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Background  This study aimed to explore the in vitro antibacterial activity of the bioglass BAG S53P4 against multi-resistant microorganisms commonly involved in osteomyelitis and to evaluate its use in surgical adjunctive treatment of osteomyelitis.    Methods   In vitro  antibacterial activity of BAG-S53P4 against methicillin resistant  Staphylococcus aureus  and  Staphylococcus epidermidis, Pseudomonas aeruginosa  and  Acinetobacter baumannii  isolates was evaluated by means of time kill curves, with colony counts performed after 24, 48 and 72 hours of incubation.  In vivo  evaluation was performed by prospectively studying a cohort of 27 patients with a clinically and radiologically diagnosed osteomyelitis of the long bones in an observational study. Endpoints were the absence of infection recurrence/persistence at follow-up, no need for further surgery whenever during follow-up and absence of local or systemic side effects connected with the BAG use.    Results   In vitro  tests regarding the antibacterial activity of BAG S53P4 showed a marked bactericidal activity after 24 hrs against all the tested species. This activity continued in the subsequent 24 hrs and no growth was observed for all strains after 72 hrs. Results of the clinical study evidenced no signs of infection in 24 patients (88.9%) at the follow-up, while 2 subjects showed infection recurrence at 6 months from index operation and one more needed further surgical procedures. BAG-S53P4 was generally well tolerated.    Conclusions  The  in vitro  and  in vivo  findings reinforce previous observations on the efficacy of BAG-S53P4 for the treatment of chronic osteomyelitis of the long bones, also in the presence of multi-resistant strains and in immunocompromised hosts, without relevant side effects and without the need for locally adding antibiotics.    Trial registration  Deutschen Register Klinischer Studien (DRKS) unique identifier:  DRKS00005332 .

Bioactive glass BAG-S53P4 for the adjunctive treatment of chronic osteomyelitis of the long bones: an in vitroand prospective clinical study