming units (CFU) and biofilm-associated (cpTi = 3.89e8, AZ91 = 1.78e7, p = 0.01) CFU of Ab307. However, in vivo results showed no significant differences in the CFU enumerated from the cpTi and AZ91 implants following a 1-week implantation in an established rodent model of Ab307 implant associated infection (cpTi = 5.23e3, AZ91 = 2.46e3, p = 0.29). It is proposed that the in vitro results were associated with an increased pH in the bacterial culture as a result of the AZ91 corrosion process. The robust in vivo buffering capacity likely diminished this corrosion associated pH antimicrobial effect. © 2017 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 106B: 221-227, 2018.

Cathodic voltage-controlled electrical stimulation of titanium for prevention of methicillin-resistant Staphylococcus aureus and Acinetobacter baumannii biofilm infections

Antibiotic resistance of bacterial biofilms limits available treatment methods for implant-associated orthopaedic infections. This study evaluated the effects of applying cathodic voltage-controlled electrical stimulations (CVCES) of -1.5V and -1.8V (vs. Ag/AgCl) to coupons of commercially pure titanium (cpTi) incubated in cultures of methicillin-resistant Staphylococcus aureus (MRSA) and Acinetobacter baumannii (A. baumannii) as a method of preventing bacterial attachment. Stimulations were applied for 2, 4, and 8h and coupon-associated and planktonic colony-forming units (CFU) were enumerated following stimulation. Compared to open circuit potential (OCP) controls, CVCES for 4h at -1.8V significantly reduced coupon-associated MRSA CFU by 99.9% (1.30×10⁴vs. 4.45×10⁷, p=0.047) and A. baumannii coupon-associated CFU by 99.9% (1.64×10⁴vs. 5.93×10⁷, p=0.001) and reduced planktonic CFU below detectable levels for both strains. CVCES at -1.8V for 8h also reduced coupon-associated and planktonic CFU below detectable levels for each strain. CVCES at -1.5V for 4 and 8h, and -1.8V for 2h did not result in clinically relevant reductions. For 4 and 8h stimulations, the current density was significantly higher for -1.8V than -1.5V, an effect directly related to the rate of water and oxygen reduction on the cpTi surface. This significantly increased the pH, a suspected influence in decreased CFU viability. The voltage-dependent electrochemical properties of cpTi likely contribute to the observed antimicrobial effects of CVCES. This study revealed that CVCES of titanium could prevent coupon-associated and planktonic CFU of Gram-positive MRSA and Gram-negative A. baumannii from reaching detectable levels in a magnitude-dependent and time-dependent manner.

STATEMENT OF SIGNIFICANCE

Periprosthetic joint infection is a devastating outcome of total joint arthroplasty and has led to increased patient morbidity and rising healthcare costs. Current treatments are limited by the growing prevalence of antimicrobial resistant biofilms. Therefore, there is a growing interest in the prevention of bacterial colonization of implants. Previous work has shown that cathodic voltage-controlled electrical stimulation (CVCES) of titanium is effective both in vitro and in vivo as an antimicrobial strategy to eradicate established implant-associated biofilm infections. The present study revealed that CVCES of titanium coupons also has utility in preventing coupon-associated and planktonic colony-forming units of Gram-positive methicillin-resistant Staphylococcus aureus and Gram-negative Acinetobacter baumannii from reaching detectable levels in a magnitude-dependent and time-dependent manner.

A Novel In Vitro System for Comparative Analyses of Bone Cells and Bacteria under Electrical Stimulation

Electrical stimulation is a promising approach to enhance bone regeneration while having potential to inhibit bacterial growth. To investigate effects of alternating electric field stimulation on both human osteoblasts and bacteria, a novel in vitro system was designed. Electric field distribution was simulated numerically and proved by experimental validation. Cells were stimulated on Ti6Al4V electrodes and in short distance to electrodes. Bacterial growth was enumerated in supernatant and on the electrode surface and biofilm formation was quantified. Electrical stimulation modulated gene expression of osteoblastic differentiation markers in a voltage-dependent manner, resulting in significantly enhanced osteocalcin mRNA synthesis rate on electrodes after stimulation with 1.4V_RMS. While collagen type I synthesis increased when stimulated with 0.2V_RMS, it decreased after stimulation with 1.4V_RMS. Only slight and infrequent influence on bacterial growth was observed following stimulations with 0.2V_RMS and 1.4V_RMS after 48 and 72 h, respectively. In summary this novel test system is applicable for extended in vitro studies concerning definition of appropriate stimulation parameters for bone cell growth and differentiation, bacterial growth suppression, and investigation of general effects of electrical stimulation.

The effect of fretting associated periodic cathodic potential shifts on the electrochemistry and in vitro biocompatibility of commercially pure titanium

This study explored how periodic cathodic polarization of commercially pure titanium (cpTi) alters its electrochemical properties and biocompatibility. MC3T3-E1 preosteoblast cells were cultured directly on cpTi samples and maintained at open circuit potential (OCP) for 24 h followed by an additional 24-h sequence of periodic cathodic polarization to -1000 or -750 mV (vs. Ag/AgCl) for 1 s followed by a 5-s recovery at OCP. Control experiments were performed where the samples were maintained at OCP throughout the entire test. Subsequent electrochemical impedance spectroscopy revealed both of the periodic cathodic polarization conditions significantly reduced the polarization resistance (R_p ), while only the -1000 mV condition significantly increased the capacitance (C) as compared to the controls. Scanning electron micrographs showed that the cells were fragmented and balled up on the samples periodically shifted to -1000 mV as compared to the cells that were well spread on the controls and samples periodically shifted to -750 mV. Additionally, live/dead fluorescence microscopy revealed that periodic polarizations to -1000 mV reduced cell viability to around 12% as compared to the greater than 95% cell viability observed on the controls and samples periodically polarized to -750 mV. This work showed that periodic cathodic potential shifts can notably alter the electrochemical behavior of cpTi and the viability and morphology of cells seeded directly onto its surface. © 2015 Wiley Periodicals, Inc. J Biomed Mater Res Part B: Appl Biomater, 104B: 1591-1601, 2016.

Surface-Selective Preferential Production of Reactive Oxygen Species on Piezoelectric Ceramics for Bacterial Killing

Reactive oxygen species (ROS) can be used to kill bacterial cells, and thus the selective generation of ROS from material surfaces is an emerging direction in antibacterial material discovery. We found the polarization of piezoelectric ceramic causes the two sides of the disk to become positively and negatively charged, which translate into cathode and anode surfaces in an aqueous solution. Because of the microelectrolysis of water, ROS are preferentially formed on the cathode surface. Consequently, the bacteria are selectively killed on the cathode surface. However, the cell experiment suggested that the level of ROS is safe for normal mammalian cells.

Cathodic Voltage-controlled Electrical Stimulation Plus Prolonged Vancomycin Reduce Bacterial Burden of a Titanium Implant-associated Infection in a Rodent Model

BACKGROUND

Cathodic voltage-controlled electrical stimulation (CVCES) of titanium implants, either alone or combined with a short course of vancomycin, has previously been shown to reduce the bone and implant bacterial burden in a rodent model of methicillin-resistant Staphylococcus aureus (MRSA) implant-associated infection (IAI). Clinically, the goal is to achieve complete eradication of the IAI; therefore, the rationale for the present study was to evaluate the antimicrobial effects of combining CVCES with prolonged antibiotic therapy with the goal of decreasing the colony-forming units (CFUs) to undetectable levels.

QUESTIONS/PURPOSES

(1) In an animal MRSA IAI model, does combining CVCES with prolonged vancomycin therapy decrease bacteria burden on the implant and surrounding bone to undetectable levels? (2) When used with prolonged vancomycin therapy, are two CVCES treatments more effective than one? (3) What are the longer term histologic effects (inflammation and granulation tissue) of CVCES on the surrounding tissue?

METHODS

Twenty adult male Long-Evans rats with surgically placed shoulder titanium implants were infected with a clinical strain of MRSA (NRS70). One week after infection, the rats were randomly divided into four groups of five: (1) VANCO: only vancomycin treatment (150 mg/kg, subcutaneous, twice daily for 5 weeks); (2) VANCO + 1STIM: vancomycin treatment (same as the VANCO group) coupled with one CVCES treatment (-1.8 V for 1 hour on postoperative day [POD] 7); (3) VANCO + 2STIM: vancomycin treatment (same as the VANCO group) coupled with two CVCES treatments (-1.8 V for 1 hour on POD 7 and POD 21); or (4) CONT: no treatment. On POD 42, the implant, bone, and peripheral blood were collected for CFU enumeration and histological analysis, where we compared CFU/mL on the implants and bone among the groups. A pathologist, blinded to the experimental conditions, performed a semiquantitative analysis of inflammation and granulation tissue present in serial sections of the humeral head for animals in each experimental group.

RESULTS

The VANCO + 1STIM decreased the implant bacterial burden (median = 0, range = 0-10 CFU/mL) when compared with CONT (median = 5.7 × 10(4), range = 4.0 × 10(3)-8.0 × 10(5) CFU/mL; difference of medians = -5.6 × 10(4); p < 0.001) and VANCO (median = 4.9 × 10(3), range = 9.0 × 10(2)-2.1 × 10(4) CFU/mL; difference of medians = -4.9 × 10(3); p < 0.001). The VANCO + 1STIM decreased the bone bacterial burden (median = 0, range = 0-0 CFU/mL) when compared with CONT (median = 1.3 × 10(2), range = 0-9.4 × 10(2) CFU/mL; difference of medians = -1.3 × 10(2); p < 0.001) but was not different from VANCO (median = 0, range = 0-1.3 × 10(2) CFU/mL; difference of medians = 0; p = 0.210). The VANCO + 2STIM group had implant CFU (median = 0, range = 0-8.0 × 10(1) CFU/mL) and bone CFU (median = 0, range = 0-2.0 × 10(1) CFU/mL) that were not different from the VANCO + 1STIM treatment group implant CFU (median = 0, range = 0-10 CFU/mL; difference of medians = 0; p = 0.334) and bone CFU (median = 0, range = 0-0 CFU/mL; difference of medians = 0; p = 0.473). The histological analysis showed no deleterious effects on the surrounding tissue as a result of the treatments.

CONCLUSIONS

Using CVCES in combination with prolonged vancomycin resulted in decreased MRSA bacterial burden, and it may be beneficial in treating biofilm-related implant infections.

CLINICAL RELEVANCE

CVCES combined with clinically relevant lengths of vancomycin therapy may be a treatment option for IAI and allow for component retention in certain clinical scenarios. However, more animal research and human trials confirming the efficacy of this approach are needed before such a clinical recommendation could be made.