Prophylaxis of implant-related infections by local release of vancomycin from a hydrogel in rabbits.

Local prophylaxis with antibiotic-loaded bone cement is a successful method to prevent post-operative infections in patients receiving orthopaedic implants. No comparable method is available for uncemented implants. Therefore, a hydrogel consisting of hyaluronic and polylactic acids was evaluated in a rabbit model for delivery of antimicrobial agents to prevent post-operative infections. In a pilot study, the suitability of the in vivo model was assessed by testing the hydrogel as carrier material for antimicrobial agents.In the main study, the antimicrobial-agent-loaded hydrogel was evaluated for infection prophylaxis. Rabbits received a titanium rod intramedullary in the tibia after contamination with Staphylococcus aureus. The rods were coated with unloaded hydrogel (Gel), hydrogel loaded with 2 % (Van2) or 5 % vancomycin (Van5), bioactive glass (BAG) or N-acetyl-L-cysteine (NAC). To analyse the infection severity after 28 d, histopathological, bacteriological, micro-computed tomographic and haematological analyses were performed. In the pilot study, the Van5 group had less infection (0/6 infected) as compared to the Gel group (5/5, p = 0.000) and the in vivo model was deemed suitable. In the main study, in the Van2 and Van5 groups, the number of infected animals was lower [1/6 (p = 0.006) and 2/6 (p = 0.044) infected, respectively]. In contrast, BAG and NAC groups showed no infection reduction (5/6 both groups, p = 0.997). The hydrogel can be used as a local carrier of vancomycin for prophylaxis of implant-related infections.The present study showed promising results for local delivery of antibacterial agents by hydrogel to prevent implant-related infections.

[Pathophysiology of implant-associated infections: From biofilm to osteolysis and septic loosening]. / Pathophysiologie der implantatassoziierten Infektion : Vom Biofilm zur Osteolyse und septischen Lockerung.

Biofilm formation is the key factor in the pathogenesis of implant-associated infections. The most common pathogens isolated are Staphylococcus species, opportunists belonging to the physiological flora of the skin. Biofilm formation starts with the adhesion of bacteria and colonisation preferentially occurs on the surfaces of the foreign body material. As an interactive symbiotic "city of microbes," biofilm formation represents an efficient survival strategy for bacteria. In clinically apparent infections the biofilm induces a local host response with infiltration of phagocytic immune cells. The proinflammatory microenvironment results in a stimulation of osteoclastogenesis, with local osteolysis, and finally septic loosening of the implant. According to the biofilm theory, retaining the implant in primary revision surgery is only recommended in early-stage infections with a stable implant; in late-stage infections, or when loosening occurs, the implant should be removed. Results of previous anti-biofilm therapies have not been satisfactory; therefore, current research is focused on prevention strategies, especially the modification of implant surfaces. Basic knowledge of the underlying pathophysiology is a prerequisite for the development of innovative interdisciplinary therapy and prevention strategies; in this context, essential aspects of biofilm formation, its consequences, and its relevance to diagnosis and therapy are described and discussed.

Expression of CD57 on CD8+ T lymphocytes of patients with Wegener's granulomatosis and microscopic polyangiitis: evidence for continuous activation of CD8+ cells.

OBJECTIVES: To gain insight into the immune pathogenesis of Wegener's granulomatosis (WG) and microscopic polyangiitis (MPA), the prevalence of circulating CD8+ T lymphocytes expressing CD57 as a marker for previous activation was analyzed. METHODS: Receptor expression of CD57 was measured in CD8+ T cells of patients with active disease (n=5) by cytofluorometry and compared with expression in patients in remission (n=80) and in age-matched healthy donors (n=34). The results were compared to clinical parameters including severity and duration of the disease. RESULTS: CD8+CD57+ were detected in patients with WG and MPA and in healthy donors as well and increased considerably with age. Compared to age-matched healthy donors, the prevalence of CD8+CD57+ was increased in the younger patients (up to 40 y). In most patients a high percentage of CD8+CD57+ coincided with severe disease and multiple organ involvement, while low CD8+CD57+ percentage was seen in patients with limited disease or in patients in complete remission. In patients with smoldering disease, the percentage of CD8+CD57+ increased with time. High numbers of CD8+CD57+ correlated with low CD4:CD8 ratio. CONCLUSIONS: In patients with WG and MPA a population of CD8+CD57+ expand, identifying terminally differentiated CD8+ cells. The prevalence of CD57+ cells was related to the course of disease. So far, the function of CD57 on CD8+ cells is not understood. However, these cells might produce certain cytokines, which play a role in the pathogenesis of AAV. The data support the hypothesis that CD8+ T cells are activated in the context of primary vasculitides.

Expression of the CXCR6 on polymorphonuclear neutrophils in pancreatic carcinoma and in acute, localized bacterial infections.

The chemokine receptor CXCR6 has been described on lymphoid cells and is thought to participate in the homing of activated T-cells to non-lymphoid tissue. We now provide evidence that the chemokine receptor CXCR6 is also expressed by activated polymorphonuclear neutrophils (PMN) in vivo: Examination of biopsies derived from patients with pancreatic carcinoma by confocal laser scan microscopy revealed a massive infiltration of PMN that expressed CXCR6, while PMN of the peripheral blood of these patients did not. To answer the question whether CXCR6 expression is a property of infiltrated and activated PMN, leucocytes were collected from patients with localized soft tissue infections in the course of the wound debridement. By cytofluorometry, the majority of these cells were identified as PMN. Up to 50% of these PMN were also positive for CXCR6. Again, PMN from the peripheral blood of these patients were nearly negative for CXCR6, as were PMN of healthy donors. In a series of in vitro experiments, up-regulation of CXCR6 on PMN of healthy donors by a variety of cytokines was tested. So far, a minor, although reproducible, effect of tumour necrosis factor (TNFalpha) was seen: brief exposure with low-dose TNFalpha induced expression of CXCR6 on the surface of PMN. Furthermore, we could show an increased migration of PMN induced by the axis CXCL16 and CXCR6. In summary, our data provide evidence that CXCR6 is not constitutively expressed on PMN, but is up-regulated under inflammatory conditions and mediates migration of CXCR6-positive PMN.

T lymphocytes in patients with primary vasculitis: expansion of CD8+ T cells with the propensity to activate polymorphonuclear neutrophils.

OBJECTIVES: To gain insight into the immune pathogenesis of primary ANCA-associated vasculitides, the prevalence of circulating T lymphocytes expressing CD11b as a marker for activation was analysed in patients with WG or microscopic polyangiitis. METHODS; Receptor expression and IFNgamma synthesis were measured in T cells of patients with active disease by cytofluorometry and compared with expression in patients in remission and in healthy donors. RESULTS: During active disease, a small but conspicuous population of CD8+CD28+CD11b+ was found which produced IFNgamma. In healthy donors and in patients in remission or undergoing immunosuppressive therapy, CD11b was exclusively associated with CD8+CD28- cells, the latter being more frequent in patients with long-lasting or severe disease. In vitro experiments confirmed that CD11b is up-regulated when T cells are activated. After multiple rounds of restimulation, the CD11b expression persists whereas CD28 expression is lost, compatible with the notion that CD8+CD28+CD11b+ represents a transient phenotype in the course of T-cell activation. The IFNgamma-producing T cells activated polymorphonuclear neutrophils (PMN) to express MHC class II, thus generating the same PMN phenotype as in patients with active ANCA-associated vasculitis. A similar PMN phenotype could be generated by cultivation with supernatants of activated T cells or by IFNgamma alone, but not by antibodies to proteinase 3. CONCLUSIONS: In active primary vasculitis, a small population of CD8+ T cells, identified by the expression of CD11b, expands, producing IFNgamma. These T cells could activate PMN, thus generating a long-living and potentially destructive PMN phenotype.

The extracellular polymer substance of Pseudomonas aeruginosa: too slippery for neutrophils to migrate on?

PURPOSE: Biofilm formation is increasingly recognized as the cause of persistent infections and there is evidence that P. aeruginosa organized into biofilms are quite resistant toward host defence mechanisms, particularly against an attack by polymorphonuclear neutrophils (PMN). Apparently, the migration of PMN through the biofilms is impaired, and thus the bactericidal activity remains highly localized. The aim of this study was to directly investigate the interaction of PMN with the biofilm and the extracted extracellular polymeric substance (EPS) of P. aeruginosa. MATERIAL AND METHODS: Chemotaxis and random migration of PMN through P. aeruginosa biofilms was tested, as was their migration through and along the EPS. RESULTS: We found that the EPS and mature biofilms, but not immature or developing ones, reduced the chemotactic migration of PMN. On EPS, rather than immobilize the cells, their random, spontaneous migration was enhanced. CONCLUSION: We propose that on EPS, the PMN lose their capacity to sense the direction and just slide over the EPS in a disoriented manner.

Combating implant infections. Remarks by a women's team.

Research on implant infections requires cooperative efforts and integration between basic and clinical expertises. An international group of women scientists is acting together in this field. The main research topics of the participants of this group are described. Formation of bacterial biofilms, antibiotic resistance and production of virulence factors like adhesins and toxins are investigated. New biomaterials, coatings and drugs designed to inhibit microbial adhesion are evaluated, and infection-resistant biomaterials are under study, such as a novel heparinizable polycarbonate-urethane (Bionate) or incorporation of diamino-diamide-diol (PIME) to reduce bacterial attachment. The correlation between biofilm production and the accessory-gene-regulator (agr) is investigated in Staphylococcus aureus. The ability to form biofilm has also been shown to be one of the important virulence factors of Enterococcus faecalis, favouring colonization of inert and biological surfaces. The study of quorum sensing has led to the discovery of a quorum sensing inhibitor termed RIP that suppresses staphylococcal biofilm and infections. The immune response and the local defence mechanisms of the host against implant-associated infections, activation and infiltration of immunocompetent cells into the sites of infection have been studied in patients with implant-associated osteomyelitis. Production of monoclonal antibodies (mAbs) as possible vaccines against the staphylococcal collagen-binding MSCRAMMs is in progress.

Paroxysmal nocturnal hemoglobinuria type III. Lack of an erythrocyte membrane protein restricting the lysis by C5b-9.

The complement-mediated lysis is inefficient when complement and target cells are homologous with regard to the species. In erythrocytes from patients suffering from paroxysmal nocturnal hemoglobinuria (PNH), the species restriction is lost: PNH-erythrocytes (PNH-E) are susceptible to lysis by human complement. In human erythrocytes (huE) the species restriction is ascribed to an integral membrane protein, designated C8-binding protein (C8bp). In the present study, we tested membranes of PNH-E type III for the presence of C8bp. A protein with C8-binding capacity could not be detected. C8bp, which was isolated from the membrane of huE, inhibited the lysis of PNH-E by C5b-9 as well as the C9 polymerization. Thus, addition of C8bp restored the species restriction in PNH-E. In conclusion, we propose that lack of C8bp might represent the defect in PNH-E type III membranes, which is responsible for their enhanced lytic susceptibility towards lysis by the late complement components.

Differentiation of polymorphonuclear neutrophils in patients with systemic infections and chronic inflammatory diseases: evidence of prolonged life span and de novo synthesis of fibronectin.

Polymorphonuclear neutrophils (PMN) are considered to be short-lived, terminally differentiated cells undergoing spontaneous apoptosis if not appropriately stimulated. In patients with systemic infections and inflammatory disease, however, PMN have an extended life span and acquire new surface receptors and functions. Expression of CD64, the high-affinity receptor for immunoglobulin, has been found, and functionally active elastase and surface-associated fibronectin as well. The latter is of particular interest since fibronectin is known as a multifunctional, multimodal extracellular matrix protein, participating in cell adherence, cell signaling, and cell cycle control. To study the surface-associated fibronectin further, PMN of healthy donors were cultivated to induce de novo synthesis of fibronectin. PMN produced fibronectin, which remained associated with the cell surface, where it was partially cleaved. PMN derived fibronectin exhibited a rare splice pattern: predominantly fibronectin containing the extradomain B (EDB) was generated, but evidently no IIICS domain; the latter is known as a receptor for beta1 integrins. How the presence of EDB affects the properties of fibronectin is not yet understood. Studies with recombinant EDB have failed to show a membrane-binding site or a direct participation of EDB in the adhesion process. The function of PMN-associated fibronectin is still under investigation. The rapid cleavage by surface-associated proteases suggests that fibronectin acts as a tightly regulated adhesion protein, and probably also as a precursor molecule for fibronectin-derived biologically active mediators.

Interaction of transforming growth factor beta 1 with human glomerular epithelial cells in culture: opposite effects on synthesis of matrix proteins and on urokinase plasminogen activator.

The effect of transforming growth factor-beta (TGF-beta) was analyzed on the synthesis of fibronectin, collagen type IV, and urokinase plasminogen activator in human glomerular epithelial cells in culture. An increase in the abundance of specific mRNA was found for collagen type IV and fibronectin. Fibronectin protein synthesis was also increased in TGF-beta treated cells; most of the de novo synthesized fibronectin was found as an unsoluble protein associated with extracellular matrix. In the same cells the amount of plasminogen activator mRNA was found leading also to a decreased surface expression of urokinase plasminogen activator. The data support the concept that by upregulating matrix protein synthesis and downregulating the plasminogen activator system, TGF-beta favors the development of sclerosis.

Transdifferentiation of polymorphonuclear neutrophils: acquisition of CD83 and other functional characteristics of dendritic cells.

Polymorphonuclear neutrophils (PMN) are in the first line of defense against bacterial infections. They are considered to be end-differentiated cells undergoing constitutive apoptosis within hours after release from the bone marrow. During pathological events, however, their life span is extended in conjunction with morphological and functional alterations indicative of a transdifferentiation of mature PMN. To further characterize differentiated PMN, the alterations seen in vivo were reproduced by cultivating PMN of healthy donors with either gamma-interferon, granulocyte/macrophage colony stimulating factor, or a combination thereof. Thus cultivated cells escaped from apoptosis, and protein synthesis was induced, notably of the major histocompatibility complex (MHC) class II antigens, CD80 and CD86. Moreover, CD83, thought to be specific for dendritic cells was synthesized, while typical markers of PMN, including CD66b, CD11a/CD11b/CD11c, CD15, CD18 were preserved. A profound alteration of both cellular morphology and of function was seen: the cultivated PMN lost their chemotactic activity but had acquired the ability to present to T-cells a peptide antigen in a MHC class II restricted manner. The data lead to the conclusion that mature PMN can differentiate further to cells with characteristics of DCs, thereby connecting PMN to the specific T-cell response.

The pathogenesis of ANCA-associated vasculitides: old hypotheses and new insights.

The pathomechanism of the ANCA-associated vasculitides is discussed in light of the abstracts presented at the ANCA- and Vasculitis Workshop 2005 in Heidelberg!

Implant-associated posttraumatic osteomyelitis: collateral damage by local host defense?

Infections following osteosynthesis or total joint replacement, also known as ''implant-associated posttraumatic osteomyelitis'', represent a major complication in orthopedic and trauma surgery. While the formation of bacterial biofilms on the implanted osteosynthesis materials is generally accepted as cause of the persistent infection, the molecular mechanisms leading to the progressive and destructive local inflammatory process and eventually to bone degradation, the osteolysis, have not been delineated. Here we provide evidence supporting the hypothesis that it is not the infection per se that causes tissue degradation and osteolysis, but rather the cytotoxic, proteolytic, and proinflammatory effector functions of cells of the host defense, particularly of the infiltrating polymorphonuclear neutrophils.

Autoantibodies to polymorphonuclear neutrophil elastase do not inhibit but enhance elastase activity.

Polymorphonuclear neutrophils (PMNs) of patients with active Wegener's granulomatosis and PMN activated in vitro express elastase on their surface as detected by autoantibodies derived from patients with ANCA-positive vasculitis or chronic staphylococcus infections. The PMN-associated elastase was enzymatically active. By affinity-purified autoantibodies to elastase, the enzymatic activity was further enhanced as measured either by a chromogenic peptide or by elastin as substrate. Antibodies to human elastase from mouse or from sheep also enhanced elastase activity, whereas unrelated immunoglobulins had no effect. Taken together, our data indicate that autoantibodies to elastase are not inhibitory but upregulate the elastase activity and thereby might contribute to tissue damage.

Release of arachidonic acid: a new function of the late complement components.

Incubation of Ehrlich-ascites cells with sublytic complement doses results in degradation of membrane phospholipids and release of arachidonic acid. Phospholipase A2 blockers inhibit arachidonic acid release indicating a phospholipase dependent cleavage of the phospholipids. Phospholipase A2 is apparently activated during complement-membrane interaction, representing a new reactivity of the late complement components.

Ehrlich ascites cells activate the alternative pathway of the human complement system.

Incubation of Ehrlich ascites cells with normal or C1q or C2 deficient human sera results in killing of the cells. Killing occurred also in the absence of free Ca++, which supported by the fact that factor B and C3 were cleaved, leads to the conclusion that the alternative pathway of the complement system is activated on the surface of the Ehrlich ascites cells.

Deafness, complement deficiencies and immunoglobulin status in patients with meningococcal diseases due to uncommon serogroups.

The prevalence of deafness and complement deficiencies in association with meningococcal disease caused by uncommon serogroups of meningococci was studied in 30 patients (Group A) and 30 controls with Serogroup B disease (Group B). In Group A 8 patients (26.6%) had hearing impairment in contrast to only 1 patient (3.3%) in Group B (P < 0.01). Complement deficiency was detected in 8 patients (26.6%) of Group A whereas none of the Group B patients showed a defect in the complement system (P < 0.01). Association between complement deficiencies and meningococcal disease was detected for Serogroups Y (n = 5; 16.6%) and W135 (n = 3; 10.0%). Localization of the defects revealed only complement deficiencies of the classical pathway (C8-beta or C7 defects). The levels of Ig and IgG subclasses were found to be within the normal range for all patients. Our results suggest that meningococcal diseases caused by uncommon serogroups are more often associated with deafness and late complement component defects.

Leukocyte Mobilization from Bone Marrow: Effect of the RGD-Containing Peptides of C3 and Fibronectin.

A peptide derived from complement component C3 caused leukocyte release in a perfused rat femur model. The function was related to the complement receptor 3 (CR3)-binding region in the α-chain of human C3. The peptide spanning this region contained RGD, a known ligand mediating cell-cell and cell-matrix interactions. We present data that also RGD and RGDS released leukocytes. Moreover the 120 kD RGD-containing fragment of fibronectin and monoclonal antibodies to its receptor α5ß1 induced a massive leukocyte release. Leukocyte detachment from the marrow is mediated by interference with RGD-peptides of C3 and fibronectin.

Bioincompatibility--perspectives in 1993.

Bioincompatibility reactions related to the non-physiology of the procedure have plagued dialysis from its early days. Although the problem is certainly multifactorial, the present overview selectively focuses on some aspects of activation of late complement (C) components, the importance of which may have been underappreciated in the past. Dialysis patients are poised for intense C activation because of cumulation of the low molecular weight factor D, an intrinsically active serine esterase which is not inhibited by any known endogenous inhibitor and catalyzes an early step in the alternative pathway. C activation reflects the net balance between activation and inhibition, the latter particularly via factor H binding. Dialyzer membrane characteristics that are related to factor H binding and regulation of initial activation steps include not only membrane surface chemistry but also its microdomain structure. Kinetic studies of the generation of the terminal complement complex (TCC) suggest ongoing generation throughout the duration of a dialysis session (in contrast to the transient release of C-derived anaphylatoxins). Potential consequences of TCC generation include amplification of the non-C-dependent cell activation signals through L-fucose-dependent steps. Efforts to reduce TCC generation by membrane engineering, for example, end group derivatization and optimization of microdomain structure, open perspectives for the development of more biocompatible membranes.

Short-term moderate aflatoxin B1 exposure has only minor effects on the gut-associated lymphoid tissue of Brown Norway rats.

Aflatoxin B1 (AFB1) is toxic to the systemic immune system in various animal species, whereas little is known about its effect on the gut-associated lymphoid tissue (GALT). It may be hypothesized that the toxicity of AFB1 and its locally generated metabolites in the intestinal tissue may result in a disturbed intestinal integrity and, subsequently, in an impaired immune response towards dietary proteins. The objective of our study was to investigate the toxic effect of short-term moderate AFB1 exposure on the intestinal epithelium and on the immune cells associated with the intestinal tract. The toxicological potential of AFB1 and its metabolites to the intestinal epithelium was determined by measuring viability and genotoxic damage in isolated jejunal epithelial cells (comet assay) after 30 min incubation in vitro. In vivo toxicology studies were carried out with Brown Norway (BN) rats, which were exposed orally once a week with AFB1 (1 x 100 microg/kg body weight (b.w.)/week) for 5 consecutive weeks. Viability and genotoxicity were measured in explanted jejunal epithelial cells. For studying the effectiveness of AFB1 on immunological parameters BN rats were treated with a high (study 1: 1 x 1 mg/kg b.w./week) or a low (study 2: 1 x 100 microg/kg b.w./week) AFB1 dose for 5 consecutive weeks with or without ovalbumin (OVA). Mesenteric lymphocytes were isolated and proliferative responsiveness, secretion of interferon-gamma, and changes in lymphocyte subpopulations as well as mucosal mast cell specific protease and anti-OVA specific antibody concentrations were measured. In vitro, AFB1 ( >30 microM) induced genotoxicity in rat jejunal epithelial cells. The oral administration of AFB1 (1 x 100 microg/kg b.w./week) did not induce DNA damage in jejunal epithelial cells. The high AFB1 dose increased the number of CD8+ and CD8/CD71 + cells in mesenteric lymph nodes. The immune response towards OVA was not affected. The low AFB1 dose only reduced the proliferative responsiveness of mesenteric lymphocytes (P < 0.05). Serum concentrations of anti-OVA specific IgE antibody, of RMCPII, and the capacity of mesenteric lymphocytes to produce interferon-gamma were not impaired by AFB1. In conclusion, exposure to moderate doses of AFB1 does not damage the intestinal epithelium and has only minor effects on the GALT. The low exposure, as it may predominantly occur in western countries, does not appear to increase the risk for sensitization to dietary antigens.