Abstract:
An antibiofilm complex formed of a polyvinylpyrrolidone (PVP) backbone, iodine anchored to the PVP backbone, Rifampin anchored to the PVP backbone, and a second antibiotic selected from the group consisting of Tobramycin and Gentamicin anchored to the PVP backbone.

Description:
CROSS-REFERENCE TO RELATED APPLICATION 
       [0001]    The present application claims the benefit of U.S. Provisional Patent Application Ser. No. 61/697,947, filed Sep. 7, 2012. 
     
    
     FIELD OF INVENTION 
       [0002]    The present invention relates in general to the prevention of surgical site infection, and in particular, to an anti-infective compound including a polyvinylpyrrolidone (PVP) backbone anchoring two antimicrobials. 
       BACKGROUND OF INVENTION 
       [0003]    The contamination of surgical sites leading to surgical site infection (SSI) and the fouling of medical prosthetics by bacterial biofilm, device associated infection (DAD, have become recognized as a leading cause of morbidity and mortality worldwide. SSI&#39;s also represent a substantial economic burden. In the United Kingdom, up to eight percent of hospitalized patients develop SSI, as reported in Leaper DJ. Risk factors for and epidemiology of surgical site infections.  Surgical Infections  2010; 11(3): 283-7. The CDC reported a rate of two SSIs per 100 procedures in US hospitals during 2002 with attributable costs ranging from $3000-$5000 (U.S.) per procedure in multi-specialty studies. See, Klevens R M, Edwards J R, Richards C U. Estimating health care-associated infections and deaths in US hospitals, 2002.  Public Health Report  2007; 122(2): 160-6; and Hollenbeak C S, Murphy D, Dunagan W C. Nonrandom selection and the attributable cost of surgical site infections.  Infection Control Hospital Epidemiology  2002; 234(2): 177-82. 
         [0004]    Another long-term study by the Inter-regional Co-ordination Centre for Nosocomial Infection Control (INCISO) Network Study group reported that 38% of the deaths that occurred in patients with an SSI were directly attributable to the infection. See, Astagneau P, Rioux C, F. G. Morbidity and mortality associated with surgical site infections.  Journal of Hospital Infection  2001; 28(4): 267-74. Patients are also more likely to have extended hospital admissions, increased expenditure and higher rates of readmissions, as reported in Jenney A W J, Harrington G A, Russo P L. Cost of surgical site infections following coronary artery bypass surgery.  ANZ Journal of Surgery  2001; 71(11): 662-4. In addition, loss of productivity of the patients adds to the economic burden. A systematic review of the epidemiological and economic burden of SSI in Europe estimated that SSIs cost European health care systems between          1.47 billion and          19.1 billion each year. Leaper, Id. 
         [0005]    DAI&#39;s have now been documented in a range of medical prosthetics including:
       K wires, orthopedic fixation, as reported in Dobbins J J, Seligson D, Raff M J. Bacterial colonisation of orthopaedic devices in the absence of clinical infection.  Journal of Infectious Diseases  1988; 158: 203-5 and Ehrlich G D, Stoodley P, Kathju S, et al. Engineering approaches for the detection and control of orthopaedic biofilm infections.  Clinical orthopaedics and related research  2005; (437): 59-66;   joint prostheses, as reported in Ramage G, Tunney M M, Patrick S, Gorman S P, Nixon J R. Formation of propionibacterium acnes biofilms on orthopaedic biomaterials and their susceptibility to antimicrobials. Biomaterials 2003; 24(19): 3221-7 and Tunney M M, Dunne N, Einarsson G, McDowell A, Kerr A, Patrick S. Biofilm formation by bacteria isolated from retrieved failed prosthetic hip implants in an in vitro model of hip arthroplasty antibiotic prophylaxis.  J Orthop Res  2007; 25(1): 2-10;   contact lenses, as reported in Donlan R M, Costerton J W. Biofilms: survival mechanisms of clinically relevant microorganisms.  Clinical microbiology reviews  2002; 15(2): 167-93;   indwelling urinary catheters, as reported in Donlan R M. Biofilms and device-associated infections.  Emerging Infectious Diseases  2001; 7(2): 277-81; and   breast implants, as reported in Tamboto H, Vickery K, Deva A K. Subclinical(biofilm) infection causes capsular contracture in a porcine model following augmentation mammaplasty.  Plastic and Reconstructive Surgery  2010; 126: 835-42 and Pajkos A, Deva A K, Vickery K, Cope C, Chang L, Cossart Y E. Detection of subclinical infection in significant breast implant capsules.  Plastic and Reconstructive Surgery  2003; 111(5): 1605-11.       
 
         [0011]    Bacteria derived from skin, such as coagulase negative  Staphylococcus epidermidis,  derive their pathogenesis primarily from their ability to form biofilms on the surfaces of indwelling medical devices, as reported in: Tunney, Id.; Donlan, Id.; O&#39;Gara J P, Humphreys H.  Staphylococcus epidermidis  biofilms: importance and implications.  Journal of medical microbiology  2001; 50(7): 582-7; Costerton J W, Montanaro L, Arciola C R. Biofilm in implant infections: its production and regulation.  The International Journal of Artificial Organs  2005; 28(11): 1062-8; and Vinh D C, Embil J M. Device-related infections: a review.  Journal of Long - term Effects of Medical Implants  2005; 15(5): 467-88. 
         [0012]    Formation of biofilms occurs in two phases. Rapid primary attachment of bacterial cells to the polymer surface is followed by a more prolonged accumulation into multilayered cell clusters in a growth-dependent process. As adherent bacteria divide and produce extracellular polymeric substance locally, they form a highly structured matrix-enclosed microcolony. The glycocalyx matrix serves to hold the microcolony together and to anchor it to the substratum or to other microcolonies. This process is particularly relevant because biofilm associated organisms are much more resistant to antimicrobial agents than are planktonic (free swimming or non biofilm) organisms, See, Donlan R M. Role of biofilms in antimicrobial resistance.  Asaio J  2000; 46(6): S47-52; Donlan R M. Biofilm formation: a clinically relevant microbiological process.  Clin Infect Dis  2001; 33(8): 1387-92; and Gilbert P, McBain A J. Biofilms: their impact on health and their recalcitrance toward biocides.  American Journal of Infection Control  2001; 29(4): 252-5. Once formed, associated inflammation around the contaminated prosthesis will result in a high risk of medium to long-term device failure. It has been estimated that the cost of revisional surgery in failed orthopedic devices alone is estimated at $1 billion (U.S.) per year, as reported in Von Eiff C, Jansen B, Kohnen W, Becker K. Infections Associated with Medical Devices : Pathogenesis, Management and Prophylaxis.  Drugs  2005; 65(2): 179-214; and Costerton J W. Biofilm theory can guide the treatment of device-related orthopaedic infections.  Clinical Orthopaedics and Related Research  2005; (437): 7-11. 
         [0013]    Strategies to reduce SSI and DAI by developing an effective antibiofilm agent for use in surgery are currently being investigated. See: Klemm P, Hancock V, Kvist M, Schembri M A. Candidate targets for antivirulence drugs : selected cases of bacterial adhesion and biofilm formation.  Future Microbiology  2007; 2(6): 643-53; and Kiedrowski M R, Horswill A R. New approaches for treating staphylococcal biofilm infections.  Annals of the New York Academy of Sciences  2011; 1241(1): 104-21. To date, whilst a number of agents have been trialed, there are no clinically proven compounds that have been shown to be effective at both prevention and/or treatment of biofilm infection, as reported in Vasiley K, Cook J, Griesser H J. Antibacterial surfaces for biomedical devices.  Expert Review of Medical Devices  2009; 6(5): 553-67. 
       SUMMARY OF INVENTION 
       [0014]    The principles of the present invention are embodied in a novel antibiofilm complex using a polyvinylpyrrolidone (PVP) backbone to anchor two antimicrobials. The antibiofilm advantageously may be used an anti-infective compound in both the treatment and prevention of bacterial contamination of medical prosthetics and in the preparation of skin, mucosa and other surgical sites prior to performing invasive procedures and deployment of medical devices. The significant advantages of the embodiments of the present principles include: (1) solubility; (2) biologic safety at working concentrations; (3) broad spectrum of activity; (4) a synergistic effect of antimicrobial compounds to penetrate and kill biofilm; (5) a synergistic effect to overcome known mechanisms of antimicrobial resistance; (6) and proven efficacy in vitro and in vivo. The novel antibiofilm complex has been designated GAAB-1. 
     
    
     
       BRIEF DESCRIPTION OF DRAWINGS 
         [0015]    For a more complete understanding of the present invention, and the advantages thereof, reference is now made to the following descriptions taken in conjunction with the accompanying drawings, in which: 
           [0016]      FIG. 1  is a diagram showing the grappling of iodine (I 3 ) by a PVP lactam hydrophilic ring attached to hydrophobic exocyclic aliphatic chain backbone to form an antibiofilm complex according to a preferred embodiment of the present invention; and 
           [0017]      FIG. 2  is a diagram comparing the activity of the antibiofilm complex with the activity of betadine when directed against certain common biofilm forming pathogens in vitro. 
       
    
    
     DETAILED DESCRIPTION OF THE INVENTION 
       [0018]    The principles of the present invention are embodied in a potent and novel antibiofilm product capable of reducing the rates of subsequent SSI and DAI when used as a prophylactic agent. The product can also be applied as a therapeutic agent to decrease the bacterial biofilm load on established DAI. The product will be delivered as an aqueous solution. Other formulations include slow release foam, coating for surfaces and a Nano-crystalline product. 
       Composition and Synthesis 
       [0019]    The preferred embodiment of the present invention is a coprecipitate of polyvinylpyrrolidone (PVP) with iodine and the two antibiotics Rifampin and Tobramycin. Rifampin is a semi synthetic derivative of rifamycin B. Rifamycins are a group of macrocyclic ring antibiotics obtained from streptomyces mediterranei. Many of the members of their chemical class, including their semi synthetic derivatives Rifampin and Rifabutine, possess broad spectrum antimicrobial activity and most notably against gram positive bacteria. They are also active against some gram-negative bacteria and many viruses. Rifampicin is relatively insoluble in water. Gentamicin and Tobramycin are broad spectrum antibiotics belonging to a large chemical class called aminoglycosides. They have a broad spectrum of activity against many common pathogens and in particular they possess a high degree of activity against Pseudomonas aeruginosa and other gram-negative bacteria. They are freely soluble in water. 
         [0020]    In the preferred embodiment, the coprecipitate is a lyophilized powder, which was found to exhibit pronounced synergistic activity against gram positive and negative bacteria. In a preferred embodiment, the coprecipitate was formulated to contain the following ingredients in 50:50 water for injection: 
         [0000]    
       
         
               
               
               
             
           
               
                   
                   
               
             
             
               
                   
                 TBA (tertiary butyl alcohol) 
                 5 to 45%, typically 5 to 25% 
               
               
                   
                 Rifampin 
                 2.5 g 
               
               
                   
                 Tobramycin 
                  80 mg 
               
               
                   
                 Povidone-iodine (10%) 
                 1.2 g 
               
               
                   
                   
               
             
          
         
       
     
         [0021]    The resulting solution was freeze dried according to the lyophilization cycle shown in the Table 1, which describes the times/temperatures and pressure utilized in the lyophilization process. The latter procedure of freeze-drying is a critical parameter for the production of the product and its resulting antimicrobial activity. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
               
               
               
               
               
               
             
               
               
               
               
               
               
             
           
               
                 TABLE 1 
               
             
             
               
                   
               
               
                 A Preferred Method For Producing A 
               
               
                 Complex Antibiofilm By Coprecipitation 
               
             
          
           
               
                   
                   
                 Ramp 
                 Pressure 
                 Time 
               
             
          
           
               
                 Step 
                 Temp. (° C.) 
                 (° C./min) 
                 (mTorr) 
                 Hours 
                 Minutes 
               
               
                   
               
             
          
           
               
                 Loading 
                 RT 
                   
                   
                   
                   
               
               
                 Freezing 
                 −25 
                 0.5-1.0 
                   
                 1 
                 30 
               
               
                   
                 −25 
                 Hold 
                   
                 10 
                 00 
               
               
                   
                 −45 
                 0.1-0.5 
                   
                 3 
                 00 
               
               
                   
                 −45 
                 Hold 
                   
                 5 
                 00 
               
               
                 Evacuation 
                 −45 
                   
                 100 
                 0 
                 30 
               
               
                 Primary Drying 
                 20 
                 0.5-1.0 
                 100 
                 2 
                 00 
               
               
                   
                 20 
                 Hold 
                 100 
                 30 
                 00 
               
               
                 Secondary 
                 40 
                 0.5-1.0 
                 150 
                 1 
                 00 
               
               
                 Drying 
               
               
                   
                 40 
                 Hold 
                 150 
                 12 
                 00 
               
               
                 Stoppering 
                 25 
                 0.5-1.0 
                 150 
                 1 
                 00 
               
               
                 Unloading 
               
               
                   
               
             
          
         
       
     
         [0022]    The antibiofilm complex, which has been designated GAAB-1, may be diluted at least seven times and maintain its synergistic efficacy in treating and reducing the development of biofilms. The most concentrated range of the product components include Rifampin 2.5 gms, Tobramycin or Gentamicin 80 mg, and PVP-I 1.2 gms in a solution of 520 ml. This would produce a concentration of 4,800 micrograms/ml of Rifampin, 154 micrograms/ml of Tobramycin or Gentamicin, and 2,300 micrograms of PVP-I (with essentially 23 micrograms or 1% of free iodine). At seven times dilution the concentrations would be 686 micrograms/ml of Rifampin, 22 micrograms/ml of Tobramycin or Gentamicin and 3.2 micrograms/ml of PVP-I. Greater dilutions produces more free iodine but may create instability in the copreciptiate&#39;s synergistic qualities. 
         [0023]    The coprecipitate is a novel antibiofilm complex capable of reducing the rates of subsequent SSI and DAI when used as a prophylactic agent. This antibiofilm complex was tested against common bacterial pathogens both in planktonic and biofilm states in vitro, as discuss further below. Specifically, the novel antibiofilm complex is composed of a polyvinylpyrroloidone (PVP) backbone, which grapples iodine and two antibiotics (Rifampicin and Gentamycin).  FIG. 1  illustrates the grappling of I 3  by a PVP j-lactam hydrophilic ring attached to hydrophobic exocyclic aliphatic chain backbone. 
         [0024]    Advantageously, PVP is an amorphous polymer that readily reacts with drugs, dyes and electron acceptors. PVP additionally increases the presence of a highly polar amide group and apolar methylene and methine groups. (See, de Faria D L A, Gil H A C, de Quieroz A A A. The Interaction Between Polyvinylpyrrolidone and I2 as Probed by Raman Spectroscopy.  Journal of Molecular Structure  1999; 479: 93-8.) It is non-toxic and was employed as a plasma expander in World War II and as a cryopreservant for red blood cells, as reported in Ford JL. The Current Status of Solid Dispersions. Pharm Acta He/v 1986; 3: 69-88. 
         [0025]    In other words, according to the present inventive principles, PVP is combined with relatively insoluble antiseptics and antibiotics. The resultant co-precipitate antibiofilm complex acts as a directed chemical “smart bomb” able to deliver its payload of antibiotics and antiseptics deep into the bacterial biofilm and thereby producing higher kill rates for comparatively lower dosages. In addition, the novel antibiofilm complex provides a number of other significant advantages in drug delivery, including: (1) membrane seeking capabilities (e.g., the penetration of biofilm exopolysaccharide); (2) higher water solubility; (3) fixed concentrations of antibiotic/antiseptic components thereby standardizing the dosage of delivery; and (4) stability with slow release of antimicrobial activity providing continued antibiofilm protection after delivery. Furthermore, the present inventive principles can be extended to produce a family of stable chemical “smart bombs” tailored to suit a specific antimicrobial or antiviral target. This will allow for design of an array of anti-infective weaponry to cater for future changes in microbial resistance patterns. 
       Experimental Results 
       [0026]    The antibiofilm activity of the novel antibiofilm complex was directed against the four most common biofilm forming pathogens in vitro. The results of the experimentation are as follows. 
         [0027]    Definitions. The following definitions apply to the discussion of the experimental results:
       Planktonic bacteria: bacteria growing free in suspension;   Biofilm bacteria: a structured community of bacterial cells enclosed in a self-produced exo-polysaccharide matrix that serves to attach them to a solid surface and to each other;   MIC: Minimum Inhibitory Concentration is the concentration of an antimicrobial that is required to inhibit the growth of a standardized inoculum of planktonic cells;   MEC: Minimum Eradication Concentration is the concentration of an antimicrobial that is required to kill all the organisms of a standardized inoculum of planktonic cells;   MBIC: Minimum Biofilm Eradication Concentration is the concentration of an antimicrobial that is required to inhibit the growth of a standardized number of organisms growing as a biofilm; and   MBEC: Minimum Biofilm Eradication Concentration is the concentration of an antimicrobial that is required to kill a standardized number of organisms growing as a biofilm.       
 
         [0034]    Test Organisms. The antibiofilm activity of the novel antibiofilm complex was directed against the four most common biofilm forming pathogens, namely:
       1.  Staphylococcus epidermidis  strain ATCC 35984;   2.  Staphylococcus aureus  strain ATCC 25932 (MSSA);   3. Methicillin resistant  Staphylococcus aureus  strain ATCC 43300 (MRSA); and   4.  Pseudomonas aeruginosa  strain ATCC 25619.       
 
         [0039]    Independent Test Solution. The independent test solution consisted of Betadine Batch 801070. Povidone-iodine antiseptic solution containing povidone iodine 10% w/v equivalent to 1%w/v available iodine. 
         [0040]    Test Parameters. The testing parameters were:
       1. Determining the efficacy the co-precipitate (antibiofilm complex) versus common biofilm forming bacteria at the 1-hour time point following reconstitution, as measured by the MIC, MEC, MBIC, MBEC;   2. Co-precipitate (antibiofilm complex) versus  S. aureus  at the 3 hour time point following reconstitution (MIC, MEC, MBIC, MBEC);   3. Physical mixture of PVP, iodine, gentamycin and rifampicin versus  S. aureus  at the 1, 3 and 24 hour time points following reconstitution (MIC, MEC, MBIC, MBEC);   4. The efficacy of Betadine (povidone iodine) against  S. aureus  and  S. epidermidis  immediately following dilution (MIC, MEC, MBIC, MBEC);   5. The efficacy of gentamycin against  S. aureus  (MIC, MEC, MBIC, MBEC); and   6. The efficacy of Rifampicin against  S. aureus  (MIC, MEC, MBIC, MBEC).       
 
         [0047]    Experimental Protocol for MIC and MEC. The protocol for the determination of MIC and MEC was:
       Day 1: Inoculate one colony of bacteria into 100% Tryptone Soy Broth (TSB) and 37° C. shaking incubation overnight.   Day 2: Dilute bacteria to give 10 7 , 10 6 , 10 5  bacteria/well and dispense in 96 well plates. Test product is added as per experimental protocol immediately or at 1 hour or 3 hours.   Day 3: Read MIC plates. Transfer 20 μl from each well of the MIC plate that shows no growth to 180 μl of fresh TSB in the MEC plate.   Day 4: Read MEC plates.       
 
         [0052]    Experimental Protocols for MBIC and MBEC. The protocol for the determination of MBIC and MBEC was:
       Day 1: Inoculate one-colony bacteria into 100% Tryptone Soy Broth (TSB) and 37° C. shaking incubation overnight.   Day 2: dilute culture to give 10 6  bacteria/ml and dispense into 96 well plates and incubate overnight to give 10 7  attached cells/well 9 (MBIC plate).   Day 3: Remove planktonic cells from MBIC plate by washing wells and add fresh media and antibiofilm products.   Day 4: Read MBIC plates. Add 180 μl fresh TSB in a new 96 well plate (MBEC plate) and transfer 20 μl from each well of the MBIC plate that shows no growth to fresh MBEC plate.   Day 5: Read MBEC plates.       
 
       Experiment 1. The Efficacy of the Co-Precipitate (Antibiofilm Complex) Versus Common Biofilm Forming Bacteria at the 1-hour Time Point Following Reconstitution 
       [0058]    The efficacy of the novel antibiofilm complex was measured against the bacteria  S. epidermidis, S. aureus  (MSSA and MRSA) and  P. aeruginosa,  of the strains identified above. The results showed Minimal Inhibitory concentration (MIC) and Minimal Eradication Concentration (MEC) for planktonic cultures. Testing of co-precipitate conducted after one hour reconstitution. 
         [0059]    A summary of the in-use dilutions and concentrations required to inhibit and eradicate planktonic bacteria (MIC/MEC) for all the tested bacteria are provided in in Table 2: 
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
           
               
                 TABLE 2 
               
             
             
               
                   
               
               
                 MIC/MEC for co-precipitate (antibiofilm complex) 
               
               
                 against four common biofilm forming pathogenic bacteria. 
               
               
                 Dilution expressed relative to in-use strength of 3.71 g/l. 
               
             
          
           
               
                 Species 
                 MIC 
                   
               
             
          
           
               
                 Commencing 
                   
                 Concen- 
                 MEC 
               
             
          
           
               
                 bacterial 
                 Dilution of 
                 tration 
                 Dilution of 
                 Concentration 
               
               
                 count 
                 neat 
                 (mg/ml) 
                 neat 
                 (mg/ml) 
               
               
                   
               
             
          
           
               
                 
                   S. epidermidis 
                 
               
             
          
           
               
                 10 7   
                 1 in 20,000 
                 0.0001855 
                 1 in 5    
                 0.742 
               
               
                 10 6   
                 1 in 20,000 
                 0.0001855 
               
               
                 10 5   
                 1 in 20,000 
                 0.0001855 
               
             
          
           
               
                 MSSA 
               
             
          
           
               
                 10 7   
                 1 in 10,000 
                 0.000371 
                 1 in 2.5   
                 1.484 
               
               
                 10 6   
                 1 in 25,000 
                 0.0001484 
                 1 in 5,000  
                 0.000742 
               
               
                 10 5   
                 1 in 25,000 
                 0.0001484 
                 1 in 5,000  
                 0.000742 
               
             
          
           
               
                 MRSA 
               
             
          
           
               
                 10 7   
                 1 in 50,000 
                 0.0000742 
                 1 in 2.5   
                 1.484 
               
               
                 10 6   
                 1 in 50,000 
                 0.0000742 
                 1 in 2500   
                 0.001484 
               
               
                 10 5   
                 1 in 50,000 
                 0.0000742 
                 1 in 10,000 
                 0.000371 
               
             
          
           
               
                 
                   P. aeruginosa 
                 
               
             
          
           
               
                 10 7   
                 1 in 50    
                 0.0742 
                 1 in 20    
                 0.1855 
               
               
                 10 6   
                 1 in 50    
                 0.0742 
               
               
                 10 5   
                 1 in 50    
                 0.0742 
               
               
                   
               
             
          
         
       
     
         [0060]    The results shown in Table 2 were interpreted as demonstrating broad spectrum activity by the novel antibiofilm complex against the planktonic bacteria tested. Its inhibitory activity against gram positive organisms (most likely to be involved in DAI) is higher than when compared with  P. aeruginosa  (Gram negative). The dilution required for eradication, however, is considerably higher (e.g., a lower concentration) for  P. aeruginosa  as compared with the gram positives tested. 
         [0061]    Experiment 1 also demonstrated Minimal Biofilm Inhibitory concentration (MBIC) and Minimal Biofilm Eradication Concentration (MBEC) for biofilm cultures during the testing of the novel antibiofilm complex conducted after one hour of reconstitution. A summary of the in-use dilutions and concentrations required to inhibit and eradicate biofilm bacteria (MBIC/MBEC) for all the tested bacteria are found in Table 3: 
         [0000]    
       
         
               
             
               
               
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
               
             
               
               
               
               
               
             
           
               
                 TABLE 3 
               
             
             
               
                   
               
               
                 MBIC/MBEC for co-precipitate (antibiofilm complex) 
               
               
                 against 3 common biofilm forming pathogenic bacteria. 
               
               
                 Dilution expressed relative to in-use strength of 3.71 g/l. 
               
             
          
           
               
                   
                 MBIC 
                 MBEC 
               
             
          
           
               
                 Species 
                 Dilution 
                   
                 Dilution 
                   
               
               
                 Commencing 
                 of 
                 Concentration 
                 of 
                 Concentration 
               
               
                 bacterial count 
                 neat 
                 (mg/ml) 
                 neat 
                 (mg/ml) 
               
               
                   
               
             
          
           
               
                 
                   S. epidermidis 
                 
               
             
          
           
               
                 10 7  CFU/well 
                 1 in 100 
                 0.0371 
                 1 in 5 
                 0.742 
               
             
          
           
               
                   S. aureus  MSSA 
               
             
          
           
               
                 10 7  CFU/well 
                 1 in 20  
                 0.1855 
                  1 in 20 
                 0.1855 
               
             
          
           
               
                 
                   P. aeruginosa 
                 
               
             
          
           
               
                 10 7  CFU/well 
                 1 in 5  
                 0.742 
                 1 in 5 
                 0.742 
               
               
                   
               
             
          
         
       
     
         [0062]    The results shown in  FIG. 3  were interpreted as demonstrating, in comparison to killing of planktonic bacteria, that the novel antibiofilm complex predictably required a higher concentration (and lesser dilution) to inhibit and kill biofilm bacteria. It is important to note the in vitro testing of biofilm bacteria was conducted in 100% tryptone soy broth, a high protein environment providing significant protein interference of antibiotic and antiseptic action. 
       Experiment 2. The Efficacy of Co-Precipitate (Antibiofilm Complex) when Used Against  Staphylococcus aureus  (MSSA) after 3 &amp; 24 Hours of Reconstitution Compared to Reconstitution After 1 Hour. (MIC, MEC, MBIC, MBEC) 
       [0063]    Table 4 summarizes dilutions and concentrations required to inhibit  S. aureus  (Strain 25923) at 1 hour, 3 hours and 24 hours following reconstitution of co-precipitate. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 4 
               
             
             
               
                   
               
               
                 The MIC/MEC/MBIC/MBEC for co-precipitate (antibiofilm complex) against  S. aureus   
               
               
                 (strain 25923) at 1 hour versus 3 and 24 hours following reconstitution. 
               
             
          
           
               
                   
                 MIC 
                 MEC 
                 MBIC 
                 MBEC 
               
               
                   
                 Planktonic cells 
                 Planktonic cells 
                 Biofilm cells 
                 Biofilm cells 
               
             
          
           
               
                   
                   
                 Conc. 
                   
                 Conc. 
                   
                 Conc. 
                   
                 Conc. 
               
               
                   
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
               
               
                   
                   
               
             
          
           
               
                 1 hour 
               
             
          
           
               
                 10 7   
                 1 in 10,000 
                 0.000371 
                 1 in 2,000 
                 0.001855 
                   
                   
                   
                   
               
               
                 10 6   
                 1 in 10,000 
                 0.000371 
                 1 in 2,000 
                 0.001855 
               
               
                 10 7   
                   
                   
                   
                   
                 1 in 20 
                 0.1855 
                 1 in 20 
                 0.1855 
               
               
                 biofilm 
               
             
          
           
               
                 3 hours 
               
             
          
           
               
                 10 7   
                 1 in 10,000 
                 0.000371 
                 1 in 2,000 
                 0.001855 
                   
                   
                   
                   
               
               
                 10 6   
                 1 in 10,000 
                 0.000371 
                 1 in 2,000 
                 0.001855 
               
               
                 10 7   
                   
                   
                   
                   
                 1 in 20 
                 0.1855 
                 1 in 20 
                 0.1855 
               
               
                 biofilm 
               
             
          
           
               
                 24 hours 
               
             
          
           
               
                 10 7   
                   
                   
                   
                   
                 1 in 25 
                 0.1484 
                 1 in 25 
                 0.1484 
               
               
                 biofilm 
               
               
                   
               
             
          
         
       
     
         [0064]    The results shown in Table 4 were interpreted as appearing to show no loss in efficacy in reconstitution of the novel antibiofilm complex at 1 hour versus 3 hours against the planktonic form of  S. aureus.  For  S. aureus  biofilm, the novel antibiofilm complex maintained its potency at both 3 hours and 24 hours following reconstitution, an added advantage in providing prolonged protection against biofilm for medical devices in situ. This also demonstrates stability in the novel antibiofilm complex following reconstitution at the 24 hour time point. 
       Experiment 3. The Efficacy of the Physical Mixture of PVP, Iodine, Gentamycin and Rifampicin Against  S. aureus at  1 and 3 Hour Time Point Following Reconstitution (MIC, MEC, MBIC, MBEC) 
       [0065]    Table 5 summarizes dilutions and concentrations of reconstituted physical mixture of povidone iodine, rifampicin and gentamycin required to inhibit  S. aureus  (MIC/MEC/MBIC/MBEC) (Strain 25923) when added to cultures at 1 hour and 3 hours following reconstitution. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 5  
               
             
             
               
                   
               
               
                 MIC/MEC/MBIC/MBEC for physical mixture of povidone iodine, rifampicin 
               
               
                 and gentamycin against  S. aureus  (strain 25923) when tested 
               
               
                 at 1 hour and 3 hours following reconstitution. 
               
             
          
           
               
                   
                 MIC 
                 MEC 
                 MBIC 
                 MBEC 
               
             
          
           
               
                   
                   
                 Conc. 
                   
                 Conc. 
                   
                 Conc. 
                   
                 Conc. 
               
               
                   
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml 
               
               
                   
                   
               
             
          
           
               
                 1 hour 
               
             
          
           
               
                 10 7   
                 1 in 2000 
                 0.001855 
                 1 in 1000 
                 0.00371 
                   
                   
                   
                   
               
               
                 10 7   
                   
                   
                   
                   
                 1 in 20 
                 0.1855 
                 1 in 20 
                 0.1855 
               
               
                 biofilm 
               
             
          
           
               
                 3 hours 
               
             
          
           
               
                 10 7   
                 1 in 2000 
                 0.001855 
                 1 in 1000 
                 0.00371 
                   
                   
                   
                   
               
               
                 10 7   
                   
                   
                   
                   
                 1 in 20 
                 0.1855 
                 1 in 20 
                 0.1855 
               
               
                 biofilm 
               
               
                   
               
             
          
         
       
     
         [0066]    The results of Table 5 were interpreted as follows. By comparison with the co-precipitate, the physical mixture of each of the parent ingredients showed significantly less potency against planktonic cultures of  S. aureus.  This indicates a synergy of action that is gained by chemically linking the antibiotics, iodine and povidone in the high-energy co-precipitate. This synergy may be the result of changes to solubility and membrane seeking properties of the antibiotics when bound into a co-precipitate with povidone. (See, Mirzabeigi M N, Sbitany H, Jandali S, Serletti J M.  The Role of Postoperative Antibiotics in Reducing Biofilm - related Capsular Contracture in Augmentation Mammaplasty.  Plastic and Reconstructive Surgery 2011; 128(1): 34e-5e.) 
       Experiment 4. The Efficacy of Betadine (Povidone Iodine) Versus  S. aureus  and  S. epidermidis  Immediately Following Dilution (MIC, MEC, MBIC, MBEC) 
       [0067]    Testing was conducted using Betadine, containing povidone iodine 10% w/v equivalent to 1%w/v available iodine as the “in-use” neat solution. Table 6 summarizes dilutions and concentrations required to inhibit  S. epidermidis  planktonic cultures (MIC/MBE) and  S. epidermidis  and  S. aureus  biofilm cultures (MBIC/MBEC) (Strain 25923) for Betadine. 
         [0000]    
       
         
               
             
               
               
               
               
               
             
               
               
               
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
               
               
               
             
               
             
               
               
               
               
               
               
               
               
               
             
           
               
                 TABLE 6 
               
             
             
               
                   
               
               
                 The efficacy of Betadine against  Staphylococcus epidermidis   
               
               
                 and  S. aureus  as measured by the MIC/MEC/MBIC/MBEC. 
               
             
          
           
               
                   
                 MIC 
                 MEC 
                 MBIC 
                 MBEC 
               
             
          
           
               
                   
                   
                 Conc. 
                   
                 Conc. 
                   
                 Conc. 
                   
                 Conc. 
               
               
                   
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
                 Dilution 
                 (mg/ml) 
               
               
                   
                   
               
             
          
           
               
                 
                   Staphylococcus epidermidis 
                 
               
             
          
           
               
                 10 7   
                 1 in 8 
                 1.25 
                 1 in 4 
                 2.5 
                   
                   
                   
                   
               
               
                 10 7   
                   
                   
                   
                   
                 1 in 8 
                 1.25 
                 1 in 4 
                 2.5 
               
               
                 biofilm 
               
             
          
           
               
                 
                   Staphylococcus aureus 
                 
               
             
          
           
               
                 10 7   
                   
                   
                   
                   
                 1 in 10 
                 1 
                 1 in 5 
                 2 
               
               
                 biofilm 
               
               
                   
               
             
          
         
       
     
         [0068]    The results of Table 6 were interpreted as demonstrating that a much higher concentration of Betadine was required to inhibit and kill planktonic  S. epidermidis  than the 1 in 20,000 dilution (Table 2) necessary for the novel antibiofilm complex. A slightly higher concentration of betadine was required to kill  S. epidermidis  biofilm compared with the novel antibiofilm complex (Table 3). 
       Analysis of Experimental Results 
       [0069]    While a 1 in 20 dilution of the novel antibiofilm complex killed  S. aureus,  Betadine required a 1 in 5 dilution. Furthermore, the concentration of free iodine in the novel antibiofilm complex is at 25% of the concentration of free iodine in betadine. Hence, one significant advantage of using the novel antibiofilm complex is that the total dose of free iodine required to achieve an equivalent kill is far less thereby reducing potential toxicity. 
         [0070]    Collectively, from the data compiled in Tables 2-6, it is clear that the novel antibiofilm complex displays marked and broad activity against a variety of both planktonic and biofilm forming bacteria. The concentrations required to inhibit and eradicate the bacteria are far lower than currently used in clinical practice. This shows a significant chemical synergy produced from combining the three antibiotic moieties with the PVP backbone as a co-precipitate. The major advantage of using this as an anti-infective is the relatively lower dosage of antibiotics and iodine required to produce an equivalent kill as compared with each of these agents in isolation. This has the added advantage of protecting the host tissues for potential toxicity and reducing the development of resistance. 
         [0071]    The activity of the novel antibiofilm complex appears to be stable at the 3 hour time point showing no immediate deterioration of antimicrobial effectiveness. For biofilm testing, activity at 24 hours still showed significant ability to both inhibit and kill biofilm bacteria in a protein rich environment. It would be interesting to test the product after a longer period (i.e., 7 days) following reconstitution to assess medium term efficacy. Its prolonged activity may be an added advantage to protect against the development of DAI once a prosthesis is in situ. 
         [0072]    By comparison, the individual physical mixture of components whilst displaying some antibiotic properties showed less activity as compared with the co-precipitate. When compared with betadine (the current favored antiseptic skin preparation and pocket preparation for prevention of SSI/DAI), the co-precipitate showed equivalent activity at a much lower dose of free iodine. There are significant advantages to using the co-precipitate as a topical anti-infective as compared with betadine. Finally, the prolonged antibiofilm activity as displayed by MBIC and MBEC at 24 hours provides an added advantage to continue to protect a prosthetic in situ following surgical implantation. Further time point studies of co-precipitate efficacy should be performed. 
         [0073]      FIG. 2  provides a comparison of activity of synergistic co-precipitate (antibiofilm complex) vs betadine for MIC, MEC (planktonic 10 7  bacteria  S. aureus  ATCC 25932 (MSSA)) and MBEC (biofilm 10 5  bacteria  S. aureus  ATCC 25932 (MSSA)) showing significantly less dosage of co-precipitate required for both bacterial inhibition and eradication. 
         [0074]    In sum, the experiments demonstrate that the chemical “smart bomb” embodied in the novel antibiofilm complex works. At a minimum, the following conclusions can be drawn from the experimentation:
       1. The novel co-precipitate shows broad activity against  S. epidermidis, S. aureus  (MSSA and MRSA) and  P. aeruginosa;      2. The co-precipitate is more active against planktonic bacteria but also is able to penetrate and eradicate biofilm;   3. The activity of the co-precipitate shows synergy with added potency when compared with individual components and when compared with povidone iodine in isolation;   4. The lower concentrations of antibiotic as a result may provide benefit in reducing host toxicity whilst being able to specifically target bacteria both in planktonic and sessile forms;   5. The activity of the co-precipitate is maintained at 24 hours following reconstitution indicating a long period of potency; and   6. There is potential to develop this compound into a powerful anti-infective with clinical use in both the prevention and treatment of SSI/DAI.       
 
       Exemplary Clinical Applications 
       [0081]    The novel antibiofilm complex embodying the present inventive principles is suitable for a wide range of uses, particularly in the reduction and control of SSI and DAI. The following examples demonstrate only a few of its potential uses, including (1) surgical site preparation; (2) surgical pocket preparation; (3) implant immersion prior to deployment; (4) treatment of established biofilm infection for implant salvage; and (5) as an antimicrobial coating on medical prosthetics. 
         [0082]    A typical clinic application begins with the preparation of stock solution. For example, a pre-determined vial containing 3.78 g of the inventive antibiofilm complex is opened under sterile conditions in the operating room. This antibiofilm complex is mixed with 20 cc of sterile water for injection (WFI). The resultant solution is then added to 500 cc of sterile WFI to provide stock solution, with a total volume of 520 cc, for use in surgical pocket preparation and/or implant decontamination. Preferably, the stock solution is reconstituted as close to the time of use as possible. 
         [0083]    During an exemplary surgical site preparation, the skin and mucosal surfaces are washed with the stock solution prior to incision. The solution is then left in contact for a minimum of 30 seconds following commencement of the surgical procedure. 
         [0084]    A typical example of surgical pocket preparation is the deployment of a mammary prosthesis. Following dissection of a suitable submammary or submuscular (dual plane) pocket and prior to deployment of the mammary implant, 150 cc of stock solution is drawn and injected into the pocket. The surgeon ensures that the solution is spread evenly over the entire pocket and the solution is left in situ for a minimum of 30 seconds prior to prosthesis deployment. 
         [0085]    Another representative use is implant immersion prior to deployment. In this example, an implant (e.g., a mammary prosthesis) is removed under sterile conditions from packaging whilst the surgical pocket is being treated by stock solution. The prosthesis is immersed in 100 cc of stock solution for a minimum of 30 seconds. The prosthesis is then removed from the solution and immediately deployed into the prepared surgical pocket. If the implant is to be excessively manipulated and/or removed from the cavity, consideration must be given to re-preparation of the pocket and re-immersion of the implant as described above. 
         [0086]    A further example of the potential uses of the stock solution containing the inventive antibiofilm complex is the orthopaedic internal fixation for fracture. Following exposure and reduction of the fracture, 150 cc of stock solution is delivered to the surgical site and surrounding skin access incision. The solution is left in contact with the tissues for a minimum of 30 seconds prior to the delivery and fixation of the orthopaedic plate/screws. During this time, any anticipated plate/screws should be placed into a sterile container with 150 cc of stock solution and be in contact with the solution for at least 30 seconds prior to deployment. 
       Summary 
       [0087]    In sum, by appropriate formulation and lyophilization procedures, a novel solid novel antibiofilm complex (GAAB-1) offers the following advantages:
       (1) It converts relatively insoluble antiseptics and antibiotics into water soluble membrane seeking agents possessing biofilm penetrating properties and excellent antimicrobial action;   (2) It exhibits a significant synergistic antimicrobial/antiseptic action which is greater than that of a simple equimolar mixture of its three pharmacologically active agents involved or their individual equimolar solutions. Its higher potency at lower concentrations than that of a mixture of its constituents results in lower toxicity of the product. The synergy may be the result of the improved solubility of its constituents, greater extent of deposition on biologic membrane due to the intimate association of the two antibodies with Povidone (a polymer which possesses membrane seeking properties that explain its cell cryoprotectant action);   (3) Possesses broad spectrum activity against common biofilm forming pathogenic bacteria even in the presence of a high protein environment which provides significant protein interference of antibiotic and antiseptic action;   (4) Provides fixed concentrations of antibiotic (antiseptic components) thereby standardizing the dosage delivery; and   (5) The activity of the product is maintained for 24 hours following reconstitution indicating a long period of potency.       
 
         [0093]    Although the invention has been described with reference to specific embodiments, these descriptions are not meant to be construed in a limiting sense. Various modifications of the disclosed embodiments, as well as alternative embodiments of the invention, will become apparent to persons skilled in the art upon reference to the description of the invention. It should be appreciated by those skilled in the art that the conception and the specific embodiment disclosed might be readily utilized as a basis for modifying or designing other structures for carrying out the same purposes of the present invention. It should also be realized by those skilled in the art that such equivalent constructions do not depart from the spirit and scope of the invention as set forth in the appended claims. It is therefore contemplated that the claims will cover any such modifications or embodiments that fall within the true scope of the invention. What is claimed is: