IMPACT OF BIOFILM ON HEALING AND A METHOD FOR IDENTIFYING IT IN THE WOUND

Mikroorganizmi mogu postojati kako u planktonskom, tako i u stanju biofi lma. Svaki fenotip ima ulogu u zakašnjelom zacjeljivanju te uzrokuje infekcije akutnih i kroničnih rana. Međutim, virulentni biofi lm je osnovni razlog da do zacjeljivanja rana ne dolazi pravodobno. Zbog hipoteze da mikroorganizmi mogu adherirati za svaku površinu, biofilm se može naći u svim kroničnim ranama. Međutim, sam po sebi biofi lm nije najveća prepreka zacjeljivanju kroničnih rana, već njegova virulentnost i patogenost. Ustanoviti koji specifi čni patogeni biofi lm uzrokuje zakašnjelo zacjeljivanje rana pomoglo bi boljoj praksi u liječenju i njezi rana, no poteškoća i daljnje provođenje velikih randomiziranih kontroliranih studija o biofilmu moguće je samo vizualnom dijagnostikom odnosno dokazom biofi lma mikroskopskom analizom histološki obrađenog bioptata rana.The skin microbiome is the aggregate of microorganisms that reside on the surface and in deep layers of the skin. Skin is colonized by bacteria, fungi, viruses and mites, maintaining a balance. Disruption in the ecosystem results in skin infections. Chronic wounds in diabetics, elderly and immobile individuals are at risk of skin organisms to invade and become pathogenic upon breach of the skin barrier. The bacteria of the skin microbiome may contribute to delayed healing and persistent infl ammation. Staphylococcus epidermidis is an invasive skin organism that causes infection, i.e. hospital acquired infection (HAI) on medical devices and form biofi lm. At the most basic level, biofi lm can be described as bacteria embedded in a thick, slimy barrier of sugars and proteins. The biofi lm barrier protects the microorganisms from external threats. Biofi lms provide a reservoir of potentially infectious microorganisms that are resistant to antimicrobial agents, and their importance in the failure of medical devices and chronic infl ammatory condition is increasingly being recognized. Particular research interest exists in the association of biofi lms with wound infection and non-healing, i.e. chronic wounds. There is now strong evidence that biofi lm is present in the majority of chronic wounds. Specialized microscopic techniques used since 2008 have allowed several research groups to demonstrate that 60% to 90% of chronic wounds have biofilm versus only 6% of acute wounds. While many studies confirm that chronic wounds often contain a polymicrobial flora, controversy remains with regard to whether these organisms directly contribute to non-healing. It seems most likely that individual bacteria themselves are no direct correlation between the presence of four or more distinct bacterial species in a wound and non-healing, suggesting that mixed microbial populations are the cause of pathology. The most reliable method to confirm the presence of a biofilm is specialized microscopy, e.g., bright-fi eld, fl uorescence in situ hybridization (FISH), and environmental scanning electron microscope (ESEM). Surface wound cultures underestimate total wound microbiota – misleading. Histological staining of deep debrided tissue shows evidence of biofi lms. Now it is recognized that the majority of microbial species in chronic wounds are anaerobic bacteria (deep swabbing techniques yield similar fi ndings to biopsies) if samples are processed within two hours. Traditional (wound culture method) cultures have limitations because all microbes (the organisms within the biofi lm) cannot be isolated in culture or cannot be detected. Therefore, the most effective methods are molecular analyses. Newer methods using microbial DNA may help decipher the role the microbes play in infection and critical colonization and provide quantitative and qualitative information on the range of microorganisms, including bacteria and biofilm formation

SPONDYLITIS - PRINCIPLES OF OPERATIVE TREATMENT OF IATROGENIC SPONDYLITIS

SAŽETAK Nedavni napredak u medicini koji uključuje razvoj snažnih antimikrobnih lijekova, suvremenu dijagnostiku i poboljšane operacijske metode, smanjio je postotak bolesti i smrtnost od infekcija kralježnice. Međutim, još uvijek ima dvojbi vezanih uz čim bržu ciljanu dijagnostiku i pravilno liječenje. Prikazana su sadašnja iskustva u strategiji liječenja infekcija kralježnice na Odjelu za ortopediju Kliničke bolnice Dubrava, Zagreb.SUMMARY Recent progress in medical technologies including the development of potent antimicrobial drugs, advanced imaging, and improved surgical methods, have reduced morbidity and mortality rates for spinal infections; however, debate still exists on the general diagnostic and proper management principles of the disease. Review of the experience about current treatment strategy for eradications of the spine infections at the Department of Orthopaedic Surgery Dubrava University Hospital Zagreb

Antimikrobna profilaksa i kontrola infekcije kod mehaničke potpore srca

Ventricular assist devices (VADs) for patients with severe heart failure are improving, and there are increasing numbers of implants, as device therapy enters the era of permanent use (i.e. destination therapy). The device-related infection of implanted pumps and sepsis remain important risk factors for death, and once infections are established on biomaterial surfaces, they usually persist despite prolonged antimicrobial therapy. Biofilm forming is the crucial moment in the pathogenesis of many subacute and chronic bacterial infections, including the infections connected with a foreign body. Biofilm is a significant clinical problem. Its eradication by conventional antimicrobial agents is rather complicated, as it disposes of several mechanisms for developing resistance to antibiotics. The role of persisting cells is crucial in the context of the tolerance of bacterial biofilm towards antimicrobials. The mechanism for biofilm forming and the consequential antimicrobial resistances are the key to developing new therapeutic strategies. Therefore, adherence to evidence-based infection control and prevention guidelines, meticulous surgical technique and optimal post-operative surgical site care form the foundation for VAD-associated infection prevention.Danas je sve većem broju bolesnika sa teškim zatajenjem srca, zbog napretka tehnologije omogućeno privremeno ili trajno liječenje uređajem (pumpom) za mehaničku potporu srca (VAD). Infekcije implantiranih srčanih pumpi i sepsa ostaju važnim fatorom rizika za smrt. Kad se na površinama biomaterijala utvrdi postojanje infekcija one perzistiraju unatoč produljenoj antimikrobnoj terapiji. Formiranje biofilma je presudni korak u patogenezi mnogih subakutnih i kroničnih bakterijskih infekcija, a osobito infekcija povezanih sa stranim tijelom. Biofilm je signifikantan klinički problem. Teško se eradicira konvencionalnim antimikrobnim lijekovima, jer posjeduje nekoliko mehanizma stvaranja antibiotske rezistencije. Perzistirajuće stanice imaju glavnu ulogu u toleranciji bakterijskog biofilma prema antimikrobnom lijeku. Mehanizam stvaranja biofilma i posljedične antimikrobne rezistencije biti će ključ za razvoj novih terapijskih strategija. Dakle, poštivanje dokazima utemeljene kontrole infekcija uz smjernice za prevenciju istih, pedantna kirurška tehnika i optimalna njega postoperativnog kirurškog mjesta čine temelje za prevenciju infekcija povezanih s VAD-om

Antimikrobna profilaksa i kontrola infekcije kod mehaničke potpore srca

Ventricular assist devices (VADs) for patients with severe heart failure are improving, and there are increasing numbers of implants, as device therapy enters the era of permanent use (i.e. destination therapy). The device-related infection of implanted pumps and sepsis remain important risk factors for death, and once infections are established on biomaterial surfaces, they usually persist despite prolonged antimicrobial therapy. Biofilm forming is the crucial moment in the pathogenesis of many subacute and chronic bacterial infections, including the infections connected with a foreign body. Biofilm is a significant clinical problem. Its eradication by conventional antimicrobial agents is rather complicated, as it disposes of several mechanisms for developing resistance to antibiotics. The role of persisting cells is crucial in the context of the tolerance of bacterial biofilm towards antimicrobials. The mechanism for biofilm forming and the consequential antimicrobial resistances are the key to developing new therapeutic strategies. Therefore, adherence to evidence-based infection control and prevention guidelines, meticulous surgical technique and optimal post-operative surgical site care form the foundation for VAD-associated infection prevention.Danas je sve većem broju bolesnika sa teškim zatajenjem srca, zbog napretka tehnologije omogućeno privremeno ili trajno liječenje uređajem (pumpom) za mehaničku potporu srca (VAD). Infekcije implantiranih srčanih pumpi i sepsa ostaju važnim fatorom rizika za smrt. Kad se na površinama biomaterijala utvrdi postojanje infekcija one perzistiraju unatoč produljenoj antimikrobnoj terapiji. Formiranje biofilma je presudni korak u patogenezi mnogih subakutnih i kroničnih bakterijskih infekcija, a osobito infekcija povezanih sa stranim tijelom. Biofilm je signifikantan klinički problem. Teško se eradicira konvencionalnim antimikrobnim lijekovima, jer posjeduje nekoliko mehanizma stvaranja antibiotske rezistencije. Perzistirajuće stanice imaju glavnu ulogu u toleranciji bakterijskog biofilma prema antimikrobnom lijeku. Mehanizam stvaranja biofilma i posljedične antimikrobne rezistencije biti će ključ za razvoj novih terapijskih strategija. Dakle, poštivanje dokazima utemeljene kontrole infekcija uz smjernice za prevenciju istih, pedantna kirurška tehnika i optimalna njega postoperativnog kirurškog mjesta čine temelje za prevenciju infekcija povezanih s VAD-om

The Effect of Chlorhexidine on Oral Bacterial Colonisation and Development of Nosocomial Infections in Life Threatened Patients

Ciljevi: Zabilježiti u bolesnika na odjelu intenzivnog liječenja učinak dekontaminacije dentalnoga plaka i bukalne sluznice antiseptikom na kolonizaciju potencijalno patogenim nozokomijalnim bakterijama i razvoj nozokomijalnih infekcija. Vrsta: Dvostruko slijepa prospektivna poredbena studija zasnovana na nasumce odabranom uzorku. Mjesto: Odjel intenzivnoga liječenja s 12 kreveta u Kliničkoj bolnici “Dubrava”, Zagreb. Ispitanici: Bolesnici koji su jedan za drugim primljeni na odjel intenzivnog liječenja s bolešću koja je indicirala najmanje trodnevo liječenje. Bezubi su bolesnici isključeni iz studije. Terapije: Nakon nasumice izabranih bolesnika, provedena je terapija te skupine s 0,2% gelom klorheksidina, tri puta na dan za vrijeme njihova boravka na odjelu intenzivnog liječenja. Standardne mjere oralne higijene i placebo gel uporabljeni su na kontrolnoj skupini. Posebna mjerenja: Uzet je dentalni status s pomoću indeksa karijesa; količina plaka utvrđena je semikvantitativnim indeksom plaka. Uzeti su uzorci bakterija dentalnoga plaka, bukalne sluznice, nazalnog i trahealnog aspirata i krvi nultog dana, zatim trećeg, šestog i dalje svaka tri dana do otpusta bolesnika s odjela intenzivnog liječenja. Rezultati: Sudjelovalo je 60 bolesnika - 30 koji su primali terapiju i 30 iz kontrolne skupine (prosjek godina: 54,5±18,2, prosječna simplificirana akutna fiziološka vrijednost II (Simplified Acute Physiological Score II): 29±13,5 bodova). Pri prijmu u bolnicu nije bilo znatnih razlika između dviju skupina što se tiče kliničkih i dentalnih podataka. Srednja vrijednost indeksa karijesa iznosila je 19,5±5,5, a plak indeksa 1,7±0,62. Na dan prijma u 63% su bolesnika iz područja dentalnoga plaka i bukalne sluznice izolirane potencijalno patogene nozokomijalne bakterije. U usporedbi s kontrolnom skupinom iznos transkolonizacije bakterija u područje bronha znatno je smanjen (19/7 bolesnika, p=0,002), kao i incidencija razvoja nozokomijalne infekcije (26,7%/6,7%, p=0,041). Ti su rezultati bili konzistentni sa znatnim preventivnim učinkom antiseptičke dekontaminacije s 75% razmjernoga smanjenja rizika. Postojao je trend smanjenja vrijednosti plak indeksa, kolonizacije potencijalno patogenim bakterijama i duljine boravka na odjelu intenzivnoga liječenja.. Zaključci: Dekontaminacija dentalnoga plaka i bukalne sluznice antiseptikom, 0,2% gelom klorheksidina smanjuje oralnu bakterijsku kolonizaciju te može smanjiti incidenciju razvoja nozokomijalnih infekcija u životno ugroženih bolesnika.Aims: To record the effect of decontamination of dental plaque and buccal mucous membrane by antiseptics on the colonisation of potential pathogenic nosocomial bacteria and development of nosocomial infections in patients in the Department of Intensive Care. Type: A double blind prospective comparative study based on a randomly selected sample. Location: Department of Intensive Care with 12 beds in the University Hospital Dubrava. Subjects: Patients admitted one after the other in the Department of Intensive Care with a disease which indicated at least three days of treatment. Edentulous patients were excluded from the study. Therapy: After randomly selecting the patients, the group was treated with 0.2% gel chlorhexidine, three times daily for the duration of their stay in the Department. Standard measures of oral hygiene and placebo gel were applied in a control group. Specific measurements: Dental status was taken by means of caries index; the amount of plaque was determined by means of semi quantitative plaque index. Samples of bacteria were taken of dental plaque, buccal mucous membrane, nasal and tracheal aspirate and blood on the first, third and sixth day and thereafter every three days until the patient\u27s release from the Department of Intensive Treatment. Results: Sixty patients participated in the study: 30 who received therapy and 30 in a control group (mean age: 54.5±5.5 years, Simplified Acute Physiological Score II: 29±13.5 points). On admittance to hospital there were no significant differences between the two groups with regard to clinical and dental data. Average value of the caries index amounted to 19.5±5.5, and plaque index 1.7±0.62. On the day of admittance potentially pathogenic nosocomial bacteria were isolated from the area of dental plaque and buccal mucous membrane in 63% of patients. In relation to the control group the amount of transcolonisation of bacteria in the region of the bronchi was significantly reduced (19/7 patients, p=0.002), as also was the incidence of the development of nosocomial infections (26.7%/6.7%, p=0.041). These results were consistent with the significant preventive effect of antiseptic decontamination with 75% relatively reduced risk. There was a trend toward a decrease in the values of plaque index, colonisation of potential pathogenic bacteria and the duration of stay in the Department of Intensive Care. Conclusions: Decontamination of dental plaque and buccal mucous membrane by antiseptics, 0.2% gel chlorhexidine, reduced oral bacterial colonisation, and can reduce the incidence of the development of nosocomial infections in life threatened patients

A Microbiological Study of Periapical Lesions in Single Rooted Teeth with Open and Closed Root Canal

Svrha ove studije bio je istražiti mikrobnu floru periapikalnih ostitičkih lezija kod jednokorijenskih zuba. Posebno su analizirani periapikalni procesi kod kojih je kanal zuba bio otvoren i oni kod kojih je kanal bio zatvoren (nadogradnja). Uzorci za mikrobiološku raščlambu uzimani su tijekom operativnoga zahvata - apikotomije. Dobiveni rezultati većim se dijelom uklapaju u dosadašnje spoznaje o mikrobnoj flori odontogene infekcije. Polimikrobijalni sastav flore sa znatnim udjelom anaerobnih bakterija te reducirana mikrobna flora u zatvorenim ostitičkim lezijama osnovne su značajke periapikalne infekcije. Najčešći izolati bili su iz skupine streptokoka, a najčešći anaerob Veillonela. Utvrđeno je da se streptokoki češće javljaju u zatvorenim ostitičkim procesima.The aim of this study was to investigate the microbial flora of periapical ostitic lesions in single rooted teeth. Periapical processes in which the root canal was open and those in which the canal was closed (reinforcement) were analysed. Samples for microbiological analysis were taken during the operation - apicotomy. On the whole the results obtained agree with current knowledge of the microbial flora in odontogenic infection. The polymicrobial composition of the flora with a significant share of anaerobic bacteria and reduced microbial flora in closed ostial lesions are the basic characteristics of periapical infection. The most frequent isolates found were from the streptococci group, and the most frequent anaerobe, Veillonela. It was determined that streptococci occur more frequently in closed ostial processes

KORIŠTENJE PALEORADIOLOŠKE I MIKROBIOLOŠKE ANALIZE ANTIČKOGA KULTURNOG MATERIJALA: MSCT, MAMOGRAFIJA I MIKROBIOLOŠKA ANALIZA KAPULJAČE S LIKOM SV. MARTINA I PROSJAKA (TROGIR, HRVATSKA)

Paleoradiology is the study of biological and other materials from archeological settings through the use of various medical imaging techniques. Although it is most often used in the scientific study of ancient human remains, it can also be used to study metals, ceramics, paper, and clothes. The aim of this study was to test two paleoimaging techniques (MSCT and mammography) in the analysis of an important Croatian liturgical vestment: the hood of a bishop’s cope from St. Lawrence’s Treasury in Trogir depicting St. Martin and a beggar. To ensure a safe environment for scientists participating in the analysis, a preliminary microbiological analysis was performed, which contributed to the database of microbiological flora found on Croatian archeological remains and relics studied to date. Due to a great amount of metal filaments, the paleoradiological analysis did not produce satisfactory results. However, a digitally enhanced image clearly showed fine metal embroidery of the hood that was not so easily perceived by naked eye. This article argues in favor of expanding paleoradiological studies on materials other than human remains and also of publishing unsatisfactory results, as important lessons for future development of techniques and methods to analyze ancient remains and seek answers about human historical and cultural heritage.Paleoradiologija je znanstvena disciplina koja se u analizi arheološki značajnih bioloških i drugih materijala služi različitim medicinskim slikovnim metodama. Iako se danas najčešće primjenjuje u istraživanju ljudskih ostataka, paleoradiologija se može koristiti i u analizi metala, keramike, papira i odjeće. Cilj je ovoga rada prikazati rezultate paleoradiološke (MSCT i mamografske) analize značajnoga hrvatskog obrednog crkvenog ruha: kapuljače biskupskog plašta s likom sv. Martina i prosjaka iz Trogirske riznice. Da bi se istraživačima osigurali sigurni uvjeti rada, izvedeno je mikrobiološko testiranje plašta, kojim su se nadopunili dosadašnji podaci o mikrobiološkoj flori hrvatskih arheoloških ostataka i relikvija. Zbog velikog broja metalnih niti prisutnih u kukuljici, paleoradiološka analiza nije dala zadovoljavajuće rezultate. Ipak, digitalno poboljšanje slike omogućilo je bolje uočavanje samog stila figuralnoga metalnog veza kapuljače, koji je teže uočiti golim okom. Naposljetku, studija obrazlaže značenje paleoradiologije u proučavanju nehumanoga arheološkog materijala kao i objavljivanje rezultata koji nisu posve zadovoljavajući, a bitni su za daljnji razvoj i poboljšavanje tehnika koje se koriste u istraživanju i arheološkog materijala i ljudske povijesti

Treatment of soft tissue infection and osteomyelitis with multi-drug resistant Acinetobacter baumannii following a tibial fracture surgery: case report

Cilj: Cilj je prikazati kirurško i antimikrobno liječenje komplicirane kirurške infekcije uzrokovane Acinetobacter baumannii. Prikaz slučaja: 57-godišnja pacijentica bila je premještena u našu ustanovu tri tjedna nakon osteosinteze proksimalnog multifragmentarnog prijeloma tibije s postoperacijskom infekcijom kosti i mekog tkiva uzrokovanom A. baumannii. Prema nalazu iz vanjske ustanove, osim na karbapeneme, fluorokinolone i aminoglikozide, soj je bio rezistentan i na sulbaktam i kolistin. U trenutku prijema pacijentica je bila febrilna, povišenih upalnih parametara i na terapiji ciprofloksacinom i rifampicinom. U našoj ustanovi ponovno su uzeti mikrobiološki uzorci iz kojih je bio izoliran multirezistentan A. baumannii, ali osjetljiv na sulbaktam i kolistin. Uz nekrektomiju mekog tkiva i sekvestrektomiju zahvaćenog dijela kosti te rekonstrukcijsko kirurško liječenje, provedena je i kombinirana terapija kolistinom i fosfomicinom tijekom 14 dana. Nakon 23 dana hospitalizacije pacijentica je dobrog općeg stanja i lokalnog nalaza otpuštena na fizikalnu terapiju. Zaključak: A. baumannii uzrokuje manje od 3% kirurških infekcija, a osobito su rizični bolesnici s prethodnim ozljedama kosti i mekog tkiva te prethodno provedenom antibiotskom terapijom. Kolistin je terapija izbora za liječenje infekcija uzrokovanih multirezistentnim A. baumannii. Iako je A. baumannii intrinzično rezistentan na fosfomicin, smatra se kako se u kombinaciji s kolistinom postiže sinergističko djelovanje. Budući da je fosfomicin mala molekula, dobro prodire i u biofilm. Kod naše pacijentice kombinacijom antimikrobne terapije i kirurškog liječenja postigao se odličan klinički ishod.Aim: The aim was to present surgical and antimicrobial treatment of complicated surgical site infection (SSI) caused by A. baumannii. Case report: 57-year-old female patient was admitted 3 weeks after plate osteosynthesis for proximal tibial multifragmented fracture. The surgery was performed in another institution. She presented with SSI and osteomyelitis due to A. baumannii. According to microbiology results from another institution, the strain was resistant to carbapenems, fluoroquinolones, aminoglycosides, and to sulbactam and colistin. At presentation she was already being treated with ciprofloxacin and rifampicin but was nevertheless febrile with elevated inflammation markers. New sets of microbiology samples were taken, and the cultures yielded a multi-drug resistant A. baumannii, although sensitive to sulbactam and colistin. In addition to soft tissue necrectomy and sequestrectomy of devitalized bone with subsequent reconstructive surgery, the patient was treated with 14-day long parenteral combination therapy – colistin and fosfomycin. After 23-day-long hospitalization, the patient was transferred to physical rehabilitation clinic in good general health and with satisfactory wound healing. Conclusion: Acinetobacter baumannii causes less than 3% of SSI-s, and patients with previous traumatic injuries and antibiotic therapy are most at risk. Colistin is preferred therapy for multi-drug resistant A. baumannii. Although A. baumannii is intrinsically resistant to fosfomycin, it is thought that combination therapy with colistin yields synergy. Since fosfomycin is a small molecule, it penetrates biofilm well. Due to extensive surgical and antimicrobial treatment, our patient had a good clinical outcome