Effectiveness of topical adjuvants in reducing biofilm formation on orthopedic implants: an in vitro analysis
Biofilms form on surfaces of shoulder arthroplasty implants where they interfere with host defenses and the action of antibiotics; thus they form, a "safe harbor" in which bacteria can persist for long periods of time. Resolution of a shoulder periprosthetic infection associated with a prosthetic biofilm usually requires implant removal and exchange.
These authors compared three topical agents, Bactisure (Zimmer Biomet, Warsaw, IN, USA), povidone-iodine (Betadine), and chlorhexidine gluconate solution (Irrisept; Irrimax, Gainesville, FL, USA) with respect to their ability in vitro to reduce biofilm formation by Staphylococcus aureus (ATCC 35556), Staphylococcus epidermidis (ATCC 35984), and Cutibacterium acnes (LMG 16711) inoculated on cobalt-chrome, titanium, and stainless steel disks.
For each bacterial strain, disks were divided into 4 groups: (1) control, (2) povidone-iodine (Betadine), (3) chlorhexidine gluconate (Irrisept), and (4) Bactisure. Bacteria were grown on 5% sheep blood agar plates.
At 48 and 72 hours after implementation of the topical adjuvant, reduction in colony forming units (measured using adenosine triphosphate bioluminescence) was observed for all topical adjuvants across all tested metals, as compared with their respective control. In most cases the number of colony forming units were reduced by over 90% as shown below
48 h
The authors concluded that through the use of topical adjuvants on S aureus–, S epidermidis–, and C acnes–inoculated disks of various implant metals, a significant reduction in biofilm production was observed.
Comment: Among the three agents included in this in vitro study, Betadine has been the most investigated in vivo. In prior reports Betadine has been shown to reduce the rate of clinical infections in primary total hip arthroplasties and total knee arthroplasties as well as in spine surgery and other surgical fields.
When determining the value (benefit/cost) of the three topical adjuncts, two factors merit consideration:
(1) While there may be statistically significant differences among the three agents, all are quite effective in reducing the colony forming units by >90% on the three metals; it is unclear whether the differences in benefit among them would be clinically significant. (2) While the costs of the proprietary preparations (Irrisept and Bactisure) are not presented in the article, they are likely to be greater than generic povidone-iodine or Betadine.
Because of our concern that Cutibacterium are routinely inoculated into shoulder arthroplasty wounds when the pilosebaceous units are severed during the skin incision, we routinely use dilute povidone-iodine lavage prior to the placement of the arthroplasty implants.
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