A comprehensive review of bacterial osteomyelitis with emphasis on Staphylococcus aureus

Intracellular Staphylococcus aureus in osteoblasts and osteocytes and its impact on bone homeostasis during osteomyelitis

Osteomyelitis is a severe infection of bone tissue that can lead to bone loss and even osteonecrosis. This condition is mostly caused by Gram-positive bacteria, with Staphylococcus aureus being the most common etiological agent. Among the pathophysiological mechanisms involved in osteomyelitis, the ability of S. aureus to be internalized by osteoblasts or osteocytes and to survive within these cells, is particularly noteworthy. Infected osteoblasts and osteocytes not only serve as reservoirs in chronic cases of osteomyelitis but also play an active role in the osteoimmunology process, notably by producing mediators that promote the bone resorption activity of osteoclasts, thereby disrupting bone homeostasis. The present review explores both historical and recent literature on the internalization of S. aureus by osteoblasts and osteocytes, its intracellular behavior following internalization, and its mechanisms for inducing cell death. Additionally, it examines how S. aureus affects bone formation activity and promotes the production of inflammatory and pro-osteoclastic mediators. This review aims to highlight the limitations of current findings and outline key questions for future investigations.

Osteonecrosis in pilot whales (Globicephala macrorhynchus)

Bone lesions, particularly osteonecrosis, have been rarely described in cetaceans, with limited studies correlating imaging, gross and microscopic findings. Aseptic osteonecrosis is especially relevant as a chronic form of decompression sickness, well-documented in human divers but controversially reported in cetaceans. This study examined the humeral heads of five stranded short-finned pilot whales (Globicephala macrorhynchus) using computed tomography (CT) and plastic embedding histologic techniques. Three specimens exhibited CT-detectable lesions, while two did not. CT imaging revealed distinct bone lesion patterns in three animals, including one case with a hypoattenuated triangular lesion constitutes histologically by well reorganized bone tissue. This lesion is highly consistent with aseptic dysbaric osteonecrosis (DON). Circular, focal, hyperattenuated necrotic bone areas most likely related to septic lesions were detected in two affected pilot whales. The two unaffected humoral heads exhibited normal bone histology, reinforcing the pathological significance of the osteonecrotic lesions of the three affected animals. As this was a retrospective study on fixed samples, microbiological analysis was not possible. Although not conclusive, this study provides the first histological evidence of chronic humeral head lesions in cetaceans consistent with DON, underscoring the need for further research using CT imaging, histology, and microbiology.

Unraveling persistent bacteria: Formation, niches, and eradication strategies

Persistent bacteria (persisters) are phenotypic variants that emerge either randomly or in response to a range of adverse environmental conditions. Persistence represents a state whereby a subpopulation of microorganisms can spontaneously enter a "dormant" state in response to environmental factors, while simultaneously exhibiting elevated tolerance to antimicrobial agents. This review provides the current definition of bacterial persistence and summarizes the mechanisms of persisters formation as well as the various niches of bacterial persistence encountered in clinical practice. Strategies targeting persisters are outlined, including but not limited to direct killing, awakening of persistent bacteria, combined clearance, and inhibition of persistence formation, and we conclude by proposing challenges and solutions for addressing bacterial persistence in current clinical practice.

RIG-I and cGAS mediate antimicrobial and inflammatory responses of primary osteoblasts and osteoclasts to Staphylococcus aureus

Staphylococcus aureus is the primary causative agent of osteomyelitis, and it is now apparent that osteoblasts and osteoclasts play a significant role in the pathogenesis of such infections. Their responses can either be protective or exacerbate inflammatory bone loss and are mediated by the recognition of microbial motifs by various pattern recognition receptors. We have recently reported that osteoblasts can respond to S. aureus challenge with the production of the type I interferon, interferon-beta, which can reduce the number of viable bacteria harbored within infected cells. In the present study, we demonstrate that S. aureus viability and internalization are necessary for maximal inflammatory cytokine and type I interferon responses of primary bone cells to this pathogen. Importantly, we show that primary murine and human bone cells constitutively express the cytosolic nucleic acid sensors, retinoic acid inducible gene I (RIG-I) and cyclic GMP-AMP synthase (cGAS), and demonstrate that such expression is markedly upregulated following S. aureus infection. The functional status of RIG-I and cGAS in osteoblasts and osteoclasts was confirmed by showing that specific ligands for each can also elevate their expression and induce cytokine responses. We have verified the specificity of such responses using siRNA knockdown or pharmacological inhibition and used these approaches to demonstrate that both sensors play a pivotal role in bone cell responses to infection with clinically relevant strains of S. aureus. Finally, we have begun to establish the biological significance of RIG-I- and cGAS-mediated bone cell responses with the demonstration that their attenuation increases S. aureus burden in infected cells, suggesting a potentially protective role for these sensors in osteomyelitis.IMPORTANCEStaphylococcal osteomyelitis is a severe infection that is often recalcitrant to current treatment strategies. We and others have demonstrated that resident bone cells are not merely passive victims but can respond to bacteria with the production of an array of immune mediators, including type I interferons, that could serve to limit such infections. Here, we demonstrate the functional expression of two cytosolic nucleic acid sensors, retinoic acid inducible gene I and cyclic GMP-AMP synthase, in primary murine and human osteoblasts and murine osteoclasts. We show that these pattern recognition receptors mediate potentially protective bone cell type I interferon responses to Staphylococcus aureus infection.

A comprehensive review of pathology and treatment of staphylococcus aureus osteomyelitis

Osteomyelitis (OM) is an inflammation of the bone and bone marrow triggered by infectious pathogens which may induce progressive bone destruction. The majority of OM cases, especially the chronic OM cases, are induced by the most prevalent and devastating pathogen Staphylococcus aureus (S. aureus), partially due to its resistance mechanisms against the immune system and antibiotic therapies. Regarding the high rate of morbidity and recurrence in patients, it is pivotal to elucidate underlying mechanisms that how S. aureus enter and survive in hosts. The accumulated discoveries have identified multiple distinct strategies associated with chronicity and recurrence include biofilm development, small colony variants (SCVs), staphylococcus abscess communities (SACs), the osteocyte lacuno-canalicular network invasion (OLCN) of cortical bones, and S. aureus protein A (SpA). Unfortunately, little clinical progress has been achieved for the diagnosis and therapeutic treatment for OM patients, indicating that numerous questions remain to be solved. Therefore, we still have a long way to obtain the clear elucidation of the host-pathogen interactions which could be applied for clinical treatment of OM. In this review, we provide insights of current knowledge about how S. aureus evades immune eradication and remains persistent in hosts with recent discoveries. The common and novel treatment strategies for OM are also described. The purpose of this review is to have in-dept understanding of S. aureus OM and bring new perspectives to therapeutic fields which may be translated to the clinic.

Transcription factor FOS promotes ferroptosis and inflammation in S. aureus- infected osteomyelitis via EIF5A

BACKGROUND

Osteomyelitis (OM) is a bone disease that can leave people disabled. Eukaryotic translation initiation factor (EIF5A) is involved in cell proliferation, apoptosis, differentiation, and inflammation, but the role of EIF5A in staphylococcus aureus (S. aureus)-infected OM remains unclear.

METHODS

The mRNA and proteins were detected by qRT-PCR and western blot. Cell viability was examined by CCK8 assay. The reactive oxygen species (ROS), malondialdehyde (MDA), ferrous iron (Fe2+), and glutathione (GSH) levels were analyzed using the ROS, MDA, GSH, and Fe2+ detection kits. The levels of tumor necrosis factor-alpha (TNF-α), interleukin-1β (IL-1β), and Interleukin-6 (IL-6) were examined using Enzyme-linked immunosorbent (ELISA) kits. The binding between FOS and promoter of EIF5A was detected by chromatin immunoprecipitation (CHIP) assay. The interaction between EIF5A and Fos proto-oncogene (FOS) was detected by dual-luciferase reporter assay. The diagnostic values of EIF5A and FOS were analyzed with blood of S. aureus-infected OM patients and healthy volunteers by ROC curve.

RESULTS

The EIF5A was up-regulated in S. aureus-infected OM. EIF5A knockdown promoted cell viability in S. aureus-infected MG-63 cells and reduced ROS, MDA, and Fe2+ levels, and increased GSH levels. Meanwhile, silencing EIF5A could increase expression of glutathione peroxidase 4 (GPX4), and ferritin heavy chain1 (FTH1) and reduce acyl-CoA synthetase long-chain family member 4 (ACSL4) expression, and silencing EIF5A could reduce immune factors (TNF-α, IL-1β, and IL-6) levels. FOS could bind to EIF5A. Silencing FOS promoted cell viability, and increased GSH levels in S. aureus-infected MG-63 cells, but reduced ROS, MDA, and Fe2+ levels. Meanwhile, promoted GPX4 and FTH1 expression, inhibited ACSL4 expression, and reduced immune factor levels in S. aureus-infected MG-63 cells. Interestingly, EIF5A overexpression could weaken the actions. FOS promotes ferroptosis and inflammation via EIF5A in S. aureus-infected MG-63 cells. Besides, the EIF5A and FOS might be potential molecular diagnostic markers in the progression of OM.

CONCLUSION

FOS promotes ferroptosis and inflammation via EIF5A in S. aureus-infected OM. This study is first to report the role of FOS and EIF5A in S. aureus-infected OM, but we found that there are still some limitations in our work, such as not covering all possible types of infection, which is the focus of future research.

In vivo virulence of Staphylococcus aureus in native versus prosthetic left-sided valve endocarditis

Objectives

Staphylococcus aureus infective endocarditis is commonly associated with invasive pathology and is worse in prosthetic valve endocarditis. In this study, we aim to examine S. aureus virulence and pathological features of native and prosthetic valve infective endocarditis.

Methods

Between 2002 and 2020, 438 patients underwent surgery for left-sided endocarditis caused by S. aureus at our center (59% native and 41% prosthetic valve endocarditis). Endocarditis registry was queried, and pathological features were based on the echocardiography and operative findings. In addition, vegetation samples were collected from 6 patients undergoing surgery for infective endocarditis (3 native and 3 prosthetic valve endocarditis). Total RNA was extracted from all specimens, and messenger RNA sequencing was executed for transcriptomic analysis. Data were pooled into STAR aligner, and gene expression related to virulence factors was compared between 2 groups.

Results

Rates of invasive pathology were higher in prosthetic versus native valve infective endocarditis (76% vs 40%, P < .0001), which impacted the complexity of surgical procedures and perioperative course, but not in-hospital mortality. Transcriptomic analysis has shown differences in gene expression between vegetation specimens of native and prosthetic valve endocarditis, including genes for stress response, biofilm formation, and virulence factors. The gene aur (encodes for aureolysin) was highly upregulated in prosthetic valve vegetations compared with native valve vegetations (P = .023).

Conclusions

Prosthetic valve endocarditis caused by S. aureus is associated with further invasive pathology compared with native valve endocarditis, which could be related to upregulation of genes responsible for biofilm formation and metalloproteinase production.

Daptomycin for Pediatric Complex Bone and Joint Infections: Real-world Efficacy and Safety Data from a Three-year Study

Bone and joint infections present a significant therapeutic challenge in children, particularly in complex or chronic cases. Staphylococcus aureus is the most common causative pathogen, with methicillin resistance rates varying by geographic location and hospital setting, underscoring the need for antibiotics effective against both methicillin-sensitive Staphylococcus aureus and methicillin-resistant Staphylococcus aureus. Daptomycin, a cyclic lipopeptide antibiotic effective against gram-positive pathogens, is increasingly used off-label in pediatric osteomyelitis. This prospective study evaluates its real-world application, focusing on clinical outcomes, dosing strategies, safety, and therapeutic potential. Over a 3-year period, 20 children (median age: 13.5 years) with bone and joint infections were treated with daptomycin. The patient cohort was highly complex, with 70% having severe orthopedic or medical comorbidities. Methicillin-sensitive Staphylococcus aureus was isolated in 60% of cases, while MRSA was identified in 35%. Daptomycin was administered following bacteremia dosing guidelines, with some patients receiving higher doses (mean: 10 mg/kg). The median duration of daptomycin therapy was 24.5 days. Treatment was successful in 90% of cases, often transitioning to oral antibiotic therapy. C-reactive protein levels showed a median reduction of 90%. A composite score evaluating clinical response-including C-reactive protein levels, type of continuation therapy, and the need for surgery-indicated substantial improvement in the majority of patients, with a median score of 4. No severe adverse events were recorded, though transient neutropenia and elevated creatine kinase levels were observed in 2 cases. This study underscores daptomycin's safety and efficacy in treating complex pediatric osteoarticular infections and suggests its potential as a first-line therapy, particularly for MRSA cases. The comprehensive data reflect the current microbiological landscape of pediatric bone and joint infections, supporting the reconsideration of daptomycin's role in initial treatment protocols. Further research and controlled trials are warranted to confirm these findings and optimize treatment strategies.

Do not treat ghosts: anti-methicillin-resistant Staphylococcus aureus (MRSA) therapy in osteomyelitis without identified MRSA

Objective

To compare the clinical outcomes of patients with lower limb osteomyelitis (LLOM) and negative methicillin-resistant Staphylococcus aureus (MRSA) cultures treated with anti-MRSA therapy (AMT) versus those treated with no-anti-MRSA therapy (NAMT).

Design

Retrospective cohort study.

Patients

Hospitalized adult (≥18 yr of age) patients admitted to multiple tertiary referral centers in a single healthcare system between April 1, 2017 and April 1, 2023, with LLOM and planned intravenous antibiotics for at least four weeks.

Methods

Electronic medical records were queried for demographic information, admission dates, treatment strategies, imaging and culture results, and discharge diagnoses. Descriptive statistics measured baseline characteristics, imaging, and culture results.

Results

Out of 473 patients, 64 met the inclusion criteria and 409 were excluded. Of the 64 patients, 26 (40%) had AMT and 38 (59%) had NAMT. A larger but statistically insignificant portion of patients in the NAMT cohort failed therapy (23% AMT vs 32% NAMT, P = 0.325). However, hospital readmission for LLOM within 180 days of antibiotic completion (46.2% vs 47%, P = 0.92), hospital length of stay (median (IQR): 6 (5-9) d vs 7 (5-12.5) d, P = 0.285), incidence of new renal replacement therapy initiation (0% vs 2.6%, P = 0.594), creatinine kinase levels (0 vs 2.6%, P = 0.594), and drug-induced immune thrombocytopenia (0% vs 5.3% P = 0.349) were comparable between the two cohorts.

Conclusions

Treatment failure rates and adverse events did not differ significantly among patients with LLOM treated with AMT or NAMT. Further investigation of determinants of clinical failures in LLOM may help optimize overall treatment.

A review of bacterial and osteoclast differentiation in bone infection

Bone infections are characterized by bacterial invasion of the bone microenvironment and subsequent bone structure deterioration. This holds significance because osteoclasts, which are the only cells responsible for bone resorption, are abnormally stimulated during bone infections. Multiple communication factors secreted by bone stromal cells regulate the membrane of osteoclast progenitor cells, thereby maintaining bone homeostasis through the expression of many types of receptors. During infection, the immunoinflammatory response triggered by bacterial invasion and multiple virulence factors of bacterial origin can disrupt osteoclast homeostasis. Therefore, clarifying the pathways through which bacteria affect osteoclasts can offer a theoretical basis for preventing and treating bone infections. This review summarizes studies investigating bone destruction caused by different bacterial infections. In conclusion, bacteria can affect osteoclast metabolic activity through multiple pathways, including direct contact, release of virulence factors, induction of immunoinflammatory responses, influence on bone stromal cell metabolism, and intracellular infections.

Assessing Biofilm at the Bedside: Exploring Reliable Accessible Biofilm Detection Methods

INTRODUCTION

Biofilm is linked through a variety of mechanisms to the pathogenesis of chronic wounds. However, accurate biofilm detection is challenging, demanding highly specialized and technically complex methods rendering it unapplicable for most clinical settings. This study evaluated promising methods of bedside biofilm localization, fluorescence imaging of wound bacterial loads, and biofilm blotting by comparing their performance against validation scanning electron microscopy (SEM).

METHODS

In this clinical trial, 40 chronic hard-to-heal wounds underwent the following assessments: (1) clinical signs of biofilm (CSB), (2) biofilm blotting, (3) fluorescence imaging for localizing bacterial loads, wound scraping taken for (4) SEM to confirm matrix encased bacteria (biofilm), and (5) PCR (Polymerase Chain Reaction) and NGS (Next Generation Sequencing) to determine absolute bacterial load and species present. We used a combination of SEM and PCR microbiology to calculate the diagnostic accuracy measures of the CSB, biofilm blotting assay, and fluorescence imaging.

RESULTS

Study data demonstrate that 62.5% of wounds were identified as biofilm-positive based on SEM and microbiological assessment. By employing this method to determine the gold truth, and thus calculate accuracy measures for all methods, fluorescence imaging demonstrated superior sensitivity (84%) and accuracy (63%) compared to CSB (sensitivity 44% and accuracy 43%) and biofilm blotting (sensitivity 24% and accuracy 40%). Biofilm blotting exhibited the highest specificity (64%), albeit with lower sensitivity and accuracy. Using SEM alone as the validation method slightly altered the results, but all trends held constant.

DISCUSSION

This trial provides the first comparative assessment of bedside methods for wound biofilm detection. We report the diagnostic accuracy measures of these more feasibly implementable methods versus laboratory-based SEM. Fluorescence imaging showed the greatest number of true positives (highest sensitivity), which is clinically relevant and provides assurance that no pathogenic bacteria will be missed. It effectively alerted regions of biofilm at the point-of-care with greater accuracy than standard clinical assessment (CSB) or biofilm blotting paper, providing actionable information that will likely translate into enhanced therapeutic approaches and better patient outcomes.

Endogenous Tissue Engineering for Chondral and Osteochondral Regeneration: Strategies and Mechanisms

Increasing attention has been paid to the development of effective strategies for articular cartilage (AC) and osteochondral (OC) regeneration due to their limited self-reparative capacities and the shortage of timely and appropriate clinical treatments. Traditional cell-dependent tissue engineering faces various challenges such as restricted cell sources, phenotypic alterations, and immune rejection. In contrast, endogenous tissue engineering represents a promising alternative, leveraging acellular biomaterials to guide endogenous cells to the injury site and stimulate their intrinsic regenerative potential. This review provides a comprehensive overview of recent advancements in endogenous tissue engineering strategies for AC and OC regeneration, with a focus on the tissue engineering triad comprising endogenous stem/progenitor cells (ESPCs), scaffolds, and biomolecules. Multiple types of ESPCs present within the AC and OC microenvironment, including bone marrow-derived mesenchymal stem cells (BMSCs), adipose-derived mesenchymal stem cells (AD-MSCs), synovial membrane-derived mesenchymal stem cells (SM-MSCs), and AC-derived stem/progenitor cells (CSPCs), exhibit the ability to migrate toward injury sites and demonstrate pro-regenerative properties. The fabrication and characteristics of scaffolds in various formats including hydrogels, porous sponges, electrospun fibers, particles, films, multilayer scaffolds, bioceramics, and bioglass, highlighting their suitability for AC and OC repair, are systemically summarized. Furthermore, the review emphasizes the pivotal role of biomolecules in facilitating ESPCs migration, adhesion, chondrogenesis, osteogenesis, as well as regulating inflammation, aging, and hypertrophy-critical processes for endogenous AC and OC regeneration. Insights into the applications of endogenous tissue engineering strategies for in vivo AC and OC regeneration are provided along with a discussion on future perspectives to enhance regenerative outcomes.

Research and Application of Chitosan Nanoparticles in Orthopedic Infections

Orthopedic infection is one of the most intractable orthopedic problems. Bacteria resistant to antibiotics also develop gradually. Chitosan is widely used in the Biomedical field because of its high biocompatibility, biodegradability, and antibacterial activity. Chitosan-based drug delivery systems are frequently utilized to produce controlled medication release. When combined with antibiotics, synergistic antibacterial effects can be achieved. Chitosan-based nanoparticles are one of the most widely used applications in drug delivery systems. The focus of this review is to provide information on new methods being developed for chitosan-based nanoparticles in the field of bone infection treatment, including chitosan nanoparticles for antibacterial purposes, Ch-loaded with antibiotics, Ch-loaded with metal, and used as immune adjuvants. It may Provide ideas for the fundamental research and the prospects of future clinical applications of orthopedic infections.

Rifampicin-Loaded Polyelectrolyte Complex Eliminates Intracellular Bacteria through Thiol-Mediated Cellular Uptake and Oxidative Stress Enhancement

The poor accumulation of antibiotics in the cytoplasm leads to the poor eradication of intracellular bacteria. Herein, a polyelectrolyte complex (PECs@Rif) allowing direct cytosolic delivery of rifampicin (Rif) was developed for the treatment of intracellular infections by complexation of poly(α-lipoic acid) (pLA) and oligosaccharide (COS) in water and loading Rif. Due to the thiol-mediated cellular uptake, PECs@Rif delivered 3.9 times higher Rif into the cytoplasm than that of the free Rif during 8 h of incubation. After entering cells, PECs@Rif released Rif by dissociating pLA into dihydrolipoic acid (DHLA) in the presence of intracellular thioredoxin reductase (TrxR). Notably, DHLA could reduce endogenous Fe(III) to Fe(II) and provide a catalyst for the Fenton reaction to produce a large amount of reactive oxygen species (ROS), which would assist Rif in eradicating intracellular bacteria. In vitro assay showed that PECs@Rif reduced almost 2.8 orders of magnitude of intracellular bacteria, much higher than 0.7 orders of magnitude of free Rif. The bacteremia-bearing mouse models showed that PECs@Rif reduced bacterial levels in the liver, spleen, and kidney by 2.2, 3.7, and 2.3 orders of magnitude, respectively, much higher than free Rif in corresponding tissues. The direct cytosolic delivery in a thiol-mediated manner and enhanced oxidative stress proposed a feasible strategy for treating intracellular bacteria infection.

Sequestration and Involucrum: Understanding Bone Necrosis and Revascularization in Pediatric Orthopedics

Sequestration, a condition where a section of bone becomes necrotic due to a loss of vascularity or thrombosis, can be a challenging complication of osteomyelitis. This review explores the pathophysiology of sequestration, highlighting the role of the periosteum in forming involucrum and creeping substitution which facilitate revascularization and bone formation. The authors also discuss the induced membrane technique, a two-stage surgical procedure for cases of failed healing of sequestration. Future directions include the potential use of prophylactic anticoagulation and novel drugs targeting immunocoagulopathy, as well as the development of advanced imaging techniques and single-stage surgical procedures.

Exploration of the Antibacterial and Anti-Inflammatory Activity of a Novel Antimicrobial Peptide Brevinin-1BW

Antibiotic resistance has emerged as a grave threat to global public health, leading to an increasing number of treatment failures. Antimicrobial peptides (AMPs) are widely regarded as potential substitutes for traditional antibiotics since they are less likely to induce resistance when used. A novel AMP named Brevinin-1BW (FLPLLAGLAASFLPTIFCKISRKC) was obtained by the Research Center of Molecular Medicine of Yunnan Province from the skin of the Pelophylax nigromaculatus. Brevinia-1BW had effective inhibitory effects on Gram-positive bacteria, with a minimum inhibitory concentration (MIC) of 3.125 μg/mL against Enterococcus faecalis (ATCC 29212) and 6.25 μg/mL against both Staphylococcus aureus (ATCC 25923) and multidrug-resistant Staphylococcus aureus (ATCC 29213) but had weaker inhibitory effects on Gram-negative bacteria, with a MIC of ≥100 μg/mL. Studies using scanning electron microscopy (SEM) and flow cytometry have revealed that it exerts its antibacterial activity by disrupting bacterial membranes. Additionally, it possesses strong biofilm inhibitory and eradication activities as well as significant lipopolysaccharide (LPS)-binding activity. Furthermore, Brevinin-1BW has shown a significant anti-inflammatory effect in LPS-treated RAW264.7 cells. In conclusion, Brevinin-1BW is anticipated to be a promising clinical agent with potent anti-Gram-positive bacterial and anti-inflammatory properties.

Osteomyelitis and non-coding RNAS: A new dimension in disease understanding

Osteomyelitis, a debilitating bone infection, presents considerable clinical challenges due to its intricate etiology and limited treatment options. Despite strides in surgical and chemotherapeutic interventions, the treatment landscape for osteomyelitis remains unsatisfactory. Recent attention has focused on the role of non-coding RNAs (ncRNAs) in the pathogenesis and progression of osteomyelitis. This review consolidates current knowledge on the involvement of distinct classes of ncRNAs, including microRNAs, long ncRNAs, and circular RNAs, in the context of osteomyelitis. Emerging evidence from various studies underscores the potential of ncRNAs in orchestrating gene expression and influencing the differentiation of osteoblasts and osteoclasts, pivotal processes in bone formation. The review initiates by elucidating the regulatory functions of ncRNAs in fundamental cellular processes such as inflammation, immune response, and bone remodeling, pivotal in osteomyelitis pathology. It delves into the intricate network of interactions between ncRNAs and their target genes, illuminating how dysregulation contributes to the establishment and persistence of osteomyelitic infections. Understanding their regulatory roles may pave the way for targeted diagnostic tools and innovative therapeutic interventions, promising a paradigm shift in the clinical approach to this challenging condition. Additionally, we delve into the promising therapeutic applications of these molecules, envisioning novel diagnostic and treatment approaches to enhance the management of this challenging bone infection.

Co-colonization of methicillin-resistant Staphylococcus aureus and Candida spp. in children with malignancies

This study aimed to evaluate the interaction between methicillin-resistant Staphylococcus aureus(MRSA) and Candida spp. in the oral cavity of children with malignancies under chemotherapy. We evaluated the expression level of Als3p and mecA in Candida spp. and MRSA strains in both single colonization and co-colonization condition. Oral and nasal samples were collected by dry sponge swabs in 10 ml of sterile phosphate-buffered saline. The MRSA and Candida spp. was confirmed using the PCR method and mecA and Als3p genes, respectively. The SYBR Green-based quantitative real-time PCR was used to evaluate the relative expression levels of mecA and Als3p genes in MRSA and Candida spp., respectively. The frequency of S. aureus in oral-only and nasal-only swab samples were 14.1% (n = 24/170). 58.3% (n = 14/24) and 29.2% (n = 7/24) of S. aureus isolated from oral and nasal samples were MRSA, respectively. Among Candida species, C. albicans (n = 28/170; 16.5%) had the highest frequency. The oral co-colonization of MRSA and Candida spp. was detected in 4.7% (n = 8/170) patients. The overall average of gene expression levels among all Candida spp. and MRSA isolates indicated that the mecA and Als3p genes expression increased six and two times in co-colonization conditions compared to single colonization conditions, respectively. Our findings revealed the importance of polymicrobial infection in clinical settings and stated that it is possible that Candida spp. facilitates the infection of S. aureus and can lead to systemic infection in co-colonized patients.

Adjuvant intra-articular vancomycin for recalcitrant Staphylococcal prosthetic joint infections of the knee

OBJECTIVE

Chronic prosthetic joint infection patients who fail conventional two-stage revision surgery are an especially difficult to treat patient population. Consequently, the objective of this study was to investigate the safety and long-term effectiveness of adjuvant intra-articular vancomycin therapy in conjunction with two-stage revision knee arthroplasties for recalcitrant Staphylococcal prosthetic joint infections.

METHODS

This was an observational cohort study of twelve patients with recalcitrant Staphylococcal prosthetic joint infections of the knee which had failed previous revision surgeries. Each patient subsequently underwent two-stage revision with placement of Hickman catheters to deliver intra-articular vancomycin therapy. In addition, systemic antibiotic therapy was administered for 6 weeks, and long-term follow-up was evaluated then for 5 years.

RESULTS

Seventy-five percent of the cohort have had no recurrence of their infections at 5 years. Two patients formed fistulas requiring above the knee amputations, and three patients had acute kidney injury. All patients had maximum measurable serum vancomycin trough levels that ranged from 6.1 to 93.6 mcg/mL.

CONCLUSION

The aggressive protocol used in this cohort with repeat two-stage revision surgery, intra-articular vancomycin and systemic antibiotics was able to prevent recurrence of infection in most patients, but higher than expected rates of acute kidney injury were observed in this study. Therefore, while intra-articular vancomycin therapy may have some effectiveness in treating recalcitrant prosthetic joint infections, its ability to eradicate all bacterial niduses is unproven, and clinicians should be cognizant of potential adverse events that can occur with this therapy.

Shifting from Ammonium to Phosphonium Salts: A Promising Strategy to Develop Next-Generation Weapons against Biofilms

Since they are difficult and sometimes impossible to treat, infections sustained by multidrug-resistant (MDR) pathogens, emerging especially in nosocomial environments, are an increasing global public health concern, translating into high mortality and healthcare costs. In addition to having acquired intrinsic abilities to resist available antibiotic treatments, MDR bacteria can transmit genetic material encoding for resistance to non-mutated bacteria, thus strongly decreasing the number of available effective antibiotics. Moreover, several pathogens develop resistance by forming biofilms (BFs), a safe and antibiotic-resistant home for microorganisms. BFs are made of well-organized bacterial communities, encased and protected in a self-produced extracellular polymeric matrix, which impedes antibiotics' ability to reach bacteria, thus causing them to lose efficacy. By adhering to living or abiotic surfaces in healthcare settings, especially in intensive care units where immunocompromised older patients with several comorbidities are hospitalized BFs cause the onset of difficult-to-eradicate infections. In this context, recent studies have demonstrated that quaternary ammonium compounds (QACs), acting as membrane disruptors and initially with a low tendency to develop resistance, have demonstrated anti-BF potentialities. However, a paucity of innovation in this space has driven the emergence of QAC resistance. More recently, quaternary phosphonium salts (QPSs), including tri-phenyl alkyl phosphonium derivatives, achievable by easy one-step reactions and well known as intermediates of the Wittig reaction, have shown promising anti-BF effects in vitro. Here, after an overview of pathogen resistance, BFs, and QACs, we have reviewed the QPSs developed and assayed to this end, so far. Finally, the synthetic strategies used to prepare QPSs have also been provided and discussed to spur the synthesis of novel compounds of this class. We think that the extension of the knowledge about these materials by this review could be a successful approach to finding effective weapons for treating chronic infections and device-associated diseases sustained by BF-producing MDR bacteria.

The major role of sarA in limiting Staphylococcus aureus extracellular protease production in vitro is correlated with decreased virulence in diverse clinical isolates in osteomyelitis

We previously demonstrated that MgrA, SarA, SarR, SarS, SarZ, and Rot bind at least three of the four promoters associated with genes encoding primary extracellular proteases in Staphylococcus aureus (Aur, ScpA, SspA/SspB, SplA-F). We also showed that mutation of sarA results in a greater increase in protease production, and decrease in biofilm formation, than mutation of the loci encoding any of these other proteins. However, these conclusions were based on in vitro studies. Thus, the goal of the experiments reported here was to determine the relative impact of the regulatory loci encoding these proteins in vivo. To this end, we compared the virulence of mgrA, sarA, sarR, sarS, sarZ, and rot mutants in a murine osteomyelitis model. Mutants were generated in the methicillin-resistant USA300 strain LAC and the methicillin-sensitive USA200 strain UAMS-1, which was isolated directly from the bone of an osteomyelitis patient during surgical debridement. Mutation of mgrA and rot limited virulence to a statistically significant extent in UAMS-1, but not in LAC, while the sarA mutant exhibited reduced virulence in both strains. The reduced virulence of the sarA mutant was correlated with reduced cytotoxicity for osteoblasts and osteoclasts, reduced biofilm formation, and reduced sensitivity to the antimicrobial peptide indolicidin, all of which were directly attributable to increased protease production in both LAC and UAMS-1. These results illustrate the importance of considering diverse clinical isolates when evaluating the impact of regulatory mutations on virulence and demonstrate the significance of SarA in limiting protease production in vivo in S. aureus.

Staphylococcus aureus enhances osteoclast differentiation and bone resorption by stimulating the NLRP3 inflammasome pathway

BACKGROUND

Osteomyelitis is one of the most challenging infectious diseases and is mainly caused by Staphylococcus aureus (S. aureus). In this study, we analyzed the effect of S. aureus on osteoclast differentiation and its possible molecular mechanism.

METHODS

We cultured RAW 264.7 cells with live S. aureus for 5 days. We assessed cell viability and the formation of resorption pits. We tested the NLRP3 inflammasome signaling pathways and measured the mRNA expression levels of osteoclastspecific genes, including TRAP, MMP9, cathepsin K, calcitonin receptor and ATP6V0d2. Furthermore, we analyzed the protein expression levels of the protein in the NF-κB and p38 MAPK signaling pathways to clarify the signaling pathways by which S. aureus promotes osteoclast differentiation.

RESULTS

Staphylococcus aureus induced NLRP3 inflammasome activation. S. aureus promoted bone resorption and enhanced the expression of osteoclastspecific genes, such as TRAP, MMP9, cathepsin K, calcitonin receptor and ATP6V0d2. MCC950 was used to inhibit NLRP3 inflammasome activity. Osteoclast differentiation and the expression of osteoclastspecific genes induced by S. aureus were inhibited by MCC950 pretreatment. The degradation of IκBα and phosphorylation of P65 were increased under the induction of S. aureus, but proteins in the p38 MAPK signaling pathway did not change significantly.

CONCLUSION

Staphylococcus aureus induces osteoclast differentiation and promotes bone resorption in vitro, and the NLRP3 inflammasome signaling pathway plays a significant role in this process. S. aureus-induced NLRP3 inflammasome activation was mainly dependent on the NF-κB signaling pathway during osteoclastogenesis.

FRZB affects Staphylococcus aureus‑induced osteomyelitis in human bone marrow derived stem cells by regulating the Wnt/β‑catenin signaling pathway

Osteomyelitis is an infectious disease of bone tissue caused by bacterial infection, which can infect through hematogenous, traumatic or secondary ways and then lead to acute or chronic bone injury and relative clinical symptoms, bringing physical injury and economic burden to patients. Frizzled related protein (FRZB) participates in the regulation of various diseases (osteoarthritis, cardiovascular diseases and types of cancer) by regulating cell proliferation, motility, differentiation and inflammation, while its function in osteomyelitis remains to be elucidated. The present study aimed to uncover the role and underlying mechanism of FRZB mediation in Staphylococcus aureus (S. aureus)-induced osteomyelitis. Human bone marrow derived stem cells (hBMSCs) were treated with S. aureus to imitate an inflammatory osteomyelitis micro-environment in vitro, then mRNA and protein expression were severally assessed by RT-PCR and western blotting. The activity, apoptosis and differentiation of the cells were characterized via CCK-8, caspase-3 activity and Alizarin red sulfate/alkaline phosphatase staining, respectively. Expression levels of FRZB were upregulated in S. aureus-infected hBMSCs. Over-expression of FRZB significantly reduced hBMSC cell viability and differentiation while promoting cell apoptosis with or without S. aureus infection. However, FRZB knockdown reversed these effects. Once Wnt was impeded, the effect of FRZB downregulation was impeded to a great extent. Taken together, FRZB participated to regulate the osteomyelitis by activating the Wnt/β-catenin signaling pathway.

Preparation of fish collagen and vancomycin microspheres based on microfluidic technology and its application in osteomyelitis

At present, the clinical treatment of osteomyelitis and osteomyelitis-induced bone defects is challenging, easy to recur, drug toxic side effects, secondary or multiple surgeries, etc. The design of biodegradable composite biomaterials to improve antibiotics in the local precise anti-infection at the same time to complete the repair of bone defects is the current research hot spot. Herein, a composite hydrogel with a double bond at the end (FA-MA) was prepared by affinity addition reaction between fish collagen (FA) and methacrylic anhydride (MA) under photoinitiator initiation conditions, then, FA-MA was amino-activated by EDC/NHC, and vancomycin was attached to FA-MA via amide bonding to prepare FA-MA-Van hydrogels, and finally, the composite hydrogel microspheres were prepared by microfluidic technology. The structure of the hydrogel was confirmed by SEM (elemental analysis), optical microscopy, FTIR, and XPS to confirm the successful preparation. The composite hydrogel microspheres showed the better antimicrobial effect of hydrogel microspheres by bacterial coated plate experiments and SEM morphology results, with the antimicrobial class reaching 99.8%. The results of immunofluorescence staining and X-ray experiments showed that the hydrogel microspheres had a better effect on promoting bone repair. This engineered design of hydrogel microspheres provides clinical significance for treating osteomyelitis at a later stage.

Size-dependent gold nanoparticles induce macrophage M2 polarization and promote intracellular clearance of Staphylococcus aureus to alleviate tissue infection

Tissue infection typically results from blood transmission or the direct inoculation of bacteria following trauma. The pathogen-induced destruction of tissue prevents antibiotics from penetrating the infected site, and severe inflammation further impairs the efficacy of conventional treatment. The current study describes the size-dependent induction of macrophage polarization using gold nanoparticles. Gold nanoparticles with a diameter of 50 ​nm (Au50) can induce M2 polarization in macrophages by inhibiting the NF-κB signaling pathway and stimulate an inflammatory response in the environment by inhibiting the MAPK signaling pathway LPS. Furthermore, the induced polarization and anti-inflammatory effects of the Au50 nanoparticles promoted the osteogenic differentiation of BMSCs in vitro. In addition, the overexpression of TREM2 in macrophage induced by Au50 nanoparticles was found to promote macrophage phagocytosis of Staphylococcus aureus, enhance the fusion of autophagosomes and lysosomes, accelerate the intracellular degradation of S. aureus, in addition to achieving an effective local treatment of osteomyelitis and infectious skin defects in conjunction with inflammatory regulation and accelerating bone regeneration. The findings, therefore, demonstrate that Au50 nanoparticles can be utilized as a promising nanomaterial for in vivo treatment of infections.

Diagnosis and treatment of chronic osteomyelitis based on nanomaterials

Chronic osteomyelitis is a painful and serious disease caused by infected surgical prostheses or infected fractures. Traditional treatment includes surgical debridement followed by prolonged systemic antibiotics. However, excessive antibiotic use has been inducing rapid emergence of antibiotic-resistant bacteria worldwide. Additionally, it is difficult for antibiotics to penetrate internal sites of infection such as bone, thus limiting their efficacy. New approaches to treat chronic osteomyelitis remain a major challenge for orthopedic surgeons. Luckily, the development of nanotechnology has brought new antimicrobial options with high specificity to infection sites, offering a possible way to address these challenges. Substantial progress has been made in constructing antibacterial nanomaterials for treatment of chronic osteomyelitis. Here, we review some current strategies for treatment of chronic osteomyelitis and their underlying mechanisms.

Neutralization of Staphylococcus aureus Protein A Prevents Exacerbated Osteoclast Activity and Bone Loss during Osteomyelitis

Osteomyelitis caused by Staphylococcus aureus is an important and current health care problem worldwide. Treatment of this infection frequently fails not only due to the increasing incidence of antimicrobial-resistant isolates but also because of the ability of S. aureus to evade the immune system, adapt to the bone microenvironment, and persist within this tissue for decades. We have previously demonstrated the role of staphylococcal protein A (SpA) in the induction of exacerbated osteoclastogenesis and increased bone matrix degradation during osteomyelitis. The aim of this study was to evaluate the potential of using anti-SpA antibodies as an adjunctive therapy to control inflammation and bone damage. By using an experimental in vivo model of osteomyelitis, we demonstrated that the administration of an anti-SpA antibody by the intraperitoneal route prevented excessive inflammatory responses in the bone upon challenge with S. aureus. Ex vivo assays indicated that blocking SpA reduced the priming of osteoclast precursors and their response to RANKL. Moreover, the neutralization of SpA was able to prevent the differentiation and activation of osteoclasts in vivo, leading to reduced expression levels of cathepsin K, reduced expression of markers associated with abnormal bone formation, and decreased trabecular bone loss during osteomyelitis. Taken together, these results demonstrate the feasibility of using anti-SpA antibodies as an antivirulence adjunctive therapy that may prevent the development of pathological conditions that not only damage the bone but also favor bacterial escape from antimicrobials and the immune system.

Nanocarriers for the delivery of antibiotics into cells against intracellular bacterial infection

The barrier function of host cells enables intracellular bacteria to evade the lethality of the host immune system and antibiotics, thereby causing chronic and recurrent infections that seriously threaten human health. Currently, the main clinical strategy for the treatment of intracellular bacterial infections involves the use of long-term and high-dose antibiotics. However, insufficient intracellular delivery of antibiotics along with various resistance mechanisms not only weakens the efficacy of current therapies but also causes serious adverse drug reactions, further increasing the disease and economic burden. Improving the delivery efficiency, intracellular accumulation, and action time of antibiotics remains the most economical and effective way to treat intracellular bacterial infections. The rapid development of nanotechnology provides a strategy to efficiently deliver antibiotics against intracellular bacterial infections into cells. In this review, we summarize the types of common intracellular pathogens, the difficulties faced by antibiotics in the treatment of intracellular bacterial infections, and the research progress of several types of representative nanocarriers for the delivery of antibiotics against intracellular bacterial infections that have emerged in recent years. This review is expected to provide a reference for further elucidating the intracellular transport mechanism of nanocarrier-drug complexes, designing safer and more effective nanocarriers and establishing new strategies against intracellular bacterial infection.

Hexapeptide decorated β-cyclodextrin delivery system for targeted therapy of bone infection

Successfully treating bone infections is a major orthopedic challenge. Clinically, oral, intravenous, or intramuscular injections of drugs are usually used for direct or complementary treatment. However, once the drug enters the system, it circulates throughout the body, leading to an insufficient local dose and limiting the therapeutic effect because of the lack of targeting in the drug system. In this study, β-cyclodextrin, modified with poly (ethylene glycol) [PEG] and aspartic acid hexapeptide (Asp6-β-CD), was used to specifically target the hydroxyapatite (HA) component of the bone. It was then loaded with norfloxacin (NFX) to treat bone infections. The antibacterial ability of NFX was enhanced by loading it into Asp6-β-CD, because the solubility of Asp6-β-CD@NFX increased significantly. Moreover, Asp6-β-CD could target bone tissue in nude mice and showed significantly enhanced accumulation (10 times) than the unmodified β-CD. In addition, in a rat model of osteomyelitis, Asp6-β-CD@NFX targeted HA well and exerted its antibacterial activity, which reduced inflammation and promoted bone tissue repair. This study indicates that the Asp6-β-CD based drug delivery system can efficiently target bone tissue to enable potential applications for treating bone-related diseases.

Electroactive Biomaterials for Facilitating Bone Defect Repair under Pathological Conditions

Bone degeneration associated with various diseases is increasing due to rapid aging, sedentary lifestyles, and unhealthy diets. Living bone tissue has bioelectric properties critical to bone remodeling, and bone degeneration under various pathological conditions results in significant changes to these bioelectric properties. There is growing interest in utilizing biomimetic electroactive biomaterials that recapitulate the natural electrophysiological microenvironment of healthy bone tissue to promote bone repair. This review first summarizes the etiology of degenerative bone conditions associated with various diseases such as type II diabetes, osteoporosis, periodontitis, osteoarthritis, rheumatoid arthritis, osteomyelitis, and metastatic osteolysis. Next, the diverse array of natural and synthetic electroactive biomaterials with therapeutic potential are discussed. Putative mechanistic pathways by which electroactive biomaterials can mitigate bone degeneration are critically examined, including the enhancement of osteogenesis and angiogenesis, suppression of inflammation and osteoclastogenesis, as well as their anti-bacterial effects. Finally, the limited research on utilization of electroactive biomaterials in the treatment of bone degeneration associated with the aforementioned diseases are examined. Previous studies have mostly focused on using electroactive biomaterials to treat bone traumatic injuries. It is hoped that this review will encourage more research efforts on the use of electroactive biomaterials for treating degenerative bone conditions.

Micro-CT analysis of osteomyelitis of rabbit tibial for model establishment and biomaterials application in tissue engineering

Osteomyelitis is one of the most difficult diseases to treat in orthopedics field. The construction of animal models of osteomyelitis is now more mature but still lacks a deeper criterion other than "successful infection". In this work, rabbit tibial osteomyelitis model with S. aureus infection was established. Whole tibia, cortical bone around bone window, and tibial condyle were characterized in considerable detail using micro-CT and other means at 2/4/6 weeks, respectively. The results show that in addition to the obvious inflammatory response and bone destruction, osteomyelitis caused some other effects on compact and cancellous bone, and in particular, changes in bone mineral density after infection were of interest. Although the modeling groups all exhibited osteolysis and bone loss, their overall bone mineral density averages and those of the control groups were mostly in the range of 870 mg/cm3 to 920 mg/cm3, without statistical difference. The results suggest that overall bone mineral density is determined by both bone destruction conditions and the amount of dead bone deposition. This work provides a reference basis for the selection of time points for the subsequent animal models establishment and some valuable reference indicators of the application of biomaterials in tissue engineering.

Research Status and Hotspots of Chronic Osteomyelitis: A Bibliometric and Visualized Analysis

OBJECTIVE

The treatment of chronic osteomyelitis (COM) is extremely challenging for physicians and patients. It is of great significance to explore the research status, development trend and future research hotspots in the field of COM to promote the development of this field. This study is aimed to explore the global research status of COM and predict its future research hotspots based on bibliometric and visualized analysis.

METHODS

Web of Science core collection database was used to search the related literature of COM from 1994 to 2020. All data were imported into Microsoft Excel 2019 for collation. Additionally, the literature quality of countries, authors, journals, and institutions is evaluated. The VOS viewer software was used for conducting co-analysis, co-citation analysis, and keyword co-occurrence analysis of literature to analyze the global status and predict the future hotspots of the COM field.

RESULTS

A total of 726 articles were retrieved in this study. The number of global publications shows a trend of wave growth, but the increase is not significant. It is expected that the number of COM articles will remain at more than 50 per year in the next decade. The COM literature published in the United States (Publications = 160, H index = 37, average citations per item = 28.63) is of the highest quality. Girschick HJ (Publications = 16, H index = 14, average citations per item = 52.25) is the most contributed scholar in the field of COM. UNIV IOWA (Publications = 15, H index = 11, average citations per item = 57.27) and UNIV WURZBURG (Publications = 18, H index = 15, average citations per item = 47.5) are influential institutions in the field of COM. The results of co-occurrence analysis show that the field of COM can be roughly divided into the following five modules: COM surgical research, COM basic research, COM diagnosis-related research, chronic recurrent multifocal osteomyelitis (CRMO)-related research, risk factors of COM. Risk factors of COM are the module with the highest concentration of hot words.

CONCLUSION

COM-related research will continue to develop further in the next decade. The diagnosis research and risk factors of COM are the most popular research modules in recent years. Some controversial or troubled issues including the efficacy of perforator flap and fascia flap covering soft tissue, searching exclusive detection methods for the diagnosis of COM and bisphosphonates and biological agents in the treatment of CRMO may lead to the development of the COM field.

Controlling skin microbiome as a new bacteriotherapy for inflammatory skin diseases

The skin serves as the interface between the human body and the environment and interacts with the microbial community. The skin microbiota consists of microorganisms, such as bacteria, fungi, mites, and viruses, and they fluctuate depending on the microenvironment defined by anatomical location and physiological function. The balance of interactions between the host and microbiota plays a pivotal role in the orchestration of skin homeostasis; however, the disturbance of the balance due to an alteration in the microbial communities, namely, dysbiosis, leads to various skin disorders. Recent developments in sequencing technology have provided new insights into the structure and function of skin microbial communities. Based on high-throughput sequencing analysis, a growing body of evidence indicates that a new treatment using live bacteria, termed bacteriotherapy, is a feasible therapeutic option for cutaneous diseases caused by dysbiosis. In particular, the administration of specific bacterial strains has been investigated as an exclusionary treatment strategy against pathogens associated with chronic skin disorders, whereas the safety, efficacy, and sustainability of this therapeutic approach using isolated live bacteria need to be further explored. In this review, we summarize our current understanding of the skin microbiota, as well as therapeutic strategies using characterized strains of live bacteria for skin inflammatory diseases. The ecosystem formed by interactions between the host and skin microbial consortium is still largely unexplored; however, advances in our understanding of the function of the skin microbiota at the strain level will lead to the development of new therapeutic methods.

Genomic characterization of Staphylococcus aureus isolates causing osteoarticular infections in otherwise healthy children

Background

Pediatric osteoarticular infections are commonly caused by Staphylococcus aureus. The contribution of S. aureus genomic variability to pathogenesis of these infections is poorly described.

Methods

We prospectively enrolled 47 children over 3 1/2 years from whom S. aureus was isolated on culture—12 uninfected with skin colonization, 16 with skin abscesses, 19 with osteoarticular infections (four with septic arthritis, three with acute osteomyelitis, six with acute osteomyelitis and septic arthritis and six with chronic osteomyelitis). Isolates underwent whole genome sequencing, with assessment for 254 virulence genes and any mutations as well as creation of a phylogenetic tree. Finally, isolates were compared for their ability to form static biofilms and compared to the genetic analysis.

Results

No sequence types predominated amongst osteoarticular infections. Only genes involved in evasion of host immune defenses were more frequently carried by isolates from osteoarticular infections than from skin colonization (p = .02). Virulence gene mutations were only noted in 14 genes (three regulating biofilm formation) when comparing isolates from subjects with osteoarticular infections and those with skin colonization. Biofilm results demonstrated large heterogeneity in the isolates’ capacity to form static biofilms, with healthy control isolates producing more robust biofilm formation.

Conclusions

S. aureus causing osteoarticular infections are genetically heterogeneous, and more frequently harbor genes involved in immune evasion than less invasive isolates. However, virulence gene carriage overall is similar with infrequent mutations, suggesting that pathogenesis of S. aureus osteoarticular infections may be primarily regulated at transcriptional and/or translational levels.

Can intracellular Staphylococcus aureus in osteomyelitis be treated using current antibiotics? A systematic review and narrative synthesis

Approximately 40% of treatments of chronic and recurrent osteomyelitis fail in part due to bacterial persistence. Staphylococcus aureus, the predominant pathogen in human osteomyelitis, is known to persist by phenotypic adaptation as small-colony variants (SCVs) and by formation of intracellular reservoirs, including those in major bone cell types, reducing susceptibility to antibiotics. Intracellular infections with S. aureus are difficult to treat; however, there are no evidence-based clinical guidelines addressing these infections in osteomyelitis. We conducted a systematic review of the literature to determine the demonstrated efficacy of all antibiotics against intracellular S. aureus relevant to osteomyelitis, including protein biosynthesis inhibitors (lincosamides, streptogramins, macrolides, oxazolidines, tetracyclines, fusidic acid, and aminoglycosides), enzyme inhibitors (fluoroquinolones and ansamycines), and cell wall inhibitors (beta-lactam inhibitors, glycopeptides, fosfomycin, and lipopeptides). The PubMed and Embase databases were screened for articles related to intracellular S. aureus infections that compared the effectiveness of multiple antibiotics or a single antibiotic together with another treatment, which resulted in 34 full-text articles fitting the inclusion criteria. The combined findings of these studies were largely inconclusive, most likely due to the plethora of methodologies utilized. Therefore, the reported findings in the context of the models employed and possible solutions for improved understanding are explored here. While rifampicin, oritavancin, linezolid, moxifloxacin and oxacillin were identified as the most effective potential intracellular treatments, the scientific evidence for these is still relatively weak. We advocate for more standardized research on determining the intracellular effectiveness of antibiotics in S. aureus osteomyelitis to improve treatments and patient outcomes.

Locally delivered antistaphylococcal lysin exebacase or CF-296 is active in methicillin-resistant Staphylococcus aureus implant-associated osteomyelitis

Abstract. Introduction: Staphylococcus aureus is the most common cause of orthopedic infections and can be challenging to treat, especially in the presence of a foreign body. The antistaphylococcal lysins exebacase and CF-296 have rapid bactericidal activity, a low propensity for resistance development, and synergize with some antibiotics. Methods: Rabbit implant-associated osteomyelitis was induced by drilling into the medial tibia followed by locally delivering exebacase, CF-296, or lysin carrier. A titanium screw colonized with methicillin-resistant S. aureus (MRSA) IDRL-6169 was inserted. Intravenous daptomycin or saline was administered and continued daily for 4 d. On day 5, rabbits were euthanized, and the tibiae and implants were collected for culture. Results were reported as log10 colony forming units (cfu) per gram of bone or log10 cfu per implant, and comparisons among the six groups were performed using the Wilcoxon rank sum test. Results: Based on implant and bone cultures, all treatments resulted in significantly lower bacterial counts than those of controls (P≤0.0025). Exebacase alone or with daptomycin as well as CF-296 with daptomycin were more active than daptomycin alone (P≤0.0098) or CF-296 alone (P≤0.0154) based on implant cultures. CF-296 with daptomycin was more active than either CF-296 alone (P=0.0040) or daptomycin alone (P=0.0098) based on bone cultures. Conclusion: Local delivery of either exebacase or CF-296 offers a promising complement to conventional antibiotics in implant-associated infections.

Antibiotic-loaded calcium sulfate in clinical treatment of chronic osteomyelitis: a systematic review and meta-analysis

Background

Present work was aimed to gather accessible evidence on the eradication rates and related postoperative complications of antibiotic-loaded calcium sulfate (CS) as an implant in the treatment of chronic osteomyelitis (COM).

Methods

Databases including PubMed, EMBASE, Medline, Ovid and Cochrane library were searched from their dates of initiation until November 2021. Two independent authors scrutinized the relevant studies based on the effectiveness of radical debridement combined with antibiotic-loaded CS for COM; data extraction and quality assessment of the Methodological Index for Non-Randomized Studies (MINORS) criteria were also performed by the authors. In addition, clinical efficacy mainly depended on the evaluation of eradication rates and complications, and all the extracted data are pooled and analyzed by STATA 16.0.

Results

A total of 16 studies with 917 patients (920 locations) were recruited, with an overall eradication rate of 92%. Moreover, the overall reoperation rate, overall refracture rate, overall delayed wound healing rate, and the rate of aseptic wound leakage were 9.0%, 2.0%, 20.0%, and 12.0%, respectively. Moreover, the choice of tobramycin-loaded CS or vancomycin combined with gentamicin-loaded CS did not affect the eradication rate, and the incidence of postoperative complications in COM patients (all $$P>0.05$$ P > 0.05 ). The general quality of the included studies was fair.

Conclusions

Our meta-analysis indicated that the overall eradication rate of COM treated with antibiotic-loaded CS was 92%. Delayed healing is the most common postoperative complication. The choice of tobramycin-loaded CS or vancomycin combined with gentamicin-loaded CS did not affect the eradication rate and the incidence of postoperative complications in COM patients.

The effect of Vitamin B6 in the prevention of hematological adverse effects of linezolid in patients with chronic osteomyelitis: A randomized double-blind placebo-controlled clinical trial

Background:

Due to the contradictory results of the effects of Vitamin B6 in reducing the hematotoxic effects of linezolid, the present study aimed to investigate the possible role of Vitamin B6 administration in reducing linezolid-related hematological toxicities in patients with chronic osteomyelitis.

Materials and Methods:

In a randomized double-blind placebo-controlled clinical trial, patients with chronic osteomyelitis were randomly divided into two groups (n = 40 each): the intervention group received Vitamin B₆40 mg twice daily from the beginning of treatment with linezolid and the control group received placebo with linezolid, both for 21 days. Blood variables including hemoglobin (Hb), white blood cells (WBC), and platelets (PLT) were measured at baseline and at the end of the 1^st, 2^nd, and 3^rd weeks (days 7, 14, and 21) of the intervention.

Results:

There was no significant difference between the groups regarding the count of WBC and PLT and level of Hb at evaluated time points. Furthermore, there was a significant decreasing trend in all parameters within both groups; however, the decreasing trend of both PLT and WBC was slower in the intervention (Vitamin B6) group compared to the placebo group.

Conclusion:

Vitamin B6 has no significant effect in the reduction of hematological adverse effects of linezolid in chronic osteomyelitis patients. However, it could retard the decreasing trend of WBC and PLT counts.

Activity of Omadacycline in Rat Methicillin-Resistant Staphylococcus aureus Osteomyelitis

Omadacycline, vancomycin, and rifampin, as well as rifampin combination therapies, were evaluated in an experimental rat model of methicillin-resistant Staphylococcus aureus (MRSA) osteomyelitis. All treatment groups had less MRSA recovered than saline-treated animals. The emergence of rifampin resistance was observed in 3 of 16 animals with rifampin monotherapy and none with rifampin combination therapy. After treatment, the median tibial bacterial loads were 6.04, 0.1, 4.81, and 5.24 log₁₀ CFU/g for saline-, rifampin-, vancomycin-, and omadacycline-treated animals, respectively. Omadacycline or vancomycin administered with rifampin yielded no detectable MRSA. Omadacycline administered with rifampin deserves evaluation in humans as a potential treatment for osteomyelitis.

Staphylococcus aureus flavohaemoglobin contributes to early stage biofilm development under nitrosative stress

Staphylococcus aureus is a Gram-positive bacterium with capacity to form biofilms, which constitute an important resistance mechanism and virulence factor. Flavohaemoglobin (Hmp) is a major nitric oxide (NO) detoxifier of several bacteria, including S. aureus. Although Hmp has a well-known physiological role linked to response of planktonic cells to nitrosative stress, its contribution to biofilm formation remains unaddressed. Hence, in this work, we investigated the role of Hmp in biofilm development of a methicillin-resistant S. aureus strain. For this purpose, we exposed the hmp mutant to nitrosative stress and examined its behaviour along biofilm development. We observed that cells inactivated in hmp and grown under nitrosative stress conditions have significantly impaired capacity to develop early stage biofilms. Furthermore, the wild-type biofilm phenotype was fully restored by trans-complementation of hmp in the hmp mutant. Coculture studies of NO-producing macrophages with S. aureus revealed that the hmp mutant has significantly lower capacity to develop biofilm biomass when compared with the wild type. Thus, we concluded that the pathogen S. aureus relies on Hmp to establish viable biofilms in the presence of cells of the host innate immune system.

Infections @ Trauma/Orthopedic Implants: Recent Advances on Materials, Methods, and Microbes-A Mini-Review

Implants and materials are indispensable in trauma and orthopedic surgery. The continuous improvements of implant design have resulted in an optimized mechanical function that supports tissue healing and restoration of function. One of the still unsolved problems with using implants and materials is infection. Trauma and material implantation change the local inflammatory situation and enable bacterial survival and material colonization. The main pathogen in orthopedic infections is Staphylococcus aureus. The research efforts to optimize antimicrobial surfaces and to develop new anti-infective strategies are enormous. This mini-review focuses on the publications from 2021 with the keywords S. aureus AND (surface modification OR drug delivery) AND (orthopedics OR trauma) AND (implants OR nails OR devices). The PubMed search yielded 16 original publications and two reviews. The original papers reported the development and testing of anti-infective surfaces and materials: five studies described an implant surface modification, three developed an implant coating for local antibiotic release, the combination of both is reported in three papers, while five publications are on antibacterial materials but not metallic implants. One review is a systematic review on the prevention of stainless-steel implant-associated infections, the other addressed the possibilities of mixed oxide nanotubes. The complexity of the approaches differs and six of them showed efficacy in animal studies.

Novel strategies to diagnose prosthetic or native bone and joint infections

INTRODUCTION

Bone and Joint Infections (BJI) are medically important, costly and occur in native and prosthetic joints. Arthroplasties will increase significantly in absolute numbers over time as well as the incidence of Prosthetic Joint Infections (PJI). Diagnosis of BJI and PJI is sub-optimal. The available diagnostic tests have variable effectiveness, are often below standard in sensitivity and/or specificity, and carry significant contamination risks during the collection of clinical samples. Improvement of diagnostics is urgently needed.

AREAS COVERED

We provide a narrative review on current and future diagnostic microbiology technologies. Pathogen identification, antibiotic resistance detection, and assessment of the epidemiology of infections via bacterial typing are considered useful for improved patient management. We confirm the continuing importance of culture methods and successful introduction of molecular, mass spectrometry-mediated and next-generation genome sequencing technologies. The diagnostic algorithms for BJI must be better defined, especially in the context of diversity of both disease phenotypes and clinical specimens rendered available.

EXPERT OPINION

Whether interventions in BJI or PJI are surgical or chemo-therapeutic (antibiotics and bacteriophages included), prior sensitive and specific pathogen detection remains a therapy-substantiating necessity. Innovative tests for earlier and more sensitive and specific detection of bacterial pathogens in BJI are urgently needed.

Staphylococcus aureus: biofilm formation and strategies against it

The formation of Staphylococcus aureus biofilm causes significant infections in the human body. Biofilm forms through the aggregation of bacterial species and brings about many complications. It mediates drug resistance and persistence and facilitates the recurrence of infection at the end of antimicrobial therapy. Biofilm formation goes through a series of steps to complete, and any interference in these steps can disrupt its formation. Such interference may occur at any stage of biofilm production, including attachment, monolayer formation, and accumulation. Interfering agents can act as quorum sensing inhibitors and interfere in the functionality of quorum sensing receptors, attachment inhibitors and affect the cell hydrophobicity. Among these inhibiting strategies, attachment inhibitors could serve as the best agents against biofilm formation. If pathogens abort the attachment, the following stages of biofilm formation, e.g., accumulation and dispersion, will fail to materialize. Inhibition at this stage leads to suppression of virulence factors and invasion. One of the best-known inhibitors is a chelator that collects metal, Fe+, Zn+, and magnesium critical for biofilm formation. These influential factors in the binding and formation of biofilm are investigated, and the coping strategy is discussed. This review examines the stages of biofilm formation and determines what factors interfere in the continuity of these steps. Finally, the inhibition strategies are investigated, reviewed, and discussed. Keywords: Biofilm, Staphylococcus, Biofilm inhibitor, Dispersion, Antibiofilm agent, EPS, PIA.

3D Cocultures of Osteoblasts and Staphylococcus aureus on Biomimetic Bone Scaffolds as a Tool to Investigate the Host-Pathogen Interface in Osteomyelitis

Osteomyelitis (OM) is an infectious disease of the bone primarily caused by the opportunistic pathogen Staphylococcus aureus (SA). This Gram-positive bacterium has evolved a number of strategies to evade the immune response and subvert bone homeostasis, yet the underlying mechanisms remain poorly understood. OM has been modeled in vitro to challenge pathogenetic hypotheses in controlled conditions, thus providing guidance and support to animal experimentation. In this regard, traditional 2D models of OM inherently lack the spatial complexity of bone architecture. Three-dimensional models of the disease overcome this limitation; however, they poorly reproduce composition and texture of the natural bone. Here, we developed a new 3D model of OM based on cocultures of SA and murine osteoblastic MC3T3-E1 cells on magnesium-doped hydroxyapatite/collagen I (MgHA/Col) scaffolds that closely recapitulate the bone extracellular matrix. In this model, matrix-dependent effects were observed in proliferation, gene transcription, protein expression, and cell–matrix interactions both of the osteoblastic cell line and of bacterium. Additionally, these had distinct metabolic and gene expression profiles, compared to conventional 2D settings, when grown on MgHA/Col scaffolds in separate monocultures. Our study points to MgHA/Col scaffolds as biocompatible and bioactive matrices and provides a novel and close-to-physiology tool to address the pathogenetic mechanisms of OM at the host–pathogen interface.

Bacillus subtilis revives conventional antibiotics against Staphylococcus aureus osteomyelitis

As treatment of Staphylococcus aureus (S. aureus) osteomyelitis is often hindered by the development of antibiotic tolerance, novel antibacterial therapeutics are required. Here we found that the cell-free supernatant of Bacillus subtilis (B. subtilis CFS) killed planktonic and biofilm S. aureus, and increased S. aureus susceptibility to penicillin and gentamicin as well. Further study showed that B. subtilis CFS suppressed the expression of the genes involved in adhesive molecules (Cna and ClfA), virulence factor Hla, quorum sensing (argA, argB and RNAIII) and biofilm formation (Ica and sarA) in S. aureus. Additionally, our data showed that B. subtilis CFS changed the membrane components and increased membrane permeabilization of S. aureus. Finally, we demonstrated that B. subtilis CFS increased considerably the susceptibility of S. aureus to penicillin and effectively reduced S. aureus burdens in a mouse model of implant-associated osteomyelitis. These findings support that B. subtilis CFS may be a potential resistance-modifying agent for β-lactam antibiotics against S. aureus.

Overexpression of Apolipoprotein C1 (APOC1) in Clear Cell Renal Cell Carcinoma and Its Prognostic Significance

Background

The aims of this study included 3 aspects: 1) assessing the expression of Apolipoprotein C1 (APOC1) in clear cell renal cell carcinoma (ccRCC) and normal groups; 2) evaluating the prognostic significance of APOC1 expression in the overall survival (OS) of ccRCC patients; and 3) exploring APOC1-related signaling pathways.

Material/Methods

The APOC1 expression value and clinical data of ccRCC patients were obtained from the cBioPortal database. We then evaluated the association of APOC1 expression with clinical characteristics of ccRCC patients. We also assessed the correlation between APOC1 expression and clinical outcome using Kaplan-Meier method. Our work then verified the independent prognostic factors of ccRCC by Cox regression analysis. Finally, the potential role of genes co-expressed with APOC1 was revealed via functional enrichment analysis.

Results

Bioinformatic data revealed that APOC1 was expressed at higher levels in ccRCC tissue than in the normal group (all P<0.05). The high expression of APOC1 was associated with unfavorable prognosis of female patients (P<0.01), but not of male patients. APOC1 high expression also shortened the survival time of ccRCC patients age ≥60 years old (P<0.05). Cox regression analysis further indicated that APOC1 expression was an independent prognostic factor for OS of ccRCC patients. Additionally, we found that APOC1 expression was significantly associated with sex, grade, clinical stage, and T stage. Finally, enrichment analysis suggested that APOC1-associated pathways were involved in tumor growth and metastasis.

Conclusions

The current study indicated that APOC1 was highly expressed in ccRCC and was significantly associated with key clinical features. APOC1 appears to be an independent prognostic factor in patients with ccRCC. Importantly, APOC1 might be a potential therapeutic target for ccRCC via regulating pathways involved in cell growth and metastasis.