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Introduction Warfighters are exposed to life-threatening injuries daily and according to the Joint Trauma System Military Clinical Practice Guideline—Global Snake Envenomation Management snakebites are a concerning threat in all theaters of operation. Snake venom is a complex mixture of toxins including phospholipases A2 (PLA2) and snake venom metalloproteinases (SVMP) that produce myotoxic, hemotoxic, and cytotoxic injuries. Antibody-based antivenom is the standard of care but new approaches including small-molecule inhibitors have gained attention in recent years. Doxycycline is an effective inhibitor of human metalloproteinases and PLA2. The enzymatic activities of 3 phylogenetically distinct snakes: Agkistrodon piscivorus, Naja kaouthia , and Daboia russelii were tested under inhibitory conditions using doxycycline. Materials and Methods Enzymatic activity of PLA2 and SVMP was measured in N. kaouthia, D. russelii , and A. piscivorus venom alone and with doxycycline using EnzChek Phospholipase A2 and Gelatinase Assay Kits. A 1-way ANOVA with Tukey's post-hoc test was used to conduct comparative analysis. The median lethal dose of the venoms, the effective dose of doxycycline, and creatine kinase (CK) inhibition levels were measured in a murine model with adult Bagg Albino (BALB/c) mice using intramuscular injections. Median lethal and effective doses were determined using Spearman-Karber's method and a 1-way ANOVA with Tukey's post-hoc test was used to compare CK inhibition levels. Results Phospholipases A2 activity was reduced to 1.5% to 44.0% in all 3 venoms in a dose-dependent manner using 0.32, 0.16, and 0.08 mg/mL doxycycline when compared to venom-only controls (P  < .0001) (Fig. 1A). Snake venom metalloproteinases activity was reduced to 4% to 62% in all 3 venoms in a dose-dependent manner using 0.32, 0.16, and 0.08 mg/mL doxycycline (P  < .0001) (Fig. 1B). The lethal dose (LD50) values of the venoms in the murine model were calculated as follows: A. piscivorus  = 20.29 mg/kg (Fig. 2A), N. kaouthia  = 0.38 mg/kg (Fig. 2B), and D. russelii  = 7.92 mg/kg (Fig. 2C). The effective dose (ED50) of doxycycline in A. piscivorus was calculated to be 20.82 mg/kg and 72.07 mg/kg when treating D. russelii venom. No ED50 could be calculated when treating N. kaouthia venom (Fig. 3). Creatine kinase activity was significantly decreased in all 3 venoms treated with doxycycline (P  < .0001) (Fig. 4). FIGURE 1. In vitro doxycycline inhibition of PLA, and SVMP activity in whole venom. The AUC was calculated for PLA and SVMP activities for 20-min and 4-h time courses, respectively using EnzChek Phospholipase A2, assay kits, and EnzChek Gelatinase (SVMP) assay kits. (A) Inhibition of PLA2, with doxycycline (Dox) was tested at concentrations of 0.32 mg/mL, 0.16 mg/mL, and 0.08 mg/mL against A. piscivorus (4 μg/mL), N. kaouthia (4 μg/mL), and D. russelii (8 μg/mL) venom. A venom-only control was included. (B) Inhibition of SVMP with doxycycline was tested at concentrations of 0.32 mg/mL, 0.16 mg/mL, and 0.08 mg/mL against A. piscivorus (120 μg/ml.), N. kaouthia (125 μg/ml.), and D. russelii (250 μg/ml.). A venom-only control was included. An ordinary 1-way ANOVA with Tukey's post-hoc test was performed for inhibition assays to compare treatments to their respective venom controls. All error bars show mean ± SD, n  = 3, (****, P  < .0001). Open in new tab Download slide FIGURE 2. Percent survival of mice receiving various dosages for each venom studied and LDs, calculation. Adult BALB/c mice received intramuscular injections of various venom dosages for each venom, (A) A. piscivorus , (B) N. kaouthia , and (C) D. russelii. The resulting percent survival was measured across 48 h and the lethal dose 50 (LD50) was calculated using the Spearman-Karber method. In each graph, each treatment group (venom dosage) has n  = 5. Open in new tab Download slide FIGURE 3. Percent survival of mice receiving various doxycycline dosages for each venom studied and ED calculation. Adult BALB/c mice received intramuscular injections of various doxycycline dosages combined with 3 times the LD50 of cach venom [ A. piscivorus (AP) (60.87 mg/kg), N. kaouthia (NK) (1.14 mg/kg). D. russelii (DR) (23.76 mg/kg)] and the resulting percent survival was measured across 48 hours and the effective dose 50 (ED50) was calculated using the Spearman–Karber method. Each treatment group has n  = 5. Open in new tab Download slide FIGURE 4. Venom-induced CK activity with doxycycline-mediated inhibition. The amount of CK produced by mice exposed to one-fourth of the LD50, strength of A. piscivorus (AP) (5.07 mg/kg), N. kaouthia (NK) (0.095 mg/kg), or D. russelli (DR) (1.98 mg/kg) venom either with or without doxycycline (64 mg/kg). All error bars show mean, ± SD, n  = 5 (NaCl—Dox, AP NaCl), n-4 (NK Dox), and n-3 (AP Dox. NK NaCl, DR Dox, DR + NaCl). Statistical differences were determined using an ordinary 1-way ANOVA with Tukey's post-hoc test comparing each venom group within itself and to the doxycycline only control (**** P  < .0001). (*** P  < .001), (** P  < .01). (* P  < .05). Open in new tab Download slide Conclusion Doxycycline reduced PLA2- and SVMP-related lethality, particularly in A. piscivorus envenomings and in a limited capacity with D. russelii revealing its promise as a treatment for snakebites. In addition, CK activity, a common indicator of muscle damage was inhibited in mice that received doxycycline-treated venom. The doxycycline concentrations identified in the ED50 studies correspond to 1,456 to 5,061 mg dosages for a 70 kg human. Factors including venom yield and snake species would affect the actual dosage needed. Studies into high-dose doxycycline safety and its effectiveness against several snake species is needed to fully translate its use into humans. Based on this work, doxycycline could be used as a treatment en route to higher echelons of care, providing protection from muscle damage and reducing lethality in different snake species. [ABSTRACT FROM AUTHOR]

Glucocorticoids may be given prior to major orthopedic surgery to decrease postoperative nausea, vomiting, and pain. Additionally, many orthopedic patients may be on chronic glucocorticoid therapy. The aim of our study was to investigate whether glucocorticoid administration influences Orthopedic-Device-Related Infection (ODRI) in a rat model. Screws colonized with Staphylococcus epidermidis were implanted in the tibia of skeletally mature female Wistar rats. The treated groups received either a single shot of dexamethasone in a short-term risk study, or a daily dose of dexamethasone in a longer-term interference study. In both phases, bone changes in the vicinity of the implant were monitored with microCT. There were no statistically significant differences in bacteriological outcome with or without dexamethasone. In the interference study, new bone formation was statistically higher in the dexamethasone-treated group (p = 0.0005) as revealed by CT and histopathological analysis, although with relatively low direct osseointegration of the implant. In conclusion, dexamethasone does not increase the risk of developing periprosthetic osteolysis or infection in a pre-clinical model of ODRI. Long-term administration of dexamethasone seemed to offer a benefit in terms of new bone formation around the implant, but with low osseointegration. [ABSTRACT FROM AUTHOR]

Orthopedic device‐related infection (ODRI) preclinical models are widely used in translational research. Most ODRI models require induction of general anesthesia, which frequently results in hypothermia in rodents. This study aimed to evaluate the impact of peri‐anesthetic hypothermia in rodents on outcomes in preclinical ODRI studies. A retrospective analysis of all rodents that underwent surgery under general anesthesia to induce an ODRI model with inoculation of Staphylococcus epidermidis between 2016 and 2020 was conducted. A one‐way multivariate analysis of covariance (one‐way MANCOVA) was used to determine the fixed effect of peri‐anesthetic hypothermia (hypothermic defined as rectal temperature <35°C) on the combined harvested tissue and implant colony‐forming unit (CFU) counts, and having controlled for the study groups including treatments received, duration of surgery and anesthesia, and study period. The results showed a significant effect of peri‐anesthetic hypothermia on the post‐mortem combined CFU counts from the harvested tissue and implant(s) (p = 0.01) when comparing normo‐ versus hypothermic rodents. Using Wilks' Λ as a criterion to determine the contribution of independent variables to the model, peri‐anesthetic hypothermia was the most significant, though still a weak predictor, of increased harvested CFU counts. Altogether, the data corroborate the concept that bacterial colonization is affected by abnormal body temperature during general anesthesia at the time of bacterial inoculation in rodents, which needs to be taken into consideration to decrease infection data variability and improve experimental reproducibility. [ABSTRACT FROM AUTHOR]

Abstract Background Recent studies using sheep critical sized defect models to test tissue engineered products report high morbidity and complications rates. This study evaluates a large bone defect model in the sheep tibia, stabilized with two, a novel Carbon fibre Poly-ether-ether-ketone (CF-PEEK) and a locking compression plate (LCP) which could sustain duration for up to 6 month with an acceptable low complication rate. Methods A large bone defect of 3 cm was performed in the mid diaphysis of the right tibia in 33 sheep. The defect was stabilised with the CF - PEEK plate and an LCP. All sheep were supported with slings for 8 weeks after surgery. The study was carried out for 3 months in 6 and for 6 months in 27 animals. Results The surgical procedure could easily be performed in all sheep and continuous in vivo radiographic evaluation of the defect was possible. This long bone critical sized defect model shows with 6.1% a low rate of complications compared with numbers mentioned in the literature. Conclusions This experimental animal model could serve as a standard model in comparative research. A well defined standard model would reduce the number of experimental animals needed in future studies and would therefore add to ethical considerations.

A significant proportion of orthopedic devices are implanted in osteoporotic patients, but it is currently unclear how estrogen deficiency and/or exposure to antiresorptive bisphosphonates (BPs) influence orthopedic device‐related infection (ODRI), or response to therapy. The aim of this study is to characterize the bone changes resulting from Staphylococcus epidermidis infection in a rodent ODRI model and to determine if ovariectomy (OVX) or BP treatment influences the infection or the success of antibiotic therapy. A sterile or S. epidermidis‐contaminated screw was implanted into the proximal tibia of skeletally mature female Wistar rats (n = 6–9 per group). Bone changes were monitored over 28 days using in vivo micro‐computed tomography scanning. OVX was performed 12 weeks before screw implantation. The BP zoledronic acid (ZOL) was administered 4 days before screw insertion. A combination antibiotic regimen (rifampin plus cefazolin) was administered from Days 7–21. In skeletally healthy animals, S. epidermidis induced marked changes in bone, with peak osteolysis occurring at Day 9 and woven bone deposition and periosteal mineralization from Day 14 onwards. Antibiotic therapy cleared the infection in the majority of animals (2/9 infected) but did not affect bone responses. OVX did not affect the pattern of infection‐induced changes in bone, nor bacterial load, but reduced antibiotic efficacy (5/9 infected). ZOL treatment did not protect from osteolysis in OVX animals, or further affect antibiotic efficacy (5/9 infected) but did significantly increase the bacterial load. This study suggests that both BPs and OVX can influence host responses to bone infections involving S. epidermidis. [ABSTRACT FROM AUTHOR]

Focused high‐energy extracorporeal shockwave therapy (fhESWT) is used to improve fracture healing in cases of nonunion. In addition, it has been shown to have direct antibacterial effects. We evaluated fhESWT as an adjunct to conventional treatment in a clinically relevant rabbit model of fracture‐related infection (FRI). A humeral osteotomy in 31 rabbits was fixed with a seven‐hole locking compression plate. FRI was established with a clinical Staphylococcus aureus isolate. After 2 weeks, a revision surgery was performed with debridement, irrigation, and implant retention. Rabbits then received: no further treatment (controls); shockwaves (4000 impulses with 23 kV at days 2 and 6 after revision); systemic antibiotics (rifampin and nafcillin); or the combination of antibiotics and shockwaves. Treatments were applied over 1 week. Blood cultures were taken before and after shockwave sessions. After another week without treatment, rabbits were euthanized and quantitative bacteriology was performed on implants and tissues to determine infection burden. Indicator organs (brain, heart, liver, lungs, kidneys, and spleen) were cultured to assess possible bacteremia. All the rabbits were infected at revision surgery as determined by the bacteriological culture of debrided materials. fhESWT in combination with antibiotic treatment lowered the bacterial burden 100‐fold compared with antibiotic treatment alone in all samples (P =.38). This effect was most prevalent for the implant sample (P =.08). No significant effect was seen for fhESWT alone compared with untreated controls. No signs of bacteremia occurred in blood cultures and organs. fhESWT appears safe and could be a helpful adjunct to conventional treatment in certain difficult‐to‐treat FRIs. [ABSTRACT FROM AUTHOR]

Fracture-related infections are burdensome conditions that affect both a patient's health and financial well-being. Preventing an infection and stabilizing the fracture are critical aspects in a care plan that rely on antibiotics and orthopedic implants, both which need to be improved. Bacteriophage or phage are viruses that specifically kill bacteria and are a promising alternative/companion to antibiotics while enhanced orthopedic implants that are osteoinductive and biodegradable are needed for bone healing. In this work we report the inhibitory effectiveness of three phages Ø K, Ø 0146, and Ø 104023 alone and in combination against a strain of methicillin-resistant Staphylococcus aureus. Single phage and cocktails were mixed with bacteria at multiplicities of infection of 5 and 2.5 and growth was measured using optical density over 48 hours. Ø K alone and Ø K + Ø 0146 were able to completely inhibit bacterial growth. We also present and the ability of Ø K to bind to and be released from a biodegradable and biocompatible orthopedic carbon scaffold. The carbon scaffold was soaked in a solution of Ø K, washed, and then incubated in sequential buffer baths while samples were removed at timepoints up to seven days to calculate phage elution. At every timepoint measured including seven days, phages were found to still be eluting from the scaffold. These results indicate that the studied phages are effective bacterial inhibitors and could be used to prevent infections. Furthermore, orthopedic implants such as a carbon scaffold can be coated with phage to provide long-term protection. In vivo infection experiments on phage loaded scaffold that test bacterial clearance, phage persistence in tissue, resolution of inflammation, and bone regrowth with an active infection are needed to further this work., (Creative Commons Attribution license.)

Aims: Fracture-related infection (FRI) is commonly classified based on the time of onset of symptoms. Early infections (< two weeks) are treated with debridement, antibiotics, and implant retention (DAIR). For late infections (> ten weeks), guidelines recommend implant removal due to tolerant biofilms. For delayed infections (two to ten weeks), recommendations are unclear. In this study we compared infection clearance and bone healing in early and delayed FRI treated with DAIR in a rabbit model., Methods: Staphylococcus aureus was inoculated into a humeral osteotomy in 17 rabbits after plate osteosynthesis. Infection developed for one week (early group, n = 6) or four weeks (delayed group, n = 6) before DAIR (systemic antibiotics: two weeks, nafcillin + rifampin; four weeks, levofloxacin + rifampin). A control group (n = 5) received revision surgery after four weeks without antibiotics. Bacteriology of humerus, soft-tissue, and implants was performed seven weeks after revision surgery. Bone healing was assessed using a modified radiological union scale in tibial fractures (mRUST)., Results: Greater bacterial burden in the early group compared to the delayed and control groups at revision surgery indicates a retraction of the infection from one to four weeks. Infection was cleared in all animals in the early and delayed groups at euthanasia, but not in the control group. Osteotomies healed in the early group, but bone healing was significantly compromised in the delayed and control groups., Conclusion: The duration of the infection from one to four weeks does not impact the success of infection clearance in this model. Bone healing, however, is impaired as the duration of the infection increases., Competing Interests: A. Vallejo Diaz, D. Arens, S. Zeiter, C. Siverino, R. G. Richards, and T. F. Moriarty report institutional funding (paid to AO Research Institute Davos) from AOTrauma as part of the Clinical Priority, (© 2024 Puetzler et al.)