Rapid degradation and non-selectivity of Dakin's solution prevents effectiveness in contaminated musculoskeletal wound models

BACKGROUND

Dakin's solution (buffered sodium hypochlorite) has been used as a topical adjunct for the treatment of invasive fungal infections in trauma patients. Prudent use of Dakin's solution (DS) for complex musculoskeletal wound management implies balancing antimicrobial efficacy and human tissue toxicity, but little empirical evidence exists to inform clinical practice. To identify potentially efficacious DS concentrations and application methods, we conducted two animal studies to evaluate the ability of DS to reduce bacterial burden in small and large animal models of contaminated musculoskeletal wounds.

METHODS

An established rat (Rattus norvegicus) contaminated femoral defect model was employed to evaluate the antimicrobial efficacy of DS as a topical adjunctive treatment for Staphylococcus aureus infection. A range of clinically-relevant DS concentrations (0.00025%-0.125%) were tested, both with and without periodic replenishment during treatment. Next, an established goat (Capra hircus) musculoskeletal wound model, consisting of a Pseudomonas aeruginosa contaminated proximal tibia cortical defect, muscle crush, and thermal injury, was utilized to evaluate the antimicrobial efficacy of dilute DS (0.0025% and 0.025%) as a surgical irrigant solution. In situ reactive chlorine concentrations were monitored throughout each treatment using an automated iodometric titration approach.

RESULTS

In a rat wound model, DS treatment did not significantly reduce S. aureus bioburden after 14 days as compared to saline control. Two treatment groups (0.01% single application and 0.025% multiple application) exhibited significantly higher bacterial burden than control. In a goat musculoskeletal wound model, neither 0.0025% nor 0.025% DS significantly altered P. aeruginosa bioburden immediately following treatment or at 48 h post-treatment. Overall, DS applied to exposed soft tissue exhibited rapid degradation, e.g., 0.125% DS degraded 32% after 5 s progressing to 86% degradation after 15 min following single application.

CONCLUSIONS

We did not observe evidence of a therapeutic benefit following Dakin's solution treatment for any tested concentration or application method in two contaminated musculoskeletal wound models. Despite confirmation of robust bactericidal activity in vitro, our findings suggest DS at current clinically-used concentrations does not kill tissue surface-attached bacteria, nor does it necessarily cause host tissue toxicity that exacerbates infection in the setting of complex musculoskeletal injury.

Characteristics of US combat veterans (2001-2011) who remain on active duty after upper extremity amputations

OBJECTIVES

Return to duty following traumatic amputations has been extensively studied in those with lower extremity amputation. As upper extremity amputations occur less frequently, the issue of return to duty for those with upper extremity amputations has received relatively little research. The purpose of this study was to determine the rate at which service members remain on active duty at least one year after having sustained traumatic upper extremity amputations during Operation Iraqi Freedom, Operation Enduring Freedom, and other overseas contingency operations of the Global War on Terrorism.

DESIGN

Retrospective.

SETTING

Military, Academic Level 1 trauma center.

PATIENTS

One hundred eighteen patients who sustained combat-related upper extremity amputations between October 2001 and December 2011.

INTERVENTION

Data was obtained from the medical record for these 118 patients.

MAIN OUTCOME MEASUREMENTS

Percentage of service member remaining on active duty one year following an upper extremity amputation, and evaluation of demographic and injury related factors associated with retention.

RESULTS

The overall rate for the upper extremity amputees studied at one year from injury who remained on active duty was 47%. Officers were more likely to remain on active duty than their enlisted counterparts (P=.021) and patients who sustained burns were also more likely to remain on active duty than patients with similar amputation types without concomitant burn injuries (P=.039).

CONCLUSIONS

The rate of service members with traumatic upper extremity amputations who were still on active duty status 1-year postinjury was 47%. The presence of burns and rank were significant factors when examining retention on active duty. Further study on war casualties who sustain upper-extremity traumatic amputations with and without burns is required to optimize outcomes in this population.

CD70 and IFN-1 selectively induce eomesodermin or T-bet and synergize to promote CD8+ T-cell responses

CD70-mediated stimulation of CD27 is an important cofactor of CD4(+) T-cell licensed dendritic cells (DCs). However, it is unclear how CD70-mediated stimulation of T cells is integrated with signals that emanate from signal 3 pathways, such as type-1 interferon (IFN-1) and IL-12. We find that while stimulation of CD27 in isolation drives weak Eomesodermin(hi) T-bet(lo) CD8(+) T-cell responses to OVA immunization, profound synergistic expansion is achieved by cotargeting TLR. This cooperativity can substantially boost antiviral CD8(+) T-cell responses during acute infection. Concomitant stimulation of TLR significantly increases per cell IFN-γ production and the proportion of the population with characteristics of short-lived effector cells, yet also promotes the ability to form long-lived memory. Notably, while IFN-1 contributes to the expression of CD70 on DCs, the synergy between CD27 and TLR stimulation is dependent upon IFN-1's effect directly on CD8(+) T cells, and is associated with the increased expression of T-bet in T cells. Surprisingly, we find that IL-12 fails to synergize with CD27 stimulation to promote CD8(+) T-cell expansion, despite its capacity to drive effector CD8(+) T-cell differentiation. Together, these data identify complex interactions between signal 3 and costimulatory pathways, and identify opportunities to influence the differentiation of CD8(+) T-cell responses.

CD27 stimulation promotes the frequency of IL-7 receptor-expressing memory precursors and prevents IL-12-mediated loss of CD8(+) T cell memory in the absence of CD4(+) T cell help

Fully functional CD8(+) T cell memory is highly dependent upon CD4(+) T cell support. CD4(+) T cells play a critical role in inducing the expression of CD70, the ligand for CD27, on dendritic cells. In this study, we demonstrate that CD27 stimulation during primary CD8(+) T cell responses regulates the ability to mount secondary CD8(+) T cell responses. CD27 stimulation during vaccinia and dendritic cell immunization controls the expression of the IL-7R (CD127), which has been shown to be necessary for memory CD8(+) T cell survival. Furthermore, CD27 stimulation during primary CD8(+) T cell responses to vaccinia virus restrained the late expression on memory precursor cells of cytokine receptors that support terminal differentiation. The formation of CD8(+) T cell memory precursors and secondary CD8(+) T cell responses was restored in the absence of CD27 costimulation when endogenous IL-12 was not available. Similarly, the lesion in CD8(+) T cell memory that occurs in the absence of CD4(+) T cells did not occur in mice lacking IL-12. These data indicate that CD4(+) T cell help and, by extension, CD27 stimulation support CD8(+) T cell memory by modulating the expression of cytokine receptors that influence the differentiation and survival of memory CD8(+) T cells.

Cytokine-induced inflammation in the ovine teat and udder

The inflammatory response, as measured by the accumulation of leukocytes and ovine serum albumin, induced by interleukin-1 beta (IL-1 beta), tumour necrosis factor-alpha (TNF-alpha), interleukin-beta (IL-8), and granulocyte-macrophage colony stimulating factor (GM-CSF) was studied in lactating ovine udders, and in test cisterns of dry ewes after surgical closure of the passage between the teat and udder cisterns. In the lactating udders, IL-1 beta and TNF-alpha, but not IL-8 and GM-CSF, induced significant accumulation of cells. In the teat cisterns, all four cytokines IL-1 beta, TNF-alpha, IL-8, and GM-CSF induced significant cell accumulation. IL-1 beta was the most potent cytokine. A slight increase in serum albumin, paralleling the changes in leukocyte numbers, was observed after infusion of IL-1 beta and, to some extent, TNF-alpha. The cell accumulation induced by IL-1 beta or TNF-alpha was dose and time dependent in lactating udders, and time-dependent in teat cisterns. The cell numbers were considerably higher in lactating udders than in teat cisterns after infusion with IL-1 beta. The first influx of cells was observed earlier, and the cell numbers peaked earlier in the teat cisterns than in the lactating udders. IL-8 and GM-CSF induced dose and time dependent cell accumulation in teat cisterns only. The differences between lactating udders and teat cisterns may be attributable to the differences in tissue area involved and the number of receptors available, or to dilution of cytokines in milk, or to presence of inhibitory factors. Differences between cytokines in their inflammatory effects may be explained by their modes of action. IL-1 beta and TNF-alpha have a wide range of cellular functions enabling them to induce a more prominent response than IL-8 and GM-CSF. Furthermore, receptors for IL-1 beta and TNF-alpha are present on a larger number of cell types. Finally, the results indicated that the teat cisterns, being the port of entry for udder infections, as well as the lactating udders are capable of a diversified inflammatory response which is important in the defence against udder infections.

Survey of intramammary infections in ewes on the New England Tableland of New South Wales

Samples of mammary secretion were collected aseptically from 1093 ewes in 8 separate flocks. Most of the ewes were suckling lambs 4 to 6 weeks old. Standard bacteriological tests were carried out on the samples to identify the organisms involved in intramammary infections. Data on age, breed, lactational status and clinical status of the gland and its secretion were recorded at the time of sampling. The prevalence of intramammary infection was 14% of ewes (8% of glands). There was a tendency for prevalence of intramammary infection to be positively correlated with age of the ewe (two-year-old and six-year-old ewes had, respectively, 4.4% and 14.0% of glands infected). This relationship was highly significant for Border Leicester x Merino ewes. There were also significant differences in infection prevalence between breeds. infected glands had a higher prevalence of clinical abnormalities of udder, teat and secretion than did non-infected glands. Staphylococcus aureus was overwhelmingly the most frequently isolated bacterium being responsible for 40% of all intramammary infections.

Immunological cross-reactivity between pseudocapsular antigens of strains of Staphylococcus aureus isolated from cases of bovine mastitis

An assay was developed to measure the degree of immunological cross-reactivity between the pseudocapsules of a vaccine (reference) strain of Staphylococcus aureus and pseudocapsules of strains of S. aureus isolated from cases of bovine mastitis. The field strains were obtained from Australia, New Zealand, Norway, the U.K. and the U.S.A. There was large variation among strains in cross-reactivity of their pseudocapsules with those of the reference strain. For 104 Australian strains, the range of cross-reactivity indices (CRI) was 6.1-63.2% (on a scale of 0-100%, with 0% being complete identity and 100% being nil identity); for 61 overseas strains the range of CRI values was 25.7-72.1%. The data indicated that pseudocapsule antigens of Australian strains were antigenically more closely related to those of the reference strain than were pseudocapsular antigens of strains from the 4 other countries.