T.F. Moriarty

AO Foundation, Давос, Grisons, Switzerland

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Publications (42)129.23 Total impact

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    ABSTRACT: Fracture fixation devices are implanted into a growing number of patients each year. This may be attributed to an increase in the popularity of operative fracture care and the development of ever more sophisticated implants, which may be used in even the most difficult clinical cases. Furthermore, as the general population ages, fragility fractures become more frequent. With the increase in number of surgical interventions, the absolute number of complications of these surgical treatments will inevitably rise. Implant-related infection and compromised fracture healing remain the most challenging and prevalent complications in operative fracture care. Any strategy that can help to reduce these complications will not only lead to a faster and more complete resumption of activities, but will also help to reduce the socio-economic impact. In this review we describe the influence of implant design and material choice on complication rates in trauma patients. Furthermore, we discuss the importance of local delivery systems, such as implant coatings and bone cement, and how these systems may have an impact on the prevalence, prevention and treatment outcome of these complications.
    Full-text · Article · Jan 2016 · Injury
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    ABSTRACT: Introduction: Implant-related infection is a challenging complication in musculoskeletal trauma surgery. In the present study, we examined the role of implant material and surface topography as influencing factors on the development of infection in an experimental model of plating osteosynthesis in the rabbit. Methods: The implants included in this experimental study were composed of: standard Electropolished Stainless Steel (EPSS), standard titanium (Ti-S), roughened stainless steel (RSS) and surface polished titanium (Ti-P). Construct stability and load-to-failure of Ti-P implants was compared to that of Ti-S implants in a rabbit cadaveric model. In an in vivo study, a rabbit humeral fracture model was used. Each rabbit received one of three Staphylococcus aureus inocula, aimed at determining the infection rate at a low, medium and high dose of bacteria. Outcome measures were quantification of bacteria on the implant and in the surrounding tissues, and determination of the infectious dose 50 (ID50). Results: No significant differences were observed between Ti-S and Ti-P regarding stiffness or failure load in the cadaver study. Of the 72 rabbits eventually included in the in vivo study, 50 developed an infection. The ID50 was found to be: EPSS 3.89×10(3) colony forming units (CFU); RSS 8.23×10(3) CFU; Ti-S 5.66×10(3) CFU; Ti-P 3.41×10(3) CFU. Significantly lower bacterial counts were found on the Ti-S implants samples compared with RSS implants (p<0.001) at the high inoculum. Similarly, lower bacterial counts were found in the bone samples of animals in the Ti-S group in comparison with both RSS and EPSS groups, again at the high inoculation dose (p<0.005). Conclusion: No significant differences were seen in susceptibility to infection when comparing titanium and steel implants with conventional or modified topographies. Ti-P implants, which have previously been shown in preclinical studies to reduce complications associated with tissue adherence, do not affect infection rate in this preclinical fracture model. Therefore, Ti-P implants are not expected to affect the infection rate, or influence implant stability in the clinical situation.
    Full-text · Article · Jan 2016 · Injury
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    ABSTRACT: The scarcity of current antibiotic-based strategies to prevent biomaterial-associated infections (BAI) and their risk of resistance development prompted us to develop a novel antimicrobial implant-coating to prevent Staphylococcus aureus-induced BAI. We incorporated the antimicrobial peptide OP-145 into a Polymer-Lipid Encapsulation MatriX (PLEX)-coating to obtain high peptide levels for prolonged periods at the implant-tissue interphase. We first confirmed that OP-145 was highly effective in killing S. aureus and inhibiting biofilm formation in vitro. OP-145 injected along S. aureus-inoculated implants in mice significantly reduced the number of culture-positive implants. OP-145 was released from the PLEX coating in a controlled zero-order kinetic rate after an initial 55%-burst release and displayed bactericidal activity in vitro. In a rabbit intramedullary nail-related infection model, 67% of rabbits with PLEX-OP-145-coated nails had culture-negative nails after 28 days compared to 29% of rabbits with uncoated nails. In rabbits with PLEX-OP-145-coated nails, bone and soft tissue samples were culture-negative in 67% and 80%, respectively, whereas all bone samples and 71% of the soft tissue samples of rabbits with uncoated nails were infected. Together, PLEX-OP-145 coatings, of which both compounds have already been found safe in man, can prevent implant colonization and S. aureus-induced BAIs.
    Full-text · Article · Dec 2015 · Journal of Controlled Release
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    ABSTRACT: Post-traumatic bone fractures are commonly fixed with implanted devices to restore the anatomical position of bone fragments and aid in the healing process. Bacterial infection in this situation is a challenge for clinicians due to the need for aggressive antibiotic therapy, debridement of infected tissues, and the need to maintain fracture stability. The aim of this study was to monitor immune responses that occur during healing and during Staphylococcus aureus infection, in a clinically relevant murine model of fracture fixation. Skeletally mature C57bl/6 mice received a transverse osteotomy of the femur, which was treated with commercially available titanium fracture fixation plates and screws. In the absence of infection, healing of the fracture was complete within 35 days and was characterized by elevated Interleukin (IL)-4 and Interferon-gamma secretion from bone-derived cells and expression of these same genes. In contrast, mice inoculated with S. aureus could not heal the fracture within the observation period and were found to develop typical signs of implant-associated bone infection, including biofilm formation on the implant and osteolysis of surrounding bone. The immune response to infection was characterized by a TH17-led bone response, and a pro-inflammatory cytokine-led (Tumor necrosis factor, TNF-α, IL-1β) soft tissue response, both of which are ineffectual in clearing implant related bone and soft tissue infections respectively. In this murine model, we characterize the kinetics of pro-inflammatory responses to infection, secondary to bone trauma and surgery. A divergent local immune polarization is evident in the infected versus non-infected animals, although the immune response is ultimately unable to clear the S. aureus infection.
    Full-text · Article · Oct 2015 · Bone
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    D. Arens · M. Wilke · L. Calabro · S. Hackl · S. Zeiter · I. Zderic · R. G. Richards · T. F. Moriarty
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    ABSTRACT: The local mechanical environment at a fracture is known to influence biological factors such as callus formation, immune cell recruitment and susceptibility to infection. Infection models incorporating a fracture are therefore required to evaluate prevention and treatment of infection after osteosynthesis. The aim of this study was to create humane, standardised and repeatable preclinical models of implant-related bone infection after osteosynthesis in the rabbit humerus. Custom-designed interlocked intramedullary nails and commercially available locking plates were subjected to biomechanical evaluation in cadaveric rabbit humeri; a 10-week in vivo healing study; a dose response study with Staphylococcus aureus over 4 weeks; and finally, a long-term infection of 10 weeks in the plate model.Outcome measures included biomechanical testing, radiography, histology, haematology and quantitative bacteriology. Both implants offered similar biomechanical stability in cadaveric bones, and when applied in the in
    Full-text · Article · Sep 2015 · European cells & materials
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    ABSTRACT: Infectious complications occur in a minor but significant portion of the patients undergoing joint replacement surgery or fracture fixation, particularly those with severe open fractures, those undergoing revision arthroplasty or those at elevated risk because of poor health status. Once established, infections are difficult to eradicate, especially in the case of bacterial biofilm formation on implanted hardware. Local antibiotic carriers offer the prospect of controlled delivery of antibiotics directly in target tissues and implant, without inducing toxicity in non-target organs. Polymeric carriers have been developed to optimize the release and targeting of antibiotics. Passive polymeric carriers release antibiotics by diffusion and/or upon degradation, while active polymeric carriers release their antibiotics upon stimuli provided by bacterial pathogens. Additionally, some polymeric carriers gelate in-situ in response to physiological stimuli to form a depot for antibiotic release. As antibiotic resistance has become a major issue, also other anti-infectives such as silver and antimicrobial peptides have been incorporated in research. Currently, several antibiotic loaded biomaterials for local infection prophylaxis are available for use in the clinic. Here we review their advantages and limitations and provide an overview of new materials emerging that may overcome these limitations. Copyright © 2015 Elsevier Ltd. All rights reserved.
    Full-text · Article · Jun 2015 · Biomaterials
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    ABSTRACT: Implant-associated bone infections caused by antibiotic-resistant pathogens pose significant clinical challenges to treating physicians. Prophylactic strategies that act against resistant organisms, such as methicillin-resistant Staphylococcus aureus (MRSA), are urgently required. In the present study, we investigated the efficacy of a biodegradable Polymer-Lipid Encapsulation MatriX (PLEX) loaded with the antibiotic doxycycline as a local prophylactic strategy against implant-associated osteomyelitis. Activity was tested against both a doxycycline-susceptible (doxyS) methicillin-susceptible S. aureus (MSSA) as well as a doxycycline-resistant (doxyR) methicillin-resistant S. aureus (MRSA).
    Full-text · Article · Apr 2015 · Journal of Controlled Release
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    ABSTRACT: Infection associated with orthopedic implants often results in bone loss and requires surgical removal of the implant. The aim of this study was to evaluate morphological changes of bone adjacent to a bacteria-colonized implant, with the aim of identifying temporal patterns that are characteristic of infection. In an in vivo study with rats, bone changes were assessed using in vivo microCT at 7 time points during a one-month postoperative period. The rats received either a sterile or Staphylococcus aureus-colonized polyetheretherketone screw in the tibia. Bone-implant contact, bone fraction, and bone changes (quiescent, resorbed, and new bone) were calculated from consecutive scans and validated against histomorphometry. The screw pullout strength was estimated from FE models and the results were validated against mechanical testing. In the sterile group, bone-implant contact, bone fraction, and mechanical fixation increased steadily until day 14 and then plateaued. In the infected group, they decreased rapidly. Bone formation was reduced while resorption was increased, with maximum effects observed within 6 days. In summary, the model presented is capable of evaluating the patterns of bone changes due to implant-related infections. The combined use of longitudinal in vivo microCT imaging and image-based finite element analysis provides characteristic signs of infection within 6 days.
    Full-text · Article · Apr 2015 · BioMed Research International
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    G.A. ter Boo · D W Grijpma · R G Richards · T F Moriarty · D Eglin
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    ABSTRACT: Infection is a common problem in trauma- and orthopaedic surgery. Antibiotic-loaded biomaterials are used locally to clear infections as an adjunct to systemic antibiotics. Gentamicin-sulphate (GEN-SULPH) is commonly used in antibiotic-loaded biomaterials, although it displays high water solubility resulting in quick diffusion from the carrier. Preparation of a lipophilic derivative of gentamicin to reduce solubility and obtain a slower release. Subsequently, entrapment of this lipophilic gentamicin within poly(trimethylene carbonate) (PTMC) matrices. Hydrophobic ion-pairing was used to prepare lipophilic gentamicin (GEN-AOT). The susceptibility of Staphylococcus aureus NCTC 12973 and Staphylococcus epidermidis 103.1 for GEN-AOT was tested and the viability of fibroblasts upon exposure to GEN-AOT was assessed. GEN-AOT was then loaded into PTMC films. GEN-AOT was successfully prepared as confirmed by FTIR-spectroscopy. GEN-AOT was bactericidal for S. epidermidis and S. aureus at 0.5 μM and 8.5 μM, respectively. At 1.1 μM GEN-AOT no reduction in fibroblast viability was observed. At 11 μM the reduction was ~50%. PTMC discs loaded with GEN-AOT were prepared by compression molding. Lipophilic GEN-AOT was at least as potent as GEN-SULPH. For S. epidermidis it was even more potent than GEN-SULPH. More than 50% fibroblast cell viability was maintained at bactericidal concentration for both bacterial strains.
    Full-text · Article · Mar 2015 · Clinical hemorheology and microcirculation
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    ABSTRACT: Infections associated with deep wounds require extensive surgical and medical care. New adjunctive treatments are required to aid in the eradication of the bacterial biofilms found on infected wounds and, in particular, any underlying hardware. Ozone has been used as a safe and efficient disinfectant in water treatment plants for many years. The purpose of this study is to investigate the anti-biofilm potential of ozonated saline against biofilms of Staphylococcus aureus, a microorganism commonly implicated in wound infections. A custom-made bacterial biofilm bioreactor was used to grow S. aureus biofilms on discs of medical grade titanium alloy. An ozone generator was connected in-line and biofilms and planktonic bacteria were exposed to ozone in saline. Cytotoxicity was assessed against primary ovine osteoblasts in the same system. In tests against planktonic S. aureus, a 99% reduction in bacterial numbers was detected within 15 minutes of exposure. S. aureus biofilms were significantly more resistant to ozone, although complete eradication of the biofilm was eventually achieved within 5 hours. Ozonated saline was not found to be cytotoxic to primary ovine osteoblasts. Ozonated saline may be suitable as an adjuvant therapy to treat patients as an instillation fluid for wound irrigation and sterilisation. © 2015 Medicalhelplines.com Inc and John Wiley & Sons Ltd.
    Full-text · Article · Jan 2015 · International Wound Journal
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    T F Moriarty · D W Grainger · R G Richards
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    ABSTRACT: Infections related to implanted medical devices have become a significant health care issue in recent decades. Increasing numbers of medical devices are in use, often in an aging population, and these devices are implanted against a background of increasing antibiotic-resistant bacterial populations. Progressively more antibiotic resistant infections, requiring ever more refined treatment options, are therefore predicted to emerge with greater frequency in the coming decades. Improvements in the prevention, diagnosis and treatment of these device-associated infections will remain priority targets both for clinicians and the translational research community charged with addressing these challenges. Preclinical strategies, predictive of ultimate clinical efficacy, should serve as a control point for effective translation of new technologies to clinical applications. The development of new anti-infective medical devices requires a validated preclinical testing protocol; however, reliable validation of experimental and preclinical antimicrobial methodologies currently suffers from a variety of technical limitations. These include the lack of agreement or standardisation of experimental protocols, a general lack of correlation between in vitro and in vivo preclinicalresults and lack of validation between in vivo preclinical implant infection models and clinical (human) results. Device-associated infections pose additional challenges to practicing clinicians concerning diagnosis and treatment, both of which are complicated by the biofilms formed on the medical device. The critical challenges facing both preclinical research and clinical laboratories in improving both diagnosis and treatment of medical device-associated infections are the focus of this review.
    Full-text · Article · Sep 2014 · European cells & materials
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    ABSTRACT: One of the most common pathogens causing musculoskeletal infections remains Staphylococcus aureus. The aim of this multicentre study was to perform a phenotypic and genotypic characterisation of clinical S. aureus isolates recovered from musculoskeletal infections and to investigate differences between isolates cultured from Orthopaedic Implant Related Infections (OIRI) and those from Non-Implant Related Infections (NIRI). OIRI were further differentiated in two groups: Fracture Fixation-Device Infections (FFI) and Prosthetic Joint Infections (PJI).
    Full-text · Article · Apr 2014 · International journal of medical microbiology: IJMM
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    ABSTRACT: Propionibacterium acnes and coagulase-negative staphylococci (CoNS) are opportunistic pathogens implicated in prosthetic joint and fracture fixation device-related infections. The purpose of this study was to determine whether P. acnes and the CoNS species Staphylococcus lugdunensis, isolated from an “aseptically failed” prosthetic hip joint and a united intramedullary nail-fixed tibial fracture, respectively, could cause osteomyelitis in an established implant-related osteomyelitis model in rabbits in the absence of wear debris from the implant material. The histological features of P. acnes infection in the in vivo rabbit model were consistent with localized pyogenic osteomyelitis, and a biofilm was present on all explanted intramedullary (IM) nails. The animals displayed no outward signs of infection, such as swelling, lameness, weight loss, or elevated white blood cell count. In contrast, infection with S. lugdunensis resulted in histological features consistent with both pyogenic osteomyelitis and septic arthritis, and all S. lugdunensis-infected animals displayed weight loss and an elevated white blood cell count despite biofilm detection in only two out of six rabbits. The differences in the histological and bacteriological profiles of the two species in this rabbit model of infection are reflective of their different clinical presentations: low-grade infection in the case of P. acnes and acute infection for S. lugdunensis. These results are especially important in light of the growing recognition of chronic P. acnes biofilm infections in prosthetic joint failure and nonunion of fracture fixations, which may be currently reported as “aseptic” failure.
    Full-text · Article · Mar 2014 · Journal of clinical microbiology
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    ABSTRACT: Polyetheretherketone (PEEK) films were oxygen plasma treated to increase surface free energy and characterized by X-ray photoelectron microscopy, atomic force microscopy, and water contact angles. A parallel plate flow chamber was used to measure Staphylococcus epidermidis, Staphylococcus aureus, and U-2 OS osteosarcomal cell-line adhesion to the PEEK films in separate monocultures. In addition, bacteria and U-2 OS cells were cocultured to model competition between osteoblasts and contaminating bacteria for the test surfaces. Plasma treatment of the surfaces increased surface oxygen content and decreased the hydrophobicity of the materials, but did not lead to a significant difference in bacterial or U-2 OS cell adhesion in the monocultures. In the S. epidermidis coculture experiments, the U-2 OS cells adhered in greater numbers on the treated surfaces compared to the untreated PEEK and spread to a similar extent. However, in the presence of S. aureus, cell death of the U-2 OS occurred within 10 h on all surfaces. The results of this study suggest that oxygen plasma treatment of PEEK may maintain the ability of osteoblast-like cells to adhere and spread, even in the presence of S. epidermidis contamination, without increasing the risk of preoperative bacterial adhesion. Therefore, oxygen plasma-treated PEEK remains a promising method to improve implant surface free energy for osseointegration. © 2014 Wiley Periodicals, Inc. J Biomed Mater Res Part A, 2014.
    Full-text · Article · Feb 2014 · Journal of Biomedical Materials Research Part A
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    ABSTRACT: One of the most common pathogen causing musculoskeletal infections remains Staphylococcus aureus. The aim of this multicentre study was to perform a phenotypic and genotypic characterisation of clinical S. aureus isolates recovered from musculoskeletal infections and to investigate differences between isolates cultured from Orthopaedic Implant Related Infections (OIRI) and those from Non-Implant Related Infections (NIRI). OIRI were further differentiated in two groups: Fracture Fixation-device Infections (FFI) and Prosthetic Joint Infections (PJI). Three-hundred and five S. aureus strains were collected from 4 different Swiss and 2 French hospitals (FFI, n = 112; PJI, n = 105; NIRI, n = 88). NIRI cases were composed of 27 Osteomyelitis (OM), 23 Diabetic Foot Infections (DFI), 27 Soft Tissue Infections (STI) and 11 postoperative Spinal Infections (SI). All isolates were tested for their ability to form biofilm, to produce staphyloxanthin and their haemolytic activity. They were typed by agr (accessory gene regulator) group, spa type and screened by PCR for the presence of genes of the most relevant virulence factors such as MSCRAMMs, Panton Valentine Leukotoxin (PVL), enterotoxins, exotoxins and toxic shock syndrome toxin. Overall, methicillin susceptible S. aureus (MSSA) was more prevalent than methicillin resistant S. aureus (MRSA) in this collection. The OIRI group trended towards a higher incidence of MRSA, gentamicin resistance and haemolysis activity than the NIRI group. Within the OIRI group, PJI isolates were more frequently strong biofilm formers than isolates from the FFI group. A statistically significant difference was observed between OIRI and NIRI isolates for the sdrE gene, the cna gene, the clfA gene and the bbp gene. Certain spa types (t230 and t041) with a specific genetic virulence pattern were only found in isolates cultured from OIRI. In conclusion, our study highlights significant trends regarding the virulence requirements displayed by S. aureus isolates associated with implant related infections in comparison to non-implant related infections. However, future studies including whole genome sequencing will be required to further examine genomic differences among the different infection cases.
    Full-text · Article · Jan 2014
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    ABSTRACT: Musculoskeletal infection remains a great challenge in orthopedic and trauma surgery. Despite best medical and surgical practice and significant advances in research and development, bone and implant associated infections are still difficult to diagnose, impossible to prevent in all cases and require invasive and debilitating treatment. The development and safe clinical implementation of novel preventative, therapeutic or diagnostic strategies requires the use of animal models of infection, which provide crucial evidence regarding performance, cytocompatibility, biocompatibility, and safety prior to clinical implementation. Many animal models of musculoskeletal infection have been described in the literature; however, there remains a dearth of fully standardized or universally accepted reference models hindering advancement in the field. The following chapter provides an overview of the animal models available for the study of musculoskeletal infection, the latest advances that are expected to improve them, and some of the most important scientific output achieved using these models.
    No preview · Article · Nov 2013
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    ABSTRACT: Musculoskeletal infection is one of the most common complications associated with surgical fixation of bones fractured during trauma. Severe fractures with extensive tissue damage are particularly prone to infection due to the high risk of wound contamination and compromised vascularity in the affected tissues. An infection associated with a fracture fixation device can delay healing, greatly increase patient morbidity, require multiple surgeries for effective treatment outcomes, and may tremendously increase treatment costs. In the following chapter, two approaches to reduce the incidence of infection associated with fracture fixation devices will be described. The first is a passive approach involving aspects of implant design and application, whereby the implant used and the techniques used to place them can influence resistance to infection, at least in animal studies. The second approach involves antibiotic-coated intramedullary nails with a focus on two different gentamicin coatings. © 2013 Springer Science+Business Media New York. All rights are reserved.
    No preview · Article · Nov 2013
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    ABSTRACT: Despite extensive use of polyetheretherketone (PEEK) in biomedical applications, information about bacterial adhesion to this biomaterial is limited. This study investigated Staphylococcus aureus and Staphylococcus epidermidis adhesion to injection moulded and machined PEEK OPTIMA(®) using a custom-built adhesion chamber with medical grade titanium and Thermanox for comparison. Additionally, bacterial adhesion to a novel oxygen plasma modified PEEK was also investigated in both a pre-operative model in physiological saline, and additionally in a post-operative model in human blood plasma. In the pre-operative model, the rougher machined PEEK had a significantly greater number of adherent bacteria compared to injection moulded PEEK. Bacterial adhesion to titanium and Thermanox was similar. Oxygen plasma surface modification of PEEK did not lead to a significant change in bacterial adhesion in the pre-operative contamination model, despite observed changes in surface characteristics. In the post-operative contamination model, S. aureus adhesion was increased from 5×10(5)CFUcm(-2) to approximately 1.3×10(7)CFUcm(-2) on the modified surfaces due to differential protein adhesion during the conditioning period. However, S. epidermidis adhesion to modified PEEK was less than to unmodified PEEK in the post-operative model. These results illustrate the importance of testing bacterial adhesion of several strains in both a pre-operative and post-operative, clinically relevant bacterial contamination model.
    Full-text · Article · Sep 2013 · Colloids and surfaces B: Biointerfaces
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    ABSTRACT: Regardless of function, location, or biomaterial used, infection is one of the most serious complications arising from the use of implanted medical devices. Every surgical procedure has an inherent risk for bacterial contamination with surgical site contaminants originating from the patient's own skin, the surgical theater, or even the outside environment. The reason some patients become infected and others do not is unfortunately less than clear. In the majority of cases, host defenses and prophylactic antibiotic administration effectively clear any contaminating bacteria. Bacterial adhesion to a biomaterial is often considered to be the event that initiates biomaterial-associated infection. Given that the number of biomaterial-associated infections is expected to rise in response to an increase in implant demand, reducing bacterial adhesion is of critical clinical importance. Small changes in topography or surface chemistry can result in large differences in bacterial adhesion in vitro and in vivo. Changes in the topography of PEEK due to manufacturing methods alter bacterial adhesion by common clinical pathogens. Additionally, altering the surface chemistry of PEEK for increased osseointegration by oxygen plasma treatment leads to no change in bacterial adhesion in the absence of a protein conditioning film. However, the presence of a protein conditioning film led to large differences in bacterial adhesion. The role of the immune response, tissue integration, individual patient variation, and the broad variation of bacteria potentially present all play important roles in the outcome of a bacterium encountering a biomaterial in the human body.
    Full-text · Chapter · Dec 2012
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    ABSTRACT: Specific bacteria imaging is highly desirable in clinical diagnostics. Probes enabling rapid and specific diagnostics of bacteria are limited. Current clinical infection diagnostics is time consuming and invasive, relays on microbiological cultures. We investigated the potential of Lysostaphin as a specific probe to label staphylococci in a new labeling protocol. We used azido (N(3)) - modified Lysostaphin-N(3) and DIBO-dye in a two-step bacteria-labeling protocol. N(3) and DIBO (di-benzocyclooctyne) are the counterparts of the "click" chemistry. In the first step, Lysostaphin-N(3) binds specifically to Staphylococcus aureus. In the second step, N(3) clicks to DIBO thus achieving the selective for S. aureus labeling. Such a two-step approach effectively distinguishes S. aureus from Escherichia coli; non-toxic and proved to work in vivo. The two-step labeling protocol is a promising approach for diagnostic imaging of staphylococci in clinical settings.
    Full-text · Article · Nov 2012 · Journal of microbiological methods

Publication Stats

572 Citations
129.23 Total Impact Points

Institutions

  • 2008-2015
    • AO Foundation
      Давос, Grisons, Switzerland
    • University of Florence
      Florens, Tuscany, Italy
  • 2006-2011
    • Queen's University Belfast
      • School of Pharmacy
      Béal Feirste, Northern Ireland, United Kingdom