Farklı antibiyotik içeren yıkama solüsyonlarının Staphylococcus aureus ile kirletilmiş allogreftlerin dekontaminasyonundaki etkinliğinin karşılaştırılması

Öz

Amaç: Bu çalışmanın amacı Staphylococcus aureus ile kontamine edilmiş allogreftlerin dekontaminasyonunda serum fizyolojik, rifampisin, gentamisin, düşük ve yüksek konsantrasyonlu fusidik asit içeren yıkama solüsyonlarının lokal antibakteriyel etkinliğinin araştırılması idi. Çalışma planı: Kemik bankasından sterilite kontrolü yapılarak elde edilmiş, taze dondurulmuş 55 femur başı metisiline duyarlı ATCC 25923 Staphylococcus aureus ile kontamine edilip gruplara ayrıldıktan sonra, yüksek basınçlı (80 psi) pulse lavaj kullanılarak serum fizyolojik, rifampisinli yıkama solüsyonu (50 mg/l), gentamisinli yıkama solüsyonu (50 mg/l), düşük (50 mg/l) ve yüksek konsantrasyonlu (500 mg/l) fusidik asitli yıkama solüsyonu ile 10 cm’lik mesafeden 30 saniye süreyle yıkandı. Yıkama sonrası allogreftler kültüre ekilerek koloni sayımı yapıldı. Ortalama±standart sapma değerleri (minimum-maksimum) hesaplandı. Dört yıkama grubu arasındaki farklılıklar Kruskal-Wallis varyans analizi ile değerlendirilerek, post-hoc Mann-Whitney U testi ile ikili gruplar halinde karşılaştırıldı. Bulgular: Rifampisinli yıkama solüsyonu ile yapılan yıkamada bir allogreft haricinde kolonizasyona rastlanmadı. Gentamisinli yıkama solüsyonu ile yıkamadan elde edilen sonuçlar, düşük konsantrasyonlu fusidik asit içeren yıkama solüsyonu ve serum fizyolojikten üstünken (sırasıyla, p=0.010 ve 0.004), yüksek konsantrasyonlu fusidik asit içeren yıkama solüsyon grubundakiler ile benzerlik göstermekteydi. Düşük ve yüksek konsantrasyonlu fusidik asit içeren yıkama solüsyonları ile elde edilen sonuçlar birbirine benzer iken, serum fizyolojikle yapılan yıkamaya göre bir üstünlükleri saptanmadı. Çıkarımlar: Staphylococcus aureus ile kontamine edilmiş allogreftlerin dekontaminasyonunda rifampisinli yıkama solüsyonunun en fazla etkili olduğu saptanırken, etkinlik sıralamasına göre gentamisinli, yüksek konsantrasyonlu fusidik asitli, düşük konsantrasyonlu fusidik asitli ve son olarak serum fizyolojikli yıkama solüsyonunun etkili olduğu gösterilmiştir.

Anahtar Kelimeler

• Fusidik asit; irrigasyon; kontamine kemik; Staphylococcus aureus

Comparison of the efficiency of different antibiotic irrigation solutions in decontamination of allografts contaminated with Staphylococcus aureus

Abstract

Objective: The purpose of this study was to investigate the local antibacterial efficacy of saline, rifampicin, gentamicin, high-concentration fusidic acid and low-concentration fusidic acid in the
decontamination of allografts contaminated with Staphylococcus aureus.
Methods: Fifty-five sterile, fresh-frozen femoral heads obtained from the bone bank were contaminated with methicillin-sensitive ATCC 25923 Staphylococcus aureus. Samples were divided into groups and debrided with high-pressure (80 psi) pulse lavage using a saline, rifampicin irrigation solution (50 mg/l), gentamicin irrigation solution (50 mg/l) and low- (50 mg/l) or high concentration (500 mg/l) fusidic acid irrigation solution for 30 seconds from a distance of 10 cm. After irrigation, allografts were incubated in the culture and developed colonies were counted. Mean±standard deviation (min-max) values were calculated. The differences between the four irrigation groups were evaluated using the Kruskal-Wallis variance analysis and groups were compared two at a time using the post-hoc MannWhitney U test.
Results: No colonization was detected with the exception of one allograft in the rifampicin irrigation group. The gentamicin irrigation group had similar results as the high-concentration fusidic acid irrigation group and both results were superior to those of the saline and low-concentration fusidic acid irrigation groups (p=0.010 and 0.004, respectively). The low- and high-concentration fusidic acid irrigation groups were similar and were not shown to have superior results than saline irrigation group.
Conclusion: Rifampicin irrigation solution was the most effective in the decontamination of allografts previously contaminated with Staphylococcus aureus. Gentamicin, high-concentration fusidic acid, lowconcentration fusidic and saline irrigation solutions may also be used respectively, according to their effectiveness.

Keywords

• Contaminated bone
• fusidic acid
• irrigation
• Staphylococcus aureus

Kaynakça

1. Gustilo RB, Mendoza RM, Williams DN. Problems in the management of type III (severe) open fractures: a new classi- fication of type III open fractures. J Trauma 1984;24:742-6.
2. Gustilo RB, Merkow RL, Templeman D. The management of open fractures. J Bone Joint Surg Am 1990;72:299-304.
3. Bhandari M, Adili A, Schemitsch EH. The efficacy of low- pressure lavage with different irrigating solutions to remove adherent bacteria from bone. J Bone Joint Surg Am 2001;83- A:412-9.
4. Conroy BP, Anglen JO, Simpson WA, Christensen G, Phaup G, Yeager R, et al. Comparison of castile soap, benzalkonium chloride, and bacitracin as irrigation solutions for complex contaminated orthopaedic wounds. J Orthop Trauma 1999; 13:332-7.
5. Burd T, Conroy BP, Meyer SC, Allen WC. The effects of chlorhexidine irrigation solution on contaminated bone-ten- don allografts. Am J Sports Med 2000;28:241-4.
6. Hooe W, Steinberg B. Management of contaminated bone grafts: an experimental in vitro study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1996;82:34-7.
7. Soyer J, Rouil M, Castel O. The effect of 10% povidone – iodine solution on contaminated bone allografts. J Hosp Infect 2002;50:183-7.
8. Tarbox BB, Conroy BP, Malicky ES, Moussa FW, Hockman DE, Anglen JO, et al. Benzalkonium chloride. A potential disinfecting irrigation solution for orthopaedic wounds. Clin Orthop Relat Res 1998;(346):255-61.

9. Owens BD, White DW, Wenke JC. Comparison of irriga- tion solutions and devices in a contaminated musculoskeletal wound survival model. J Bone Joint Surg Am 2009;91:92-8.
10. Kural C, Kaya I, Yilmaz M, Demirbafl E, Yücel B, Korkmaz M, et al. A comparison between three irrigation methods in the debridement of contaminated bovine cancellous bone and the effect of duration of irrigation on the efficiency of debridement. Acta Orthop Traumatol Turc 2009;43:359-65.
11. Svoboda SJ, Bice TG, Gooden HA, Brooks DE, Thomas DB, Wenke JC. Comparison of bulb syringe and pulsed lavage irrigation with use of a bioluminescent musculoskele- tal wound model. J Bone Joint Surg Am 2006;88:2167-74.
12. Anglen JO, Apostoles S, Christensen G, Gainor B. The effi- cacy of various irrigation solutions in removing slime-pro- ducing Staphylococcus. J Orthop Trauma 1994;8:390-6.
13. Lee EW, Dirschl DR, Duff G, Dahners LE, Miclau T. High-pressure pulsatile lavage irrigation of fresh intraarticu- lar fractures: effectiveness at removing particulate matter from bone. J Orthop Trauma 2002;16:162-5.
14. Draeger RW, Dirschl DR, Dahners LE. Debridement of can- cellous bone: a comparison of irrigation methods. J Orthop Trauma 2006;20:692-8.
15. Crowley DJ, Kanakaris NK, Giannoudis PV. Irrigation of the wounds in open fractures. J Bone Joint Surg Br 2007;89: 580-5.
16. Calfee DP. Rifamycins. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett’s principles and prac- tices of infectious diseases. 7th ed. Philadelphia: Churchill Livingstone; 2010. p. 403-17.
17. Liu JW, Chao LH, Su LH, Wang JW, Wang CJ. Experience with a bone bank operation and allograft bone infection in recipients at a medical centre in southern Taiwan. J Hosp Infect 2002;50:293-7.
18. Hirn M, Laitinen M, Pirkkalainen S, Vuento R. Cefuroxime, rifampicin and pulse lavage in decontamination of allograft bone. J Hosp Infect 2004;56:198-201.
19. Hirn M, Laitinen M, Vuento R. Pulse lavage washing in decon- tamination of allografts improves safety. Chir Organi Mov 2003;88:149-52.
20. Kittinger C, Marth E, Windhager R, Weinberg AM, Zarfel G, Baumert R, et al. Antimicrobial activity of gentamicin palmi- tate against high concentrations of Staphylococcus aureus. J Mater Sci Mater Med 2011;22:1447-53.
21. Gilbert DN, Leggett JE. Aminoglycosides. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett’s principles and practices of infectious diseases. 7th ed. Philadelphia: Churchill Livingstone; 2010. p. 359-84.
22. Wang JL, Tang HJ, Hsieh PH, Chiu FY, Chen YH, Chang MC, et al. Fusidic acid for the treatment of bone and joint infections caused by meticillin-resistant Staphylococcus aureus. Int J Antimicrob Agents 2012;40:103-7.
23. Mandell LA. Fusidic acid. In: Mandell GL, Bennett JE, Dolin R, editors. Mandell, Douglas and Bennett’s principles and practices of infectious diseases. 7th ed. Philadelphia: Churchill Livingstone; 2010. p. 355-7.
24. Drugeon HB, Caillon J, Juvin ME. In-vitro antibacterial activ- ity of fusidic acid alone and in combination with other antibi- otics against methicillin-sensitive and -resistant Staphylococcus aureus. J Antimicrob Chemother 1994;34:899-907.
25. Neut D, Hendriks JG, van Horn JR, Kowalski RS, van der Mei HC, Busscher HJ. Antimicrobial efficacy of gentamicin- loaded acrylic bone cements with fusidic acid or clindamycin added. J Orthop Res 2006;24:291-9.
26. Ersoz G, Oztuna V, Coskun B, Eskandari MM, Bayarslan C, Kaya A. Addition of fusidic acid impregnated bone cement to systemic teicoplanin therapy in the treatment of rat osteomyelitis. J Chemother 2004;16:51-5.
27. Hirn MY, Salmela PM, Vuento RE. High-pressure saline washing of allografts reduces bacterial contamination. Acta Orthop Scand 2001;72:83-5.
28. Gross A, Bhaskar SN, Cutright DE, Beasley JD 3rd, Perez B. The effect of pulsating water jet lavage on experimental con- taminated wounds. J Oral Surg 1971;29:187-90.
29. Dirschl DR, Wilson FC. Topical antibiotic irrigation in the prophylaxis of operative wound infections in orthopedic sur- gery. Orthop Clin North Am 1991;22:419-26.
30. Bahrs C, Schnabel M, Frank T, Zapf C, Mutters R, von Garrel T. Lavage of contaminated surfaces: an in vitro evaluation of the effectiveness of different systems. J Surg Res 2003;112:26- 30.
31. Bhandari M, Schemitsch EH, Adili A, Lachowski RJ, Shaughnessy SG. High and low pressure pulsatile lavage of con- taminated tibial fractures: an in vitro study of bacterial adher- ence and bone damage. J Orthop Trauma 1999;13:526-33.
32. Hassinger SM, Harding G, Wongworawat MD. High-pres- sure pulsatile lavage propagates bacteria into soft tissue. Clin Orthop Relat Res 2005;(439):27-31.
33. Boyd JI 3rd, Wongworawat MD. High-pressure pulsatile lavage causes soft tissue damage. Clin Orthop Relat Res 2004; (427):13-7.