Epidemiology and microbiology of prosthetic joint infections: a nine-year, single-center experience in Pavia, Northern Italy.

BACKGROUND: Prosthetic joint infections (PJIs) are a growing matter of concern due to their economic and social burden on health systems. In Italy, surgical data on PJIs are available in a national registry, but microbiological data are still scarce. MATERIALS AND METHODS: We performed a retrospective study at a single center with records of patients treated for primary PJIs of knee or hip from January 1, 2011, to May 30, 2018. Patients with infections of osteosynthesis means and external devices were excluded, as well as PJI recurrences and polytrauma patients. Infections were diagnosed according to IDSA and MSIS criteria. We collected data on demographics, risk factors and microbiology. All patients seen at our center undergo blood cultures and synovial fluid cultures, periarticular biopsy and prosthesis sonication by Bactosonic®. This was used only after 2014. Bacterial identification is achieved by MALDI-TOF, PHOENIX 100 and standard methods. Chi-square or Fisher tests were used to test statistical differences in proportions. RESULTS: Fifty-one patients matched our inclusion criteria. Of these, 16 (31.4%) were enrolled before 2014. The median age was 68.5 (range 22-88). The most common risk factors were obesity (34%), diabetes (21%) and chronic kidney disease (14%). Seventeen patients were diagnosed with a culture-negative PJIs (33.3%). Staphylococcus aureus was the most commonly isolated pathogen (14/51, 27.5%), followed by coagulase-negative staphylococci (7/51, 13.7%). Methicillin-resistant S. aureus rate was 28.6%. The rate of culture-negative PJIs dropped from 56 to 22% after 2014, with a significant difference between the two time periods (p = 0.016). CONCLUSIONS: The introduction of sonication dramatically increased our diagnostic accuracy. Our microbiological data are in line with those from other studies conducted in Italy.

Prosthetic Joint Infection from Carbapenemase-Resistant Klebsiella pneumoniae Successfully Treated with Ceftazidime-Avibactam.

Antimicrobial resistance in Gram-negative bacteria, particularly Enterobacteriaceae, has become a leading cause of morbidity and mortality and a serious public health concern. Gram-negative bacteria carrying extended-spectrum beta-lactamase (ESBL) enzymes now represent a significant proportion of all bacteria isolated from different countries worldwide. Furthermore, the increasing number of isolates carrying carbapenemases in recent years includes multidrug-resistant (MDR), extensively drug-resistant (XDR), and pandrug-resistant (PDR) bacteria. Here, we describe what, to our knowledge, is the first case of a patient with a prosthetic joint infection from carbapenemase-resistant Klebsiella pneumoniae (CRKP) successfully treated with ceftazidime-avibactam in Italy.

Polyphosphazene membranes and microspheres in periodontal diseases and implant surgery.

Membranes or microcapsules made from polyphosphazenes bearing amino acid side groups are proposed for the treatment of periodontal diseases. Polyphosphazene membranes, prepared with alanine ethyl ester and imidazole in the molar ratio of 80:20 as phosphorus substituents, gave a degradation rate that corresponded to the healing of the bone defect. These membranes were much more successful in promoting healing of rabbit tibia defects than polytetrafluoroethylene membranes. Antibacterial or anti-inflammatory drugs, useful in periodontal tissue regeneration, could be entrapped in the polyphosphazene membranes and released both in vitro and in vivo at a rate that ensured therapeutic concentrations in the surrounding tissue. Polyphosphazene microspheres, prepared with phenylalanine ethyl ester as a phosphorus substituent and loaded with succinylsulphathiazole or naproxen, were also obtained. The kinetics of release from these matrices were very convenient in yielding local concentrations of the two drugs that are useful per se or when mixed with hydroxyapatite for better bone formation.

In vitro and in vivo evaluation of a somatostatin analogue released from PLGA microspheres.

The purpose of this study was to design poly(lactide-co-glycolide) (PLGA) microspheres for the continuous delivery of the somatostatin analogue, vapreotide, over 2-4 weeks. The microspheres were produced by spray-drying and the desired characteristics, i.e. high encapsulation efficiency and controlled release over 2-4 weeks, achieved through optimizing the type of polymer, processing solvent, and co-encapsulated additive. The in vitro release was tested in fetal bovine serum preserved with 0.02% of thiomersal. Furthermore, formulations were injected intramuscularly into rats to obtain pharmacokinetic profiles. Encapsulation efficiency was between 34 and 91%, depending on the particular formulation. The initial peptide release (within 6 h) was lowest, i.e. <20%, when acetic acid was used as processing solvent and highest, i.e. 57%, with dichloromethane. The various co-encapsulated additives generally lowered the encapsulation efficiency by 15-30%. The best formulation in terms of low burst and effective drug serum levels (>1 ng/ml) over 21-28 days in rats was the one made with end-group uncapped PLGA 50:50, the solvent acetic acid and the additive polyethyleneglycol. In conclusion, the optimization of formulation parameters allowed us to produce vapreotide-loaded PLGA microspheres of suitable characteristics for therapeutic use.

PEG-Ara-C conjugates for controlled release.

The antitumour agent 1-beta-D arabinofuranosilcytosyne (Ara-C) was covalently linked to poly(ethylene glycol) (PEG) in order to improve the in vivo stability and blood residence time. Eight PEG conjugates were synthesised, with linear or branched PEG of 5000, 10000 and 20000 Da molecular weight through an amino acid spacer. Starting from mPEG-OH or HO-PEG-OH, conjugation was carried out to the one or two available hydroxyl groups at the polymer's extreme. Furthermore, to increase the drug loading of the polymer, the hydroxyl functions of PEG were functionalised with a bicarboxylic amino acid yielding a tetrafunctional derivative and, by recursive conjugation with the same bicarboxylic amino acid, products with four or eight Ara-C molecules for each PEG chain were prepared. A computer graphic investigation demonstrated that aminoadipic acid was a suitable bicarboxylic amino acid to overcome the steric hindrance between the vicinal Ara-C molecules in the dendrimeric structure. In this paper we report the optimised conditions for synthesis and purification of PEG-Ara-C products with a low amount of remaining free drug, studies toward the hydrolysis of PEG-Ara-C and the Ara-C deamination by cytidine deaminase, pharmacokinetics in mice and cytotoxicity towards HeLa human cells were also investigated. Increased stability towards degradation of the conjugated Ara-C products, in particular for the highly loaded ones, improved blood residence time in mice and a reduced cytotoxicity with respect to the free Ara-C form was demonstrated.

Importance of the test medium for the release kinetics of a somatostatin analogue from poly(D,L-lactide-co-glycolide) microspheres.

The determination of in vitro release kinetics of peptides from poly(d,l-lactide-co-glycolide) (PLGA) microspheres generally requires optimization of the test conditions for a given formulation. This is particularly important when in vitro/in vivo correlation should be determined. Here, the somatostatin analogue vapreotide pamoate, an octapeptide, was microencapsulated into PLGA 50:50 by spray-drying. The solubility of this peptide and its in vitro release kinetics from the microspheres were studied in various test media. The solubility of vapreotide pamoate was approximately 20-40 microg/ml in 67 mM phosphate buffer saline (PBS) at pH 7.4, but increased to approximately 500-1000 microg/ml at a pH of 3.5. At low pH, the solubility increased with the buffer concentration (1-66 mM). Very importantly, proteins (aqueous bovine serum albumin (BSA) solution or human serum) appeared to solubilize the peptide pamoate, resulting in solubilities ranging from 900 to 6100 microg/ml. The release rate was also greatly affected by the medium composition. Typically, in PBS of pH 7.4, only 33+/-1% of the peptide were released within 4 days, whereas 53+/-2 and 61+/-0.9% were released in 1% BSA solution and serum, respectively. The type of medium was found critical for the estimation of the in vivo release. The in vivo release kinetics of vapreotide pamoate from PLGA microspheres following administration to rats were qualitatively in good agreement with those obtained in vitro using serum as release medium. Finally, sterilization by gamma-irradiation had only a minor effect on the in vivo pharmacokinetics.

Specificity and sensitivity of 3rd generation EIA for detection of HCV antibodies among intravenous drug-users.

Serum samples from 487 ambulatory I.V. drug users were screened for HIV and HCV antibodies to determine the prevalence of coinfection in this high risk group for AIDS. For anti-HCV antibody screening we first used a 3rd generation EIA using, as antigen synthetic peptides which were not subjected to false positive results due to antibodies against superoxide dismutase or against yeast proteins (which may copurify with the recombinant proteins employed in the first and second generation test). The specimens that were positive in the screening test were confirmed by a more specific EIA system that detect antibodies to proteins encoded by structural (HCV-st EIA) and non structural (HCV-nst-EIA) regions of the HCV genome. A second confirmation assay was also performed: sera were run in presence or absence of blocking reagents which inhibits antibodies to C200 and C22 HCV epitopes for binding to the solid phase. The sensitivity of the HCV EIA screening for human HCV antibody detection revealed a 100% positivity for HCV infection. The confirmatory strategy presented in this paper revealed an HCV EIA specificity of 98.6%. In this work we demonstrated a significantly higher prevalence (p < 0.001) of HCV exposure in HIV infected individuals compared to the general population. Our experimental data also confirmed that HBV infection in drug-users at high risk for HIV infection was significantly associated with HCV infection (p < 0.001). In contrast, the acquisition of HIV by sexual contact was not a statistically significant risk factor for HCV coinfection.

Control of hepatitis B: evaluation of two different vaccinal schedules in newborns from HBsAg negative mothers.

504 healthy infants, born to HBsAg negative mothers from May 1st to December 31st 1991, were randomly allocated to an accelerated (group A) or traditional (group B) immunization schedule. The group A infants were immunized at 4 days, 1 month and 3 months of life with 10 micrograms of recombinant HBV vaccine (Engerix B, SKF) while the group B infants were immunized at 4 days, 1 month and 6 months of life with the same dose of vaccine. One month after the first dose of vaccine, 9.2% of the infants in both groups had an HBsAb serum level > 10 mIU/ml. One month after the booster dose, at 4 months of life for group A and at 7 months for group B, 97.40% and 98.53% of the infants presented a serum level > 10 mIU/ml respectively. None in group A and only 2 patients in group B could be considered non-responders (serum concentration below 2 mIU/ml) and 4 infants in group A and 4 in group B were considered hypo-responders (serum level between 2.1 and 9.9 mIU/ml). Immunogenetic study performed on the 2 non-responders and 6 of the hypo-responders, revealed the presence in all but two of the HLA haplotypes, classically involved in the lack of hyporesponsiveness to foreign peptides, namely: HLA-DR7; DQ2, DR4; DQ3, DR15; DQ6 and DR3; DQ2. Surprisingly, 2 hypo-responders carried the HLA haplotypes (DR11, DQ7 and DR13, DQ6), usually associated with hyperresponsiveness. Both vaccinal cycles provided evidence that infants respond well to vaccination, started at birth, against hepatitis B virus with a high degree of protection.(ABSTRACT TRUNCATED AT 250 WORDS)

In vitro evaluation of ceftazidime (GR 20263), amikacin and sisomicin, in a model simulating serum pharmacokinetics of therapeutic doses.

The activity of ceftazidime, amikacin and sisomicin was investigated in an in vitro model using varying concentrations of antibiotic which mimic the serum levels of patients after the intramuscular administration of a 500, 250 and 70 mg dose respectively. Using this test, during the time of the agar MIC value correlation, ceftazidime, amikacin and sisomicin proved to be active against strains sensitive to 16 micrograms/ml, 8 micrograms/ml and 4 micrograms/ml respectively. Using the above concentrations as the cut-off points in defining the sensitivity of the strains, ceftazidime revealed the same level of activity as amikacin (6 and 5 resistant strains respectively out of the 185 tested) and proved much more active than sisomicin (48 resistant strains).

Effect of non-steroidal antiinflammatory drugs on some biological activities dependent on complement activation.

The paper presents the results of a study on the action of five non-steroidal antiinflammatory agents (phenylbutazone, indometacin, acetylsalicylic acid, niflumic and flufenamic acids) on two biological activities which are dependent on complement activation: opsonization of bacteria and membrane damage, the latter evaluated both with the classic immunohemolytic system and with a bactericidal assay. The three biological assays differ for complement sequences involved. Flufenamic and niflumic acids showed high inhibitory activity in the lytic assays. Human complement was more sensitive to inhibition than guinea-pig complement. Phagocytic test confirmed the inhibitory activity of flufenamic acid on complement dependent opsonization.

Synergistic interaction of bactericidal drugs and a factor present in serum ultrafiltrate.

Ultrafiltrate of serum of guinea-pig and man contains a factor which interacts synergistically with cephaloridine, kanamycin, and nalidixic acid against Escherichia coli. The factor on its own is not bactericidal. Gel filtration showed that the main peaks of the fractions with biological activity correspond to a MW of about 200. Chemical analysis excluded the presence of carbohydrates, proteins, ribonucleic acid at levels detectable with standard methods. Moreover the activity of the factor was not destroyed by meat nor by acid and enzymatic hydrolysis. A sequential mechanism or a reaction of the factor with drugs are considered as two possible explanations of the interaction.

Experimental infections for the evaluation of beta-lactamase resistance.

The antibacterial activity and pharmacokinetics of the beta-lactamase-stable cephalosporin cefuroxime and the gram-negative beta-lactamase-susceptible cephalosporin cefazolin were compared in two contrasting infection models in which Proteus morganii 82, which produces chromosomally mediated beta-lactamase, was the pathogen. In the rat paw model, characterized by high numbers of localized bacteria, cefazolin was destroyed at the site of infection and consequently did not produce a therapeutic response. In the mouse intraperitoneal model cefazolin was also inactive, despite peritoneal concentrations being unaffected by high counts of the beta-lactamase-producing P. morganii in the body cavity. In contrast the pharmacokinetics of cefuroxime was unaffected by the presence of the beta-lactamase-producing P. morganii, and good therapeutic responses were seen in both models.

Duration of immune protection after hepatitis B vaccine in newborns from HBsAg-positive carrier mothers.

A group of 43 healthy neonates born from HBsAg-positive mothers were evaluated for the presence of protective HBsAb titre after administration of hepatitis B plasma-derived vaccine and hepatitis B hyperimmune-globulin. At 36 months of life we found that a significant number of children had a low HBsAb serum level. This suggests that a close serologic follow-up is necessary to evaluate the optimal timing for the administration of a booster dose of the vaccine.

Immunogenicity of hepatitis B vaccine in term and preterm infants.

Some studies have suggested that decreased seroconversion rates might be found in premature infants with low birthweight (< 2000g) following administration of hepatitis B vaccine at birth. The aim of the present investigation was to evaluate possible differences in seropositive rates between full-term and preterm infants after primary vaccination, in particular when gestational age or birthweight is very low. Two-thousand and nine neonates born to HBsAg-negative mothers were vaccinated with 10 microg of recombinant hepatitis B virus (HBV) vaccine, from May 1991 to October 1994. Children with infections, congenital malformations or serious illnesses were excluded. HBV vaccine was administered intramuscularly, on the fourth day of life and again at 1 and 6 months of age. A 1-ml blood sample was drawn from each infant 1 month after the third vaccine dose for determination of the level of anti-HBs antibody. The response to HBV vaccination was evaluated in 241 preterm (gestational age <38 weeks) infants and 1727 term neonates. No statistical difference was observed in the distribution of anti-HBs antibody level, either between preterm infants (<38 weeks) and newborns of normal gestational age, or between low birthweight (<2500 g) and normal weight infants. The results suggest that preterm and low birthweight infants (<2500g) respond to HBV vaccine in the same measure as normal-term infants.

Identification of two subtypes of serotype 4 human rotavirus by using VP7-specific neutralizing monoclonal antibodies.

Two distinct subtypes of human rotavirus serotype 4 were identified by using neutralizing monoclonal antibodies directed to the major outer capsid glycoprotein, VP7, of strains ST3 (subtype 4A) and VA70 (subtype 4B). Specimens containing serotype 4 rotavirus, obtained from different countries, were examined for subtyping by using solid-phase immune electron microscopy, enzyme-linked immunosorbent assay, and, for cell culture-adapted strains, neutralization assay. All 59 human rotavirus strains identified as serotype 4 by using animal antisera were classified into either subtype by monoclonal antibodies. This suggests that the antigenic difference between the two subtypes is a consequence of critical variations within the immunodominant serotype 4-specific neutralization site of rotavirus VP7. Subtype 4A (ST3-like) strains were predominant and were detected in stools from patients with gastroenteritis, as well as from healthy infants and young children.

Human immunodeficiency virus (HIV): an ultrastructural study.

H-9 cells producing HIV were examined by electron microscopy to value the virus-host cell relationships. HIV fine structure was also studied. HIV induces little cellular damages and it can penetrate into the cytoplasm by phagocytosis. Phagocytosis of the virus could play an important role in the mechanism of cellular infection.

Kinetics of p24 antigenemia, IgM, IgG antibodies to p24 and p41 and Ig virus isolation in rabbits experimentally infected with HIV-1.

In rabbits experimentally infected with 1.10(5) u.i./ml HIV, IgM antibodies were detected 10-15 days after infection, reaching peak value two weeks later and remaining stable for two weeks long. Then a the IgM serotiters progressively decreased and were negative at ten weeks. HIV p24 antigen was detected ten-fifteen days after infection, reaching peak value five-six weeks later. Antigenemia subsequently decreased and reached a second peak after nine weeks. In our experimental conditions, the antigenemia persisted throughout the observation period. The IgG antibody titer reached a maximum two weeks after infection; the time course showed a decrease after ten weeks, followed by progressively decreasing fluctuating course. After twenty four weeks of infection the serotiter values though lower were always positive. Three-four weeks after infection we detected IgG antibodies to the major core protein p24. Reactivity of IgG antibodies to gp41 was observed earlier than reactivity to p24; these antibodies were detected over six months after infection. Viruses indistinguishable from HIV were isolated from the peripheral blood mononuclear cells of infected rabbits 30, 60 and 180 days after infection. These data further confirm that the rabbit may serve as an economical and reproducible model for HIV infection in which vaccines and antiviral agents could be tested.

Detection of IgG anti-HIV antibodies in mice experimentally infected with HIV-1.

In the present work we report our preliminary data demonstrating the susceptibility of mouse to HIV infection. IgG antibodies were found in mice intraperitoneally inoculated with H9/HTLV-IIIB infected cells. Infected mice showed a humoral response and the antibodies detection includes specific immunoglobulin directed against the major gene product of HIV. Two weeks after infection with HIV infected cells we detected in mice IgG antibodies to p24, and the reactivity to gp41 was observed as early as reactivity to p24 and persisted throughout observation period. The persistence of specific antibody response to HIV after one year seems to demonstrate the possibility of the use of the mouse as animal model for HIV in vivo experiments. Studies concerning the degree and kinetic of HIV infection in mouse are in progress in our laboratory.