- Mucosal Tissue Dermatology 2002;204(suppl 1):86-91 New Aspects of the Tolerance of the Antiseptic Povidone-lodine in Different ex viv0 Models A. Kramer H. Below W. Behrens-Baumann G. Müller P. Rudolph K. Reimer Institute of Hygiene and Environmental Medicine, Ernst Moritz Arndt University, Greifswald, Germany Key Words Povidone-iodine lrritating potency Tissue toxicity Eye resorption Nasal tolerance Cartilage tolerance M e thici IIin-resista nt Staphylococcus aureus - Objective - In the German-speaking countries, the following fields of application have established themselves for povidoneiodine (PVP-I): hand disinfection in cases of intolerance of alcohols, antisepsis of the skin, antisepsis of the oral cavity with the Special indications of prevention of mucoAbstract lnvestigating n e w possibilities for the application of 1 YO sitis and application prior to tooth extraction in the sulcus (v/v) iodophors, povidone-iodine (PVP-I) was better toler- gingivae to prevent bacteremia, antisepsis of the Vagina ated in the HET-CAM or explant test than 1% (w/v) silver and orificium urethrae, wound antisepsis except bums nitrate or tetracycline. After application t o the eye, at after transplantation, antiseptic irrigation of body cavities least 2.6% o f used iodine were adsorbed. Therefore PVP- except Peritoneum and intraoperative application to the I is more effective than silver nitrate or erythromycin, bowel before surgical anastomosis [I]. Given the wide meaning a possible alternative for the prevention o f oph- therapeutic scope of the iodophors, their clinical efficacy, thalmia neonatorum. PVP-I is more active against methi- their high therapeutic range (table I), their good tolerance cillin-resistant Staphylococcus aureus (MRSA) in a hu- for wounds [2] and their inhibition of bacterial mediators m a n ex viv0 Skin model, which results in a complete of inflammation as well as of mediators of the host cells eradication of S. aureus in the nasal cavity o f volunteers [3], we carried out supplementary studies on the field of after 2 daily applications and will be better tolerated by application of the eye and examined the suitability of human nasal cilial epithelium than chlorhexidine. Having iodophors for the biotopes nasal cavity and cartilage the Same clinical tolerance as mupirocin, PVP-I is a useful tissue. alternative for the antiseptic therapy of germ Carriers o f MRSA. The synthesis o f proteoglycans in articular cartilage of bovine sesamoid bones was increased after application of 5% (v/v) PVP-I without any increase in catabolism revealing possibilities for the use as irrigation Solution in the joint. Copyright02002 S. Karger AG, Basel KARG ER Fax+4161306 1234 E-Mail [email protected] www. karger.com 02002 S. Karger AG, Basel 1018-8665/02/2045-0086$18.50/0 Accessible online at: www. karger. com/joumals/drm Prof. Dr. Axel Kramer Institute of Hygiene and Environmental Medicine Emst Moritz Amdt University Greifswald, Hainstrasse 26 D- 17487 Greifswald (Germany) Tel. +49 3834 83 46 10, Fax +49 3834 83 46 00, E-Mail [email protected] Studies to Define the Ways of Using PVP-I as Prophylaxisagainst Ophthalmia neonatorum HET-CAM (Irritating Potency) Method. The study was carried out in the classical manner [4] by way of an objective quantification of the response. For this purpose, the reaction at the chorioallantoic membrane was recorded with an S-VHS-C video camera (Panasonic NV-S 70 E) and the image evaluated by morphometry using the image analyzer Kontron IBAS 2000. In effecting a comparison with the stereomicroscopic assessment [4], an area of < 128% (median) could be ascertained as tolerable range for the application of antiseptics to the eye. Results und Discussion. With an exposure time of 30 s, 1Oo/ PVP-I meets the requirements for tolerance of an eye Table 1. Calculated therapeutic range as quotient of oral LD50 for rats (mmol/kg) and minimal microbicidal concentration at 5 min exposure Agent Quotient S.aureus Chlorhexidine Octenidine Benzalkonium Chloride PVP-I Table 2. Growth rate (O/O) 0.9 3.2 8 500 P.aeruginosa 0.9 3.2 8 1,000 in explant test with prepared peritoneal tissue Agent Goncentration Exposure min Growth rate, YO (control = 100%) PVP-I 10% 1 63 30 1 40 Tetracycline 30 mg Table 3. Iodine resorption after conjunctival and periorbital application of PVP-I on one eye 0 PVP-I concentration, % 10 1.5 Tolerance of PVP-I antiseptic with a median of 128%, whereas 1% AgN03 induces complete lysis and hence fails to meet the requirements of tolerance. Explant Test (Tissue Tolerability) Method. 1 mm x 1 mm pieces of Peritoneum of neonatal rats (inbreeding Lew 1 A) were exposed to the agents, thereafter washed with Ringer’s Solution and cultivated in 24-well culture plates for 10 days [2]. Result und Discussion. Tetracycline proved to be highly toxic to tissue, as compared to PVP (table 2), although the latter was undiluted (i.e. 10% PVP-I). Resorption by Eye Antisepsis Method. Prior to the extraction of the lens and subsequent implantation of a posterior chamber lens, antisepsis of the conjunctiva and the periorbital skin was carried out, each by way of a swab freshly impregnated with PVPI Solution (calculated average application 0.4-0.8 ml). For the antisepsis of the conjunctiva, the PVP-I Solution was applied on an Ethikeil swab, to wipe the conjunctiva for about 10 s. Prior to surgery and after 24 h, the iodide in the Urine was determined by the modified Wawschinek method [5]. Creatinine was analyzed by the Jaffk method using system packs from Boehringer Mannheim and a Hitachi 7 17 device. Results und Discussion. The elevated excretion of iodine is clearly below the theoretic maximum of full resorption (table 3). In no case was any iodine contamination (for Germany, quotient > 300) ascertained; in fact, the values were within the desirable range of the WHO classification [61. 2.5% PVP-I on the eye causes severe burning so that we recommend I .25% PVP-I on the grounds of our findings on tolerance and efficacy. With this concentration, Neisseria gonorrhoeae is reduced >5 log within 15 s, Staphylococcus aureus, Escherichia coli and Pseudomonas aeruginosa within 30 s and adenoviruses type 2 are inactivated within 5 min by >4 log [7]. Chlamydia trachomatis strain D is even destroyed by 0.1 13% PVP-I within 30 s by >5 log [7]. By contrast, AgN03 and erythromycin are Renal iodine excretion 24 h after surgery, pg I-/g creatinine resorbed I% calculated increase determined increase total excretion 5,000 750 70 20 160 1.4 130 2.6 Dermatology 2002;204(suppl 1):86-9 1 87 4.5 4.0 3.5 1 After 15 s 0After 1 min [7 After 10 min 3.36 3.0 0 $ 2.0 Chlorhexidine 1.5% PVP-I 10% 2-Propan01 70% Fig. 1. Efficacy of PVP-I against MRSA on human ex viv0 skin. without effect against the chlamydial stem in a period of 15 min (reduction 0.9 and 1.7 log, respectively) [ 81. Conclusion Hence I .25% PVP-I for prophylaxis against ophthalmia neonatorum is a clearly more effective and efficient alternative to local antibiotics and likewise silver nitrate. For the Same reasons, 1.25% PVP-I is the treatment of choice for preoperative eye antisepsis and 0.5 O/o PVP-I with 5 min exposure for the prevention of infection in corneal transplants [9]. Nasal Cavity Task For two reasons, there is a need for an alternative to mupirocin, currently used as Standard for MRSA Carriers in nasal antisepsis: because of the effect that is only microbiostatic, a failUre of therapy in up to 27% is observed [ 101; for about 10 years, an increase has been ascertained in methicillin-resistant S. aureus (MRSA) strains resistant to mupirocin [ 113. Contrary to mupirocin, PVP-I has a microbicidal effect without the risk of developing resistance [ 121. Prior to testing PVP-I for tolerance in the nasociliary epithelium, we checked its efficacy against MRSA in an ex viv0 model on amputated skin, as requirement for the application of PVP-I to eliminate MRSA Carriers. 88 Dermatology 2002;204(suppl 1):86-9 1 Antiseptic Efficacy of PVP-I against MRSA O n Human ex viv0 Skin Method. Testing was carried out on skin areas from freshly amputated Skin of the thigh carried out for surgical indications. Othenvise the test was carried out in the Same way as the testing of skin antiseptics in volunteer trials [ 131. Nevertheless, instead of contaminating the resident flora as marker for efficacy, the amputated Skin was contaminated with an MRSA Patient strain [ 108CFU/ml]. Results und Discussion. 10% PVP-I is significantly more effective than chlorhexidine and achieves practically the Same effect as 2-propanol (fig. 1). Since PVP-I is also highly effective on oral and genital mucosa [ 14, 151, it would seem to be promising, in view of the evidence of tolerance, for the antisepsis of nasal cavities. Tolerancefor the Ciliated Epithelium Cells of the Nasal Mucosa Method. Ciliated epithelium was taken out from the concha nasalis inferior with a bronchoscopic brush without application of local anesthetics. The brushes were washed out in 100 p1 DMEM at 37 "C. The activity of the cilia was measured with a photocell under a Special microscope. The Signals were analyzed with the PC program Turbolab [ 161. Results und Discussion. No suppression of ciliary activity was caused by 1.25% PVP-I. By contrast, 0.2% chlorhexidine induced inhibition so that the activity of the cilia was reduced to below the range of the physiological minimum (fig. 2). Since chlorhexidine - despite the lack of a tolerance test for ciliated epithelium - was used, albeit with unsatisKramer/Below/Behrens-Baumann/Miiller/ Rudolph/Reimer .. PV?4 2.5% PVP-I 1.25% i I I 1 I 0 20.0 40.0 60.0 l I I Ringer's solution 0 100.0 l20.0 Fig. 2. Frequency (median) of cilia (100 celldagent). Sesamoid bones from metacarpophalangeal joints of adult animals were used [20]. Medial sesamoid bones were dissected within 2-4 h after slaughter under aseptic conditions. The cartilage from the medial sesamoid bones of a particular animal is uniform with respect to glycosaminoglycan synthesis, glycosaminoglycan content and proteoglycan composition. The sesamoid bones were rinsed with 10 ml of sterile Ringer's solution for 10 min, incubated, respectively, in 10 ml of sterile Ringer's solution (control), 10°/o PVP-I, 1O!o PVP-I, 0.1 Q!o Octenisept@ and 0.0 1O/o Octenisept in Ringer's Solution at 37 "C for 2 h in a humidified atmo- sphere with 5% CO2 and subsequently rinsed again for 5 x 5 min in 10 ml Ringer's Solution in each case. Thereafter sesamoid bones were incubated in 10 ml Ham's F- 12 medium supplemented with antibiotics for 7 days at 37 "C in a humidified atmosphere with 5% CO2 changing the medium daily. On day 6, 1.85 MBq 35S-sulfatewas added to the medium to labe1 newly synthesized proteoglycans. After the labeling experiments, nonincorporated 35S-sulfatewas largely removed from the cartilage matrix by way of a 5-fold washing process of the sesamoid bones; 10 ml Ringer's Solution was used for each wash for 5 min. Cartilage plugs of 2.8 mm in diameter were carefully removed and extracted thereafter in a stepwise manner [21, 221. The first extraction was effected in 0.5 ml of 0.15 M Na-acetate buffer, pH 6.8, in the presence of protease inhibitors, by shaking 1.5-ml Eppendorf vials at 4 " C for 24 h (iso-osmolar conditions). The second extraction of cartilage plugs was carried out in 0.5 ml of 4 M guanidinium hydrochloride, 50 mM Na-acetate buffer, pH 5.8, containing Protease inhibitors for 2-3 days at room temperature (dissociative conditions). The doubly preextracted plug was digested in 0.5 ml tris(hydroxymethy1)aminomethane hydrochloride buffer, pH 8.0, containing 1 mg pronase per milliter for 24 h at 56 "C (remaining proteoglycans). The culture media of sesamoid bones and extractsl digests of cartilage plugs were used for the quantitative determination of sulfated glycosaminoglycans by way of the dimethylmethylene blue method [23]. Extracts and digests of cartilage plugs were used for the estimation of 3%-sulfate incorporation into cartilage matrix by way of Tolerance of PVP-I Dermatology 2002;204(suppl 1):86-9 1 factory results on the MRSA colonization [ 171, we used PVP-I on volunteers with S. aureus colonization. After twice daily application for 3 days, total eradication was achieved [ 181. Hence PVP-I is a more effective alternative to mupirocin, with the Same clinical tolerance as mupirocin [ 181. Cartilage Task After Kallenberger et al. [ 191had furnished evidence of inhibited growth with fetal cartilage and the release of glycosaminoglycan in the medium, iodophors were deemed to be unsuitable for use on the joint. Since, however, this model does not relate to the status of the adult cartilage, the issue should be taken up again with a sensitive relevant in vitro test. Method 89 Table 4. Metabolism marker of cartilage after 2 h exposure with test substances and 7 days cultivation in vitro Agent Concentration Differences to the control (Ringer’s solution) proteoglycans p g h g wet weight cartilage PVP-I Octenidine 10 1 0.1 0.0 1 COMP pg/mg wet weiht cartilage -2.13 +1.79 - 16.44* - 1.69 +2.62 +0.25 -1.35 + 1.02 * p < 0.01. COMP = Cartilage oligomeric matrix protein. Table 5. Incorporation rate of 35S-sulfate into the proteoglycan fraction Agent PVP-I Octenidine Differences of proteoglycansto the control (Ringer’s Solution) conc. 96 iso. cpmlmg diss. cpmlmg remaining cpdmg total cpmlmg 10 1 0.1 0.0 1 +53 -6 -25 -35 +691 +1,013 - 1,432 -1,167 -384 -417 - 1,950 - 1,970 + 307* +597* -3,381* -3,137* * p < 0.001. conc. = Concentration; iso. = extraction under iso-osmolarconditions; diss. = extraction under dissociative conditions. scintillation ß-counting. In the culture media of the sesamoid bones and in extraction solutions of the cartilage plugs, the content of the cartilage oligomeric matrix protein was determined by way of a quantitative ELISA method [24]. Results und Discussion PVP-I as well as octenidine did not induce catabolic metabolism with an increased loss of proteoglycans (table 4). Under the influence of PVP-I, the incorporation rate of 35S-sulfatewas increased by 10 and 20%, respectively (table 5). Until now, this phenomenon, the Stimulation of proteoglycan synthesis, has not been reported in the literature for antimicrobials. By contrast, corresponding to the eluated amounts of proteoglycan and cartilage oligomeric matrix protein, octenidine nearly completely inhibits the synthesis of proteoglycan, depending on the concentration of octenidine (table 5). In the meantime, the tolerability of 0.5% PVP-I is confirmed in the Synovia and hyaline cartilage of the rabbit joint [25]. 90 Dermatology 2002;204(suppl 1):86-9 1 Since, in contrast to the comparatively tested mucosal antiseptics of chlorhexidine, polyhexanide, hexetidine and cetylpyridinium Chloride, PVP-I loses none of its efficacy in vitro from 0.25% chondroitin Sulfate [26], the requirements for efficacy in the joint are given. Conclusion In evaluating the test results and in light of the status of knowledge on PVP-I, the following new application fields can be Seen for iodophors: the prevention of ophthalmia neonatorum, already empirically successful in Kenya [27], the antisepsis of nasal cavities, especially with MRSA colonization, and the antisepsis of joints. Kramer/Below/Behrens-Baumann/Miiller/ Rudolph/Reimer References 1 Kramer A: Antiseptika und Händedesinfektionsmittel; in Korting HC, Sterry W (eds): Therapeutische Verfahren in der Dermatologie. Berlin, Blackwell, 2001, pp 273-294. 2 Kramer A, Adrian V, Rudolph P, Wurster S, Lippert H: Explantationstest mit Haut und Peritoneum der neonatalen Ratte als Voraussagetest zur Verträglichkeit lokaler Antiinfektiva fur Wunden und Körperhöhlen. Chirurg 1998; 69:840-845. 3 König B, Reimer K, Fleischer W, König W: Effects of betaisodona On Parameters of host defense. Dermatology 1997;195(suppl 2):242248. 4 Kramer A, Adrian V, Rudolph P, Kühl H: Invitro-Prüfung der Verträglichkeit ausgewählter antiseptischer Wirkstoffe bzw. Präparate; in Kramer A, Wendt M, Wemer H-P (eds): Möglichkeiten und Perspektiven der klinischen Antiseptik. Wiesbaden, mhp, 1995, pp 41-48. 5 Zöllner H, Kramer A, Hampel R: IodmangelScreening. GIT Labormed 1995;18:330-332. 6 WHO, UNICEF, ICCIDD: Indicators for Assessing Iodine Deficiency Disorders and Their Control through Salt Iodization (unpubl document WHO/NUT/94.6). Geneva, WHO/NUT, 1994, pp 28-36. 7 Wutzler P, Sauerbrei A, Klöcking R, Burkhardt J, Schacke M, Thust R, Fleischer W, Reimer K: Virucidal and chlamydicidal activities of eye drops with povidone-iodine liposome complex. Ophthalmic Res 2000;32:118-125. 8 Kramer A, Aspöck C, Below H, Behrens-Baumann W, Fusch C, Reimer K, Rudolph P, Wutzler P: Prevention of ophthalmia neonatorum; in Kramer A, Behrens-Baumann W (eds): Antiseptic Prophylaxis and Therapy of Ocular Infections. Basel, Karger, in press. 9 Wilhelm F, Jendral G, Bredehom T, Duncker G, Wilhelms D, Kramer A: Antimikrobielle Dekontamination von Homhautspendermaterial. Ophthalmologe 2000;98: 143-1 46. Tolerance of PVP-I 10 Bommer J, Vergetis W, Hingst V, Lenz W: Elimination of Stuphylococcus uureus in dialysis patients by pseudomonic acid nasal ointment. Am SOCNephrol NY, November 17-20, 1991. I 1 Layton MC, Patterson JD: Mupirocin resistance among consecutive isolates of oxacillinresistant and borderline oxacillin-resistant Stuphylococcus uureus at a university hospital. Antimicrob Agents Chemother 1994;38:16641667. 12 Reimer K, Schreier H, Erdos G, König B, König W, Fleischer W: Molecular effects of a microbicidal substance on relevant microorganisms: Electron-microscopic and biochemical study on povidone-iodine. Zentralbl Hyg Umweltmed 1997/98;200:423-434. 13 Christiansen B, Eggers H-J, Exner M, Gundermann K-0, Heeg P, Hingst V, Höffler U, Krämer J, Martiny H, Rüden H, Schliesser T, Schubert R, Sonntag H-G, Spicher G, Steinmann J, Thofern E, Thraenhart 0, Wemer HP: Richtlinie fur die Prüfung und Bewertung von Hautdesinfektionsmitteln. Zentralbl Hyg Umweltmed 1991;192:99-103. 14 Pitten F-A, Kramer A: Antimicrobial efficacy of antiseptic mouthrinse solutions. Eur J Clin Pharmacol 1999;55:95-100. 15 Rudolph P, Fritze F, Reimer K, Klebingat K-J, Kramer A: Efficacy and local tolerability of povidone iodine (Betaisodona@)and octenidine hydrochloride Solution (Octenisept@) for the antiseptic preparation of the orificium urethrae. Infection 1999;27:108-1 13. 16 Rudolph P, Reimer K, Mlynski G, Reese M, Kramer A: Nose compatibility of local antiinfectives - An in-vitro model using ciliated epithelium. Hyg Med 2000;25:500-503. 17 Illiams JD, Waltho CA, Ayliffe GAJ, Lowburry GJL: Trials of five antibacterial creams in the control of nasal carriage of Stuphylococcus uureus: Lancet 1967;ii:390-392. 18 Kramer A, Glück U, Heeg P, Werner H-P: Antiseptik; in Kramer A, Heeg P, Botzenhart K (eds): Krankenhaus- und Praxishygiene. München, Fischer, 2001, pp 252-268. 19 Kallenberger A, Kallenberger C, Willenegger H: Experimental investigations on tissue compatibility of antiseptics. Hyg Med 1991;16: 383-395. 20 Korver GHV, Van de Stadt RL, Van Kampen GPJ, Kiljan E, Van der Korst J K Bovine sesamoid bones: A culture system for anatomically intact articular cartilage. In Vitro Ce11 Dev Biol 1989;25:1099-1 106. 21 Brand HS, Korver GHV, van de Stadt RJ, van Kampen GPJ: Studies on the extraction of different proteoglycan populations in bovine articular cartilage. Biol Chem Hoppe-Seyler 1990;371:58 1-587. 22 Müller G, Hanschke M: In vitro model of characterizing the effects of compressive loading on proteoglycans in anatomically intact articular cartilage. Int J Sports Med 1997;18:438-448. 23 Müller G, Hanschke M: Quantitative and qualitative analyses of proteoglycans in cartilage extracts by precipitation with 1.9-dimethylmethylene blue. Connect Tissue Res 1996;33: 243-248. 24 Müller G, Michel A, Altenburg E : COMP (cartilage oligomeric matrix protein) is synthesized in ligament, tendon meniscus, and articular cartilage. Connect Tissue Res 1998;39:233244. 25 Ganzer D, Völker L, Follak N, Wolf E, Granzow H : Reaktion des hyalinen Gelenkknorpels und der Synovialis auf eine intraartikuläre Instillation von verschiedenen Antiinfektiva. Arthroskopie 2001; 14:31-44. 26 Müller G, Kramer A: In vitro action of a combination of selected antimicrobial agents and chondroitin Sulfate. Chem Biol Interact 2000 124177-85. 27 Isenberg SJ, Apt L, Wood M: A controlled trial of povidone-iodine as prophylaxis against ophthalmia neonatorum. N Eng1 J Med 1995;332: 562-566. Dermatology 2002;204(suppl 1):86-9 1 91
© Copyright 2024