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Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?
Section:  Infection

I have used PMMA beads with either vancomycin or aminoglycosides for many years, successfully. However, there have been many times I have had pathogens that I needed to cover that the aforementioned antibiotics would not do the job.  Also using the PMMA beads required another surgery to remove them.  Recently I have been using Ceramant bone void filler with either vancomycin, timentin, fortaz, zosyn, primaxin, tobramyacin, and a vancomycin/tobramycin combo against MRSA and timentin, fortaz, zosyn, primaxin, tobramyacin, and a vancomycin/tobramycin combo against Pseudomonas with excellent results in 20+ patients thus far.  The elusion data and zone of inhibition data is very impressive.  The zone of inhibition data was presented at APMA in Toronto last month.  What I also like about this carrier vehicle for the antibiotics is that the Ceramant is biodegradable so I do not need remove the beads after implantation.

I am curious  what your thoughts on this carrier vehicle would be and why or why not would you use this in your practice?

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RE: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

I've used osteoset (calcium sulfate beads) mixed with tobramycin in the past. As you mentioned, the beauty is that we don't have to remove them like PMMA beads. 

http://www.wmt.com/Physicians/Products/Biologics/OSTEOSETResorbableBeadKit.asp

I would like to say "my results are great!", but I am not sure if it would truly make differences in resolution of osteomyelitis. The patients need to be on IV ABx anyways, so I am not sure if I can fully justify the added expense of ABx and the beads. I think we still need more data before the resorbable and inplantable abx beads becomes the standard of care. If you know any recent study on this topic, please share it with us here in this forum.

It is my understanding that the choice of implantable antibiotics is based on the stability and release rate, rather than matching the pathogen perfectly.  

Lastly, I always recommend HBOT (Hyperbaric Oxygen therapy) when I see chronic osteomyelitis. We monitor the treatment with MRI and CRP as well. It is a nice adjunctive therapy, especially if there is an open wound associated with it.
 
Just my 2 cents... 

RE: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

I have used Osteoset before as well with success.  I like that the Ceramant has calcium sulfate and hydroxyapatitie (HA).  The calcium sulfate is absorbed faster than the bone ingrowth rate.  The HA is not absorbed and provides a scaffold for bone ingrowth.  The reason that vancomycin and aminoglycosides are used with PMMA cement is that they are heat stable.  When PMMA sets it is an exothermic reaction so the other antibiotics are heat sensitive and can not be used.  The bioabsorbable cements are isothermic when they set and can use heat sensitive antibiotics.  Cerament has good off-label information for mixing antibiotics on request.

Just to clarify, in my opinion, the antibiotic bead placement is an adjunctive therapy to good surgical debridement, antibiotics, and other treatments such as HBO.


Here are some references for bioabsorbable antibiotic beads.

 

Calcium Sulfate and Hydroxyapatite Human Studies

 

1. Gitelis S, Brebach GT.  The treatment of chronic osteomyelitis with a biodegradable antibiotic-impreganted implant.  J Orthop Surg. Vol 10 No 1:53-60. 2002.

2. Mckee MD, Wild LM, Schemitsch EM, Waddell JP.  The use of an antibiotic-impregnated, osteconductive, bioabsorbable bone substitute in the treatment of infected long bone defects:early results of a prospective trial. J Orthop Surg. Vol 16 No 9:622-627. 2002.

3.  Yamashita Y, Uchida A, Yamakawa T, Shinto Y, Araki N, Kato K.  Treatment of chronic oasteomyilitis using calcium hydroxyapatite ceramic implants impregnated with antibiotic.  International Orthop (SICOT) 22:247-251.  1998.

 

Calcium Sulfate and Hydroxyapatite In Vivo Studies

 

1.   Shinto Y, Uchida A, Korkusuz F, Keiro O.  Caclium hydroxyapatitie used as a delivery system for antibiotics. J Bone Joint Surg 74B:600-604, 1992.

2.     Danhers LE, Underburk.  Gentamycin-loaded plaster of paris as a treatment of experimental osteomyelitis in rabbits. Clinical Ortho and related research 1987; No 219:278-282. Lippinincott Williams & Wilkins.

 

Calcium Sulfate In Vivo Studies

 

1. Nikulin A, Ljubovic E. Der Gipsstift in der experimentellen knochenregenerstion. Acta Med Iugosl. 10:1. 1956.

2. .  Peltier LF.  The use of plaster of paris to fill defects in bone.  Clin. Orthop 21:1, 1961.

3. Dahners LE, Funderburk CH.  Gentamycin-loaded plaster of paris as a treatment of experimental osteomyelitis in rabbits. Clinical Ortho and related research 1987; No 219:278-282.  Lippinincott Williams & Wilkins.

4. Turner TM, Urban RM, Gitelis S, Andersson GBJ.  Radiographic and histological assessment of calcium sulfate in experimental animal models and clinical use as a resorbable bone-graft substitute, a bone-graft expander, and a method for local antibiotic delivery. J Bone Joint Surg. Vol 83A, Supplement 2, part 1:8-18. 2001.

5. Turner TM, Urban RM, Hall DJ, Chye PC, Segreti J, Gitelis S.  Local and systemic levels of Tobramycin delivered from calcium sulfate bone substitute pellets.  Clin Orthop Related Research.  No 437:97-104. 2005.

6.  Nelson CL, McLaren SG, Skinner RA, Smelzer MS, Thomas JR, Olsen KM.  The treatment of experimental osteomyelitis by surgical debridement and the implantation of calcium sulfate Tobramycin pellets.  J Orthop Res. 20:643-647. 2002.

 

Hydroxyapatite In Vivo Studies

 

1.   Solberg BD, Gutow, AP, Baumgaetner MR.  Efficacy of Gentamycin impregnated resorbable hydroxyapatite cement in treating osteomyelitis in a rat model.  J. Orthop Trauma. Vol 13, No2:102-106.  1999.

2.   Hing, KA, Best SM, Tanner KE, Bonfield W.  Quantification of bone ingrowth   within bone-derived porous hydroxyapatite implants of varying density.  J Materials  Science: Materials in Medicine.  10:663-670.  1999.

3.  Sato S, Koshino T, Saito T.  Osteogenic response of rabbit to hydroxyapatite particle-plaster of paris mixture.  Biomaterials 19:1895-1900.  1998.

4.  Epply BL.  Hydroxyapatite cranioplasty: 1.  experimental results from a new quick-setting material.  J Craniofascial Surg.  Vol 14 No 1:85-88. 2003.

5.  Epply BL.  Hollier LH, Stal SS. Hydroxyapatite cranioplasty: 2. Clinical experience with a new quick-setting material.  J Craniofascial Surg.  Vol 14 No 2:209-214. 2003.

6. Cornell CN, Tyndall D, Waller S, Lane JM, Brause BD.  Treatment of experimental osteomyeilitis with antibiotic-impregnated bone graft substitute. J. Orthop Res. Vol 11, No 5: 619-626. 1993.

 

Calcium Sulfate and Hydroxyapatite In Vitro Studies

 

1.  Rauschmann MA, Wichelhaus TA, Stirnal V, Dingelderin E, Zichner L, Schnettler R, Alt V.  Nanocrystalline hydroxyapatite and calcium sulfate as biodegradable composite carrier material for local delivery of antibiotics in bone infections.  Biomaterials 26:2677-2684, 2005.

 

Calcium Sulfate In Vitro Studies

 

  1. Sanicola SM, Albert SF.  The in vitro elution characteristics of Vancomycin and Tobramycin from calcium sulfate beads.  J Foot Ankle Surg. Vol 44, No. 2:121-124. 2005.

2. Bowyer GW, Cumberland N.  Antibiotic release from impregnated pellets and beads.  J. Trauma. Vol 36. No3:331-335. 1994.

 

 

Calcium Sulfate and Hydroxyapatite Zone of Inhibition Studies

 

1. Buranapanitkit B, Oungbho K, Ingviya N.  The efficacy of hydroxyapitite composite impregnated with amphotericin B. Clinical Ortho and related research 2005; No 437:236-241. Lippinincott Williams & Wilkins.

2. Buranapanitkit B, Srinilta V, Ingviga N, Oungbho K, et al.  The efficacy of a hydroxyapatite compositie as a biodegradable antibiotic delivery system. Clinical Ortho and related research 2004; No 424:224-252.  Lippinincott Williams & Wilkins.

3. Chotanaphuti T, Surijamorn P, Luenam S, Ongnamthip P. In vitro antimicrobial activity of pharmongkutklao hydroxyapitite antibiotic pellet.  J Med Assoc Thai Vol. 91, No12: 1868-1872. 2008.

 

 

RE: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?



Here is an example of one of the many osteomyelitis case with Cerament antibiotic beads:

A 42-year-old non-smoking male presented with a chronic Diabetic foot ulcers with underlining 4th metatarsal osteomyelitis and 4/5th toe gangrene  Picture 1 Clinical pre-operative presentaton(Picture 1).  The MRSA osteomyelitis involved the fourth metatarsal and forth toe proximal phalanx. (Picture 2)












Picture 2 Pre-operative xrayThe osteomyelitis was unresponsive first to oral then intravenous antibiotics.  The gangrene had started the day before surgery.  The patient’s past medical history was significant for poorly controlled type II Diabetes, hypertension, coronary artery disease with history of MI, and chronic renal insufficiency.  Lower extremity arterial non-invasive vascular study demonstrated no significant stenotic disease.  Surgical intervention was planned.

 

In the operating room a 10 ml Cerament™|Bone Void Filler kit was mixed with 2 grams of vancomycin utilizing the 1-2-3-4 technique.    Picture 1                         This is an off-label use of the Cerament.  First, the Omnipaque was mixed with the Cerament™|Bone Void Filler with rotation of the wrist for two minutes  (Picture 3). 


Picture 3 Add the Omnipaque








At two minutes the Cerament™|Bone Void Filler was placed in a sterile bowl  (Picture 4).    Picture 4 Place Cerament At three minutes two grams of Vancomyacin was added and mixed with a wide spatula in a rolling fashion (Picture 5). 












 
Picture 5 Added Vancomycin














By four minutes the placement of the mixture in the bead mold was completed (Picture 6).  
Picture 6 Cerament













At 15-20 minutes the antibiotic beads were removed from the mold and were ready for implantation  (Picture 7).  Picture 7 Vancomycin Cerament
Surgical management included ulcer debridement, amputation of the 4/5th toes, and partial resection of the forth metatarsal (Picture 8).

 The Cerament™|Bone Void Filler beads were place in opposition to the remaining fourth metatarsal (Picture 9,10).  Typical closure followed.  The patient progressed very well.  The Cerament™|Bone Void Filler vancomycin impregnated beads started to show signs of reabsorbing at fourteen days after surgery and were completely absorbed at four weeks.  The diabetic ulcers were healed at eleven weeks after surgery and there were no formed beads remaining.  There was HA remaining that elicited no foreign body or immune host response.  This patient had no recurrence of the osteomyelitis at six months post-op (Picture 11).

 

 

 

RE: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Here are pictures 10-11.  Had some issue with uploading the final pictures, could not upload pictures 8-9, sorry/


 Picture 10 Rdiographic bead placement    

           Picture 11 No recurrence of the osteomyelitis

RE: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Dr. Karr,

Thank you for sharing your expertise and resources with us. Your case looks impressive. It certainly looks promising and perhaps make the use of PMMA beads (that necessitates the removal) obsolete.   

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?


So a good question to be asked is how effective is the release of the antibiotic from a carrier vehicle such as calcium sulfate and hydroxyapatite.  One way is to measure the zone of inhibition and compare that zone to as defined by the standard set by the Clinical and Laboratory Standard Institute (CLSI) formally the National Committee for Clinical Laboratory Standards. 

CLSI provide guidelines for the most up-to-date techniques for the determination of minimal inhibitory concentration of bacteria by broth micro- and macrodilution plus criteria for quality control testing.  The clinical outcomes of the selected antibiotics in this study against MRSA did not always correlate clinically with these in vitro results as the CLSI breakthrough zones of inhibition are set up for serum antibiotic levels and does not consider the higher local levels of antibiotic release from the antibiotic discs/beads.   

The average zone of inhibition was 30 mm or 100% greater for vancomycin 1g and 29 mm and 91% greater for vancomycin 2g when compared to the minimal zone of inhibition required which is 15 mm.  I added a vancomycin 4g I had for comparison.

vancomycin 1g mrsa2 



 

          Vancomycin 1 gram vs MRSA







vancomycin 2g mrsa




     Vancomycin 2 gram vs MRSA





 vancomycon 4g 2 mrsa





   Vancomycin 4 grams vs MRSA

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

While I appreciate the versatility of various media, such as osteoset which is largely what we used in residency, i've found that the absorbable beads seemed to generate SUCH drainage that incision-line maceration which ultimately lead to some wound healing issues.  While PMMA beads or blocks need to be removed, there is some argument for the placement of an antibiotic spacer/ threaded beads in conjunction with serial debridement in the management of infected wounds.  In my residency training i worked with attendings who swore by both --and others who were adamant about using one or the other --and each could make compelling arguments......

 

For those of you who utilize and prefer absorbable media, how do you manage the concomitant drainage issues that develop?

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Ryan has a very good point.

 With any biodegradable carrier vehicle there will be product released and the body can only absorb so much product over time.  When drainage occurs it is generally because too many beads were placed outside the bone cavity/defect and they are in the soft tissue field, then you will have drainage. 

I generally like to place just enough beads  so they are in contact with the remaining bone and not stack them in.  The release "zone" of antibiotic is generally 3-4 cm.

Karr 

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

One more thought is, if possible during your procedure, preserve a flap of deep tissue to close over the beads, like creating a pocket.  This works quite well.  Except in toes, were I sometimes place too many beads, I have not had any drainage issues.  

Sometimes if the calcium sulphate beads are not completely dry and the field is fairly wet they will start to immediately breakdown.

Karr 

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

I don't even use them anymore.  I don't say that my results are worse now. All my infected diabetic foot ulcers in the hospital are on IV antibiotics. I've use PMMA beads and the osteoset beads. Both are fine, but have their drawbacks (removal, drainage).  I've never seen any studies that show that adding antibiotics beads improve outcomes in a bad infection of bone or soft tissue...or am I wrong.

 

I get great results with simple I&D, bone and soft tissue debridement, packing, VAC whatever...just don't see the need for antibiotics beads in my practice anymore.

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Chris brings up some good points.

There are too many articles to site for antibiotic beads pros/con/clinical benefit to site in this forum.  One good review/summery article I have is:

DeCoster TA, et al.  Surgical Techniques Antibiotic Beads.   J. Amer Acad Ortho Surg. Vol 16 No 11 Nov 2008.

For the biodegradable beads there are those with only calcium sulfate and one with calcium sulfate and hydroxyapatitie (HA).  The addition of HA helps alot with the drainage issue.  However, irregardless of the carrier vehicle for biodegradable beads, if they are not dry they will seep. 

Karr 

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Slide1c   Here is the poster presentation of the in vitro data of antibiotic Cerament beads against MRSA and Pseudomonas aerginosa at the APMA 2009 conference in Toronto.

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Jeff,

I'm working on your article and I would probably add this information before publication. 

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Jeff,

I've sent off this article to Dr.'s Frykberg and Dr. Rogers for review (Issue 4 of the JDFC).  They will be contacting you soon on this manuscript. 

a m
Re:


Great info, thanks

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

The contact in formation for Bone Support from the UK is:

 

Ian Kirkwood

Ian.kirkwood@bonesupport.com

Phone (from US): 46 70-616 53 58

 

Mr. Kirkwood had communicated to me that even though Cerament from Bone Support is not yet available from a distributor in the US, he can have some product sent to your hospital. 

 

One thought I would like to share with you.  All of the in-vitro studies and patient cases done to date and were completed in the US.  The antibiotics do differ from the US to other regions in the world mainly by preservatives.  Although I do not believe this would present any issues with antibiotic bead mixing I did wish to point that out.  With the 10 ml kits I recommend 1 gram of Vancomycin for the beads.  Othe antibiotics are available for use.  If you have a particular bacteria(s) that you wish to cover and I will be happy to relay additional mixing information.

 

Attached is a mixing illustrational guild line as well as written instructions below.  Please only use a flexable mold for the beads,

080923 Wallchart jpegPR 0040-02 EN FINAL (h














Figure 6 CeramentBiomet makes a nice blue mold – picture attached.  Do not use the hard, non-flexable bead molds as they generally will not release the beads properly.

 


Vancomycin


 

Vancomycin mixing instructions: Before starting, under sterile conditions, break up the Vancomycin into powder as the Vancomycin tends to clump up in the vial.  Mix the 10 ml Cerament™| Bone Void Filler with 8 ml Iohexol solution 180 mg I/ml (CERAMENT™│C-TRU or Omnipaque™) in the syringe for 2 minutes and extrude into a bowl. Add antibiotic at 3 minutes (from the start of mixing) to the mixed paste in the bowl.  Mix with a wide spatula e.g. the spatula (not a wood tongue depressor) for a maximum of one minute.  Do not use anything narrow. When mixing, mix the antibiotic in large smooth strokes rolling the mixture onto itself; similar to mixing bread.  Have the mix in the mold and done by 4 minutes.  The beads should be hard to remove from the mold at twenty five minutes.

 

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

I would like to thank everyone for the kind words after I presented this information at Desert Foot in Phoenix, Arizona last week.  Which by the way was a very well run conference with an excellent program presented.  Kudos to Dr. Frieburg, and epresent. I did receive alot of questions about the use of ancef so here is some more information.

This is one gram each  of ancef and vancomycin plated against MRSA.  The minimal zone of inhibition for Staph aureus for vancomycin is 15 mm and ancef is 18 mm.  The average zone of inhibition obtained was 39 mm in vitro.

vanc and ancef vs mrsa2 










This is two grams of ancef  plated against MRSA.  The minimal zone of inhibition for Staph aureus fo ancef is 18 mm.  The average zone of inhibition obtained was 40 mm in vitro.

ancef 2g 3 mrsa











Karr 



 

a m
Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?



This product has great promise but I have one major concern, prior studies have demonstrated the issue with PMMA beads loaded with antibiotic that Biofilm can actually form on the bead itself, it was observed in 18/20 cases upon bead removal in a paper by Danielle Neut et al from Groningen. The same problem would exist for the non-resorbable HA element of Cerament, it is a potential nidus for biofilm bacteria. This is made more problematic by the failure of standard cultures to detect biofilm and as such the issue can continue undetected unless more advanced techniques are used.

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?



AM

Very good question.  

I have do have a response but I would like to review the article first.  Is the article one of these? 

1.  The combination of ultrasound with antibiotics released from bone cement decreases the viability of planktonic and biofilm bacteria: an in vitro study with clinical strains.

Ensing, Geert T. 1,2; Neut, Danielle 1,2,*; van Horn, Jim R. 2; van der Mei, Henny C. 1; Busscher, Henk J. 1

 

Journal of Antimicrobial Chemotherapy. 58(6):1287-1290, December 2006.

[Report.][Brief report]

 

AN: 00004548-200612000-00030.

 

2.  Intraoperative Contamination Influences Wound Discharge and Periprosthetic Infection.

Knobben, Bas A S MD, PhD *,+; Engelsma, Yde MD *; Neut, Danielle PhD +; van der Mei, Henny C PhD +; Busscher, Henk J PhD +; van Horn, James R MD, PhD *

 

Clinical Orthopaedics & Related Research. 452:236-241, November 2006.

[Article.][SECTION II: ORIGINAL ARTICLES: Infection]

 

AN: 00003086-200611000-00044.

 

3. Perioperative Contamination in Primary Total Hip Arthroplasty.

Maathuis, Patrick G. M MD *; Neut, Danielle PHD *+; Busscher, Henk J PHD +; van der Mei, Henny C PHD +; van Horn, Jim R MD, PHD *

 

Clinical Orthopaedics & Related Research. 433:136-139, April 2005.

[Article.][SECTION II: ORIGINAL ARTICLES: Hip]

 

AN: 00003086-200504000-00021.

 

4.  Detection of Biomaterial-Associated Infections in Orthopaedic Joint Implants.

Neut, Danielle *,**; van Horn, Jim R. PhD, MD *; van Kooten, Theo G. PhD **; van der Mei, Henny C. PhD **; Busscher, Henk J. PhD **

 

Clinical Orthopaedics & Related Research. 413:261-268, August 2003.

[Article.][SECTION II ORIGINAL ARTICLES: Infection]

 

AN: 00003086-200308000-00030.

 

5.  Biomaterial-associated infection of gentamicin-loaded PMMA beads in orthopaedic revision surgery.

Neut, Danielle a,b; van de Belt, Hilbrand a,b; Stokroos, Ietse c; van Horn, Jim R. a; van der Mei, Henny C. b; Busscher, Henk J. b,*

 

Journal of Antimicrobial Chemotherapy. 47(6):885-891, June 2001.

[Report.][Brief reports]

 

AN: 00004548-200106000-00020.

 

 

a m
Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?


5th on your list, Biomaterial-associated infection of gentamicin-loaded PMMA beads in orthopaedic revision surgery.

The problem is it is unknown when the adherent, inactive bacteria will re-emerge as wound pathogens!

A more recent article on the same is:

2008, Vol. 79, No. 2, Pages 302-307 , DOI 10.1080/17453670710015120

 

 

Persistence of bacterial growth on antibiotic-loaded beads: Is it actually a problem?

Konstantinos Anagnostakos1, Philip Hitzler1, Dietrich Pape1, Dieter Kohn1 and Jens Kelm1
1Universitätsklinikum des Saarlandes, Klinik für Orthopädie und Orthopädische Chirurgie, Homburg/Saar, Germany
Correspondence: Konstantinos Anagnostakos,
Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

I agree that colonizing bacteria/adherent colonies continues to be an important consideration in orthopedics in regard to implants and bone cement.  In a recent article:  

Persistence of bacterial growth on antibiotic-loaded beads: Is it actually a problem?  
Acta Orthopaedica 2008, Vol. 79, No. 2, Pages 302-307 , DOI 10.1080/17453670710015120 

 

The authors examined PMMA non-absorbable antibiotic beads upon removal found a persistence of bacterial growth (biofilm) on the beads.  I would expect not to see this with bio-absorbable antibiotic beads as there is little product left  i.e. hydroxyapatite (HA) for the bacteria to adhere to.  

 

I can understand a biofilm around PMMA as there is a fibrous capsule separating the PMMA from bone (probably initially created by the exotherm which kills bone around the implant).

 

With respect to Cerament™ the HA has a carbonated apatite layer around it making it highly attractive for osteoblasts which progress the bone formation process. Therefore I see little opportunity for a biofilm to form.

Proof is in the long term data that is collected.  To date I have managed 34 cases with 31 success and  3 failures.  Of the 31 success there have been no reoccurrence.  The longest follow-up is about 18 months.  The three failures were all poor patient selection that ended up with BKA's due to non-compliance and uncontrolled co-morbidities.

I plan on submitting for publication next year multi-center data.

Karr 


a m
Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?


Thank you for your response, isn't Cerament 40% HA? On radiograph's I've seen in the product literature the cement is visible and denser than bone at 12 months, presumably the HA element? It is also worth bearing in mind that any infection inhibits bone formation so the bonding of HA and the apatite layer seen in standard fx scenarios wouldn't translate to an active infection site, that said your results seem impressive with over a 90% success,  presuming there's not a remanant biofilm!

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?



40% is the correct HA content by weight.  

In my opinion, it is hard to see the HA at 12 months, but there is some increased density.   I believe that so much antibiotic is released in a zone that all bacterial are killed.  I also agree bonding would occur without infection but what about with infection? - a very good question indeed.

I would theorize that bonding will be impeded  with bacteria or biofilm present.  However clinical cases to date are promising.  I am actually updating a lecture and here is some of the information from the lecture in regards to clinical cases:

33 patients - follow-up 3 to 18 months involving:

   Metatarsal - 18     Phalanx - 2

   Mid-foot - 1 Fibula (ankle) - 3

   Tibia - 6

Success in 30 of 33 patients, three failures from poor patient selection involving:

   Metatarsal - 1 Calcaneus   1  

   Tibia - 1

The antibiotics used in the beads were:

Vancomycin, vancomycin/tobramycin, timentin, fortaz, and zosyn.

Bacteria treated successfully was:

MRSA, MSSA, enterobacter, enterococcus, citrobacter, stenotrophomonas, and pseudomonas, E. coli, streptococcus


Karr 





Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Dr Karr
Do you have experience with injectable antibiotic cement for the treatment of osteomyelitis?  If so, what have you used, for which organisms, and what are your outcomes?  Thank you. Dr. Weiner

Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?



Rick,

That is a very good question.  I mostly use the injectable antibiotic cement (off-label use) for filling bone defects after removal of hardware.  The hardware removed and the defect to be filled can be as small as a screw or as large as an IM rod.  I have done both with success.  Success would be defined as no reoccurrence of osteomyeltis. 

I also use flowable bone void filler without antibiotic (on-lable use) to fill cyst and and other bone voids.

Here are some mixing instructions in regards to flowable antibiotic cement.  When preparing the cement you should be ready for placement of the flowable antibiotic cement at the time of mixing.  This is very important, as you should not prepare this ahead of time as you do with antibiotic beads, because the window for use of the flowable antibiotic cement is not very long and a delay before usage may allow the antibiotic cement to set in the chamber.  General guidelines for preparing the flowable antibiotic cement are as follows. Mix the 8 ml Iohexol solution 180 mg I/ml (CERAMENT™│C-TRU or Omnipaque™) with antibiotic powder in a small sterile plastic cup on the back table.  Redraw the Iohexal/antibiotic solution back into a 10 cc syringe.  Now add to the mixture to the 10 ml Cerament™| Bone Void Filler chamber and mix for one minute.  Attach a 11 or 8 gauge jamshidi needle with a lure lock, not all jamshidi needles have lure locks.  Because of the incorporation of the Omnipaque™, the placement of the antibiotic flowable cement can be verified in actual time with intra-operative fluoroscopy. The flowable times are in chart two.

Table 2:  Recommended flowable antibiotic mixing guidelines

 

Antibiotic

Iohexol 180mg I/ml

NaCl 14.6% vol.

Mixing time of Cerament™ with Iohexol

Flowable until

Cefazolin 1g

8 ml

n/a

1 minute

3.5 min

Timentin 1 g

8 ml

n/a

1 minute

15 min

Vancomycin 2 g

8 ml

n/a

1 minute

13 min

 

 

 

This is an older blog that I came across. I was going to start a blog on the very topic but figured this one was an excellent start.
I am curious to hear any feedback from anyone using the beads and their experiences....
Re: Osteomyelitis and antibiotic beads - what do you think about using antibiotics other than vancomycin or aminoglycosides?

Over my years of practice and experience in complex foot infections, I have used antibiotic impregnated beads on a plethora of occasions.

The main purpose for using aminoglycocide antibiotics, especially with the non-resorbable PMMA beads, is not so much related to the broad spectrum of these antibiotics but more due to their stability to heat. If one recalls, when PMMA beads are mixed, this creates an exothermic reaction which will affect most other antibiotics (they are heat labile), whereas the amioglycocides (gentamycin, vancomycin, tobramycin, etc.) are heat stable.

The issue of heat stability as well as antibiotic spectrum is addressed with the calcium based absorbable beads. With these products you also have the added benefit of not needing to retrieve the antibiotic beads in a subsequent procedure (bedside or otherwise).

With the calcium based absorbable beads one can use whatever powdered or liquid antibiotic which may be indicated based on cultures or suspected organisms. One main drawback to these beads is increased drainage and associated risk of maceration and seroma formation. Personally, I mitigated these risks and rarely had an issue by simply packing the wund open and performing frequent packing / dressing changes.  Occasionally I painted the wound margins with gentian violet or betadine. I have allot of clinical cases and photos and i was a big advocate in using antibiotic beads in complex or deep / wide space infections.

Alex - (or whoever else would like to join in);
1) Did you ever or would you consider giving antibiotic impregnanted beads as your sole antibiotic treatment?
2) were you using it for mainly soft tissue infection? Osteo or both?
3) have you or to your knowledge can the impregnated beads have an effect on osteomyelitic bone without debriding the bone?
Another words, if one wants to give bone a chance to heal and not be amputated could the beads reverse the infectious process or stagnate it so that it lays dormant?
4) it sounded from your initial comment you were speaking in past tense....do you still utilize the technique or have you abandoned it?
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Alex - (or whoever else would like to join in); 1) Did you ever or would you consider giving antibiotic impregnanted beads as your sole antibiotic treatment? 2) were you using it for mainly soft tissue infection? Osteo or both? 3) have you or to your knowledge can the impregnated beads have an effect on osteomyelitic bone without debriding the bone? Another words, if one wants to give bone a chance to heal and not be amputated could the beads reverse the infectious process or stagnate it so that it lays dormant? 4) it sounded from your initial comment you were speaking in past tense....do you still utilize the technique or have you abandoned it?



Jeff, to answer your questions:

1. I'd not consider using the antibiotic beads as sole treatments as I am confident this would be a significant deviation from "standard of care", regardless of how strongly I felt of the efficacy of this treatment.

2. I have used the antibiotic beads for BOTH soft tissue and oseteomyeliitis. Again, I have a several photos and if I had time, I could probably come up with come case studies. I often resected frankly osteomyelitic bone (discolored / brittle bone) and ream out the medullary canal and then stuff it with the beads or even the bone cement paste before it had set. Again, excellent results. Was this result due to the resection of the infected bone, the oral/IV antibiosis, the implanted beads, or all of the above? I don't know, what I can say though is that I could sleep well at night knowing that I used everything in my armamentarium to prevent further spread of infection / amputation mitigation. Was this my standard approach? Certainly not, I only used the beads in severe enough / limb at risk cases.

3. See #2. Furthermore, I believe that whatever bone appears non-viable, needs to be resected / debrided. Barring vascular compromise or some other co-morbidity which would preclude surgical management, this is "non-negotiable" in my opinion.

4. I'd still use this technique if I were still in practice.  In the event you don't recall, I am in a year long training program and hence am not in a clinical setting at this juncture in time.

I forgot my bad.....thanks for the reply.
The impetus for my inquiry was a hallux amp, that did not heal.
The patient was sent for an MRI which revealed osteo of the head and neck of the first met post hallux amp not Pre hallux amp.
When one examines the wound, thre is no evidence of any necrotic bone. Since, nothing looks necrotic, I do not want to resect anything.
I went back to the OR, used a versa jet to clean all tissue, examine for sinus tracts and then placed the antibiotic beads around the periphery off the head and neck. I also had a picc line placed and have him on IV antibiotics.
(I did come across articles that used purely the beads without the IV meds but was not that ballsy to do anything like that.)
Additionally, we put a wound vac on the patient and so far he seems to be doing well. (According to wound nurse, I see him Tuesday.)
(Non compliant diabetic - so I realize things may change fast.)
I ask about the beads as I am new to them......