Patent Publication Number: US-2023149687-A1

Title: Therapeutic delivery device

Description:
CLAIM OF PRIORITY 
     This application is a continuation-in-part of U.S. patent application Ser. No. 16/994,578, filed on Aug. 15, 2020, which is a continuation of U.S. patent application Ser. No. 16/047,917 filed on Jul. 27, 2018, which issued as U.S. Pat. No. 10,744,313 on Aug. 18, 2020, which claims the benefit of U.S. Provisional Application No. 62/537,596 filed on Jul. 27, 2017, all of the above-listed applications are hereby incorporated by reference in their entirety for all purposes. 
    
    
     BACKGROUND OF THE INVENTION 
     In the fields of medicine and therapy, there are various advantages and benefits to delivering therapeutic agents to one or more local regions of a patient instead of providing those therapeutic agents to the entire system of the patient receiving the therapeutic agents. Advantages and benefits include, but are not limited to, achieving high local concentrations of therapeutic where needed most, as opposed to systemic therapy which produces lower therapeutic concentrations indiscriminately through the tissues of the whole body. Often times, providing the therapeutic agents to exactly the site that needs them allows for much higher (and often times more effective) concentrations of therapeutic agents to be provided to the patient and those higher concentrations could not be safely administered systemically to the same patient. Additionally, delivering therapeutic agents locally provides a variety of benefits and advantages, including but not limited to, minimizing side effects in non-target tissues, using less therapeutic agent over the life of delivery (which can reduce costs and/or and morbidity) and effectively delivering the therapeutic agents to the exact site of interest/injury. Several types of therapies that can benefit from local delivery of the therapeutic agents include, but are not limited to, antimicrobial, analgesic, antiseptic, chemotherapeutic, anti-inflammatory and/or anesthetic management. 
     As an example, patients who suffer from open fractures of the extremities are susceptible to high levels of bacterial contamination, especially those bacteria that reside in biofilms. Estimates suggest that greater than 99% of bacteria in natural ecosystems (e.g., soil, dirt, human skin, GI tract, etc.) preferentially dwell in the biofilm phenotype. Mud, dirty water, debris, or other exogenous vectors that harbor biofilms, or high numbers of planktonic bacteria, have potential to contaminate open fracture wounds at the time of trauma and result in biofilm-related infection. However, current antibiotic therapies, which often consist of short-term prophylactic administration, have not been optimized against biofilms. Indeed, almost every, if not every, antibiotic on the market has been optimized against planktonic bacteria. As such, current dosing therapies may not reach sufficient blood levels to effectively eradicate biofilms and their associated bacteria. Notably, the situation is not unique to open fractures alone. Patients who receive implantable devices including total joint prosthetics, vascular devices, pacemakers, fracture fixation devices, or who undergo surgery in general are at risk of being contaminated with bacteria, including those in the biofilm phenotype. Often times, those patients that receive implantable devices must have their implantable device adjusted and or replaced, increasing the odds of repeat bacterial infection. Those patients may need repeated dosages of therapeutic agents or different therapeutic agents throughout the course of their therapy and treatment and accordingly would benefit from a therapeutic delivery device that can be filled and refilled with one or more therapeutic agents without breaking, leaking, or malfunctioning or creating additional trauma to the patient receiving the therapeutic agent(s). Additionally, patients will benefit from having a therapeutic delivery device that can be inserted and reinserted into a patient multiple times without breaking, leaking, or malfunctioning and creating little to no trauma to the patient that the therapeutic delivery device is being inserted into. 
     Current clinical antimicrobial therapies that are currently in clinical use remain limited in their ability to effectively treat and prevent biofilm-related infections, in particular those that accompany the use of implanted devices. Current antibiotic therapies, including prophylactic antibiotic dosing administered systemically, may not reach intrawound levels to effectively eradicate biofilm bacteria or high concentration planktonic inocula. It is now well established that bacterial biofilms are resilient and can withstand over 1,000 times the antibiotic concentration compared to their planktonic counterparts. As such, despite antibiotic intervention, biofilms may remain in a contaminated wound site and serve as a reservoir of infection that can endanger the patient and prevent or prolong the patient&#39;s full and speedy recovery. 
     The use of implanted biomaterials (either temporarily or permanently) is commonplace in modern medicine for restoring health and treating disease. One example is the fixation hardware used for repairing fractured bones. Sites containing these and other implantable devices are susceptible to device-related infection. Device-related infections are difficult to treat with clinically available antimicrobial therapies. The characteristic microbiology at the implant surface underlies the unique pathology of device-related infections. Bacteria colonize the foreign surface and evade the host immunity, in part, through secretion of a sticky protective extracellular polymeric (EP) matrix that envelopes the bacteria. Because of a variety of factors including but not limited to the changes in the bacterial phenotype, the surface-attached biofilm community may be tolerant of antibiotics and other therapeutic agents up to 1,000 times the concentration typically required to eradicate the metabolically active free-living planktonic forms—concentrations which are toxic to susceptible tissues like the cochlea, liver, and kidneys when delivered systemically. The implant surface thus often serves as a nidus for infection harboring a community of bacteria, which frequently withstand the gold-standard systemic antibiotic treatments employed clinically. 
     The recalcitrant infections frequently seen in clinical scenarios are a result of the biofilm problem. Since Gustilo et al. defined the Type IIIB open fracture in 1984, infection rates (52%) of these fracture types have remained largely unchanged. These high rates of infection hinder surgical outcomes and healing in soldiers and civilian patients. There are at least two main reasons why this unacceptably high rate of infection has persisted. First, current clinical therapies were not designed to target biofilms or high inocula of planktonic bacteria. As mentioned, biofilms have significant opportunity to contaminate open fractures or other wound sites at the time of trauma and current antibiotic therapies frequently provide insufficient coverage. Second, current clinical therapies do not maintain sufficiently high doses/concentrations of antibiotic to prevent biofilm-related infection in the traumatic wound site with mechanically impaired vasculature. There exists a need for drug delivery devices that are easy and intuitive to use, thereby reducing the odds of error during use, and can be inserted, reinserted and/or refilled in the patient numerous times without leaking, breaking, or malfunctioning all the while not causing additional or unnecessary trauma to the patient receiving the therapeutic device. 
     High energy traumatic wounds and infection outcomes are highlighted in military-related healthcare. In military conflicts, lower extremity injuries are common. Murray outlines that a large percentage of lower extremity combat wounds are complicated by infection. In the military theater, rates of open fracture formation are much higher compared to the civilian population. For example, 26% of all injuries in soldiers have been reported to be fractures. Of those, 82% were open with rates of infection that have reached as high as 60%. Additional data from Brook Army Medical Center (BAMC) shows that 40% of injured soldiers (26% of which had orthopaedic trauma) from January to June of 2006 received courses of antibiotics. Furthermore, Johnson et al. showed that in a group of 25 soldiers who suffered Type IIIB open fractures of the tibia, 77% of their wounds had bacteria present. Taken together, these data indicate that the proposed problem is common and adversely affects wounded warriors, as well as civilian patients, and limits successful surgical outcomes. 
     Biofilm-related infection is of ever-growing concern across a broad spectrum of healthcare-related practices. Bacteria can either contaminate a wound or surgical site, then form into a biofilm, or well-established biofilms can contaminate these sites at the time of trauma, injury, or during surgery. Accordingly, there exists a need for an improved therapeutic delivery device that solves the problems and limitations of the above and provides various additional benefits and advantages, all of which is accomplished by the present invention described herein. 
     SUMMARY OF THE INVENTION 
     To address these growing concerns, an improved therapeutic (e.g., antimicrobial) delivery device containing a reservoir, stem, and port is described herein for use subcutaneously in a mammal and in conjunction with a variety of implantable devices or body locations. The devices of the inventions disclosed herein can also be used as a standalone product to expedite healing wounds or surgical sites. 
     Preliminary in vitro tests have shown efficacy by eradicating both biofilm and planktonic bacteria in the presence of the antimicrobial releasing device. For example, under flow conditions consistent with lymphatic clearance rates of viable tissues (fluid exchange rate of approximately 14%/hr) in brain heart infusion broth, the device (filled with 15 mL of PBS that contained 70 mg/mL fosfomycin, 25 mg/mL gentamicin and 2 mg/mL rifampin) was able to fully eradicate 10 9  colony forming units (CFU) of methicillin-resistant  Staphylococcus aureus  (MRSA) within a 24 hr period. In the presence of serum, the same antibiotic combination in the device was able to reduce MRSA biofilms by more than 6 log 10  units in 24 hr. In vivo testing in a sheep model of Type IIIB open fracture, wherein the device was placed sub-dermally yet directly over an implant site that contained 10 9  CFU of MRSA in biofilms, showed the ability of the device to treat and prevent biofilm implant-related infection. 
     In one embodiment of the present disclosure, a device for delivering one or more therapeutic agents to a mammal subcutaneously is provided. The device provides, among other things, the ability to release high doses of a therapeutic compound (e.g., an antibiotic) in a local area (important for effective biofilm eradication or eradication of high numbers of planktonic bacteria), sustain that high dose release with a percutaneous port that allows for reloadability of the device, and be versatile for use with multiple types of antimicrobials and/or implant systems with a variety of benefits and advantages no seen with other devices. In at least some embodiments of the present disclosure, the port has a stem that is in fluid communication with a reservoir inserted subcutaneously into a mammal in need of the one or more therapeutic agents. A rate-controlling membrane is disposed in the reservoir that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate. A rate determining/controlled release membrane is used to modulate the molecular mobility of the therapeutic compounds thereby controlling the therapeutic release profile. One of the many benefit&#39;s and advantages of the devices disclosed herein is that the device has eliminated the sleeve found in other devices and functions using the rate-controlling membrane which can be comprised of any rate controlling membrane that is appropriate for the particular application. The rate controlling membrane can be comprised of any material that is suitable for the particular patient and therapeutic agent(s), some of which include but are not limited to, polyester, polypropylene, polyethylene terephthalate, polyvinyl chloride, polyether sulfone, polyvinylidene fluoride, polyvinylidene difluoride, polydimethylsiloxane, silicone, polyethylene, polystyrene, polyvinylchloride, polytetrafluoroethylene, polyethylene-vinyl acetate, polyacrylate, polystyrene, polyurethane, regenerated cellulose, or cellulose acetate. 
     In another embodiment of the present disclosure, a device for delivering one or more therapeutic agents subcutaneously to a mammal in need thereof is provided. The device comprises (1) a port for receiving one or more therapeutic agents that is to be delivered to a mammal subcutaneously, the port having a stem and (2) a reservoir in fluid communication with the stem and comprised of at least two areas, the first area being comprised of a more rigid elastic material and the second area being comprised of a less rigid elastic material and (3) a rate-controlling porous or non-porous membrane disposed in the reservoir that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate. The reservoir is capable of being inserted subcutaneously into a mammal in need of the one or more therapeutic agents and filled or refilled to contain the therapeutic agents that are to be delivered to the mammal subcutaneously while at least the reservoir of the device is inserted subcutaneously in the mammal in need of one or more therapeutic agents. At least the reservoir portion of the device is capable of being inserted subcutaneously into the body of the mammal in need of one or more therapeutic agents and the one or more therapeutic agents can be removed from the reservoir of the device or filled or refilled into the reservoir of the device without the device being removed from the body of the mammal in need of the one or more therapeutic agents. 
     In yet another embodiment, a device for delivering one or more therapeutic agents subcutaneously to a mammal in need thereof is provided. The device comprises (1) a port for receiving one or more therapeutic agents that is to be delivered to a mammal subcutaneously, the port having a stem; (2) a reservoir in fluid communication with the stem and comprised of a less compliant elastic material abutting a more compliant elastic material at least at the edges of the reservoir, the reservoir being capable of being inserted subcutaneously into a mammal in need of the one or more therapeutic agents and filled or refilled to contain the therapeutic agents that are to be delivered to the mammal in need thereof; and (3) a rate-controlling porous or non-porous membrane disposed in the reservoir that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate where at least the reservoir portion of the device is capable of being inserted subcutaneously into the body of the mammal in need of one or more therapeutic agents and the one or more therapeutic agents can be removed from the reservoir of the device or filled or refilled into the reservoir of the device without the device being removed from the body of the mammal in need of the one or more therapeutic agents. 
     In yet another embodiment, a device for delivering one or more therapeutic agents subcutaneously to a mammal in need thereof is provided. The device comprises (1) a port for receiving one or more therapeutic agents that is to be delivered to a mammal subcutaneously, the port having a stem and (2) a reservoir that is comprised of a compliant elastic material and a rate-controlling membrane that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate, wherein the rate-controlling membrane is disposed in at least the center area of the reservoir and a compliant elastic material is disposed in at least the end of the reservoir and the rate-controlling membrane and the compliant elastic material are attached to each other to form at least a semi-continuous layer and the reservoir is capable of being inflated to contain one or more therapeutic agents and deflated to be substantially flat to remove the device from the mammal in need thereof or to receive or refill one or more therapeutic agents that are to be delivered to the mammal in need thereof, the reservoir being in fluid communication with the stem of the device. In at least some embodiments, at least the reservoir portion of the device is capable of being inserted subcutaneously into the body of the mammal in need of one or more therapeutic agents and the one or more therapeutic agents can be removed from the reservoir of the device or filled or refilled into the reservoir of the device without the device being removed from the body of the mammal in need of the one or more therapeutic agents. 
     In at least one aspect of at least one embodiment of the present disclosure, the reservoir is further comprised of a reinforcement or composite membrane located between the more rigid elastic material and the less rigid elastic material of the reservoir. 
     In at least another aspect of at least one embodiment of the present disclosure, the reinforcement or composite membrane is cladded on both sides of the reinforcement or composite membrane with the more rigid elastic material or the less rigid elastic material and the more rigid material and the less rigid material overlap at least a portion of the reinforcement or composite membrane and create a heat seal with the reinforcement membrane in the reservoir, which provides a variety of benefits and advantages, including but not limited to causing the reservoir of the device to be much stronger, allowing filling, refilling and reuse of the device without the device failing or increased risk of the therapeutic agent leaking from the device in a way that could be harmful to the patient, removing blunt ends and providing a tapered end allowing the device to be removed from the patient and inserted into the patient easier and with less risk of damage to the device itself, providing a device with barbed and/or glued connections that increase pullout strength of the device, kink resistant tube that allows some to all of the therapeutic agents to be removed from the device, heat sealed joints and a rate controlling membrane that is integrated into the device. 
     In at least another aspect of at least one embodiment of the present disclosure, the more rigid elastic material and the less rigid elastic material sufficiently overlap the reinforcement or composite membrane and create a heat sealed joint of the more rigid elastic material, the less rigid elastic material and the reinforcement or composite membrane at least at the outer edges of the reservoir. Among other things, the more rigid elastic material and less rigid elastic material overlapping and creating a heat seal joint provides structure and rigidity to the device that allows it to be inserted, remove, filled and refill from the patient easier and with less risk of failure. 
     In at least another aspect of at least one embodiment of the present disclosure, at least a substantial portion of both ends of the reservoir are comprised of the more rigid elastic material and at least a substantial portion of the middle of the reservoir is comprised of the less rigid elastic material. 
     In at least another aspect of at least one embodiment of the present disclosure, the device does not have a sleeve covering the reservoir, the reservoir is tapered from at least the reservoir to the stem and the largest diameter of the device when the reservoir does not contain any therapeutic agents is the diameter of the port or the stem allowing for easy removal of the device from the mammal in need of one or more therapeutic agents. 
     In at least another aspect of at least one embodiment of the present disclosure, the device further comprises one or more tabs or holes near the edges or outside the reservoir that can be used to fasten the device subcutaneously to the mammal in need of the one or more therapeutic agents. 
     In at least another aspect of at least one embodiment of the present disclosure, the device further comprises at least one tube having holes, wherein the at least one tube is in fluid communication with the stem and is substantially inside the reservoir and assists with inflation and deflation of the reservoir with therapeutic agents. Among other things, the at least one tube allows for most if not all of the therapeutic agents from being removed from the device. 
     In at least one aspect of at least one embodiment of the present disclosure, the rate-controlling membrane has pores and the device further comprises one or more chemical stabilizers or plasticizers to keep the pores of the rate-controlling membrane open. 
     In at least one aspect of at least one embodiment of the present disclosure, the chemical stabilizer is, by way of example and not limitation, glycerol. 
     In yet another embodiment of the present disclosure, a device that includes a port that has a stem that is in fluid communication with a reservoir inserted subcutaneously into a mammal in need of the one or more therapeutic agents is provided. At least a substantial portion of both ends of the reservoir are comprised of the more rigid elastic material and at least a substantial portion of the middle of the reservoir is comprised of the less rigid elastic material and is capable of being inflated and deflated. The port is configured to extend percutaneously from the body to the surrounding environment such that the port is exposed thereby allowing one or more therapeutic agents to be removed from the device or filled or refilled into the device without the device being removed from the body of the mammal in need of the one or more therapeutic agents. 
     In yet another embodiment of the present disclosure, a device comprising a reservoir for a therapeutic agent and configured to be deployed subcutaneously near a surgical site, the reservoir including a membrane for controlled release of the therapeutic agent to the surgical site, a port including a stem, the port in fluid communication with the reservoir and being configured such that the port allows a user to refill the reservoir via the port, and one or more tabs or holes outside the reservoir that can used to fasten the device relative to the surgical site. 
     In yet another embodiment of the present disclosure, a device comprising a reservoir for receiving a therapeutic agent and configured to be deployed subcutaneously near a surgical site, a rate-controlling membrane disposed in the reservoir for providing a controlled release of the therapeutic agent to the surgical site, a port having a stem in fluid communication with the reservoir, the reservoir including a region configured to receive a fastener, and at least one tube or cylinder with one or more perforations throughout the at least one tube or cylinder that is disposed in the interior of the reservoir and the at least one tube or cylinder being in fluid communication with the stem and reservoir of the device is provided. 
     In yet another embodiment of the present disclosure, a device that includes a reservoir that is comprised of a less compliant elastic material abutting a more compliant elastic material is provided. The reservoir being capable of being inflated and deflated and allowing the therapeutic agent to and inserted subcutaneously into a mammal in need of the one or more therapeutic agents. 
     In yet another embodiment of the present disclosure, a device with a rate-controlling membrane that is disposed in the reservoir or attached to the reservoir, where the device allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate and the reservoir has a less compliant elastic material abutting a more compliant elastic material, is provided. 
     In yet another embodiment of the present disclosure, a device with a reservoir that is comprised of at least two different materials, a rate-controlling membrane that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate that is disposed in at least the center area of the reservoir and a compliant elastic material that is disposed in at least the end of the reservoir and rate-controlling membrane and the compliant elastic material being attached to each other to form at least a semi-continuous layer and the reservoir being capable of being inflated to a substantially cylindrical shape and deflated to receive or refill one or more therapeutic agents that are to be delivered to the mammal in need thereof is provided. 
     In yet another embodiment of the present disclosure, a therapeutic delivery device is provided that includes a multi-lumen tube in the reservoir of the device. During insertion of the device into the patient and also after the device has been positioned in place in the patient, the device may twist, curl, kink or fold on itself, often at or near the entry site, causing a blockage that prevents or restricts the flow of the one or more therapeutic agent(s) through the device, which may prevent the device from functioning as intended. 
     In another aspect of at least some of the embodiments of the present disclosure, the multi-lumen tube passes through at least the neck of the device preventing the blockage of the one or more therapeutic agents and in at least some embodiments the tube is somewhat flexible. 
     Accordingly, the multi lumen tube allows the device or a portion of the device (e.g., the reservoir) to twist, curl, kink or fold without partially or completely blocking the flow of the one or more therapeutic agent(s) throughout the device. Among other things, the flexible multi-lumen tube allows the fluid path of the device to remain open and function as intended even if and when the device twists, curls, kinks or folds over on itself. The multi-lumen tube allows the therapeutic agent(s) to flow through the device as intended even if the device is under sever deformation. It should be appreciated that the multi-lumen tube prevents blockage or restricted flow of the one or more therapeutic agent(s) and allows the device to remain functional and operate as intended. It should also be appreciated that the multi-lumen tube provides a variety of benefits and advantages, including but not limited to, allowing the one or more therapeutic agents to travel throughout the device, as intended, and avoid blockages even when the device is subject to severe deformation and force. 
     Material characteristics and the cross-sectional shape of the multi-lumen tube determine the ability of the multi-lumen tube to function to transport the one or more therapeutic agents regardless of loading type, magnitude, or orientation of the device. 
     Other features and aspects of the invention will become apparent by consideration of the following detailed description and accompanying drawings. 
    
    
     
       BRIEF DESCRIPTION OF THE DRAWINGS 
       The foregoing and other objects, aspects, features, and advantages of the present disclosure will become more apparent and better understood by referring to the following description taken in conjunction with the accompanying drawings, in which: 
         FIG.  1    is a diagram of the original device being used adjacent to a fracture fixation plate secured to bone. 
         FIG.  2    is a diagram of how biofilm might contaminate an open fracture. Soil, dirt and/or mud contain tens of billions of bacteria/g of material. The biofilm phenotype predominates in nature. Open fractures are at significant risk of contamination with biofilms at the time of injury. 
         FIG.  3    is a graph of release curves of common local delivery products compared to sustained antibiotic delivery by the device. Device curves were obtained in-house using a flow chamber. Other release curves were adapted from literature references. 
         FIG.  4    is a set of images of the devices, their components, and method of application. The devices disclosed herein were tested in an animal model wherein two simulated fracture fixation plates, on which biofilms were grown, were secured to the proximal medial aspect of a tibia. The devices were placed over the plates and refilled with antibiotic solution daily for 10 days to maintain antibiotic(s) delivery at the site of interest. 
         FIG.  5    is a set of images of side-by-side diffusion cells for permeability testing showing ability of rate-controlling membranes to control diffusion of methylene blue (representative compound, at 0.05% in saline) from a donor cell to a receptor cell. (A) Glass PermeGear diffusion cell. (B) Custom 3D printed cells. (C) Multiple cell setup allows for higher throughput membrane permeability testing. 
         FIG.  6 A  is a set of graphs illustrating permeabilities (P) of representative rate-controlling membrane materials. The top line is data from the donor cell; bottom line from the receptor cell. A) Regenerated cellulose membrane used in pilot testing. B) Hydrophobic PVDF membrane with limited diffusion. C) Synder brand PES membrane rated at 30,000 MWC. 
         FIG.  6 B  is a set of graphs illustrating permeabilities (P) of representative rate-controlling membrane materials. The top line is data from the donor cell; bottom line from the receptor cell. D) Synder brand PES membrane rated at 300,000 MWCO. E) Hydrophilic PVDF membrane. F) MCE membrane with support material. 
         FIG.  7    is a photograph of the rate-controlling membrane with a polyester backing (white material) and a polyurethane material (clear) heat-sealed together via impulse sealing. 
         FIG.  8    is a photograph of a thermal press unit that heat seals polymeric materials together. The iron can be customized to create various shapes/sizes of a device iteration. 
         FIG.  9    is a photograph of a 3D printed mold around which copper bar can be wrapped to make an iron for heat sealing membrane and polyurethane materials. Mold had dimensions of 2″×2⅛″. FormLabs tough resin was used for printing. 
         FIG.  10    is a photograph of the copper iron made using the 3D printed template. Copper bar that was bent around the template had dimensions of ⅜″× 1/16″ and was ground and polished to create a flat face for heat sealing. Copper was soldered to seal the joints and soldered to a copper base plate to create the iron. Solder joints were tested and determined to maintain integrity up to ˜450° F. Notably, the copper iron can also be machined from a copper block to desired dimensions. 
         FIG.  11    is a photograph of a copper iron attached to the heating block of a thermal press being brought down on top of materials that are “sandwiched” between a Teflon sheet and a silicone pad to heat seal materials together. 
         FIG.  12    is a photograph of a template (paper) used to align the copper iron on the heat block with materials on the thermal press stage. Alignment tabs (four arms) keep the template in place. A silicone pad allows slight compression and improves the heat seal. 
         FIG.  13    is a photograph of the MK membrane and polyurethane materials placed on the thermal press stage. Alignment tabs keep the materials in place and maintain alignment with the copper iron. 
         FIG.  14    is a photograph of Teflon sheet (folded back) being placed over MK membrane/polyurethane materials. The rationale for placing a Teflon sheet over the materials that are intended to be heat sealed is to prevent the materials from being burned by the hot copper iron once it is engaged. 
         FIG.  15    is a photograph of Teflon sheet placed over MK membrane/polyurethane (from  FIG.  13   ). The alignment tabs and outline of the MK membrane can be seen underneath the Teflon sheet. The Teflon sheet had four holes punched out to align with the MK membrane/polyurethane and to keep the Teflon sheet in place. MK membrane and polyurethane can be seen under the Teflon sheet. The materials were “sandwiched” between the Teflon sheet and silicone pad. 
         FIG.  16    is a photograph of tabs cut away from the MK membrane after heat sealing the membrane and polyurethane materials together. 
         FIG.  17    is a photograph of the heat-sealed materials folded over in preparation for the second heat seal step to create the device design. 
         FIG.  18    is a photograph of the 3D printed template to create a copper iron for shaping the device. FormLabs tough resin was used to print. 
         FIG.  19    is a photograph of copper iron designed to seal a device design out of polyurethane material. The gap was specifically left so that the folded portion of the MK membrane would not be sealed or burnt. 
         FIG.  20    is a photograph of a Teflon sheet placed over the MK membrane/polyurethane that was folded over in  FIG.  17   . 
         FIG.  21    is a photograph of a heat-sealed polyurethane material created in the shape of a device using the iron from  FIG.  19   . While the MK membrane is a fairly rigid material, the polyurethane makes it so the MK membrane can be incorporated into a tubular-like, device design. Notably, the size of the device and/or membrane can be customized by varying the iron shape. 
         FIG.  22    is a photograph of a device that has excess polyurethane material trimmed away from edges and a Luer lock connector attached. This Luer lock is used to connect catheter tubing to the device. 
         FIG.  23    is a photograph of a device connected to catheter tubing and filled with water. 
         FIG.  24    is a photograph of a simple representation of how the device is filled with/connected to a syringe. See  FIG.  4   , which shows the complete setup including how a needleless connector is placed to allow for draining and filling the device with fluids. 
         FIG.  25    is a photograph of two simulated fracture fixation plates secured to the proximal medial aspect of a sheep tibia, and a photograph of the biofilms of MRSA grown on a plate. Each plate contained ˜3×10 9  CFU/plate. 
         FIG.  26    is a photograph of the proximal medial aspect of right sheep tibia prior to being blasted with an air impact device (AID) blast. 
         FIG.  27    is a photograph of the proximal medial aspect of a right sheep tibia after being blasted with an AID. The AID blast resulted in burst blood vessels/capillaries and soft tissue trauma. 
         FIG.  28    is a photograph that illustrates the device removal from the secondary site (created by trocar at surgery). 
         FIG.  29    is a set of photographs representative of surgical/wound sites in comparative study groups taken at a 21-day endpoint. Suture lines in sheep from the device (pouch) group were the only ones to heal. 
         FIG.  30    is a set of graphs that show colony forming units (CFU) represented as bioburden per g of tissue. Tissues were collected directly over one of the plates (from  FIG.  25   ), homogenized and weighed. The device (pouch) was the only treatment to reduce site bioburden below a 10 5  threshold, usually regraded as the quantitative metric for infection. Stimulan® beads, commonly used to deliver antibiotics locally, served as a nidus of infection and resulted in the worst infection outcome. 
         FIG.  31    is a graph that shows summation of site bioburden including biofilm on site hardware and on bioburden in site tissues. All groups had 21-day endpoints. Positive control group received biofilm-contaminated plates and no antibiotic treatment. Gentamicin-loaded beads contained 120 mg/12 cc Stimulan® beads. Vancomycin was administered for 10 days (2 g/day). Device (pouch) resided in place for 10 days; antibiotic solution (vancomycin, gentamicin, rifampin) was replenished once daily. 
         FIG.  32    is a set of images representative of microCT scans. These scans were collected directly underneath a superior, or proximal, simulated fracture fixation plate (from  FIG.  25   ). The “Time=0” bone sample was a piece of native bone that had an osteotomized fracture created with a bone saw but no other treatment. The + control corresponds to sheep treated with biofilms only; intravenous corresponds to sheep treated with IV vancomycin; pouch corresponds to sheep treated with the device; Stimulan® corresponds to sheep treated with antibiotic-loaded Stimulan® beads. In these images, the roughness correlates with the degree of osteomyelitis: i.e., the rougher the surface, the greater the osteomyelitis, or the more the bone was affected by bacteria. 
         FIG.  33    is a set of graphs that show the porosities of bone surfaces from each of the sheep groups. Data indicated that bone surfaces of sheep treated with the device (pouch) were protected against osteomyelitis to a greater degree than sheep that received clinical standards of care or no treatment at all. 
         FIG.  34 A  is one view of a set of images representative of microCT scans indicating depth profiles of the osteotomized saw blade (after being in a sheep for 21 days) and depth of osteomyelitic response in bone surfaces. Sheep that were treated with the device (pouch) had notably less osteomyelitis compared to sheep from other groups. 
         FIG.  34 B  is one view of a set of images representative of microCT scans indicating depth profiles of the osteotomized saw blade (after being in a sheep for 21 days) and depth of osteomyelitic response in bone surfaces. Sheep that were treated with the device (pouch) had notably less osteomyelitis compared to sheep from other groups. 
         FIG.  35    is a diagram of a simulated fracture fixation plate on which biofilms are grown and which is surgically placed on bone as in  FIG.  25   . 
         FIG.  36    is a rendering of 2×2 cm simulated fracture fixation plate with four holes for bone screw placement. 
         FIG.  37    is a rendering of a modified CDC biofilm reactor arm designed to hold simulated fracture fixation plates. Two plates are shown in the bottom of the holding arm. 
         FIG.  38    is a rendering of a modified CDC biofilm reactor lid showing broth inlet ports, air vent port, rectangular slots into which holding arms can be placed, and center port through which a rod is placed to support the reactor baffle. 
         FIG.  39    is a rendering of a modified CDC biofilm reactor lid with holding arms and simulated fracture fixation plates in place. 
         FIG.  40    is a photograph of an assembled modified CDC biofilm reactor prepared for autoclaving. 
         FIG.  41    is a photograph of tubing C and D connected with straight line barbed connectors and reduction connectors on the ends of Tubing C. 
         FIG.  42    is a photograph of a full setup of a modified CDC biofilm reactor with broth in carboy, connected tubings, tubing inserted through peristaltic pump head, and effluent tube placed in waste container. Foil is placed over the lid of the reactor in this instance to reduce risk of contamination. 
         FIG.  43    is a photograph close up view of tubings, connectors, and air filter connected to Tubing B on reactor lid. 
         FIG.  44    is a photograph showing an outer right hind sheep limb clipped from ankle region to above the thigh and up to udders. 
         FIG.  45    is a photograph showing an inner right hind sheep limb clipped from ankle region to above the thigh and up to udders. 
         FIG.  46    is a photograph of sheep on polyurethane foam mats and a lift table. Left hind limb is secured to a bar with a tie down so it does not interfere with blast to the right hind limb. 
         FIG.  47    is a photograph of lower portion of right hind limb tied down (not overtight) to reduce rebound during blast procedure. 
         FIG.  48    is a photograph of a nozzle of an air cannon approximately 4 inches away from the proximal medial aspect of a tibia. 
         FIG.  49    is a photograph of a heavy canvas cloth covering sheep limb to prevent wool from spreading throughout operating room and to provide a barrier from air. 
         FIG.  50    is a photograph of sheep on a surgical table that is covered with chucks. 
         FIG.  51    is a photograph of an IV post secured to a surgical table with a C clamp so it is stabilized. 
         FIG.  52    is a photograph close up of the dB meter microphone near the opening of the MD. 
         FIG.  53    is a photograph of a side view of the dB meter microphone near the opening of the AID. 
         FIG.  54    is a photograph of a metal frame built to hold a NEULOG force plate. 
         FIG.  55    is a photograph of a force plate placed on a metal frame approximately 4″-6″ away from AID to perform testing. 
         FIG.  56    is a photograph of a cadaveric sheep limb attached to a metal frame. The distance from the nozzle of the AID (orange threaded portion) to the limb was approximately 4″ (red arrow indicates gap). The metal brace (blue arrow) on the back of the limb provided support to the femur and prevented breakage or ligament damage from occurring. 
         FIG.  57    is a photograph of the AID and prototype frame system that can be used in the OR to perform the AID discharge. The AID is secured by tie-downs. A metal frame is connected to wooden posts such that a sheep leg can be braced against it. 
         FIG.  58    is a photograph of a sheep leg (not a live animal) braced against the metal frame. Securing the limb reduces risk of ligament or other damage. 
         FIG.  59    is a set of photographs that demonstrate creating an incision to expose periosteum (Incision), suturing the subdermal tissue (Suture  1 ) and dermal layers (Suture  2 ). Note the cortical bone in the Incision image is visible to allow for periosteum disturbance when necessary. 
         FIG.  60    is a photograph of a gauge to determine PSI in the AID. 
         FIG.  61    is a photograph of a representative digital readout of the Reed dB meter. 
         FIG.  62    is a set of photographs of still shots from AID testing on a cadaveric sheep limb. Note the limb is still intact and attached to the metal stand at all times. 
         FIG.  63    is a photograph of a suture line before AID procedure. 
         FIG.  64    is a photograph of a suture line after the AID procedure. 
         FIG.  65    is a radiograph from specimen ( FIG.  62   ) that showed no signs of gross fracturing or damage to the femur (vertical arrow). The radiolucency seen at the left end of the bone (angled arrow) was damage caused by the bolt used to secure the limb to the metal frame. 
         FIG.  66    is a photograph of the proximal medial aspect of a right sheep tibia (AP view). Boxed region is approximately where simulated fracture fixation plates reside under the skin. Markers identify surgically-relevant points. 
         FIG.  67    is a photograph of an incision line exposing the fascia at the proximal medial aspect of a sheep tibia. 
         FIG.  68    is a photograph of a section of periosteum removed from proximal medial aspect of tibia. 
         FIG.  69    is a photograph of simulated fracture fixation plates situated over the proximal medial aspect of a right sheep tibia. Plates/screws are removed after templating in order to create an osteotomized fracture. 
         FIG.  70    is a photograph of an osteotomized fracture that runs at a slight angle across the region where a simulated fracture fixation plate resides. 
         FIG.  71    is a photograph of simulated fracture fixation plates with Stimulan® beads placed over them. 
         FIG.  72    is a photograph of simulated fracture fixation plates with a device placed over them. 
         FIG.  73    is a photograph of a percutaneous tube protruding through the skin via a secondary site that is created with the trocar. 
         FIG.  74    is a photograph of sutures closing a surgical site and Stimulan® beads are underneath the skin. 
         FIG.  75    is a photograph of the sutures closing a surgical site and a device is underneath the skin. 
         FIG.  76    is a photograph of a surgical/wound site at necropsy (was treated with Stimulan® beads). 
         FIG.  77    is a photograph of the surgical/wound site after being cleaned and prepped for sample collection. 
         FIG.  78    is a photograph of an exposed inferior (distal) plate at necropsy. 
         FIG.  79    is a schematic of a simulated fracture fixation plate and the sequence in which screws are removed for microbiological analysis. 
         FIG.  80    is a photograph showing what a surgical site looks like after removing screws and plate. 
         FIG.  81    is a photograph of a surgical site after tissue that was over the inferior (distal) plate has been removed. 
         FIG.  82    is a photograph of the site after a bone sample has been collected using a circular trephine. 
         FIG.  83    is a photograph of the conical tubes showing weights of the tube (with lids on) prior to and after adding tissue sample into them. 
         FIG.  84    is a photograph of the conical tubes showing what tissue samples look like after being blended. 
         FIG.  85    is a schematic showing the pattern in which to create a streak plate on an agar surface. 
         FIG.  86    is a photograph of small test tubes with 900 μl PBS prepped for a 10-fold dilution series. 
         FIG.  87    is a photograph of agar plates used to plate diluted samples for CFU quantification. 
         FIG.  88    shows a stress map that indicates regions of the device that are under stress when the device is inflated. 
         FIG.  89    shows another stress map that indicates regions of the device that are under stress when the device is inflated. 
         FIG.  90    shows another stress map that indicates regions of the device that are under stress when the device is inflated. 
         FIG.  91    shows another stress map that indicates regions of the device that are under stress when the device is inflated. 
         FIG.  92    is an image of the flat shape of the device overlayed with a stress map from modeling the stresses in the final inflated 3-dimensional device of panel  FIG.  23   . The location of the drug-releasing diffusive membrane (see the dashed box) was positioned within the low stress zones for two reasons: First, the membrane material is non-extensible or inelastic and thus unable to accommodate the stresses of the inflated device; second, this design minimizes the stresses felt on the more delicate membrane thus protecting it from rupture during use. 
         FIG.  93    is an image of a 3-dimensional rendering of the device with the inset membrane material (light grey) integrated into a more distensible elastic or yielding material (dark grey). 
         FIG.  94    is a graph that shows data outlining the force of the 2″ AID discharge opening at 90 PSI and 120 PSI. 
         FIG.  95    is a picture of backscatter electron images of sheep bones with (top) and without (bottom) therapeutic device treatment. The bone surface with (top) therapeutic device treatment is largely unchanged, whereas the bone surface without (bottom) therapeutic device treatment shows signs of bone resorption, sequestra formation, and moth-eaten bone indicative of osteomyelitis. 
         FIG.  96    is a drawing of one embodiment of the invention shown and described herein. 
         FIG.  97    is a drawing of another embodiment of the invention shown and described herein. 
         FIG.  98    is a drawing of yet another embodiment of the invention shown and described herein. 
         FIG.  99    is a drawing of yet another embodiment of the invention shown and described herein. 
         FIG.  100    is a drawing of a trocar, which can be used with at least some embodiments of the invention shown and described herein. 
         FIG.  101    is another drawing of a trocar, which can be used with at least some embodiments of the invention shown and described herein. 
         FIG.  102    is another drawing of a trocar, which can be used with at least some embodiments of the invention shown and described herein. 
         FIG.  103    is a drawing of the deflation assist tube that can be used with at least some embodiments of the invention shown and described herein. 
         FIG.  104    is another drawing of the deflation assist tube that can be used with at least some embodiments of the invention shown and described herein. 
         FIG.  105    is another drawing of the deflation assist tube that can be used with at least some embodiments of the invention shown and described herein. 
         FIG.  106    is a drawing of yet another embodiment of the invention shown and described herein with a deflation assist tube shown in the device reservoir. 
         FIG.  107    is a drawing of yet another embodiment of the invention shown and described herein. 
         FIG.  108    is a drawing of yet another embodiment of the invention shown and described herein. 
         FIG.  109    is a drawing of yet another embodiment of the invention shown and described herein. 
         FIG.  110    is a schematic of how the cladding material bridges the less compliant and more compliant materials in accordance with at least some embodiments of the present invention. 
         FIG.  111    is a graph showing the cumulative biofilm burden remaining in various surgical/treatment sites of sheep inoculated with monomicrobial biofilms of  P. aeruginosa  or  S. aureus  and treated with the therapeutic device or clinical standards of care. Inoculation amount indicates the amount of bacteria that was on simulated fracture fixation plates at the time of surgery (the inoculation level). Bioburden is the total aggregate of bacteria quantified in the surgical site (soft tissue, hard tissue, and hardware) at necropsy. 
         FIG.  112    is a graph showing the cumulative biofilm burden remaining in various surgical/treatment sites of sheep inoculated with polymicrobial biofilms of  P. aeruginosa  and  S. aureus  and treated with a therapeutic device or clinical standards of care.  P. aeruginosa  and  S. aureus  are isolated using selective media and thus presented separately but show the same trend: when treated with the device shown and described herein, bioburden is reduced to a greater degree (˜1 log 10  unit) than standards of care (VT is vancomycin and tobramycin powders; STIM is Stimulan® beads loaded with vancomycin and tobramycin). Inoculation indicates the amount of bacteria that was on the plates at the time of surgery (the inoculation level). Bioburden is the total aggregate of bacteria quantified in the surgical site (soft tissue, hard tissue, and hardware) at necropsy. 
         FIG.  113    is a rendering of a multi-lumen deflation assist tube that reduces the risk of kinking. 
         FIG.  114    is a rendering of the cross section of a multi-lumen deflation assist tube that reduces the risk of kinking. 
         FIG.  115    is a rendering of the cross section of a deflation assist tube with coiled material that reduces the risk of kinking. 
         FIG.  116    is another rendering of a deflation assist tube with coiled material that reduces the risk of kinking of the tube. 
         FIG.  117    is another rendering of a deflation assist tube with coiled material that reduces the risk of kinking. 
         FIG.  118    is a rendering of various iterations of variations of the device of the present disclosure, including older versions of the device. The two devices shown at the top of page of  FIG.  118    are older versions of the device that included a sleeve, a contiguous rate controlling membrane and blunt ends, among other things. The two devices directly below the two devices shown at the top of the page of  FIG.  118    show the devices of one or more embodiments of the current invention and include some of the improvements of the new device design, including but not limited to a non-contiguous rate controlling membrane, a tapered end and elimination of blunt ends that could harm the patient and device during insertion and remove into the patient, elimination of the protective sleeve of the device, kink resistant tube that allows most if not all of the therapeutic agent(s) to be removed, heat sealed joins that add structure, rigidity and allow the device to be filled, refilled and reused numerous times. 
         FIG.  119    is a Table 1, showing the results of experiments for sheep groups, biofilm inocula (monomicrobial or polymicrobial), treatments, dosing and endpoints using the inventions of the present disclosure. 
         FIG.  120    is a drawing in accordance with at least one embodiment of the device of the present disclosure that shows the stem area of the device past the transitioning connector portion of the device that may prevent the flow of the one or more therapeutic agents if exposed to forces and/or bending. 
         FIG.  121    is a drawing of the stem portion of at least one embodiment of the device. The drawing illustrated what can happen to the device when forces are applied to the device and the device bends and/or is contorted, which can cause the reservoir and/or other portions of the device to restrict fluid flow or collapse leading to the fluid path of the one or more therapeutic agent(s) being restricted or blocked. 
         FIG.  122    is a graph showing stress/strain curves comparison of various materials and multi-lumen tubes that were tested as indicated herein. As an example, when the multi-lumen tube was made out of material  90 A, it was shown to perform better than some of the other materials shown in this Figure. See those materials on this Figure that have the largest area under the curve. Various factors were considered including: Ultra Heavy Molecular Weight Polyethylene (C-compression, T-tension), TPU: Thermoplastic Polyurethane (C-compression, T-tension) w/Product Identifiers are shown. 
         FIG.  123    are schematic drawings of the various multi-lumen configurations that were tested and described herein. The drawings show several different lumen configurations that were tested in real-world conditions to see which of them, if any, would prevent the blockage of the one or more therapeutic devices in the devices shown and described herein. One of the lumen variations commonly referred to as “Double Y” provided the benefit of preventing blockage of the therapeutic agent(s) while providing the desired amount of flexibility/bending moment rigidity, torsional rigidity, maximum flow area and ease of fabrication for the lumen shown and described. 
         FIG.  124    are drawings showing a sequence of multi-lumen tube deformations that were performed on the various multi-lumen tubes that were tested leading to the eventual folding of the tube in some cases. 
         FIG.  125    are 3D renderings of the dimensions and orientation of the folded tubes described herein. It is important to note that there are still some fluid paths on the outside of the crease and the tube is likely not completely blocked off from flow of the one or more therapeutic agents if there were I, H, or Y web cross pieces in the center cross-section of the tube. The webs will prevent a total collapse of the tube walls regardless of the neutral axis orientation. There will always be a fluid path, even when folded a complete 180° upon itself and for a 180°-fold it results in approximately a 325% strain of the material. The internal webbing structure causes increased strain in some parts of the tube but remains well below the material limits. 
         FIG.  126    is a chart showing the data and results of the various multi-lumen tubes that were tested to determine which performed better than the others. 
         FIG.  127    is a graph showing test results of the various multi-lumen tubes folded 180°. The test samples are labeled and placed on the graph according to the σ U  and ε U  properties. The results also indicate the number of lumens for the specific variations that were tested. Only one sample of a single lumen tube failed. The stars indicate some of the selected material that performed better than the other materials and configurations that were tested. 
         FIG.  128    is a graph showing test results of the various multi-lumen tubes that were tested by folding them 180° and twisting them 180°. The various multi-lumen tubes were labeled and placed on the graph according to the σ U  and ε U  properties. The tubes having four-lumen layout that were tested consistently passed. The star indicates one of the materials that performed better than the other materials that were selected and tested. 
         FIG.  129    is a graph showing microbiological results following quantification of soft and hard tissue samples as well as metal hardware in a sheep model of long bone open fracture and biofilm implant-related infection. Data show log 10  reductions of biofilm burden in the surgical site following one of several treatments. Specifically, moving from left to right: levofloxacin (L) and rifampin (R) were administered systemically (via oral administration) for 10 Days (10D) or 20 Days (20D); vancomycin (V) and tobramycin (T) were administered as direct antibiotic powders in addition to systemic L and R; STIM (Stimulan®) beads were loaded with V and T and administered locally in addition to systemic L and R; and the invention described herein (pouch or reservoir) was used to deliver V and T locally for 10 Days (10D) or 20 Days (20D) in addition to systemic L and R. Data indicated that sheep treated with the invention described herein reduced bacteria to a greater degree than those sheep that were not treated with the invention described herein. 
     
    
    
     Before any embodiments of the invention are explained in detail, it is to be understood that the invention is not limited in its application to the details of construction and the arrangement of components set forth in the following description or illustrated in the following drawings. The invention is capable of other embodiments and of being practiced or of being carried out in various ways. Also, it is to be understood that the phraseology and terminology used herein are for the purpose of description and should not be regarded as limiting. 
     DETAILED DESCRIPTION 
     The rate-controlling, rate-determining, or control release membrane broadly describe membranes which can be used with any of the embodiments of the invention, rather than a narrower term “semi-permeable membrane”. Nearly all membranes fit broadly into one of two classes: size exclusion membranes and affinity membranes. Size exclusion membranes are semi-permeable membranes which use physical pores to selectively pass solutes. These include: ultrafiltration membranes, microfiltration membranes, nanofiltration membranes, and dialysis membranes. In at least some embodiments, passage of solutes through these membranes is limited by the diffusion rate of the solute through the limited number of tortuous membrane pores. Affinity membranes, on the other hand, use molecular affinity interactions between the solute and the membrane components or functional groups to slow down the solute diffusion rate within the membrane. Affinity membranes include hydrogels, polymer systems, and functionalized polymer systems. If selected carefully, any number of these membranes or membrane types might be used in the device to achieve the target therapeutic delivery profile. 
       FIGS.  96 - 109    illustrate various embodiments and components of the device disclosed herein that allow for the subcutaneous delivery of one or more therapeutic agents (e.g., antibiotics, antimicrobials, anti-tumor agents, steroids, analgesics, anti-inflammatories, etc.) to a wound site, surgical site, or body cavity of a mammal in need thereof. In one embodiment, the reservoir is placed within a wound/surgical site to deliver an antimicrobial agent within the wound/surgical site to prevent or treat infections. Examples of such wounds/surgical sites include implants/implant sites, abscesses, chronically infected wounds, and other localized infections. In one example, the device shown and described herein may be placed within a wound/surgical site after an open fracture of a bone within one of a patient&#39;s extremities (e.g., reduced with a fixation plate) to provide high doses of antimicrobial agents over an extended period of time to prevent and treat biofilm infection. 
     With reference to  FIGS.  96 - 109   , the reservoir includes a port that has a stem. The port is in fluid communication with the reservoir such that a liquid antimicrobial agent may be introduced into the reservoir. 
     A rate-controlling membrane is disposed in the reservoir that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate and the reservoir selectively communicates antimicrobial agents with the surrounding environment. That is, the membrane facilitates a controlled release of the antimicrobial agents. The rate-controlling membrane disposed in the reservoir allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate. 
     In an embodiment, a device for delivering one or more therapeutic agents subcutaneously to a mammal in need thereof is provided. The device comprises (1) a port for receiving one or more therapeutic agents that is to be delivered to a mammal subcutaneously, the port having a stem and (2) a reservoir in fluid communication with the stem and comprised of at least two areas, the first area being comprised of a more rigid elastic material and the second area being comprised of a less rigid elastic material and (3) a rate-controlling porous or non-porous membrane disposed in the reservoir that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate. The reservoir is capable of being inserted subcutaneously into a mammal in need of the one or more therapeutic agents and filled or refilled to contain the therapeutic agents that are to be delivered to the mammal subcutaneously while at least the reservoir of the device is inserted subcutaneously in the mammal in need of one or more therapeutic agents. 
     At least the reservoir portion of the device is capable of being inserted subcutaneously into the body of the mammal in need of one or more therapeutic agents and the one or more therapeutic agents can be removed from the reservoir of the device or filled or refilled into the reservoir of the device without the device being removed from the body of the mammal in need of the one or more therapeutic agents. 
     In another embodiment, a device for delivering one or more therapeutic agents subcutaneously to a mammal in need thereof is provided. The device comprises (1) a port for receiving one or more therapeutic agents that is to be delivered to a mammal subcutaneously, the port having a stem; (2) a reservoir in fluid communication with the stem and comprised of a less compliant elastic material abutting a more compliant elastic material at least at the edges of the reservoir, the reservoir being capable of being inserted subcutaneously into a mammal in need of the one or more therapeutic agents and filled or refilled to contain the therapeutic agents that are to be delivered to the mammal in need thereof; and (3) a rate-controlling porous or non-porous membrane disposed in the reservoir that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate where at least the reservoir portion of the device is capable of being inserted subcutaneously into the body of the mammal in need of one or more therapeutic agents and the one or more therapeutic agents can be removed from the reservoir of the device or filled or refilled into the reservoir of the device without the device being removed from the body of the mammal in need of the one or more therapeutic agents. 
     In yet another embodiment, a device for delivering one or more therapeutic agents subcutaneously to a mammal in need thereof is provided. The device comprises (1) a port for receiving one or more therapeutic agents that is to be delivered to a mammal subcutaneously, the port having a stem; and (2) a reservoir that is comprised of a compliant elastic material and a rate-controlling membrane that allows the one or more therapeutic agents to be delivered to the mammal at a controlled rate, wherein the rate-controlling membrane is disposed in at least the center area of the reservoir and a compliant elastic material that is disposed in at least the end of the reservoir and rate-controlling membrane and the compliant elastic material being attached to each other to form at least a semi-continuous layer and the reservoir being capable of being inflated to contain one or more therapeutic agents and deflated to be substantially flat to remove from the mammal in need thereof or to receive or refill one or more therapeutic agents that are to be delivered to the mammal in need thereof, the reservoir being in fluid communication with the stem of the device. At least the reservoir portion of the device is capable of being inserted subcutaneously into the body of the mammal in need of one or more therapeutic agents and the one or more therapeutic agents can be removed from the reservoir of the device or filled or refilled into the reservoir of the device without the device being removed from the body of the mammal in need of the one or more therapeutic agents. 
     In at least one aspect of at least one embodiment, the reservoir is further comprised of a reinforcement or composite membrane located between the more rigid elastic material and the less rigid elastic material of the reservoir. 
     In at least one aspect of at least one embodiment, the reinforcement or composite membrane is cladded on both sides of the reinforcement or composite membrane with the more rigid elastic material or the less rigid elastic material and the more rigid material and the less rigid material overlap at least a portion of the reinforcement or composite membrane and create a heat seal with the reinforcement membrane in the reservoir. 
     In at least one aspect of at least one embodiment, the more rigid elastic material and the less rigid elastic material sufficiently overlap the reinforcement or composite membrane and create a heat sealed joint of the more rigid elastic material, the less rigid elastic material and the reinforcement or composite membrane at least at the outer edges of the reservoir. 
     In at least one aspect of at least one embodiment, at least a substantial portion of both ends of the reservoir are comprised of the more rigid elastic material and at least a substantial portion of the middle of the reservoir is comprised of the less rigid elastic material. 
     In at least one aspect of at least one embodiment, the device does not have a sleeve covering the reservoir, the reservoir is tapered from at least the reservoir to the stem and the largest diameter of the device when the reservoir does not contain any therapeutic agents is the diameter of the port or the stem allowing for easy removal of the device from the mammal in need of one or more therapeutic agents. 
     In at least one aspect of at least one embodiment, the device further comprises one or more tabs or holes near the edges or outside the reservoir that can used to fasten the device subcutaneously to the mammal in need of the one or more therapeutic agents. 
     In at least one aspect of at least one embodiment, the rate-controlling membrane has pores and the device further comprises one or more chemical stabilizers or plasticizers to keep the pores of the rate-controlling membrane open 
     In at least one aspect of at least one embodiment, the chemical stabilizer is, by way of example and not limitation, glycerol. 
     In yet another embodiment, the body has an end of the outer wall that is opposite the port heat sealed to at least partially enclose the reservoir. However, other methods of sealing the body in order to form an internal reservoir may be utilized. In another embodiment, the membrane is a semi-permeable size exclusion membrane with a molecular cut off of approximately 0.1-0.5 kDaltons (e.g., based on the molecular weights of cefepime, levofloxacin, fosfomycin, gentamicin, or rifampin). However, this and the other embodiments disclosed herein are merely exemplary and the molecular weight cut off of the semi-permeable membrane may be selected/customized in order to function with other therapeutic agents. For example, membranes in the nano- and ultra-filtration ranges with pore sizes from approximately 1-100 nm and molecular cutoffs from 1-14 kDa may be used. The semi-permeable membrane, in this example, is configured to enable delivery of the antimicrobial/therapeutic agent to the surrounding tissue according to an elution profile as defined by characteristics of the semi-permeable membrane. For example, the semi-permeable membrane may be configured to regulate molecular mobility and slow down the diffusion of the liquid antimicrobial agent through the semi-permeable membrane. In other examples, the membrane may create a steady-state elution profile or a variable rate elution profile, among others. In any case, the elution profile is set such that a high concentration of the antimicrobial agent is maintained within the surgical site for a predetermined amount of time to prevent local infection. In addition, the device can be modular such that rate of release (based on membrane or other material selection) can be rapid, given as a bolus dose, which may be beneficial to eradicate biofilms quickly, or throttled to deliver lower doses over a longer period of time, which may be of interest for an alternate indication such as pain management. Other factors that may be utilized to control elution profiles include the density of pores on the semi-permeable membrane and the thickness of the semi-permeable membrane. 
     In another embodiment, the stem is a non-permeable tube interconnecting the injection cap and the body. As such, the therapeutic agent is delivered from the injection cap to the body through the tube. In other embodiments, however, the stem may be at least partially constructed from a membrane (e.g., a similar membrane as described above) such that the therapeutic agent is delivered to a greater volume within the wound site. For example, in this configuration, the therapeutic agent would further be delivered directly to the areas surrounding the percutaneous incision to prevent surgical site infection. 
     In yet another embodiment, the stem may have holes in it that facilitate filling and emptying of the reservoir. 
     In yet another embodiment, the stem may be variable based on the application. For example, the length of the stem may be varied, the type of connection may be varied (e.g. needled or needleless connection), and/or can be made of various materials (e.g., permeable or non-permeable materials). In addition, the device may include multiple stems to, for example, facilitate the introduction of different therapeutic agents or to form an inlet to fill the reservoir and a separate outlet to empty the reservoir. 
     In yet another embodiment, the port and, more specifically, the stem, may extend through the reservoir of the body to provide structural support to the body, aid in maintaining a more uniform body profile (e.g., when the reservoir is empty), and to facilitate more even filling of the reservoir. In this embodiment, at least a portion of the stem (e.g., the portion lying within the reservoir) includes apertures, perforations, permeable membrane portions, or other means for fluid communication between the stem and the reservoir. 
     In yet another embodiment, the device further comprises a multi-lumen tube that is in fluid communication with at least the stem of the device. 
     In yet another embodiment, the reservoir is further comprised of a reinforcement or composite membrane located between the more rigid elastic material and the less rigid elastic material of the reservoir and the reinforcement or composite membrane is cladded on both sides of the reinforcement or composite membrane with the compliant elastic material and the reinforcement or composite membrane and the compliant elastic material overlap at least at portions of the reservoir and create a heat seal for the reservoir. 
     In yet another embodiment, the device further comprises a multi-lumen tube that is located at least at the stem of the device. 
     The therapeutic delivery device may vary in size. In one embodiment, the body is approximately 10 cm long. However, all aspects of the device may be tailored for specific uses and specific placements within the anatomy. For example, the size of the body or the length of the stem may be varied (e.g., made longer so the device may be placed deeper into tissue). In addition, an introducer device may be used to aid in deployment of the device in applications when a separate surgery is not being performed (e.g., in the case of treatment as opposed to prophylaxis) such as treatment of osteomyelitis or infections associated with previously implanted devices. 
     The therapeutic delivery device has been tested for in vitro efficacy in treating biofilms. In one test, the device was filled with an antibiotic solution and placed in test tubes that contained either 10 8  CFU/mL or well-established biofilms of MRSA. Fresh bacteria and solution were added to the test tubes daily for 10 days and quantified each day. With n=6 repeats, it was shown that planktonic and biofilm bacteria were eradicated completely. 
     Iteration PES 3  ( FIGS.  22  and  23   ) and PES 4  ( FIG.  106   ) of the therapeutic device have also been tested for in vivo efficacy in treating biofilm implant-related infection. To do so, a sheep model of recalcitrant long bone open fracture infection was used. As part of this model, biofilms are first grown on the surface of 2 cm×2 cm×1.8 mm titanium squares that simulate fracture fixation plates ( FIGS.  35  &amp;  36   ). Two plates are inserted into the holding arm of a modified CDC biofilm reactor ( FIGS.  37 - 39   ). The reactor unit is assembled and autoclaved and 500 ml of broth are added to the vessel ( FIGS.  40 - 43   ). The broth is inoculated with ˜7.5×10 7  CFU of bacteria. Biofilms are grown on the titanium plates over a period of 48 h: the reactor is placed on a hot plate at 34° C. for 24 h (batch phase growth for bacteria to divide and condition the environment) after which a 10% solution of broth is flowed through the reactor at a rate of 6.9 ml/min for an additional 24 h (the latter growth phase allows biofilms to mature on the metal surface). Following biofilm growth, simulated fracture fixation plates are aseptically removed. An n=2 of the plates are reserved and quantified by vortexing, sonicating, and plating on agar using a 10-fold dilution series to determine the baseline of CFU/plate. The remaining n=6 plates (each reactor holds a total of n=8 simulated fracture fixation plates; see  FIG.  39   ) are transported to an operating room for implantation in the right tibia of sheep. 
     Immediately prior to surgery, the proximal medial aspect of a sheep&#39;s right tibia is blasted with an air impact device (AID; see  FIGS.  52 - 64  and  94    for representative procedures of AID setup and outputs). The purpose of this blast is to create soft tissue trauma, which is consistent with a Type IIIB open fracture ( FIGS.  26  &amp;  27   ). A Type IIIB open fracture is defined as having periosteal stripping, soft tissue trauma, and massive contamination. Following the AID blast, a sheep is prepped for surgery. 
     Surgical preparation and procedure are as follows: briefly, after the skin is prepped and sterile coverings placed ( FIGS.  44 - 51   ), an incision is made from the tibial tuberosity and down the shin, i.e., the front-most region of the tibia ( FIGS.  66  &amp;  67   ). The incision length is approximately 5-7 cm. The fascia is moved/removed and a ˜2×5 cm area of periosteum is removed from the proximal medial aspect of the tibia using a periosteal elevator ( FIG.  68   ). Sterile simulated fracture fixation plates and sterile cortical bone screws are used to template the placement of the plates/screws ( FIG.  69   ). Once templated, an osteotomized fracture is created using a hand-held bone saw ( FIG.  70   ). The osteotomized fracture has a depth of ˜1-2 mm. Biofilm-ridden plates are then secured to the proximal medial aspect of the sheep tibia ( FIG.  25   ). Sites are then ready to be sutured closed, or to receive a treatment ( FIGS.  71 - 75   ). 
     In the case of sheep that receive a therapeutic device, it is placed over the simulated fracture fixation plates and the surgical site closed (see  FIGS.  72 - 75   ). The therapeutic device is filled and refilled daily with antibiotic solution and remains in place for 10 or 20 days, after which time it is removed (see  FIG.  28   ). The same sheep model is also used to test the efficacy of clinical standards of care including systemic antibiotic therapy, antibiotic-loaded Stimulan beads, or antibiotic powders that are sprinkled into a wound site. 
     To date, the therapeutic device has been tested in n=63 sheep with a variety of antibiotic therapies (see Groups 2, 3, 4, 8, 9, 10, 11, 13, and 14 in Table 1, See  FIG.  119   ) and compared to multiple standards of care including: gentamicin-loaded Stimulan® beads (see  FIG.  76   ), cefazolin and rifampin systemic therapy, cefepime and rifampin systemic therapy, levofloxacin and rifampin systemic therapy, vancomycin systemic therapy, or vancomycin and tobramycin powders sprinkled directly into wound sites (see Groups 5, 6, 7, 12, 15 and 16 in Table 1, See  FIG.  119   ). 
     After treatment is completed in any given group, sheep are euthanized, legs are photographed, tissue samples and hardware are quantified microbiologically to determine the CFU/sample, and additional samples are analyzed by microCT and histologically to assess bone response (see  FIGS.  29 - 34  and  76 - 87   ). 
     Data indicate that the therapeutic device reduces biofilms by a minimum of 10 and up to 10,000 times more than clinical standards (see  FIGS.  30 ,  31 ,  111 , and  112   ). Furthermore, microCT and histological analyses show that sites treated with the therapeutic device have significantly less signs of infection than any other treatment group (see  FIGS.  32 - 34  and  111 - 112   ). 
     During animal studies described herein, it was determined that the devices disclosed herein, especially the reservoir and the tube of the device, may twist, kink or fold on itself or against a portion of the patients body, often restricting or stopping the flow of the one or more therapeutic agents to the reservoir of the device and patient, causing the device to not function properly or as intended. Often times, the disruption in the flow of the one or more therapeutic agents was at or near the neck area of the device where the one or more therapeutic agents enter into the reservoir of the device. Numerous experiments using the devices disclosed herein demonstrated that during use in a patient, the fluid pathway of the one of more therapeutic agents, was constricted, often at or near the neck area of the device, even though there was no visible or otherwise discernible change to the condition of any component of the therapeutic device, including but not limited to, the tubing near the neck or reservoir of the device. Constriction and/forces to the device can hinder the transfer of therapeutic agents in and out of the reservoir of the device and to the patient it is being administered to. Accordingly, various styles, shapes and configurations of different tubes having various different characteristics and shapes were tested to determine which if any of them would allow the devices disclosed herein to function as intended and avoid the flow of the one or more therapeutic agents in the device from being constricted anywhere in the device. Based on the results disclosed herein, a single lumen tube through the neck of the pouch was found to be an unsuitable remedy to the problem. Evaluations were conducted of many alternate materials and various multi-lumen configurations, and it was found that tube having more than two lumens performed better and four-lumen tubes consistently remain unblocked even though the devices underwent severe deformations and forces that were well beyond what one would expect the devices of the present disclosure to encounter in normal applications using the devices of the present disclosure. 
     A variety of available materials with various lumen configurations and layout patterns were obtained and tested. The lumen and tube characteristics were selected based on the material characteristics of ultimate stress (σ U ) and ultimate Strain (ε U ). These were tested by attaching each, individually, to a 25-cc syringe filled with water and dispensing the fluid through the tube to gage ease of fluid flow. Next the tubes were folded 180° onto themselves and the syringe dispensing repeated. If water could transfer through the tube without a moderate increase in applied pressure it was recorded as a success (yes). If fluid did not flow or required a significant increase in applied pressure it was recorded as a failure (no). This testing was repeated on the tubes with the addition of a 180° twist applied prior to the 180°-fold over and results recorded.  FIGS.  126 - 128    show and describe the materials and different lumen tested, their characteristic, the number of lumens, a simplified sketch of the lumen layout, and the syringe dispense results for a 180° bend (fold) and the combination of 180° twist and fold tests that were performed on the various different lumen shown and described herein. 
     As shown by the results in  FIGS.  126 - 128   , all of the multi-lumen samples passed the 180°-Fold test. Only one single lumen sample failed. Refer to  FIGS.  126 - 128    for the data and graphical representation of the results of the test covering the multi-lumen tube. As the results demonstrate, several multi-lumen configurations passed the 180°-Twist combined with a 180°-Fold test. Only the four-lumen configurations consistently passed. 
     The results of our test indicated that a flexible single lumen tube under bending or twisting loads can deform to the point it no longer allows fluid to transfer through the tube. By modifying the cross-section of the tube with a support structure it can be made to withstand severe deformation and continue to function as intended to allow the unrestricted flow of the one or more therapeutic agents. Multi-lumen tubes, particularly configured to create an internal web and flange design (H-beam) will not fail. By selecting a material that has a low modulus of elasticity and high strain limit, the tube will stretch yet not tear as the cross members prevent the tube walls from closing the fluid path. Certain cross-section design shown in the results of  FIGS.  126 - 128    demonstrate that certain multi-lumen tubes were able withstand any loading orientation regardless of the neutral axis location. Those multi-lumen tubes can be used to obtain a non-closable fluid pathway for the devices disclosed herein. 
     Although the invention has been described in detail with reference to certain preferred embodiments, variations and modifications exist within the scope and spirit of one or more independent aspects of the invention as described.