Editorial - Infectious-disease research during a pandemic: the importance of global unity.

The orthopaedic and trauma community have faced the threat of infection since the introduction of operative fracture fixation many decades ago. The parallel emergence and spread of antimicrobial resistance in clinically relevant pathogens has the potential to significantly complicate patient care. This editorial serves to provide a global context to the issue of antimicrobial resistance and how infectious disease research in general plays a crucial role both on a global scale as evidenced by the current pandemic, but also on a more personal scale for the daily management of orthopaedic trauma patients. The special issue on Orthopaedic Infection in the eCM journal provides a snapshot of the clinically relevant basic research that is being performed in this field.

Phagocytosis and macrophage polarization on bacterially contaminated dental implant materials and effects on tissue integration.

Bacterial contamination is hard to avoid during dental implant surgery. Macrophages and their polarisation play a decisive role in bacterial colonisation and tissue integration on bacterially contaminated dental implants. The present study investigated the role of macrophages in stimulating tissue coverage overgrowth of contaminating oral bacteria on polished titanium (Ti-P) and acid-etched zirconium dioxide (ZrO2-MA) dental implant materials. Different co-culture models were employed to determine phagocytosis rates of Streptococcus mitis or Staphylococcus aureus contaminating a dental implant surface and the influence of contaminating bacteria and osteoblasts (U2OS) on macrophage polarisation. S. aureus was phagocytized in higher numbers than S. mitis in bi-cultures on smooth Ti-P surfaces. Contaminating S. mitis stimulated near full polarisation of macrophages from a non-Ym1-expressing- to a Ym1-expressing-phenotype on smooth Ti-P, but on ZrO2-MA both phenotypes occurred. In tri-cultures with U2OS-cells on smooth Ti-P, a larger percentage of macrophages remained in their non-Ym1-expressing, "fighting" M1-like phenotype to clear Ti-P surfaces from contaminating bacteria. On ZrO2-MA surfaces, more macrophages tended towards their "fix- and-repair" M2-like phenotype than on Ti-P surfaces. Surface coverage of smooth, bacterially contaminated Ti-P surfaces by U2OS-cells was more effectively stimulated by fighting, M1-like macrophages than on ZrO2-MA surfaces. Comprehensive guidelines are provided for the development of infection-resistant, dental implant materials, including bacteria, tissue and immune cells. These guidelines point to more promising results for clinical application of Ti-P as compared with ZrO2-MA.

Influence of surface roughness on silicone rubber voice prostheses on in vitro biofilm formation and clinical lifetime in laryngectomised patients.

OBJECTIVES: Evaluation of the influence of a smooth surface moulding technique of silicone rubber indwelling voice prostheses on in vitro biofilm formation and analysis of the clinical in situ lifetime. DESIGN: Biofilm formation on smooth and Groningen ultra low resistance (URL) prostheses was studied in an artificial throat model. The clinical lifetime of smooth voice prostheses was compared to the previous lifetime of URL by counting the number of replacements in a consecutive 6-month period in the same patient. PARTICIPANTS: Eleven laryngectomised patients in follow-up who required frequent replacement of their voice prostheses. SETTINGS: Tertiary University Medical Center. RESULTS: Use of a smoother mould and less viscous silicone rubber yielded a decrease in surface roughness from 46 to 8 nm and was accompanied by a 40% reduction in the prevalence of bacteria and yeast in in vitro formed biofilms. Clinically, the lifetime was significantly (P<.005) increased by a factor of 2.1. CONCLUSIONS: This combined in vitro and clinical study suggests that the choice of material and in particular its surface finishing may be determining factors with respect to the clinical lifetime of silicone rubber implants and devices failing due to biofilm formation.

A biodegradable gentamicin-hydroxyapatite-coating for infection prophylaxis in cementless hip prostheses.

A degradable, poly (lactic-co-glycolic acid) (PLGA), gentamicin-loaded prophylactic coating for hydroxyapatite (HA)-coated cementless hip prostheses is developed with similar antibacterial efficacy as offered by gentamicin-loaded cements for fixing traditional, cemented prostheses in bone. We describe the development pathway, from in vitro investigation of antibiotic release and antibacterial properties of this PLGA-gentamicin-HA-coating in different in vitro models to an evaluation of its efficacy in preventing implant-related infection in rabbits. Bone in-growth in the absence and presence of the coating was investigated in a canine model. The PLGA-gentamicin-HA-coating showed high-burst release, with antibacterial efficacy in agar-assays completely disappearing after 4 days, minimising risk of inducing antibiotic resistance. Gentamicin-sensitive and gentamicin-resistant staphylococci were killed by the antibiotic-loaded coating, in a simulated prosthesis-related interfacial gap. PLGA-gentamicin-HA-coatings prevented growth of bioluminescent staphylococci around a miniature-stem mounted in bacterially contaminated agar, as observed using bio-optical imaging. PLGA-gentamicin-HA-coated pins inserted in bacterially contaminated medullary canals in rabbits caused a statistically significant reduction in infection rates compared to HA-coated pins without gentamicin. Bone ingrowth to PLGA-gentamicin-HA-coated pins, in condylar defects of Beagle dogs was not impaired by the presence of the degradable, gentamicin-loaded coating. In conclusion, the PLGA-gentamicin-HA-coating constitutes an effective strategy for infection prophylaxis in cementless prostheses.

The implant infection paradox: why do some succeed when others fail? Opinion and discussion paper.

Biomaterial-implants are frequently used to restore function and form of human anatomy. However, the presence of implanted biomaterials dramatically elevates infection risk. Paradoxically, dental-implants placed in a bacteria-laden milieu experience moderate failure-rates, due to infection (0.0-1.1%), similar to the ones of joint-arthroplasties placed in a near-sterile environment (0.1-1.3%). Transcutaneous bone-fixation pins breach the immune-barrier of the epidermis, exposing underlying sterile-tissue to an unsterile external environment. In contrast to dental-implants, also placed in a highly unsterile environment, these pins give rise to relatively high infection-associated failure-rates of up to 23.0%. Herein, we attempt to identify causes as to why dental-implants so often succeed, where others fail. The major part of all implants considered are metal-made, with similar surface-finishes. Material choice was therefore discarded as underlying the paradox. Antimicrobial activity of saliva has also been suggested as a cause for the success of dental-implants, but was discarded because saliva is the implant-site-fluid from which viable bacteria adhere. Crevicular fluid was discarded as it is largely analogous to serum. Instead, we attribute the relative success of dental-implants to (1) ability of oral tissues to heal rapidly in the continuous presence of commensal bacteria and opportunistic pathogens, and (2) tolerance of the oral immune-system. Inability of local tissue to adhere, spread and grow in presence of bacteria and an intolerant immune-system are identified as the likely main causes explaining the susceptibility of other implants to infection-associated failure. In conclusion, it is the authors' belief that new anti-infection strategies for a wide range of biomaterial-implants may be derived from the relative success of dental-implants.

Real-time quantification of matrix metalloproteinase and integrin αvß3 expression during biomaterial-associated infection in a murine model.

Biomaterial implants and devices increase the risk of microbial infections due to the biofilm mode of growth of infecting bacteria on implant materials, in which bacteria are protected against antibiotic treatment and the local immune system. Matrix-metalloproteinases (MMPs) and cell surface integrin receptors facilitate transmigration of inflammatory cells toward infected or inflamed tissue. This study investigates the relationship between MMP- and integrin-expression and the clearance of infecting Staphylococcus aureus around implanted biomaterials in a murine model.MMP- and integrin αvß3-expression were monitored in mice, with and without subcutaneously implanted biomaterial samples, in the absence and presence of bioluminescent S. aureus Xen36. Staphylococcal persistence was imaged longitudinally over time using bioluminescence imaging. The activatable MMPSense®680 and integrin-targeted IntegriSense®750 probes were injected on different days after implantation and their signal intensity and localisation monitored using fluorescence imaging. After sacrifice 7 or 16 days post-implantation, staphylococci from biomaterial samples and surrounding tissues were cultured on agar-plates and presence of host inflammatory cells was histologically evaluated.MMP- and integrin-expression were equally enhanced in presence of staphylococci or biomaterials up to 7 days post-implantation, but their localisation along the biomaterial samples differed. Bacterial clearance from tissue was higher in the absence of biomaterials. It is of clinical relevance that MMP- and integrin-expression were enhanced in presence of both staphylococci and biomaterials, although the immune system in the presence of biomaterials remained hampered in eradicating bacteria during the first 7 days post-implantation.

Antimicrobial penetration in a dual-species oral biofilm after noncontact brushing: an in vitro study.

OBJECTIVES: Oral biofilm is inevitably left behind, even after powered brushing. As a special feature, powered brushing removes biofilm in a noncontact mode. When the brushing distance becomes too large, biofilm is left behind. We hypothesize that biofilm left behind after brushing has different viscoelastic properties than before brushing, impacting antimicrobial penetration. MATERIALS AND METHODS: In vitro grown dual-species biofilms were subjected to 20 % mechanical deformation before and after powered brushing at 4-mm brushing distance. Biofilm thickness and stress relaxation were measured for unbrushed and brushed biofilms. Stress relaxation was analyzed with a three-element Maxwell model. Antimicrobial penetration from five mouthrinses was microscopically evaluated for unbrushed and brushed biofilms. RESULTS: Thicknesses of unbrushed and brushed biofilms were similar. Brushing decreased the prevalence of fast and increased the prevalence of slow relaxation elements, which was accompanied by deeper penetration of chlorhexidine and cetylpyridinium chloride. Penetration of antimicrobials from other mouthrinses was relatively low in unbrushed and brushed biofilms. CONCLUSIONS: This confirmation of our hypothesis points to an additional advantage of powered toothbrushing in a noncontact mode, changing the viscoelastic properties of biofilm in a direction that increases antimicrobial penetration of chlorhexidine and cetylpyridinium. CLINICAL RELEVANCE: The biofilm left behind after noncontact powered toothbrushing may have less recalcitrance toward penetration of chlorhexidine and cetylpyridinium chloride than prior to brushing.

Heterogeneity in liquid shaken cultures of Aspergillus niger inoculated with melanised conidia or conidia of pigmentation mutants.

Black pigmented conidia of Aspergillus niger give rise to micro-colonies when incubated in liquid shaken medium. These micro-colonies are heterogeneous with respect to gene expression and size. We here studied the biophysical properties of the conidia of a control strain and of strains in which the fwnA, olvA or brnA gene is inactivated. These strains form fawn-, olive-, and brown-coloured conidia, respectively. The ΔolvA strain produced larger conidia (3.8 µm) when compared to the other strains (3.2-3.3 µm). Moreover, the conidia of the ΔolvA strain were highly hydrophilic, whereas those of the other strains were hydrophobic. The zeta potential of the ΔolvA conidia in medium was also more negative when compared to the control strain. This was accompanied by the near absence of a rodlet layer of hydrophobins. Using the Complex Object Parametric Analyzer and Sorter it was shown that the ratio of individual hyphae and micro-colonies in liquid shaken cultures of the deletion strains was lower when compared to the control strain. The average size of the micro-colonies of the control strain was also smaller (628 µm) than that of the deletion strains (790-858 µm). The size distribution of the micro-colonies of the ΔfwnA strain was normally distributed, while that of the other strains could be explained by assuming a population of small and a population of large micro-colonies. In the last set of experiments it was shown that relative expression levels of gpdA, and AmyR and XlnR regulated genes correlate in individual hyphae at the periphery of micro-colonies. This indicates the existence of transcriptionally and translationally highly active and lowly active hyphae as was previously shown in macro-colonies. However, the existence of distinct populations of hyphae with high and low transcriptional and translational activity seems to be less robust when compared to macro-colonies grown on solid medium.

Effect of adsorbed fibronectin on the differential adhesion of osteoblast-like cells and Staphylococcus aureus with and without fibronectin-binding proteins.

The influence of fibronectin (Fn) coated surfaces patterned with poly(ethylene glycol) microgels having inter-gel spacings between 0.5 and 3.0 µm on the adhesion of Staphylococcus aureus strains with and without Fn-binding proteins and cellular adhesion/spreading was investigated. Quantitative force measurements between a S. aureus cell and a patterned surface showed that the adhesion force between the bacterium and the patterned surface increased substantially after Fn adsorption, regardless of the strain used, but decreased with decreasing inter-gel spacing. In flow-chamber experiments, the Fn-binding strain adhered at a higher rate after Fn adsorption than the strain lacking Fn-binding proteins. In both cases, the adhesion rates decreased with decreasing inter-gel spacing. Osteoblast-like cells could bind to patterned surfaces despite the microgels, and adsorbed Fn substantially amplified this effect. Even under highly non-adhesive conditions associated with closely spaced microgels, adsorbed Fn preserves a window of inter-gel spacing around 1 µm where the adhesion of staphylococcal cells is hindered while cells can still adhere and spread.

Inheritance of physico-chemical properties and ROS generation by carbon quantum dots derived from pyrolytically carbonized bacterial sources.

Bacteria are frequently used in industrial processes and nutrient supplementation to restore a healthy human microflora, but use of live bacteria is often troublesome. Here, we hypothesize that bacterially-derived carbon-quantum-dots obtained through pyrolytic carbonization inherit physico-chemical properties from probiotic and pathogenic source-bacteria. Carbon-quantum-dots carbonized at reaction-temperatures below 200 â€‹°C had negligible quantum-yields, while temperatures above 220 â€‹°C yielded poor water-suspendability. Fourier-transform infrared-spectroscopy demonstrated preservation of amide absorption bands in carbon-quantum-dots derived at intermediate temperatures. X-ray photoelectron-spectroscopy indicated that the at%N in carbon-quantum-dots increased with increasing amounts of protein in source-bacterial surfaces. Carbonization transformed hydrocarbon-like bacterial surface compounds into heterocyclic aromatic-carbon structures, evidenced by a broad infrared absorption band (920-900 â€‹cm-1) and the presence of carbon in C-C functionalities of carbon-quantum-dots. The chemical composition of bacterially-derived carbon-quantum-dots could be explained by the degradation temperatures of main bacterial cell surface compounds. All carbon-quantum-dots generated reactive-oxygen-species, most notably those derived from probiotic lactobacilli, carrying a high amount of surface protein. Concluding, amide functionalities in carbon-quantum-dots are inherited from surface proteins of source-bacteria, controlling reactive-oxygen-species generation. This paves the way for applications of bacterially-derived carbon-quantum-dots in which reactive-oxygen-species generation is essential, instead of hard-to-use live bacteria, such as in food supplementation or probiotic-assisted antibiotic therapy.

Bacterial biofilm formation versus mammalian cell growth on titanium-based mono- and bi-functional coating.

Biomaterials-associated-infections (BAI) are serious complications in modern medicine. Although non-adhesive coatings, like polymer-brush coatings, have been shown to prevent bacterial adhesion, they do not support cell growth. Bi-functional coatings are supposed to prevent biofilm formation while supporting tissue integration. Here, bacterial and cellular responses to poly(ethylene glycol) (PEG) brush-coatings on titanium oxide presenting the integrin-active peptide RGD (arginine-glycine-aspartic acid) (bioactive "PEG-RGD") were compared to mono-functional PEG brush-coatings (biopassive "PEG") and bare titanium oxide (TiO2) surfaces under flow. Staphylococcus epidermidis ATCC 35983 was deposited on the surfaces under a shear rate of 11 s-1 for 2 h followed by seeding of U2OS osteoblasts. Subsequently, both S. epidermidis and U2OS cells were grown simultaneously on the surfaces for 48 h under low shear (0.14 s-1). After 2 h, staphylococcal adhesion was reduced to 3.6-/+1.8 x 103 and 6.0-/+3.9 x 103 cm-2 on PEG and PEG-RGD coatings respectively, compared to 1.3-/+0.4 x 105 cm-2 for the TiO2 surface. When allowed to grow for 48 h, biofilms formed on all surfaces. However, biofilms detached from the PEG and PEG-RGD coatings when exposed to an elevated shear (5.6 s-1) U2OS cells neither adhered nor spread on PEG brush-coatings, regardless of the presence of biofilm. In contrast, in the presence of biofilm, U2OS cells adhered and spread on PEG-RGD coatings with a significantly higher surface coverage than on bare TiO2. The detachment of biofilm and the high cell surface coverage revealed the potential significance of PEG-RGD coatings in the context of the "race for the surface" between bacteria and mammalian cells.

Energy transfer, volumetric expansion, and removal of oral biofilms by non-contact brushing.

Non-contact removal of oral biofilms offers advantages beyond the reach of bristles, but it is unknown how energy transfer for removal from brush-to-biofilm occurs. In the present study we evaluated non-contact, oral biofilm removal by oscillating-rotating and sonic toothbrushes, and their acoustic output up to 6 mm distance. Whereas some brushes removed biofilm when used at a distance of up to 6 mm, others lost efficacy at a distance of 2-4 mm from the biofilm. Loss of efficacy was accompanied with high standard deviations and volumetric biofilm expansion. Both sonic and oscillating-rotating brushes caused fluid flows and the inclusion of air-bubbles, while non-contact acoustic energy-transfer was demonstrated to decay with distance for both types of brushes. We put forward the following mechanism for non-contact removal: (i) brush energy is absorbed by biofilm, resulting in the visco-elastic expansion of the biofilm; (ii) if the energy absorbed is sufficient and deformation is beyond the yield point, biofilm removal occurs; and (iii) if deformation is in the plastic range but below the yield point (i.e. at the limiting distance for non-contact removal), biofilm is expanded but not removed.

Retention of antimicrobial activity in plaque and saliva following mouthrinse use in vivo.

The aim of this study was to determine the contribution of plaque and saliva towards the prolonged activity, also called substantivity, of three antimicrobial mouthrinses (Listerine®, Meridol®, Crest Pro Health®), used in combination with a toothpaste (Prodent Coolmint®). Volunteers brushed for 4 weeks with a toothpaste without antimicrobial claims, while during the last 2 weeks half of the volunteers used an antimicrobial mouthrinse in addition to brushing. At the end of the experimental period, plaque and saliva samples were collected 6 h after oral hygiene, and bacterial concentrations and viabilities were determined. The contribution of plaque and saliva towards substantivity was assessed by combining plaque obtained after mechanical cleaning only with plaque and saliva obtained after additional use of an antimicrobial rinse. Subsequently, resulting viabilities of the combined plaques were determined. The viabilities of plaque samples after additional rinsing with mouthrinses were lower than of plaque obtained after mechanical cleaning only, regardless of the rinse involved. Moreover, plaque collected 6 h after rinsing with antimicrobial mouthrinses contained a surplus of antimicrobial activity. Only Listerine showed decreased viability in saliva, but none of the mouthrinses showed any residual antimicrobial activity in saliva. The findings indicate that plaque left behind after mechanical cleaning contributes to the prolonged substantivity of antimicrobial mouthrinses.

Microbubble-enriched lavage fluid for treatment of experimental peritonitis.

BACKGROUND: Relaparotomies and closed postoperative peritoneal lavage (CPPL) are performed to treat persistent peritonitis. This experimental animal study compared open abdominal lavage with CPPL, and evaluated the potential of microbubble-enriched lavage fluids to improve the efficiency of CPPL and reduce clinical morbidity, mortality and cost. METHODS: Fluorescent polystyrene spheres were injected intraperitoneally into 22 male Wistar rats to simulate localized peritonitis. After 18 h the rats received open abdominal lavage and CPPL, with and without microbubbles. Microbubbles were obtained by adding ultrasound contrast agents to continuous ambulatory peritoneal dialysis fluid. RESULTS: Open abdominal lavage was 3.5 times more effective in particle removal than CPPL, owing to better fluid dynamics. The introduction of air-liquid interfaces in the form of microbubbles made CPPL up to 2.4 times more effective than lavage without bubbles. Best detachment results were obtained when microbubbles with a flexible surfactant shell and longer blood elimination half-life were used. CONCLUSION: Open abdominal and CPPL lavage techniques are not efficient beyond a certain duration and volume as they do not cause bacterial detachment from the peritoneal membrane. Using surface tension forces from microbubbles significantly enhanced polystyrene particle detachment. These findings may have great consequences for the treatment of patients with peritonitis.

Morphological aspects of surgical meshes as a risk factor for bacterial colonization.

BACKGROUND: Prosthetic meshes are increasingly popular in abdominal wall reconstructive surgery owing to a reduction in hernia recurrence rate. Individual meshes have been evaluated with respect to the formation of infectious biofilms, but no comprehensive comparison yet exists. The aim of this study was to evaluate the effect of the material and morphology of surgical meshes on biofilm growth. METHODS: Biofilms of a coagulase-negative staphylococcus, Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa were grown in vitro on different meshes. Intact biofilms were stained fluorescently and evaluated with confocal laser scanning microscopy to distinguish dead from live bacteria and slime. RESULTS: Numbers of adhering bacteria and the amount of slime in the biofilm were dependent on the morphology of the mesh. Hydrophobicity and the presence of niches in multifilament meshes contributed most to increased biofilm growth. CONCLUSION: The morphological properties of surgical meshes as well as their hydrophobicity influence bacterial growth and slime production. Differences in slime production may explain why the effectiveness of antibiotic treatment varies for different types of mesh.

Effects of amine fluoride on biofilm growth and salivary pellicles.

The amine fluoride (AmF) N'-octadecyl-trimethylene-diamine-N,N,N'-tris(2-ethanol)-dihydro-fluoride is a cationic antimicrobial which can have beneficial effects on plaque formation. Here, we determine changes in pellicle and bacterial cell surface properties of the strains Actinomyces naeslundii HM1, Streptococcus mutans NS, S.mutans ATCC 700610, S. sobrinus HG1025 and S. oralis HM1 upon adsorption of this AmF and accompanying effects on bacterial adhesion and biofilm growth. In vitro pellicles had a zeta potential of -12 mV that became less negative upon adsorption of AmF. The chemical functionalities in which carbon and oxygen were involved changed after AmF adsorption and AmF-treated pellicles had a greater surface roughness than untreated pellicles. Water contact angles in vitro decreased from 56 to 45 degrees upon AmF treatment, which corresponded with water contact angles (44 degrees ) measured intraorally on the front incisors of volunteers immediately after using an AmF-containing toothpaste. All bacterial strains were negatively charged and their isoelectric points (IEP) increased upon AmF adsorption. Minimal inhibitory concentrations were smallest for strains exhibiting the largest increase in IEP. Adhesion to salivary pellicles and biofilm growth of the mutans streptococcal strains were significantly reduced after AmF treatment, but not of A. naeslundii or S. oralis. However, regardless of the strain involved, biofilm viability decreased significantly after AmF treatment. The electrostatic interaction between cationic AmF and negatively charged bacterial cell surfaces is pivotal in establishing reduced biofilm formation by AmF through a combination of effects on initial adhesion and killing. The major effect of AmF treatment, however, was a reduction brought about in biofilm viability.

How a fungus escapes the water to grow into the air.

Fungi are well known to the casual observer for producing water-repelling aerial moulds and elaborate fruiting bodies such as mushrooms and polypores. Filamentous fungi colonize moist substrates (such as wood) and have to breach the water-air interface to grow into the air. Animals and plants breach this interface by mechanical force. Here, we show that a filamentous fungus such as Schizophyllum commune first has to reduce the water surface tension before its hyphae can escape the aqueous phase to form aerial structures such as aerial hyphae or fruiting bodies. The large drop in surface tension (from 72 to 24 mJ m-2) results from self-assembly of a secreted hydrophobin (SC3) into a stable amphipathic protein film at the water-air interface. Other, but not all, surface-active molecules (that is, other class I hydrophobins and streptofactin from Streptomyces tendae) can substitute for SC3 in the medium. This demonstrates that hydrophobins not only have a function at the hyphal surface but also at the medium-air interface, which explains why fungi secrete large amounts of hydrophobin into their aqueous surroundings.

Sequence of oral bacterial co-adhesion and non-contact brushing.

Non-contact plaque removal offers advantages in interproximal spaces, fissures, and pockets. It requires the generation of strong fluid flows and the inclusion of air bubbles to become effective. A pair of co-adhering streptococci and actinomyces has been used previously to demonstrate non-contact removal by sonic brushing. Here we determined the influence of the sequence of co-adhesion of streptococci and actinomyces on non-contact removal from a salivary pellicle by rotary and sonic brushing. After bacterial adhesion, pellicles were brushed in a wet and immersed state, with a distance up to 4 mm to the bristle tips. Bacteria adhering to pellicles from the sequence streptococci followed by actinomyces appeared more difficult to remove and left more large co-aggregates than from the sequence actinomyces followed by streptococci. At contact, rotary and sonic brushing performed equally well in bacterial removal, while at 4 mm, both had lost some efficacy.

Guiding periodontal pocket recolonization: a proof of concept.

The complexity of the periodontal microbiota resembles that of the gastro-intestinal tract, where infectious diseases are treatable via probiotics. In the oropharyngeal region, probiotic or replacement therapies have shown some benefit in the prevention of dental caries, otitis media, and pharyngitis, but their effectiveness in the treatment of periodontitis is unknown. Therefore, this study addressed the hypothesis that the application of selected beneficial bacteria, as an adjunct to scaling and root planing, would inhibit the periodontopathogen recolonization of periodontal pockets. Analysis of the data showed, in a beagle dog model, that when beneficial bacteria were applied in periodontal pockets adjunctively after root planing, subgingival recolonization of periodontopathogens was delayed and reduced, as was the degree of inflammation, at a clinically significant level. The study confirmed the hypothesis and provides a proof of concept for a guided pocket recolonization (GPR) approach in the treatment of periodontitis.

Evaluation of measures to decrease intra-operative bacterial contamination in orthopaedic implant surgery.

The aim of this study was to evaluate whether behavioural and systemic measures will decrease intra-operative contamination during total hip or knee replacements. The influence of these measures on subsequent prolonged wound discharge, superficial surgical site infection and deep periprosthetic infection was also investigated during an 18-month follow-up period. Four swabs were taken from instruments at the beginning and end of the procedure for 207 procedures. Removed bone material (acetabulum and femur in case of the hip joint; femur and tibia in case of the knee joint) was also tested for contamination. Initially, 70 operations performed under original control conditions were included, after which the first behavioural measure was introduced (i.e. better use of the plenum). Cultures were taken during 67 operations using better use of the plenum (Group 1), followed by disciplinary measures and the installation of a new laminar flow system. Seventy operations were monitored after this second intervention (Group 2). The control group showed intra-operative contamination in 32.9% (23/70) of cases, Group 1 showed contamination in 34.3% (23/67) of cases and Group 2 showed contamination in 8.6% (6/70) of cases. Prolonged wound discharge and superficial surgical site infection decreased significantly in Group 2, as did the incidence of deep periprosthetic infection; however, the latter did not reach statistical significance. This study shows that the combination of systemic and behavioural changes in an operating room significantly decreases the incidence of intra-operative bacterial contamination, subsequent prolonged wound discharge and superficial surgical site infection. After 18 months of follow-up, there was also a decrease in deep periprosthetic infection.