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  • Spinal Instrumentation and Biofilms: A Paradigm Shift

    Final Number:

    Lydia Du BS; Daniel Altman MD; Derrick Andrew Dupre MD

    Study Design:
    Clinical Trial

    Subject Category:

    Meeting: Congress of Neurological Surgeons 2018 Annual Meeting

    Introduction: Chronic infections in which bacteria have formed biofilms have demonstrated delayed bone healing and failed fusion. These slime-enclosed communities isolate bacteria from the body’s immune responses, which can cause antibiotic resistance. Biofilm bacteria are extremely difficult to detect by culture methods used in the hospital setting. These persistent bacteria pose significant risk for postoperative care, particularly for surgical implants, which can require additional surgery if infected. The purpose of this study is to determine if and to what degree biofilms are present on spine instrumentation.

    Methods: Wound cultures taken from each specimen underwent microbiological analysis. Polymerase chain reaction (PCR) electrospray ionization-mass spectrometry (ESI-MS) was performed. Based on the PCR/ESI-MS results, specific crossed immune electrophoresis detected the bacterial species within biofilms observed on the removed devices. Fluorescent in situ hybridization (FISH) probes corresponding to specific bacterial species were used with confocal microscopy to visualize the bacteria in tissues (within 50 microns).

    Results: Fifteen patients presented for surgical revision of spinal implantation: five for clinical infection, six for adjacent segment disease (ASD), one with ASD and pseudarthrosis (PA), two with only PA, and one for pain. A specimen from a participant with ASD was lost and excluded from the results. Infections were diagnosed with PCR/ESI-MS for all five who presented with an infection, as well as for four patients for whom infection was not clinically suspected. The positive predictive value for clinical signs of infection compared to the PCR/ESI-MS was 100%. The negative predictive value was 55.6%. Of the presumed non-infected hardware, 44.4% demonstrated the presence of infectious biofilms. Half of revisions due to pseudoarthrosis are shown to harbor biofilms.

    Conclusions: Culture was inadequate as a diagnostic modality to detect biofilm infections of the spine. The PCR/ESI-MS results for bacterial detection were all confirmed using direct species-specific microscopic techniques for DNA and antigen.

    Patient Care: The implications of this research topic are highly significant due to the risk that infections pose to postoperative patient outcomes. Biofilms clearly have a larger presence than current methodology would lead one to believe, providing the basis for a more targeted approach to combating the infections and complications arising from sessile bacteria. As these types of infections can be antibiotic resistant with increased morbidity and mortality rates, there is a demonstrated need for improved therapeutic measures. Other complications include non-fusion and reduced bone healing, as in pseudoarthrosis. Half of the pseudoarthrosis cases in this study had bacteria present, demonstrating yet another area in need of additional research to explore the association with biofilms. Future studies focused on current sterilization techniques, as well as materials used for implantation, could further reduce the effects felt by patients by eliminating the origin of biofilms entirely. With the increasing utilization of implantation procedures to correct defects across specialties, it is becoming exceedingly imperative that the scientific community places a spotlight on biofilm research. The results of this study suggest that it will prove to be pivotal in the development of neurosurgical views on bacteria.

    Learning Objectives: By the conclusion of this session, participants should be able to: 1) Describe the identifiable characteristics of a biofilm 2) Explain the importance of biofilm identification 3) Identify the implications that biofilms have on patient care

    References: [1] Ehrlich, G.D., Hu, Z.F., and Post, J.C. Role for Biofilms in Infectious Disease. In: Ghannoum, M., and O’Toole, G.A. (eds). Microbial Biofilms. Washington, DC: ASM Press, pp332-358. (2004) [2] Ehrlich GD, Hu FZ, Shen K, Stoodley P, Post JC. Bacterial plurality as a general mechanism driving persistence in chronic infections. Clin Orthop Relat Res 2005:20–4. [3] Stoodley P, Kathju S, Hu FZ, Erdos G, Levenson JE, Mehta N, et al. Molecular and imaging techniques for bacterial biofilms in joint arthroplasty infections. Clin Orthop Relat Res 2005:31–40. doi:10.1097/01.blo.0000175129.83084.d5. [4] Wolcott RD, Ehrlich GD. Biofilms and Chronic Infections. JAMA 2008;299:2682. doi:10.1001/jama.299.22.2682. [5] Kathju S, Nistico L, Hall-Stoodley L, Post JC, Ehrlich GD, Stoodley P. Chronic Surgical Site Infection Due to Suture-Associated Polymicrobial Biofilm. Surg Infect (Larchmt) 2009;10:457–61. doi:10.1089/sur.2008.062. [6] Ehrlich GD, Ahmed A, Earl J, Hiller NL, Costerton JW, Stoodley P, et al. The distributed genome hypothesis as a rubric for understanding evolution in situ during chronic bacterial biofilm infectious processes. FEMS Immunol Med Microbiol 2010;59:269–79. doi:10.1111/j.1574-695X.2010.00704.x. [7] Stoodley P, Conti SF, DeMeo PJ, Nistico L, Melton-Kreft R, Johnson S, et al. Characterization of a mixed MRSA/MRSE biofilm in an explanted total ankle arthroplasty. FEMS Immunol Med Microbiol 2011;62:66–74. doi:10.1111/j.1574-695X.2011.00793.x. [8] Ehrlich GD, Hu FZ, Sotereanos N, Sewicke J, Parvizi J, Nara PL, et al. What role do periodontal pathogens play in osteoarthritis and periprosthetic joint infections of the knee? J Appl Biomater Funct Mater 2014;12:13–20. doi:10.5301/jabfm.5000203. [9] Stoodley P, Ehrlich GD, Sedghizadeh PP, Hall-Stoodley L, Baratz ME, Altman DT, et al. Orthopaedic biofilm infections. Curr Orthop Pract 2011;22:558–63. doi:10.1097/BCO.0b013e318230efcf. [10] Percival SL, Suleman L, Vuotto C, Donelli G, Percival StevenPercival SL. Healthcare-associated infections, medical devices and biofilms: risk, tolerance and control n.d. doi:10.1099/jmm.0.000032. [11] Oliveira WF, Silva PMS, Silva RCS, Silva GMM, Machado G, Coelho LCBB, et al. Staphylococcus aureus and Staphylococcus epidermidis infections on implants. J Hosp Infect 2017;0. doi:10.1016/j.jhin.2017.11.008. [12] Zimmerli W, Sendi P. Orthopaedic biofilm infections. APMIS 2017;125:353–64. doi:10.1111/apm.12687. [13] Kostakioti M, Hadjifrangiskou M, Hultgren SJ. Bacterial biofilms: development, dispersal, and therapeutic strategies in the dawn of the postantibiotic era. Cold Spring Harb Perspect Med 2013;3:a010306. doi:10.1101/cshperspect.a010306. [14] Høiby N, Ciofu O, Krogh Johansen H, Song Z-J, Moser C, Østrup Jensen P, et al. The clinical impact of bacterial biofilms. Int J Oral Sci Int J Oral Sci 2011;3:55–65. doi:10.4248/IJOS11026. [15] Wolcott RD, Rhoads DD, Dowd SE. Biofilms and chronic wound inflammation. J Wound Care 2008;17:333–41. doi:10.12968/jowc.2008.17.8.30796. [16] Arciola CR, Campoccia D, Ehrlich GD, Montanaro L. Biofilm-Based Implant Infections in Orthopaedics, Springer, Cham; 2015, p. 29–46. doi:10.1007/978-3-319-11038-7_2. [17] Charles Welliver Jr R, Hanerhoff BL, Henry GD, Köhler TS. Significance of Biofilm for the Prosthetic Surgeon 2014. doi:10.1007/s11934-014-0411-8. [18] Kasliwal MK, Tan LA, Traynelis VC. Infection with spinal instrumentation: Review of pathogenesis, diagnosis, prevention, and management. Surg Neurol Int 2013;4:S392-403. doi:10.4103/2152-7806.120783. [19] Borriello G, Werner E, Roe F, Kim AM, Ehrlich GD, Stewart PS. Oxygen limitation contributes to antibiotic tolerance of Pseudomonas aeruginosa in biofilms. Antimicrob Agents Chemother 2004;48:2659–64. doi:10.1128/AAC.48.7.2659-2664.2004. [20] Borriello G, Richards L, Ehrlich GD, Stewart PS. Arginine or Nitrate Enhances Antibiotic Susceptibility of Pseudomonas aeruginosa in Biofilms. Antimicrob Agents Chemother 2006;50:382–4. doi:10.1128/AAC.50.1.382-384.2006. [21] Hall-Stoodley L, Nistico L, Sambanthamoorthy K, Dice B, Nguyen D, Mershon WJ, et al. Characterization of biofilm matrix, degradation by DNase treatment and evidence of capsule downregulation in Streptococcus pneumoniae clinical isolates. BMC Microbiol 2008;8:173. doi:10.1186/1471-2180-8-173. [22] Lawson MC, Hoth KC, Deforest CA, Bowman CN, Anseth KS. Inhibition of Staphylococcus epidermidis biofilms using polymerizable vancomycin derivatives. Clin Orthop Relat Res 2010;468:2081–91. doi:10.1007/s11999-010-1266-z. [23] Yang-En Tan S, Chuen Chew S, Yang-Yi Tan S, Givskov M, Yang L, author C. Emerging frontiers in detection and control of bacterial biofilms. Curr Opin Biotechnol 2014;26:1–6. doi:10.1016/j.copbio.2013.08.002. [24] Palmer MP, Altman DT, Altman GT, Sewecke JJ, Ehrlich GD, Hu FZ, et al. Can we trust intraoperative culture results in nonunions? J Orthop Trauma 2014;28:384–90. doi:10.1097/BOT.0000000000000043. [25] Nelson CL, Mclaren AC, Mclaren SG, Johnson JW, Smeltzer MS. Is Aseptic Loosening Truly Aseptic? n.d. doi:10.1097/01.blo.0000175715.68624.3d. [26] Zimmerli W. Clinical presentation and treatment of orthopaedic implant-associated infection. J Intern Med 2014;276:111–9. doi:10.1111/joim.12233. [27] Veeh RH, Shirtliff ME, Petik JR, Flood JA, Davis CC, Seymour JL, et al. Detection of Staphylococcus aureus Biofilm on Tampons and Menses Components. J Infect Dis 2003;188:519–30. doi:10.1086/377001. [28] How NE, Street JT, Dvorak MF, Fisher CG, Kwon BK, Paquette S, et al. Pseudarthrosis in adult and pediatric spinal deformity surgery: a systematic review of the literature and meta-analysis of incidence, characteristics, and risk factors. Neurosurg Rev 2018. doi:10.1007/s10143-018-0951-3.

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