No abstract

Implantable medical devices such as catheters are indispensable in the management of critically and chronically ill patients for the administration of electrolytes, drugs, parenteral nutrients, blood components or drainage of secretions and pus. Artificial heart valves, prosthetics, ceramics, metals and bone cements are standard implants. All of these implants save human lives and enhance quality of life. At the same time they are the leading cause for millions of primary nosocomial bloodstream infections with substantial morbidity and mortality 1 . A property common to all these biomaterials is the ease by which they are colonized by pathogenic and nonpathogenic microorganisms, often requiring immediate removal.Several methods have been devised to decrease the risk of foreign body-associated infections. These include the use of meticulous hygienic precautions, the development of hydrophilic materials to minimize bacterial adhesion and impregnation with antiseptics and antibiotics. Silver, in particular free silver ions 2 , is well known for its powerful and broad-spectrum antimicrobial activity still allowing the independent use of therapeutic antibiotics. The investigation of the antimicrobial activity of implants containing silver as an antimicrobial agent is difficult because many silver compounds are poorly water soluble, resulting in low concentrations of silver ions released into the surrounding medium. Therefore, the antimicrobial efficacy of polymers impregnated with elementary silver cannot be tested by routine agar diffusion measurements 3 . Like other procedures 4,5 , the agar diffusion technique was also inappropriate for a simultaneous highthroughput screening of silver prototypes.Reliable in vitro methods for antimicrobial activity testing of surfaces are essential for the development of new anti-infective biomaterials. Cell proliferation is an important step in the course of infection 6 and must be included in any evaluation procedure. To date, assays 7-10 have focused on the monitoring of bacterial adherence but lack an analysis of the microbial proliferatory behavior. For a precise testing of antimicrobial efficacy three independent aspects must be considered: adhesion (the test must detect and quantify adherent microorganisms); proliferation (the test should assay the potential of adherent bacteria for proliferation); and detection of bactericidal and bacteriostatic activity.Here, we introduce a new technique for testing antimicrobial properties of biomaterials using a microplate system (Fig. 1). As a selected example, we show in vitro data for the antimicrobial activity of silver polymers, which correlate positively with multicenter clinical trials 11 . Implications of the approach.The number of new biomaterials in medicine is steadily growing. Highly efficient in vitro methods are required for quality control, screening and product improvement. Such comparative techniques should meet the following requirements: a quantification method to monitor microbial adherence; a sensitive and reproducib...

A central venous catheter with a new form of silver impregnation of the internal and external surfaces was investigated for antimicrobial activity and tolerance in patients in a controlled comparative, prospective and randomized clinical study. Commercially available catheters with no antimicrobial activity were used as controls. One hundred sixty-five catheters were included in the final evaluation. All catheters were percutaneously inserted for the first time with a duration of > or = 5 days and a microbiological examination of the catheter tip. Catheter location (> 90% internal jugular vein), mean duration of catheterization (8-9 days), patients' age and diagnosis were comparable in both groups. Silver-impregnated catheter tips showed an incidence of colonization in 14.2/1000 catheter days and control catheters in 22.8/1000 catheter days. This represents a reduction of 37.7%. Catheter-associated infections were diagnosed in the silver group in 5.26/1000 catheter days and 18.34/1000 catheter days in the control group, indicating a reduction rate of 71.3% (P < 0.05, chi 2-test). No complications or side effects were documented in either group.

The antimicrobial activity of a silver-impregnated polymer catheter (the Erlanger silver catheter) was demonstrated by determining the microbial adhesion to the surface of the catheter and by measuring the rate of proliferation (viability) of microorganisms at this site. On the surface of a catheter impregnated with silver, according to previously described methods, the bacterial adhesion of Staphylococcus epidermidis is reduced by 28-40%. Bacterial proliferation on the surface of the catheter and biofilm production are also substantially reduced by the elution of free silver ions from the catheter matrix. Bacteriostatic and bactericidal activities can be determined. The antimicrobial efficacy of the silver catheter is not reduced by blood components. There is no loss in antimicrobial activity for weeks after preincubation in water or phosphate buffered saline. The antimicrobial activity depends on the extent of the active silver surface.

The purpose of this study was to establish a reliable and cost-effective microplate proliferation assay for in vitro antimicrobial testing of bone cement samples. Cement samples devoid of antimicrobial agents, loaded with 2% gentamicin or with different concentrations of high-porosity silver, were incubated in a 96-well microplate with several staphylococcal, Pseudomonas aeruginosa, and Enterococcus faecium isolates exhibiting different susceptibilities to gentamicin. After being rinsed, the samples were brought into a soy medium in which adherent cells on the cement surface either were killed by the antimicrobial surface or started to release clonal counterparts. The medium was monitored in real time by recording a time proliferation curve for each well. Microplate testing revealed no antibacterial effect of plain bone cement. The antibacterial activity of gentamicin-loaded bone cement was shown by the microplate test to depend on the gentamicin susceptibilities of the strains. The effect of high-porosity silver was dose dependent. Bactericidal activity against all tested strains was found for bone cement loaded with 1% high-porosity silver. The accuracy of this new proliferation assay was shown by the high correlation between the types of proliferation curves and antibiotic susceptibility. In contrast to routine agar diffusion testing, it assesses the dynamic response of microorganisms to antimicrobial agents in biomaterials and allows high-throughput screening and detection of antimicrobial properties of poorly water-soluble compounds like silver.Infections in total joint arthroplasty are devastating situations (19), and many strategies have been undertaken to reduce infection rates, including the use of helmet aspirator suits (22), laminar airflow (5, 10, 18), and prophylactic intravenous antibiotics (9, 13, 15). Loading polymethylmethacrylate (PMMA) bone cement with antibiotics to reduce infection rates has also been postulated in the literature (6,16,24,26).As in all other fields of medicine, new ideas in orthopedics should be evaluated stepwise, with in vitro and subsequent in vivo investigations of antimicrobial properties occurring before clinical trials. Therefore, testing the antimicrobial activity of bone cement with new antibiotics or other antimicrobial agents should begin with in vitro studies. Agar diffusion testing has been the standard method for many years for in vitro assessment of antibiotic-loaded bone cements (17,23,27,28). However, the assessment by agar diffusion testing of the anti-infective activities of some antimicrobial agents requires accurately defined standard conditions (20). For example, large molecules, such as vancomycin and teicoplanin, harbor a reduced diffusion capacity and their susceptibilities are difficult to determine exactly. Other anti-infective agents, e.g., fosfomycin, are able to interact with components of the culture medium in agar plates, resulting in reduced activity. Therefore, adequate culture media are required (20). New anti-infective agents like microdis...