Rev. Bras. Anestesiol. vol.64 número2

RevBrasAnestesiol.2014;64(2):105---108

REVISTA

BRASILEIRA

DE

ANESTESIOLOGIA

www.sba.com.br

SCIENTIFIC

ARTICLE

In

vitro

evaluation

of

antimicrobial

features

of

sugammadex

夽

Volkan

Hanci

,

Ahmet

Vural

,

Sevgi

Yılmaz

Hanci

,

Hasan

Ali

Kiraz

,

Dilek

Ömür

,

Ahmet

Ünver

a_{DepartmentofAnesthesiologyandReanimation,MedicalFacultyofDokuzEylülUniversity, ˙Izmir,Turkey} b_{DepartmentofMicrobiology,MedicalFacultyofC¸anakkaleOnsekizMartUniversity,C¸anakkale,Turkey} c_{ClinicofMicrobiology,C¸anakkaleStateHospital,C¸anakkale,Turkey}

d_{DepartmentofAnesthesiologyandReanimation,MedicalFacultyofC¸anakkaleOnsekizMartUniversity,C¸anakkale,Turkey}

Received10September2012;accepted10June2013 Availableonline11October2013

KEYWORDS

Sugammadex; Antimicrobialeffect;

S.aureus;

E.fecalis;

E.coli;

P.aeruginosa

Abstract

Background: Drugs administered byintravenous routesmay be contaminatedduring several

stages ofproductionorpreparation. Sugammadex isamodified gammacyclodextrin.While

researchintotheantibacterial effectsofvarietiesofcyclodextrin isavailable,thereareno studiesfocusingontheantibacterialeffectsofsugammadex.Thisstudyinvestigatestheinvitro antimicrobialactivityofsugammadex.

Materialsandmethods: The invitroantimicrobial activityofsugammadex was investigated

using thebroth microdilutionmethod. The pH ofthetest solution was determinedusing a

pHmeter.ThetestmicroorganismsincludedStaphylococcusaureusATCC29213,Enterococcus

fecalisATCC29212,EscherichiacoliATCC25922andPseudomonasaeruginosaATCC27853.In

the secondphaseofthestudy 100mg/mLsugammadex(50␮g)was contaminatedwithtest

microorganisms(50␮g),includingS.aureusATCC29213,E.fecalisATCC29212,E.coliATCC

25922andP.aeruginosaATCC27853,lefttoincubatefor24handthenthebacterialproduction

insugammadexwasevaluated.

Results:ThepHofthetestsolutionsrangedbetween7.25and6.97.Usingthemicrodilution method,sugammadexhadnoantibacterialeffectonS.aureus,E.fecalis,E.coliandP. aerugin-osaatanyconcentration.Inthesecondphaseofthestudybacterialproductionwasobserved after24hin100mg/mLsugammadexcontaminatedwiththetestmicroorganismsS.aureus,E. fecalis,E.coliandP.aeruginosa.

Conclusions: Sugammadexhadnoantimicrobialeffectonthetestmicroorganisms,S.aureus,E. fecalis,E.coliandP.aeruginosa.Careshouldbetakenthatsterileconditionsaremaintainedin

thepreparationofsugammadex;thatthesamesugammadexpreparationnotbeusedformore

thanonepatient;andthatstorageconditionsareadheredtoaftersugammadexisputintothe injector.

© 2013SociedadeBrasileirade Anestesiologia.Publishedby ElsevierEditoraLtda.Allrights reserved.

夽 _{Apartofthismanuscriptwaspresentedasaposterpresentationatthe46thAnnualTARKCongress,Cyprus,7---11November2012.}

∗_{Correspondingauthor.}

E-mail:vhanci@gmail.com(V.Hanci).

0104-0014/$–seefrontmatter©2013SociedadeBrasileiradeAnestesiologia.PublishedbyElsevierEditoraLtda.Allrightsreserved.

106 V.Hancietal.

Introduction

Some anesthetic agents such as propofol are known to

support the growth of microorganisms,1---5 _{while other}

anesthetic agents such as morphine sulphate, thiopental

sodium, fentanyl citrate, dexmedetomidine and

midazo-laminhibitmicrobial growth.3---7 _{Anestheticagentsmaybe}

contaminated by microorganisms at various stages during

preparationforuse.2_{Itisimportantforthisreasonthatthe}

antibacterialproperties,ortheabilitytoenhancebacterial

production,ofanestheticagentsinacontaminatedsituation

beknown.8

Sugammadex is a modified gamma cyclodextrin.9---11

Cyclodextrins are water soluble cyclic oligosaccharides

with a lipophilic core. Sugammadex has quickly found a

placeinclinicaluseasaselectiveneuromuscularblockade

reverser.9---11 _{Sugammadex quickly encapsulates steroidal}

neuromuscularblockers, increasing the amount of

encap-sulated steroidal neuromuscular blockers in plasma and

separating the blockers from the nicotinic acetylcholine

receptors.9---11

Cyclodextrins are molecules that are often used in

the food and pharmaceutical industries. They are

com-monlyusedtoconvertlipophilicmedicationstohydrophilic

forms.Otherapplicationsofcyclodextrinsincludethefield

of microbiology. Some cyclodextrins, such as

dimethyl-b-cyclodextrin, have been used to increase production of

Helicobacter pylori,12 _{while others, like}

hydroxypropyl-b-cyclodextrin, have been reported to prevent bacterial

production when used to coat vascular prostheses.13

Howevertherearenostudiesevaluatingtheeffectof

sug-ammadex,amodified gammacyclodextrinmoleculelately

beingusedinanesthesiology,onbacterialproduction.

Theaimofthisstudywastoevaluatetheantimicrobial

effectsofsugammadexonthetestmicroorganisms.Thetest

microorganismschosen wereStaphylococcusaureus

Amer-ican Type Culture Collection (ATCC) 29213, Enterococcus

fecalisATCC29212,EscherichiacoliATCC25922and Pseu-domonasaeruginosaATCC27853.

Materials

and

methods

Theantibacterialactivityofsugammadexwasinvestigated

usingthebrothmicrodilutionmethodaccordingtothe

pro-ceduresoutlinedbythe ClinicalandLaboratoryStandards

Institute(CLSI).14

Briefly, sugammadex was diluted with 0.9% sterile

saline to final concentrations of 512␮g/mL, 256␮g/mL,

128␮g/mL, 64␮g/mL, 32␮g/mL, 16␮g/mL, 8␮g/mL,

4␮g/mL,2␮g/mL,1␮g/mLand0.5␮g/mL.Foreach

neu-romuscularblockingdrug,thepHvaluesofallthedilutions

weredeterminedwithapHmeter (SartoriuspHMeter

PB-11).S. aureus ATCC29213, E. fecalisATCC29212, E.coli

ATCC25922andP.aeruginosaATCC27853wereusedas

con-trolmicroorganisms.The bacteria(5×105 colony-forming

unitspermilliliter;(CFU/mL)),MHB(Mueller---Hiltonbroth)

andthesugammadexinthe specifiedconcentrationswere

incubated in wells on microplates at 35◦_{C for 20h. The}

minimal inhibitory concentrations (MIC) were determined

by observing the lowest concentration of the agent that

Table1 ThepHvaluesoftesteddilutionsofsugammadex.

Dilutionofsugammadex(␮g/mL) pH

512␮g/mL 7.25

256␮g/mL 7.22

128␮g/mL 7.14

64␮g/mL 7.09

32␮g/mL 7.04

16␮g/mL 7.04

8␮g/mL 7

4␮g/mL 6.99

2␮g/mL 6.98

1␮g/mL 6.97

0.5␮g/mL 6.97

Physiologicalserum0.9% 6.8

inhibitedvisiblegrowthofthebacterium.Hazeorturbidity inthewellswasanindicatorofbacterialgrowth.

Inthesecondstageofthestudy100mg/mLsugammadex wascontaminatedwiththetestorganisms,S.aureusATCC 29213,E.fecalisATCC29212,E.coliATCC25922andP. aeru-ginosaATCC27853.Bacteria,50␮L(5×105colony-forming

units per milliliter; (CFU/mL)), and 50␮L sugammadex

(100mg/mL)wereincubatedat35◦_{Cfor24h.After24hthe}

bacterialproductioninthesugammadexwasevaluated.

Results

Using the microdilution technique, sugammadex had no antibacterialeffectonS. aureus,E.fecalis,E.coliandP. aeruginosaatanyconcentration.

In the second part of the study, after 24h incubation 100mg/mL sugammadexcontaminated with S. aureus, E. fecalis, E. coli and P. aeruginosa, bacterial growth was observed.

The pH of thetest solutions ranged between 7.25 and 6.97.ThepHvaluesarelistedinTable1.

Discussion

In this study, we found that sugammadex does not have

antimicrobialpropertieswithregardtothetestorganisms,

S.aureus,E.fecalis,E.coliandP.Aeruginosa.

Drugsmanufacturedfor intravenoususe shouldbe

pre-pared and administered in sterile conditions. Infectious

microorganismscanbeintroducedintothepatientthrough

contaminatedcontainers,rubber diaphragms,needlesand

infusionsets.

Anestheticagentsmaybecontaminatedby

microorgan-ismsduringpreparation.Forthisreason,theantimicrobial

effectsoftheusedagentsareimportant.8_{Itisknownthat}

propofolsupportsthegrowthofmicroorganisms.2---4,7,8,15---18

Ontheotherhand,morphinesulphate,thiopentalsodium,

fentanyl citrate, dexmedetomidine, atracurium,

rocuro-niumandmidazolamhaveantimicrobialeffects.3,5---8

Sugammadex is a modified gamma cyclodextrin.9---11

Cyclodextrins are molecules that are often used in the

food and pharmaceutical industries. They are commonly

usedtoconvertlipophilicmedicationstohydrophilicforms.

Antimicrobialfeaturesofsugammadex 107

alipophiliccore.Otherapplicationsofcyclodextrinsinclude

the field of microbiology. Some cyclodextrins, such as

dimethyl-b-cyclodextrin, have been used to increase

pro-ductionofH.pylori.12_{Whenaddedtoagargelscyclodextrins}

suchasalpha-andbeta-cyclodextrin/hexadecaneare

suit-able foodbeds for the growth of microorganisms such as

CandidalipolyticaandC.tropicalis.19 _{Researchhasshown}

that cyclodextrin molecules, such as beta-cyclodextrin,

when added to liquid cultures neutralize potential toxic

combinations and increase the growth of microorganisms

such as H. pylori.20---22 _{Solid cultures including modified}

cyclodextrins have been used for selective isolation of

microorganismssuchasBordetellapertussis.23---26

However other cyclodextrins, such as

hydroxypropyl-b-cyclodextrin, have been reported to prevent bacterial

production when used to coat vascular prostheses.13

Previous studies have reported methyl-beta-cyclodextrins

inhibitingthegrowthofbacillustypes.27_{Researchersfound}

thatmethyl-beta-cyclodextrinscrossedthecellmembranes

of bacillus species and caused cell lysis; however they

emphasized that this activity wasnot observed for other

gramnegativeandpositivebacteria.27_{Anotherstudyfound}

thatcyclodextrinderivativesactedlikeantimicrobialpeptid

polymixinBandcouldinhibitbacterialproliferation.28

There are no studies evaluating the effect of

sugam-madex, a modified gamma cyclodextrin molecule lately

beingusedinanestheticpractice,onbacterialproduction.

Inourstudy,wefoundthatsugammadexdidnothave

antimi-crobialpropertieswithrespecttothegrowthofS.aureus,

E.coli,P.aeruginosaandE.fecalis.

MostbacteriapreferafairlynarrowpHrange,between6

and8,forsurvival.3,17_{ThegrowthofS.aureus(ATCC25923),}

E.coli(ATCC25922)orP.aeruginosa(ATCC27853)wasnot

affectedby growthconditionswitha pHbetween5.0 and

8.0.29_{Thebactericidalpropertiesofthiopentalarethought}

to berelated to itshigh pH.30 _{Similarly, the pH rangeof}

midazolam was shown to be responsible for its bacterial

inhibitoryeffect.5,7,31 _{Inourstudy,priortoperformingthe}

recommendeddilution,thepHofsugammadexwas

approx-imately 7.5.The dilutedsugammadexhadpH ina narrow

rangebetween6.97and7.25.ThesepHvaluesarewithinthe

rangeforproliferationofthetestmicroorganismsS.aureus

(ATCC25923),E.coli(ATCC25922)andP.aeruginosa(ATCC

27853).

In conclusion,sugammadexhad noantibacterialeffect

onS.aureus,E.fecalis,E.coliandP.aeruginosa.

Conflicts

of

interest

Theauthorsdeclarenoconflictsofinterest.

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