Methods for treating localized infections with topically administered antibiotics

Abstract

Methods are described for treating a localized infection of living tissue in a human patient in need thereof, which may include locally administering a daily dose of at least one antibiotic that substantially exceeds the maximum recommended daily dose of the at least one antibiotic, and providing a peak or trough serum concentration of the at least one antibiotic that is below the maximum safe serum concentration level.

Description

[Technical Field]

[0001] CROSS-REFERENCE TO RELATED APPLICATIONS This application claims priority to U.S. Provisional Application No. 63 / 486,186, filed February 21, 2023, U.S. Provisional Application No. 63 / 493,577, filed March 31, 2023, U.S. Provisional Application No. 63 / 519,923, filed August 16, 2023, U.S. Provisional Application No. 63 / 596,130, filed November 3, 2023, and U.S. Provisional Application No. 63 / 613,533, filed December 21, 2023, the contents of each of which are incorporated by reference in their entirety.

[0002] The present disclosure relates generally to methods, dosages, and concentrations for antibiotic irrigation of living tissue. In particular, the disclosure relates to methods, dosages, and concentrations for topical antibiotic irrigation in or around wounds, including surgical wounds, traumatic wounds, wounds caused or exacerbated by infection, and wounds containing infected tissue or medical devices. [Background technology]

[0003] Local infections (including septic arthritis, prosthetic joint infection (PJI), breast implant infection (BII), and fracture-related infection (FRI)) are uncommon but serious pathologies with severe complications. Successful management of local infections most often involves surgical intervention and systemic antibiotics. A critical part of the surgical procedure is the reduction of bacterial bioburden. Bioburden removal is achieved through intraoperative irrigation and surgical debridement of infected tissues. Antibiotic therapy to treat infections is generally systemic antibiotics (administered orally or intravenously). Local antibiotics may be given during the surgical procedure, but maintaining local therapeutic concentrations postoperatively is difficult. This is why systemic antibiotic therapy is considered a treatment for infections.

[0004] Infected implants may be replaced or maintained at the time of treatment, depending on clinical findings. Many pathogenic bacteria commonly found in PJI, BII, FRI, or other infections involving implants are known to form protective structures called biofilms in the presence of implanted medical devices. Such biofilms are not susceptible to systemic antibiotics, and therefore infected implants must be surgically removed as part of any treatment if the infection is to be completely eliminated with a high success rate. If the infection is well established, the implant is typically replaced in a one- or two-stage replacement procedure. In acute cases, infections in medically compromised patients, and cases with very difficult-to-remove implants, the most common surgical procedure is implant retention, known as irrigation and debridement (I&D) or debridement, antibiotics, and implant retention (DAIR). Although implant replacement is more invasive than implant retention, it reduces bacterial bioburden, especially biofilm, and provides improved outcomes compared to implant retention.

[0005] Infections of traumatic wounds are common, and surgical site infections (SSIs) occur postoperatively and after virtually all surgical procedures. While such infections may be superficial and relatively easy to treat uneventfully, others, such as PJIs, involve deeper tissues (with or without a surgically implanted device) and are very difficult to completely remove.

[0006] In systemic antibiotic therapy for musculoskeletal infections, the dose (e.g., total daily dose) and concentration administered in a 24-hour period are strictly limited by the maximum safe concentration of the antibiotic in the circulatory system, and the dose and concentration obtainable at the local infection site are further limited by pharmacokinetics.

[0007] Therefore, there is a need for improved methods, dosages, and concentrations of antibiotic wound irrigation. Summary of the Invention

[0008] According to some implementations of the disclosed subject matter, antibiotic wash treatment methods, dosages, and concentrations are provided for treating a variety of wounds.

[0009] The present disclosure is directed to a method of treating a localized infection in a human patient. In certain embodiments, the method comprises administering a solution to the human patient at a dose substantially exceeding the maximum recommended daily systemic dose of at least one antibacterial agent within a 24-hour period, wherein the solution provides a peak or trough serum concentration within the 24-hour period that is less than or equal to the maximum safe serum concentration level of the at least one antibacterial agent.

[0010] Another aspect of the present disclosure is a method of treating a localized infection in a human patient by administering to the human patient at least one antibacterial agent at a local administration concentration that exceeds a maximum recommended concentration, the method providing a peak or trough serum concentration that is less than a maximum safe serum concentration of the at least one antibacterial agent.

[0011] The present disclosure is further directed to a method of treating a musculoskeletal infection in a human patient by administering to the human patient at least one antimicrobial agent at a topical administration concentration that exceeds the minimum biofilm eradicating concentration (MBEC) of the at least one antimicrobial agent, wherein the method provides a peak or trough serum concentration of the at least one antimicrobial agent that is less than the maximum safe serum concentration of the at least one antimicrobial agent.

[0012] Another aspect of the present disclosure is a method of treating a localized infection in a human patient by topically administering to the human patient a total dose of a first antibiotic within a 24-hour period that substantially exceeds a maximum recommended systemic daily dose, wherein the method provides a peak or trough serum concentration within the 24-hour period that is less than or equal to a maximum safe serum concentration of the first antibiotic.

[0013] The present disclosure additionally provides a method of treating a localized infection in a human patient in need thereof by topically administering to the human patient, within a 24-hour period, a total dose of a first antibiotic that substantially exceeds the maximum recommended systemic daily dose and a total dose of a second antibiotic that substantially exceeds the maximum recommended systemic daily dose, wherein the method provides peak or trough serum concentrations within said 24-hour period that are less than or equal to the maximum recommended safe serum concentrations of said first antibiotic and said second antibiotic.

[0014] A further aspect of the present disclosure is a method of treating a localized infection in a human patient by topically administering to the human patient, within a 24 hour period, a total dose of at least two antibiotics, the total dose substantially exceeding the maximum recommended systemic daily dose of each of said at least two antibiotics; the method providing peak or trough serum concentrations that are less than or equal to the maximum safe serum concentration of each of said at least two antibiotics.

[0015] An additional aspect of the present disclosure is a method of treating a localized infection in a human patient by topically administering to the human patient a total dose of a first antibiotic within a 24-hour period that substantially exceeds the maximum recommended systemic daily dose, wherein the method provides a peak or trough serum concentration within said 24-hour period that is less than or equal to the maximum safe serum concentration of said first antibiotic.

[0016] A further aspect of the present disclosure is a method of treating a localized infection in a human patient in need thereof by locally administering to the human patient, within a 24-hour period, a total dose of a first antibiotic that substantially exceeds the maximum recommended systemic daily dose and a total dose of a second antibiotic that substantially exceeds the maximum recommended daily dose, wherein the method provides peak or trough serum concentrations within said 24-hour period that are less than or equal to the maximum recommended safe serum concentrations of the first antibiotic and the second antibiotic.

[0017] The present disclosure additionally provides a method of treating a localized infection in a human patient by topically administering to the human patient, within a 24-hour period, a total dose of at least two antibiotics that substantially exceeds the maximum recommended systemic daily dose of each of said at least two antibiotics, wherein the method provides peak or trough serum concentrations within said 24-hour period that are less than or equal to the maximum safe serum concentration of each of said at least two antibiotics.

[0018] The present disclosure further provides a method of treating biological tissue of a human patient by locally administering to the human patient, within a 24 hour period, a total dose of at least one therapeutic agent that substantially exceeds the maximum recommended systemic daily dose, wherein the method provides a peak or trough serum concentration that is less than or equal to the maximum safe serum concentration of said at least one therapeutic agent.

[0019] The present disclosure also provides a method of treating a localized infection of living tissue in a human patient by locally administering to the human patient, within a 24-hour period, a total 24-hour dose of at least one antibiotic of greater than 3,000 mg.

[0020] Embodiments of the present disclosure include methods of treating a localized infection in a human patient by topically administering to the human patient, within a 24-hour period, a total 24-hour dose of vancomycin of greater than 3,000 mg / day and / or a total 24-hour dose of tobramycin of greater than 100 mg / day.

[0021] Another aspect of the present disclosure includes a kit for treating a localized infection in a human patient, which may include at least one antibiotic, a therapeutic delivery system and / or an irrigation device configured to topically irrigate the localized infection with at least one dose of the at least one antibiotic, and instructions for administering the at least one dose of the at least one antibiotic.

[0022] An additional aspect of the present disclosure includes a method of treating a localized infection in a human patient by locally administering to the human patient two or more doses of at least one antibiotic within a 24-hour period, the dose being a concentration above the MBEC level of at least one antibiotic for the localized infection.

[0023] A further aspect of the present disclosure includes a method of treating a localized infection in a human patient by topically administering to the human patient two or more doses of at least one antibiotic within a 24-hour period, wherein the AUC / MBE at the site of the localized infection is maintained for at least five hours per day.

[0024] A further aspect of the present disclosure includes a method of treating a localized infection in a human patient by topically administering to the human patient, over two or more days, at least one antibiotic at a concentration that is above the MBEC for the localized infection of the at least one antibiotic on at least day 1 and that is less than the concentration of the at least one antibiotic on day 1. The concentration of the at least one antibiotic on the subsequent day may be above the minimum inhibitory concentration for the at least one antibiotic for the localized infection.

[0025] The present disclosure provides a method of treating a localized infection in a human patient in need thereof by administering at least a 25 mg dose of vancomycin at a concentration of 3,000 mcg / mL or greater by topical irrigation to the human patient, which method provides a trough serum concentration in the patient of less than 30 mcg / mL for 24 hours after administration.

[0026] The present disclosure further provides a method for treating a localized infection in a human patient in need thereof by administering doses of vancomycin and tobramycin by topical irrigation to the human patient. The doses may include at least a 50 mg dose of vancomycin at a concentration of 3,000 mcg / mL or greater and at least a 50 mg dose of tobramycin at a concentration of 2,000 mcg / mL or greater. The administration provides the patient with a trough serum concentration of vancomycin of less than 30 mcg / mL and a peak serum concentration of tobramycin of less than 10 mcg / mL for 24 hours after administration.

[0027] Further aspects of the present disclosure include methods of treating a localized infection in a human patient by identifying at least one microorganism within the localized infection; and locally administering two or more antibiotics to the human patient, wherein at least one of the antibiotics is administered at a concentration above the MBEC level of the at least one antibiotic for the at least one bacterium.

[0028] The present disclosure further provides a method of treating a localized infection in a human patient by locally administering two or more antibiotics to the human patient, wherein at least one of the antibiotics is administered at a concentration above the MBEC level of the at least one antibiotic for the at least one bacterium; identifying at least one microorganism within the localized infection during said administration; and switching at least one of the antibiotics for another antibiotic after identifying the at least one microorganism.

[0029] The present disclosure further provides a method of treating a localized infection in a human patient by topically administering to the human patient a first antibiotic combination comprising two or more antibiotics, identifying at least one microorganism within the localized infection, and switching at least one antibiotic to provide a second antibiotic combination, and administering the second antibiotic combination comprising two or more antibiotics to the human patient, wherein the second antibiotic combination reduces the log 100% or less of the identified at least one microorganism compared to the first antibiotic combination against the identified microorganism. 10 This results in an increase in the reduction (LogR).

[0030] These and other aspects will now be described in detail with reference to the following figures. [Brief explanation of the drawings]

[0031] [Figure 1] Figure 1 is a table of generally accepted susceptibility limits for common antimicrobial agents against S. aureus. [Figure 2] Figure 2 shows the production and attachment of biofilms formed by certain bacterial and fungal pathogens. [Figure 3A] Figure 3A is a graphical representation of the minimum biofilm eradication concentration (MBEC) of tobramycin sulfate against common strains found in periprosthetic joint infections. [Figure 3B] Figure 3B graphically depicts the minimum biofilm eradication concentrations of vancomycin hydrochloride against common strains found in periprosthetic joint infections. [Figure 3C] Figure 3C graphically depicts the minimum biofilm eradication concentrations of vancomycin hydrochloride and tobramycin sulfate against common strains found in periprosthetic joint infections. [Figure 4] FIG. 4 shows the mean relative elution of vancomycin over time from commercially available bone cements commonly used to stabilize bone during two-stage exchange treatment for periprosthetic joint infection. [Figure 5]Figure 5 is a table showing recommended safe doses and systemic concentrations of selected antibiotics. [Figure 6] FIG. 6 is a graph showing serum concentrations of vancomycin hydrochloride in a human patient during a 7-day treatment involving cyclic regional perfusion of vancomycin hydrochloride. [Figure 7A] FIG. 7A shows an example of a therapeutic delivery system and kit. [Figure 7B] FIG. 7B shows a detailed view of the therapeutic delivery system and kit of FIG. 7A. DETAILED DESCRIPTION OF THE INVENTION

[0032] The disclosed subject matter relates to antibiotics administered locally at high concentrations, which may improve wound treatment, including local infections (particularly infections involving medical devices such as artificial joints or reconstructive implants). Disclosed herein are dosing and methods for safely administering high doses and concentrations of antibiotics. Also disclosed are methods for administering antibiotics at doses and concentrations that exceed those of previously administered systemic therapy, while maintaining the patient's systemic exposure at levels below or equal to safe systemic concentration limits.

[0033] Locally administered antimicrobial therapy has not been optimized for controlled delivery, in part due to a lack of medical devices to safely and effectively administer such therapy, and in part due to a lack of research and development specifically aimed at maximizing the effectiveness of topical antimicrobial agents and minimizing the risks associated with concentrated therapeutics and exposing the wound to the environment during therapy. Recent advances in wound irrigation devices, particularly cyclic instillation and aspiration of wounds with saline, offer opportunities for safe and effective local delivery of therapeutic agents, such as antibiotics, that were previously unattainable by the irrigation administration route.

[0034] The successful eradication of an infection through antimicrobial therapy depends on the specific antimicrobial agent used, the specific pathogen, the pathogen's susceptibility or resistance to the antimicrobial agent, and the pathogen's exposure to the antimicrobial agent (including dose, concentration, and exposure time), based on the antimicrobial agent's mechanism of action and pharmacodynamic target. In clinical settings, pathogen susceptibility is determined by exposing pathogen samples collected from patients to various antimicrobial agents at therapeutic concentrations and confirming effective eradication of the pathogen in clinical trials. The lowest antimicrobial concentration at which a specific pathogen is susceptible to a particular antimicrobial agent is known as the minimum inhibitory concentration (MIC). Pathogens that are not eradicated after exposure to an antimicrobial agent within the therapeutic or clinically achievable range are considered resistant to that antimicrobial agent. Pathogens may be resistant to a single drug, multidrug-resistant (MDR), extensively drug-resistant (XDR) (i.e., resistant to all antimicrobial agents except those in two or fewer classes), or pan-drug resistant (PDR). The generally accepted susceptibility limits for common antimicrobial agents against S. aureus are listed in Figure 1. The data in Figure 1 show that the MIC at which a resistant strain of an organism (MRSA) is susceptible to an antimicrobial may be 2 to 10 times greater than the MIC for a susceptible strain of the same organism (MSSA). It also shows that the MIC of a specific antibiotic may be 1 to 2 orders of magnitude greater than the MIC of other antibiotics against the same strain of the organism. MIC values ​​are reported for susceptibility in organisms in a planktonic (planktonic) state. Typical breakpoint MICs used in clinical practice do not take into account the presence of biofilms and the associated potential inherent increase in MIC.

[0035] The biofilm formation process is illustrated in Figure 2. Although biofilms may be formed by a single bacterial species, they generally consist of a rich mixture of many bacterial species, as well as fungi, algae, protozoa, and other microorganisms. In polymicrobial infections involving both bacteria and fungi, synergistic effects have been reported, demonstrating that the combined biofilm's antimicrobial resistance is superior to that of biofilms formed by either pathogen individually. Biofilms are held together by polysaccharide molecular chains, collectively referred to as "extracellular polymeric substances" or "EPS." Cells produce EPS, and these chains hold them together, allowing them to generate complex, three-dimensional, resilient, and cohesive communities. Depending on environmental conditions, biofilms can be as thin as a few cell layers or several inches thick.

[0036] Planktonic cells utilize nutrients but lack sufficient metabolic activity to detach substrates from their surroundings. Meanwhile, the collective metabolic activity of biofilm cells creates substrate concentration gradients and local chemical microenvironments. Protective stress responses are effectively implemented by some cells in biofilms at the expense of others. The collective neutralizing capacity of the cells also slows or results in incomplete penetration of antimicrobial agents into biofilms.

[0037] Persister cells, i.e., antibiotic-resistant bacteria, accumulate and are physically supported by the biofilm matrix. Persister cells comprise a subpopulation of bacteria that emerge through a dormant state (defined here as a state in which cellular metabolism is inactive or anaerobic) and become highly resistant to antibiotics. Biofilm persister cells are thought to be responsible for the recalcitrance of chronic infections because, although antibiotics kill the majority of cells, persister cells remain viable and repopulate the biofilm when antibiotic levels decline. Based on decades of research, persister cells are thought to be less susceptible to antibiotics because they are dormant and do not experience cellular activities that antibiotics may disrupt, or are anaerobic, resulting in resistance (i.e., no growth and slow death). This antibiotic resistance occurs in biofilms containing many different genera (including Escherichia coli, Pseudomonas aeruginosa, Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Staphylococcus epidermidis, Lactobacillus acidophilus, and Gardnerella vaginalis).

[0038] Biofilm formation (frequently observed in in situ infected wounds involving medical devices, such as PJI, BII, or FRI) begins early after infection and provides an additional resistance mechanism to antibiotic therapy. It is well established that organisms within mature biofilm structures, which form over only a few days or weeks, are not susceptible to common antibiotics with typical MICs in planktonic tissue. However, significantly increasing the antimicrobial concentration may be bactericidal against pathogens within mature biofilms. This is known as the biofilm bactericidal concentration (BBC) and is defined as a 99.9% reduction in colony-forming units (CFUs). The concentration at which eradication of organisms in biofilms is achieved is known as the minimum biofilm eradication concentration (MBEC) for the specific antimicrobial and organism tested. The MBECs of antimicrobial agents used to treat the same organism are not identical, nor are the MBECs of an antimicrobial agent applied to different species or organisms. The MBECs of antibiotics most often used to treat common PJI organisms may be 100–1000 times the MIC for the same antibiotic and organism combination. The MBEC of tobramycin for common PJI organisms is shown in Figure 3A. The MBEC of vancomycin for common PJI organisms is shown in Figure 3B. The MBEC of vancomycin and tobramycin (at a 1:1 ratio) for common PJI organisms is shown in Figure 3C. This clinical study demonstrates that clinically occurring organisms in mature biofilm structures exhibit MBEC levels far exceeding those achievable by systemic antibiotic administration (intravenous or oral), and the MBEC far exceeds the safe systemic concentration of the antibiotic.

[0039] The standard treatment for chronic PJI is a two-stage replacement procedure, which begins with surgical removal of the infected implant, aggressive debridement of bone and soft tissue, placement of a temporary implant made from antibiotic-soaked polymethyl methacrylate (PMMA), and subsequent systemic antibiotic therapy. Antibiotics in PMMA leach into the surrounding tissue, and the concentration of eluted antibiotics decreases exponentially over time, decreasing the further away from the temporary implant. The goal of surgical removal is to dramatically reduce the bioburden of infection, allowing the patient's immune system to eradicate any remaining microorganisms through systemic antibiotic therapy in conjunction with local antibiotic elution. Examples of antibiotic elution rates from commercially available PMMA devices are shown in Figure 4. In clinical practice, elution rates vary widely due to differences in the elution characteristics of available PMMA materials and significant differences in surgeon-specific antibiotic mixing methods and dosages. Alternative materials to PMMA, such as calcium sulfate, have also been used as carriers for locally eluting antibiotics. In localized biofilm infections where the structural support of a temporary implant is not necessary, such as BII or FRI, a two-stage replacement may be performed without an intermediate stage implant between the two surgical procedures.

[0040] The therapeutic effectiveness of antibiotics eluted from temporary implants is limited to tissues close enough to the temporary implant to achieve therapeutic concentrations of antibiotics, and only occurs briefly after temporary implant placement until local tissue concentrations fall below therapeutic levels. Given the local bioburden, the nature of biofilms remaining after surgical debridement, and the minimum biofilm-eradicating concentrations of selected antibiotics, locally eluted antibiotic therapy may not be sufficient. Commercially available products using this technology are approved for sale in the United States only as an adjunct to systemic antibiotic therapy. After attempted two-stage exchange arthroplasty using local antibiotic elution, clinically successful PJI treatment (replacement of infected prosthesis without reinfection, reoperation, or administration of suppressive antibiotics) has only been reported in approximately 50% of cases 1 year after initial surgical treatment. Local antibiotics are absorbed into tissues and the circulatory system, where they accumulate in addition to co-administered systemic antibiotics. Patients with two-stage exchange arthroplasty are also at risk for nephrotoxicity and ototoxicity due to the very high initial concentrations of toxic antibiotics in the PMMA device, which cannot be adjusted without surgical intervention to remove the device. PMMA also becomes structurally weaker as the volume of antibiotic in the mixture increases. These toxicological and mechanical considerations limit the maximum local concentration that may be clinically delivered by antibiotic-eluting temporary implants.

[0041] Another limitation of antibiotic-impregnated carriers is the inability to optimize pharmacodynamic target delivery. Antibiotics (e.g., the aminoglycosides tobramycin / gentamicin) target PK concentrations above the MIC, but have a limited exposure time, reaching a maximum log kill at approximately 2 hours, after which adaptive resistance and the risk of toxicity increase. Continuous exposure of pathogens to subinhibitory concentrations without eradication increases the chance of adaptive resistance.

[0042] Local injection of antibiotics in solution for the treatment of PJI has been reported, using antibiotics repeatedly administered via a catheter into the periarticular tissues or joint space after aggressive debridement and one-stage exchange. However, because injections are, by definition, unidirectional (none of the injected antibiotic is aspirated or flushed away from the infected site), the unidirectional injection dose is absorbed into the tissue and bloodstream, and systemic toxicity considerations limit the local dose and concentration that may be safely administered. Whiteside et al. reported that once- or twice-daily injections of very high concentrations (50,000–100,000 mcg / mL) of vancomycin into the joint space resulted in serum concentrations exceeding safety limits in multiple patients, necessitating a reduction in injection dose and concentration. Although peak and trough vancomycin concentrations in the joint cavity exceeded serum concentrations and remained above the vancomycin MIC for common vancomycin-susceptible organisms, this sustained local concentration was limited by exceeding safe systemic concentrations and was not maintained above the vancomycin MBEC (>4000 mcg / mL) for several common PJI organisms. Similarly, the maximum daily dose delivered by this infusion method was 1000 mg.

[0043] Both elution from antibiotic-soaked carriers and local injection of antibiotics in solution carry the risk of local tissue toxicity and even tissue necrosis due to uncontrolled local accumulation of antibiotics.

[0044] The present invention represents a significant improvement and departure from the prior art because, in one embodiment, it comprises one or more doses of at least one antibiotic delivered via irrigation (injection followed by aspiration) to a localized infection and / or living tissue (e.g., periprosthetic tissue or joint cavity, breast capsule) of a human patient in need thereof. Thus, in one embodiment, the one or more doses of at least one antibiotic at a concentration above the BBC or MBEC delivered to a localized infection and / or living tissue of a human patient in need thereof may be bidirectional or multidirectional, rather than unidirectional. In another aspect, the present invention improves over the prior art by providing locally administered antibiotic concentrations and doses that exceed safe systemic concentrations and doses but do not provide unsafe systemic plasma concentration levels in a human patient. Thus, the present invention provides methods for maintaining a concentration of at least one antibiotic at or above the BBC or MBEC (e.g., greater than 4,000 mcg / mL for vancomycin) for multiple common PJI organisms at a local infection site and / or living tissue site in a human patient at least 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, or 12 times per day. Similarly, the method allows for the administration of a total daily dose of at least one antibiotic that is greater than that tolerated by systemic administration (e.g., the maximum daily dose provided by this local administration method can be greater than or equal to 3,000 mg / day, greater than or equal to 4,000 mg / day, greater than or equal to 5,000 mg / day, greater than or equal to 6,000 mg / day, greater than or equal to 7,000 mg / day, greater than or equal to 8,000 mg / day, or greater than or equal to 9,000 mg / day of vancomycin or vancomycin hydrochloride, or greater than 100 mg / day, greater than 200 mg / day, greater than 300 mg / day, greater than 400 mg / day, greater than 500 mg / day, greater than 750 mg / day, or greater than 1,000 mg / day of tobramycin or tobramycin sulfate).

[0045] From the above examples, it is clear that the effectiveness of prior art elution and injection methods is limited to organisms that are sensitive to sustainably available concentrations of the delivered antibiotic and achieve their pharmacodynamic targets. However, musculoskeletal infections are often polymicrobial and form biofilms, and identification of the pathogen(s) is generally achieved using tissue cultures 7–14 days after initiation of treatment. In a significant minority of cases, the pathogen is never identified by tissue culture methods, and recent studies using genetic sequencing techniques have identified multiple organisms in both culture-negative cases and cases in which a single pathogen was identified by tissue culture. Thus, localized elution or injection of a single antibiotic at a safe dose and concentration is frequently ineffective at eradicating one or more organisms within an established biofilm, and antibiotics cannot be tailored to the organisms, which are often unknown at the time of antibiotic administration.

[0046] Broad-spectrum systemic antibiotic therapy is the standard first-line treatment for localized infections, especially when the pathogen has not yet been identified or may be polymicrobial. In cases of infection involving implanted devices such as PJI, BII, or FRI, broad-spectrum therapy that exceeds the BBC or MBEC for all identified or potential pathogens is preferred. Preclinical studies to quantify the BBC and MBEC of antibiotics for pathogens found in localized human infections are not comprehensive. Because the number of potential antibiotics and known pathogens is vast, the BBC and MBEC values ​​identified to date generally far exceed the safe systemic doses and concentrations of the antibiotics tested. In many studies to establish MBEC values, none of the concentrations of antibiotics tested were found to eradicate biofilms of specific organisms, resulting in the MBEC for the specific antibiotics and organism strains tested remaining unknown.

[0047] Broad-spectrum antibiotic therapy for localized infections generally includes a glycopeptide (e.g., vancomycin hydrochloride) to cover Gram-positive bacteria and an aminoglycoside (e.g., gentamicin or tobramycin sulfate) to cover Gram-negative bacteria. The recommended safe dosages and systemic concentrations of these antibiotics are shown in Figure 5.

[0048] As a route of administration, irrigation is defined as the administration of antibiotics to cleanse or flush an open wound or body cavity. By controlling the dose, concentration, and exposure (irrigation or flushing) time, novel methods have been developed to treat localized infections in human patients. However, irrigation of vancomycin and tobramycin within the manufacturer-recommended doses and concentrations does not provide local concentrations of antibiotics above the MBEC for several common PJI organisms. Furthermore, the dose and concentration required to achieve the MEBC for biofilm-forming organisms varies depending on the organism, biofilm maturity, biofilm location, the implant or tissue to which the biofilm is attached, the rate of antibiotic dilution and absorption at the irrigation site, and other factors. It should be noted that musculoskeletal infections may be monomicrobial or polymicrobial in nature. In polymicrobial infections, the associated pathogens may include gram-positive and gram-negative bacteria, fungi, or any combination of these pathogens. In such cases, and in cases of culture-negative infections (i.e., where no pathogen is identified), it is best practice to administer multiple antimicrobial agents for the broadest possible coverage. What is clinically needed is a systemically safe antibiotic therapy that provides localized broad-spectrum biofilm eradication under these highly variable clinical conditions.

[0049] In one aspect, provided herein is a method for treating a localized infection in a living tissue of a human patient in need thereof. The novel method described herein involves continuously administering one or more antibiotics by a perfusion route of administration at a dose and / or concentration that exceeds previously established safe systemic doses and / or concentrations of the antibiotic(s), while simultaneously providing a safe systemic (serum) concentration of the antibiotic(s). In at least one embodiment, the novel methods described herein involve continuously administering one or more antibiotics via a perfusion route of administration at a dose and / or concentration that is at least equal to or exceeds the MBEC (e.g., greater than or equal to 100% of the MBEC, greater than or equal to 105% of the MBEC, greater than or equal to 110% of the MBEC, greater than or equal to 125% of the MBEC, greater than or equal to 150% of the MBEC, greater than or equal to 175% of the MBEC, greater than or equal to 200% of the MBEC, greater than or equal to 300% of the MBEC, greater than or equal to 400% of the MBEC, greater than or equal to 500% of the MBEC, greater than or equal to 600% of the MBEC, greater than or equal to 700% of the MBEC, greater than or equal to 800% of the MBEC, greater than or equal to 900% of the MBEC, greater than or equal to 1000% of the MBEC), while providing a safe systemic (serum) concentration of the one or more antibiotics.

[0050] In some embodiments, the method may include topically administering to a human patient a total daily dose of at least one antibiotic that substantially exceeds the maximum recommended daily systemic dose of the at least one antibiotic, and providing a peak or trough serum concentration that is at or below the maximum safe level of serum concentration of the at least one antibiotic.

[0051] The local infection may be monomicrobial, polymicrobial, or involve an unidentified pathogen. In various embodiments, the local infection may include, but is not limited to, Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), Staphylococcus epidermidis, enterococci, Escherichia coli, Pseudomonas aeruginosa, undiagnosed / unidentified, or a combination thereof. The local infection may be within or adjacent to a wound, a surgical site or incision, a prosthetic joint, a breast implant, or a combination thereof. Various antibiotics used to treat infections and biofilms may be used in the disclosed methods. Non-limiting examples of antibiotics include aminoglycosides, glycopeptides, cyclic lipopeptides, vancomycin, tobramycin, gentamicin, daptomycin, and combinations thereof.

[0052] A daily dose may include a single administration or multiple administrations per day. For example, a daily dose may be administered 1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, or 24 times per day. In some examples, a daily dose may be administered at least 1, at least 2, at least 5, at least 10, at least 15, at least 20, at least 21, at least 21.5, or at least 22 times. Administration may be every 30 minutes or less, about every hour, about every 2 hours, about every 3 hours, about every 4 hours, about every 5 hours, about every 6 hours, about every 7 hours, about every 8 hours, about every 9 hours, about every 10 hours, about every 12 hours, about every 18 hours, or about every 24 hours.

[0053] Antibiotics may be administered locally by perfusing the tissue with at least one antibiotic one or more times. Perfusing the tissue involves immersing the tissue in at least one antibiotic and then aspirating the antibiotic from the tissue after a period of time. Surprisingly, this allows for high local concentrations at the site of infection to be maintained without high systemic absorption. This provides for achieving high local MBEC concentrations at the site of infection to eradicate the infection / biofilm while maintaining serum concentrations below recommended limits to avoid adverse patient effects.

[0054] Perfusing the biological tissue may include immersing the biological tissue in the antibiotic for about 30 minutes to about 180 minutes, about 30 minutes to about 45 minutes, about 30 minutes to about 60 minutes, about 60 minutes to about 90 minutes, about 60 minutes to about 120 minutes, or about 120 minutes to about 180 minutes. In various embodiments, perfusing the biological tissue may include immersing the biological tissue in the antibiotic for 30 minutes, 60 minutes, 90 minutes, 120 minutes, 150 minutes, or 180 minutes.

[0055] The volume of antibiotic administered may be sufficient to expose all living tissue throughout the entire soaking period, and the volume of the dose administered in each soaking step may be about 20 cc, about 30 cc, about 40 cc, about 50 cc, about 60 cc, about 70 cc, about 80 cc, about 90 cc, about 100 cc, or more.

[0056] Irrigation may be performed at least once a day, at least twice a day, at least five times a day, at least 10 times a day, at least 15 times a day, at least 20 times a day, at least 21 times a day, or at least 22 times a day. In some instances, an antibiotic may be perfused into the infected site hourly for 20 to 22 hours. In some instances, two or more antibiotics may be perfused into the infected site of the living tissue. The two or more antibiotics may be perfused at different frequencies. For example, one antibiotic may be perfused into the infected site hourly for 12 to 24 hours, and a second antibiotic may be perfused into the infected site once or twice a day. The first antibiotic may be aspirated from the infected site before the second antibiotic is injected / soaked. Alternatively, two or more antimicrobial agents, including antibiotics, may be perfused simultaneously from a single solution source or from separate solution sources.

[0057] In some embodiments, the method may further include irrigating the local infection and / or vital tissue with a irrigation fluid (e.g., saline) one or more times between antibiotic administrations. In some aspects, the irrigation fluid may be sterile saline or water. Irrigation of the infected site may further aid in reducing bioburden or removing previously administered antibiotics to allow for subsequent administration of higher doses.

[0058] The daily dose of the at least one antibiotic can substantially exceed the maximum recommended systemic daily dose of said at least one antibiotic. Substantially exceeding the maximum recommended systemic daily dose of said at least one antibiotic can include a daily dose that is at least 125%, at least 150%, at least 175%, at least 200%, at least 225%, at least 250%, at least 275%, at least 300%, at least 400%, at least 500%, at least 600%, at least 700%, at least 800%, at least 900%, at least 1,000% or more greater than the maximum recommended systemic daily dose of said at least one antibiotic.

[0059] In some embodiments, the at least one antibiotic is vancomycin. The concentration of locally administered vancomycin may be at least 3,000 mcg / mL, at least 5,000 mcg / mL, at least 7,000 mcg / mL, at least 10,000 mcg / mL, at least 20,000 mcg / mL, at least 40,000 mcg / mL, or at least 50,000 mcg / mL. In various examples, the concentration of locally administered vancomycin may be greater than 2,500 mcg / mL, about 18,333 mcg / mL, about 34,167 mcg / mL, or about 50,000 mcg / mL. As an example, the maximum recommended systemic daily dose of vancomycin is 60 mg / kg / day, which may be about 1,200 mg / day to 7,500 mg / day for 95% of the U.S. population. Thus, the daily dose of locally administered vancomycin can be from about 3,000 mg / day to about 50,000 mg / day. In various examples, the daily dose of locally administered vancomycin is at least 3,500 mg / day, at least 4,000 mg / day, at least 5,000 mg / day, at least 6,000 mg / day, at least 7,000 mg / day, at least 8,000 mg / day, at least 9,000 mg / day, at least 10,000 mg / day, at least 12,000 mg / day, at least 14,000 mg / day, at least 16,000 mg / day, at least 18,000 mg / day, at least 20,000 mg / day, at least 30,000 mg / day, at least 40,000 mg / day, at least 50,000 mg / day, or greater than 50,000 mg / day. In at least one example, the daily dose of topically administered vancomycin may be about 9,450 mg / day. In this example, each topical dose may be about 450 mg (e.g., 450 mg vancomycin in a 0.9% saline solution) when administered 21 times per day.

[0060] The total dose of vancomycin administered over all dosing days may range from about 15 g to 100 g, about 15 g to 20 g, about 20 g to 25 g, about 25 g to 30 g, about 30 g to 35 g, about 35 g to 40 g, about 40 g to 45 g, about 45 g to 50 g, about 50 g to 60 g, about 60 g to 70 g, about 70 g to 80 g, about 80 g to 90 g, or about 90 g to 100 g. For longer treatment courses, the total dose of vancomycin administered over all dosing days may be about 100 g to 200 g, 100 g to 300 g, or about 200 g to 400 g, or more.

[0061] Despite the high concentrations being administered locally, an advantage of the disclosed methods is that the serum concentration of the antibiotic is maintained below the maximum safe level. Thus, the patient receives the benefit of a high concentration of the antibiotic (e.g., above the BBC or MBEC level) to treat the infection while maintaining safe serum levels and minimizing side effects to the patient. The maximum safe trough level of vancomycin serum concentration may be about 30 mcg / mL or about 25 mcg / mL. In some examples, the trough serum concentration of vancomycin when administered according to the disclosed methods is less than 30 mcg / mL, less than 25 mcg / mL, less than 20 mcg / mL, less than 15 mcg / mL, less than 10 mcg / mL, or less than 7 mcg / mL.

[0062] In some embodiments, the at least one antibiotic is tobramycin. The concentration of locally administered tobramycin may be at least 2,000 mcg / mL, at least 3,000 mcg / mL, at least 4,000 mcg / mL, at least 5,000 mcg / mL, at least 6,000 mcg / mL, at least 7,000 mcg / mL, at least 8,000 mcg / mL, at least 10,000 mcg / mL, at least 12,000 mcg / mL, at least 15,000 mcg / mL, at least 20,000 mcg / mL, at least 25,000 mcg / mL, at least 30,000 mcg / mL, at least 35,000 mcg / mL, or at least 40,000 mcg / mL. In some instances, the concentration of locally administered tobramycin is greater than 1,60 mcg / mL, and may be about 14,400 mcg / mL, about 27,200 mcg / mL, or about 40,000 mcg / mL. As an example, the maximum recommended systemic daily dose of tobramycin is about 10 mg / kg / day, which may be about 200 mg / day to about 1,250 mg / day for 95% of the U.S. population. In various instances, the daily dose of locally administered tobramycin is at least 100 mg / day, at least 200 mg / day, at least 400 mg / day, at least 600 mg / day, at least 800 mg / day, at least 1,000 mg / day, at least 1,200 mg / day, at least 1,400 mg / day, at least 1,600 mg / day, at least 2,000 mg / day, or greater than 2,500 mg / day. In at least one example, the daily dose of topically administered tobramycin may be about 450 mg / day. In this example, each topical dose may be about 450 mg (e.g., 450 mg of tobramycin in a saline solution (0.9%)) when administered once daily.

[0063] The total dose of tobramycin administered over all dosing days may range from about 1 g to 2 g, about 2 g to 3 g, about 3 g to 4 g, about 4 g to 6 g, about 6 g to 8 g, or about 8 g to 10 g. For longer treatment courses, the total dose of tobramycin administered over all dosing days may be about 10 g to 15 g, or about 15 g to 20 g, or more.

[0064] The maximum safe level of peak serum concentration of tobramycin may be less than 10 mcg / mL. In some examples, the peak serum concentration of tobramycin is less than 9 mcg / mL, less than 8 mcg / mL, less than 7 mcg / mL, less than 6 mcg / mL, less than 5 mcg / mL, or less than 3 mcg / mL.

[0065] In some embodiments, the at least one antibiotic is daptomycin. The concentration of the locally administered daptomycin may be at least 3,000 mcg / mL, at least 5,000 mcg / mL, at least 7,000 mcg / mL, at least 10,000 mcg / mL, at least 20,000 mcg / mL, at least 40,000 mcg / mL, or at least 50,000 mcg / mL. In various examples, the concentration of the locally administered daptomycin may be greater than 2,500 mcg / mL, about 18,333 mcg / mL, about 34,167 mcg / mL, or about 50,000 mcg / mL. As an example, the daily dose of locally administered daptomycin may be about 3,000 mg / day to about 50,000 mg / day. In various examples, the daily amount of topically administered daptomycin is at least 3,500 mg / day, at least 4,000 mg / day, at least 5,000 mg / day, at least 6,000 mg / day, at least 7,000 mg / day, at least 8,000 mg / day, at least 9,000 mg / day, at least 10,000 mg / day, at least 12,000 mg / day, at least 14,000 mg / day, at least 16,000 mg / day, at least 18,000 mg / day, at least 20,000 mg / day, at least 30,000 mg / day, at least 40,000 mg / day, at least 50,000 mg / day, or greater than 50,000 mg / day.

[0066] The total dose of daptomycin administered over all dosing days can range from about 15 g to 100 g, about 15 g to 20 g, about 20 g to 25 g, about 25 g to 30 g, about 30 g to 35 g, about 35 g to 40 g, about 40 g to 45 g, about 45 g to 50 g, about 50 g to 60 g, about 60 g to 70 g, about 70 g to 80 g, about 80 g to 90 g, or about 90 g to 100 g. For longer treatment courses, the total dose of daptomycin administered over all dosing days can be about 100 g to 200 g, or about 200 g to 400 g, or more.

[0067] As an example, to achieve local concentrations and safe serum levels that are MBECs for multiple organisms, vancomycin concentrations up to 10,000 mcg / mL may be administered by local irrigation with 30-minute immersion-and-aspiration cycles every hour, maintaining vancomycin trough serum concentrations below the maximum safe level of 30 mcg / mL. Tobramycin concentrations up to 6,400 mcg / mL may be administered by local irrigation once or twice daily with 120-minute immersion followed by aspiration, maintaining tobramycin peak serum concentrations below the maximum safe level of 10 mcg / mL and trough serum concentrations below 2 mcg / mL. Toxicity has been associated with sustained trough levels above 2 mcg / mL. Specific concentrations and daily doses may be modified by administering the antibiotic in shorter or longer dipping and aspirating cycles (resulting in shorter or longer local exposure times and less or more systemic absorption and accumulation) while maintaining safe serum concentrations. Concentrations and daily doses may be increased substantially during the initial period of treatment to maximize initial bactericidal activity and then decreased for the remainder of the treatment period. In some instances, the initial concentration and daily dose are 2, 3, 5, 10, or 20 times the remaining dose.

[0068] In some embodiments, the method includes topically administering two or more antibiotics. The two antibiotics may be administered sequentially or not simultaneously. In other embodiments, at least one dose of each antibiotic may be administered simultaneously. In further embodiments, the two antibiotics may be administered at different frequencies. For example, a first antibiotic may be administered topically once daily by soaking for 15 minutes to 4 hours, 30 minutes to 4 hours, 45 minutes to 4 hours, 1 hour to 4 hours, 15 minutes to 3 hours, 30 minutes to 3 hours, 45 minutes to 3 hours, 1 hour to 3 hours, 15 minutes to 2 hours, 30 minutes to 2 hours, 45 minutes to 2 hours, or 1 hour to 2 hours, followed by suction over 30 minutes. A second antibiotic may be administered topically every hour for 10 hours to 15 hours, 15 hours to 20 hours, 20 hours to 22 hours, or 20 hours to 24 hours. The second antibiotic may be administered after the first antibiotic is aspirated, or the two antibiotics may be administered simultaneously while the first antibiotic is being administered.

[0069] In some instances, the two antibiotics may be vancomycin and tobramycin. In at least one instance, vancomycin is topically administered hourly for 20 to 22 hours or 20 to 24 hours by soaking for about 30 minutes followed by suction over 30 minutes, while tobramycin is topically administered once daily. In other instances, the two antibiotics may be tobramycin and daptomycin. In at least one instance, daptomycin is topically administered hourly for 20 to 22 hours or 20 to 24 hours by soaking for about 15, 30, 45, or 60 minutes followed by suction over 30 minutes, while tobramycin is topically administered once daily.

[0070] In various embodiments, topical administration of one or more antibiotics may occur for 24 hours, 2 days, 3 days, 4 days, 5 days, 6 days, 7 days, 10 days, or 14 days. High daily doses of topical administration of one or more antibiotics may allow for a reduction in the amount of time antibiotics need to be administered compared to intravenous, oral, or lower concentration topical administration.

[0071] When two or more antibiotics are administered, at least one of the antibiotics may be administered at a daily dose substantially exceeding the maximum recommended systemic daily dose for that antibiotic. In some instances, both antibiotics may be administered at daily doses substantially exceeding the maximum recommended systemic daily dose for that antibiotic. For example, when vancomycin and tobramycin are administered, the concentration of the daily dose of locally administered vancomycin may range from about 3,000 mcg / mL to about 50,000 mcg / mL, and the daily dose of locally administered tobramycin may range from about 2,000 mcg / mL to about 40,000 mcg / mL. When daptomycin and tobramycin are administered, the concentration of the daily dose of locally administered daptomycin may range from about 3,000 mcg / mL to about 50,000 mcg / mL, and the daily dose of locally administered tobramycin may range from about 2,000 mcg / mL to about 40,000 mcg / mL.

[0072] At least two antibiotics may be administered at a fixed dose ratio. For example, vancomycin / daptomycin and tobramycin may be administered at a fixed dose ratio of 5:1 to 40:1, 5:1 to 10:1, 10:1 to 15:1, 15:1 to 20:1, 20:1 to 25:1, 25:1 to 30:1, 30:1 to 35:1, or 35:1 to 40:1. In some examples, the fixed dose ratio of vancomycin / daptomycin to tobramycin may be 32.8:1, 22:1, or 11:1. The daily dose of vancomycin / daptomycin may be about 3,000 mg / day to 50,000 mg / day, or the daily dose of tobramycin may be about 100 mg / day to 1,200 mg / day. As one example, the daily dose of vancomycin / daptomycin may be at least 3,000 mg / day and / or the daily dose of tobramycin may be at least 100 mg / day. As another example, the daily dose of vancomycin / daptomycin may be at least 4,000 mg / day and / or the daily dose of tobramycin may be at least 125 mg / day. As yet another example, the daily dose of vancomycin / daptomycin may be at least 5,000 mg / day and / or the daily dose of tobramycin may be at least 150 mg / day. Other combinations of timing and dosage are contemplated to effectively treat specific infections and patients in need of treatment.

[0073] Local administration of at least two antibiotics via perfusion may maintain peak or trough serum concentrations of each of the at least two antibiotics below the maximum safe serum concentration of each antibiotic. The maximum safe serum concentration may vary for each antibiotic and may vary from patient to patient. In some examples, the maximum safe trough serum concentration of vancomycin or daptomycin may be 20 mcg / mL to about 30 mcg / mL, and the maximum safe peak serum concentration of tobramycin may be about 4 mcg / mL to about 10 mcg / mL. In some examples, the trough serum concentration of vancomycin or daptomycin may be less than about 30 mcg / mL, less than about 25 mcg / mL, less than about 20 mcg / mL, or less than about 10 mcg / mL, and the trough serum concentration of tobramycin may be less than about 10 mcg / mL, less than about 5 mcg / mL, or less than about 3 mcg / mL.

[0074] Further provided herein is a method of treating a localized infection in a human patient by locally administering to the human patient by perfusion a local concentration that exceeds the maximum recommended concentration of at least one antibiotic, such that the local administration by perfusion provides a peak or trough serum concentration that is less than the maximum safe serum concentration of the at least one antibiotic.

[0075] Also provided herein are methods for treating a musculoskeletal infection in a human patient by administering at least one antibiotic to the human patient at a local administration concentration that exceeds the minimum biofilm eliminating concentration (MBEC) of the at least one antibiotic against one or more of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Staphylococcus epidermidis, enterococci, Escherichia coli, and Pseudomonas aeruginosa. Administering the at least one antibiotic at a concentration that exceeds the MBEC may provide a serum concentration of the antibiotic that is less than the maximum safe serum concentration of that antibiotic. In some embodiments, the method may include administering two antibiotics, at least one of which is administered at a local administration concentration that exceeds the MBEC of that antibiotic against one or more of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Staphylococcus epidermidis, enterococci, Escherichia coli, and Pseudomonas aeruginosa. In other embodiments, the method may include administering at least two antibiotics at local administration concentrations each exceeding the MBEC of at least one antibiotic against one or more of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Staphylococcus epidermidis, enterococci, Escherichia coli, and Pseudomonas aeruginosa. The peak or trough serum concentrations of both antibiotics may be less than the maximum safe serum concentration of each antibiotic.

[0076] In various examples, the at least two antibiotics are vancomycin or daptomycin and tobramycin. The concentration of the locally administered vancomycin or daptomycin may range from about 3,000 mcg / mL to about 50,0000 mcg / mL, and the concentration of the locally administered tobramycin may range from about 100 mcg / mL to about 1,200 mcg / mL. By way of example, the concentration of the locally administered vancomycin or daptomycin may be at least 6,000 mcg / mL, and the concentration of the locally administered tobramycin may be at least 200 mcg / mL. The peak serum concentration of tobramycin may be less than 10 mcg / mL, and the trough serum concentration of vancomycin or daptomycin may be less than 30 mcg / mL.

[0077] Further provided herein is a method of treating a localized infection in a human patient by locally administering to the human patient a daily dose of a first antibiotic that substantially exceeds the maximum recommended systemic daily dose of the first antibiotic, and providing a peak or trough serum concentration of the first antibiotic that is less than or equal to the maximum safe serum concentration of the first antibiotic.

[0078] In certain embodiments, the method may include locally administering to a human patient a daily dose of a first antibiotic and a daily dose of a second antibiotic that substantially exceeds the maximum recommended daily dose of the first antibiotic and the maximum recommended daily dose of the second antibiotic, and providing peak or trough serum concentrations of the first antibiotic and the second antibiotic that are less than or equal to the maximum safe serum concentration of the first antibiotic and the second antibiotic. In some embodiments, the maximum recommended daily dose of each antibiotic is the maximum recommended systemic daily dose.

[0079] In another embodiment, the method may include locally administering to a human patient daily doses of at least two antibiotics that substantially exceed the maximum recommended systemic daily dose of each of the at least two antibiotics, and providing peak or trough serum concentrations that are less than or equal to the maximum safe serum concentration of each of the at least two antibiotics. In some embodiments, the maximum recommended daily dose of each antibiotic is the maximum recommended systemically administered daily dose.

[0080] Also disclosed herein are methods for treating a localized infection in a living tissue of a human patient by locally administering to the human patient a dose of at least one antibiotic greater than 3,500 mg / day. In some examples, the at least one antibiotic is vancomycin or daptomycin, and the locally administered dose is at least 3,500 mg / day, at least 4,000 mg / day, at least 5,000 mg / day, at least 6,000 mg / day, at least 7,000 mg / day, at least 8,000 mg / day, at least 9,000 mg / day, or at least 10,000 mg / day.

[0081] Also disclosed herein are methods for treating a localized infection in a living tissue of a human patient by topically administering to the human patient a dose of tobramycin greater than 150 mg / day, in various examples, the locally administered dose is at least 200 mg / day, at least 300 mg / day, at least 400 mg / day, or at least 500 mg / day.

[0082] In a method for treating a localized infection in a living tissue of a human patient, the method may include topically administering to the human patient two or more doses of at least one antibiotic within a 12- to 24-hour period at a concentration above the MBEC level of the at least one antibiotic for the localized infection. In one example, two to five doses of at least one antibiotic may be topically administered within a 12- or 24-hour period at a concentration above the MBEC level of the at least one antibiotic for the localized infection. In another example, three to seven doses of at least one antibiotic may be topically administered within a 12- or 24-hour period at a concentration above the MBEC level of the at least one antibiotic for the localized infection. In yet another example, eight to twelve doses of at least one antibiotic may be topically administered within a 12- or 24-hour period at a concentration above the MBEC level of the at least one antibiotic for the localized infection.

[0083] In various embodiments, topical administration by any of the disclosed methods reduces or eliminates a localized infection (e.g., Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), Staphylococcus epidermidis, enterococci, Escherichia coli, Pseudomonas aeruginosa, unconfirmed infection, or a combination thereof) by 3 log or more, 3.1 log or more, 3.2 log or more, 3.3 log or more, 3.4 log or more, 3.5 log or more, 3.6 log or more, 3.7 log or more, 3.8 log or more, 3.9 log or more, 4 log or more, 4.1 log or more, 4.2 log or more, 4.3 log or more, 4.4 log or more, 4.5 log or more, 4.6 log or more, or a combination thereof) within 7 days (e.g., after 7 days of topical administration), within 5 days, within 3 days, or within 24 hours of antibiotic administration. or greater, 4.7 log or greater, 4.8 log or greater, 4.9 log or greater, 5 log or greater, 5.1 log or greater, 5.2 log or greater, 5.3 log or greater, 5.4 log or greater, 5.5 log or greater, 5.6 log or greater, 5.7 log or greater, 5.8 log or greater, 5.9 log or greater, 6 log or greater, 6.1 log or greater, 6.2 log or greater, 6.3 log or greater, 6.4 log or greater, 6.5 log or greater, 6.6 log or greater, 6.7 log or greater, 6.8 log or greater, 6.9 log or greater, 7 log or greater, 7.1 log or greater, 7.2 log or greater, 7.3 log or greater, 7.4 log or greater, 7.5 log or greater, 7.6 log or greater, 7.7 log or greater, 7.8 log or greater, 7.9 log or greater, 8 log or greater, or greater. In other words, topical administration by any of the disclosed methods can reduce or eliminate a 3, 3.5, 4, 4.5, 5, 5.5, 6, 6.5, or greater log 20 reduction in localized infections within 7 days (e.g., after 7 days of topical administration), within 5 days, within 3 days, or within 24 hours of antibiotic administration. 10 The localized infection may result in a reduction (LogR) in the infection. In some examples, a localized infection may be considered eradicated if there is a 3-log reduction or greater in infection. Localized administration by any of the disclosed methods may result in killing greater than 98%, 98.5%, 99%, 99.9%, 99.99%, 99.999%, or 100.0% of the CFUs of the localized infection within 7 days, 5 days, 3 days, or 24 hours of administration.

[0084] The methods disclosed herein can be used to provide personalized therapy to patients. In some embodiments, a method for treating a localized infection in a human patient includes identifying at least one microorganism within the localized infection and topically administering two or more antibiotics to the human patient, where at least one of the antibiotics is administered at a concentration above the MBEC level of the at least one antibiotic for the at least one microorganism. In one example, when the microorganism is one or more of Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa, the two or more antibiotics are vancomycin and tobramycin. In another example, when the microorganism is methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococcus (VRE), the two or more antibiotics are daptomycin and tobramycin.

[0085] Identification of at least one microorganism can be used to determine which antibiotics should be administered locally to the patient. The at least one microorganism may be identified by clinical testing of a sample from the local infection site. In some instances, the microorganism may be identified before administration of the two or more antibiotics. In other instances, the microorganism may not be identified, or may be identified after administration has already begun. For example, it may take several hours to several days, or several days to several weeks, to receive the results of the identification of the microorganism(s). Therefore, it may be in the patient's interest to begin local administration of at least two antibiotics before knowing the identity of the microorganisms, and then switch one or more antibiotics during the course of administration if the identified microorganism(s) would be more susceptible to a different antibiotic or a different antibiotic combination of the at least two antibiotics.

[0086] In some embodiments, a method of treating a localized infection in a human patient may include topically administering two or more antibiotics to the human patient, identifying at least one microorganism within the localized infection during administration, and optionally switching at least one of the antibiotics to a different antibiotic after identifying the at least one microorganism. In another embodiment, provided herein is a method of treating a localized infection in a human patient, including topically administering a first antibiotic combination comprising two or more antibiotics to the human patient, identifying at least one microorganism within the localized infection, and optionally switching at least one of the antibiotics to provide a second antibiotic combination comprising two or more antibiotics, wherein the second antibiotic combination has a log 100% reduction in the number of microorganisms identified compared to the first antibiotic combination against the identified microorganism. 10 or greater than 0.5 log reduction (LogR) (e.g., greater than 0.5 log, greater than 1 log, greater than 1.5 log, greater than 2.0 log, greater than 2.5 log, greater than 3.0 log, greater than 3.5 log, greater than 4.0 log, or greater improvement within 7 days, 6 days, 5 days, 4 days, 3 days, 2 days, or 24 hours of administration of the second antibiotic combination). At least one of the antibiotics may be administered at a concentration above the MBEC level of the at least one antibiotic for at least one microorganism, and at least one of the antibiotics may be switched if treatment is more effective against the identified microorganism. In one example, if the two or more antibiotics initially administered are vancomycin and tobramycin, the administration may remain the same when the microorganism is one or more of Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa, but the vancomycin may be switched to daptomycin when the microorganism is methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), or a combination thereof.

[0087] The methods disclosed herein may result in reduced reinfection rates, reduced hospital readmission rates, and / or reduced mortality or sepsis rates compared to patients treated without high local concentrations of antibiotics. In some examples, patients treated with the disclosed methods may have reinfection rates that are at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% lower than patients not treated using the disclosed methods. In some examples, patients treated with the disclosed methods may have readmission rates that are at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% lower than patients not treated using the disclosed methods. In additional examples, treated patients may not be readmitted to the hospital for at least 30 days, at least 90 days, at least 180 days, or at least one year. In some examples, patients treated with the disclosed methods may have mortality rates that are at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% lower than patients not treated using the disclosed methods. In some examples, patients treated with the disclosed methods may have sepsis or other infection rates that are at least 10%, at least 20%, at least 30%, at least 40%, or at least 50% lower than patients not treated using the disclosed methods.

[0088] In another embodiment, local administration of two or more doses of at least one antibiotic within a 12-hour or 24-hour period to a human patient can maintain the AUC / MBEC in biological tissue for at least 5 hours per day, at least 10 hours per day, at least 12 hours per day, at least 18 hours per day, or at least 22 hours per day.

[0089] In yet another embodiment, the method may comprise administering to a human patient a dose of at least 25 mg of vancomycin or daptomycin at a concentration of 3,000 mcg / mL or greater by topical irrigation, and providing the patient with a trough serum concentration of less than 30 mcg / mL for 24 hours after administration.

[0090] In additional embodiments, the method may comprise administering a dose of vancomycin or daptomycin and a dose of tobramycin to a human patient by topical lavage, wherein the doses comprise a dose of at least 50 mg of vancomycin or daptomycin at a concentration of 3,000 mcg / mL or greater and a dose of at least 50 mg of tobramycin at a concentration of 1,500 mcg / mL or greater. Subsequent administration by topical lavage may provide the patient with a trough serum concentration of vancomycin or daptomycin of less than 30 mcg / mL and a peak serum concentration of tobramycin of less than 10 mcg / mL for 24 hours after administration.

[0091] In one method, 50 cc of vancomycin or daptomycin and tobramycin may be administered sequentially at equal concentrations of 3,000 mcg / mL for 7 days, with vancomycin or daptomycin administered hourly for 20 hours and tobramycin administered once daily, for a fixed dose ratio of 20:1. The daily doses for this method are 150 mg tobramycin and 3,000 mg vancomycin / daptomycin, for a total dose of 1.05 g tobramycin and 21 g vancomycin / daptomycin. In another method, vancomycin / daptomycin is administered hourly for 20 hours at 10,000 mcg / mL, twice the concentration of tobramycin, and tobramycin is administered once daily at 5,000 mcg / mL, for 5 days, for a fixed dose ratio of 40:1. In this method, the daily dose is 250 mg tobramycin and 20,000 mg vancomycin / daptomycin, for a total dose of 1.25 g tobramycin and 100 g vancomycin / daptomycin. In this method, either or both of the antibiotic concentrations and daily doses administered exceed the previously known safety limits for each antibiotic. In this method, new doses and concentrations are administered while providing safe serum concentrations of each antibiotic that are below clinically established limits. The maximum dose and concentration that may be administered are pharmacokinetically calculated based on the selected daily exposure and known values ​​of pharmacokinetic parameters, and such doses and concentrations may be empirically adjusted before or during administration for patients with abnormal antibiotic absorption or excretion.

[0092] In one method, one or more antibiotics may be administered at a concentration that exceeds the previously known safe concentration of such antibiotics, at a previously known safe dose, while simultaneously providing a clinically established safe systemic level of the antibiotic. This is achieved by perfusing the infected site at a higher concentration and less frequently per day to administer a daily dose that remains within previously known safety limits. In another method, one or more antibiotics may be administered at a concentration within known safety limits, at a daily dose that exceeds the previously known safe daily dose, while simultaneously providing a clinically established safe systemic level of the antibiotic. This is achieved by perfusing the infected site at a higher concentration and less frequently per day to administer a daily dose that remains within previously known safety limits.

[0093] When two or more antibiotics are administered in the methods described herein, they may be administered at a 1:1 fixed dose ratio. However, based on the wide variability in MBEC values ​​of different antibiotics for the same organism, it may be beneficial to administer the antibiotics at a fixed dose ratio that exceeds the previously established maximum safe daily dose ratio for such antibiotics. For example, based on the 5th and 95th percentiles of patient weight in the United States, the minimum and maximum recommended daily systemic doses of vancomycin are approximately 1,200 g and 7,500 g, respectively, and the minimum and maximum recommended daily systemic doses of tobramycin are approximately 200 g and 1,250 g, respectively. The resulting recommended fixed dose ratio of vancomycin to tobramycin is 6:1. The methods disclosed herein describe administering antibiotics at or above the MBEC of the target organism while maintaining safe systemic levels of the antibiotic. In such cases, the fixed dose ratio may exceed previously known systemic dose ratios. In one method, as described above, the vancomycin to tobramycin dose ratio is 40:1. In another method, the fixed dose ratio of vancomycin to tobramycin is 125: 1. In yet another method, the fixed dose ratio of vancomycin to tobramycin is 10: 1.

[0094] Not all antibacterial agents may be administered simultaneously due to incompatibility of antibiotic solutions or differences in their pharmacodynamic targets. For example, tobramycin is administered for an optimal concentration-dependent target with an optimal exposure time of 2 hours at therapeutic levels, while vancomycin is administered for an optimal pharmacodynamic target of AUC / MIC or total daily exposure. An additional advantage of administering antibiotics via the perfusion route is that multiple antimicrobial solutions may be administered simultaneously or sequentially at or above the therapeutic target, thereby successfully treating multiple pathogens within an acceptable clinical time frame. For example, tobramycin may be administered for 2 hours once or twice daily, while vancomycin may be administered for the remainder of the day to maximize total daily exposure.

[0095] In general, therapeutics are developed with the goal of safely delivering the minimum effective dose to a patient for the treatment of a specific condition, symptom, or set of symptoms. The clinical challenge of treating localized musculoskeletal infections, such as BII or FRI, is that the specific pathogen(s) involved are unknown or polymicrobial (known or unknown) and are likely to be biofilm-forming and / or antibiotic-resistant. Highly effective antibiotic eradication of localized infections in the presence of antibiotic-resistant organisms and / or organisms that have formed mature biofilms has not been achieved to date. This is primarily due to the direct conflict between the extremely high doses and concentrations of antibiotics required to eradicate such organisms and maintaining patient safety, as well as the previously unknown doses, concentrations, and combinations capable of eradicating biofilms.

[0096] While the antibiotic doses and concentrations and methods described herein may be described in the context of a particular infection, it should be understood that other infections or conditions are contemplated as well. For example, if a method is described as useful for periprosthetic joint infections, the method may also be used for breast implant infections, other infected wounds such as traumatic wounds, diabetic ulcers, osteomyelitis, surgical site infections, etc. The antibiotics and methods described herein may be configured for use in a variety of localized infections and treatment sites beyond those specifically listed herein.

[0097] The treatment methods described herein may be performed manually (e.g., injecting antibiotics with a syringe and removing fluid via a gravity drain), semi-automatically (e.g., injecting with a syringe pump and aspirating with an active drainage device), or automatically (e.g., via a purpose-built perfusion delivery system). The perfusion delivery system may control the perfusion of multiple antibiotics (e.g., delivery and removal of therapeutic antibiotics) according to a set protocol, including one or more sequential stages for delivery at one or more times and durations per day.

[0098] Also provided herein are therapeutic delivery systems and / or perfusion devices for treating localized infections in biological tissue of a human patient in need thereof. The therapeutic delivery systems and / or perfusion devices may be configured to locally administer a daily dose of greater than 3,500 mg of vancomycin to biological tissue and / or a daily dose of greater than 150 mg of tobramycin.

[0099] In some embodiments, the therapy delivery system and / or irrigation device may further include a suction component and / or a flushing component. The suction component may be configured to apply suction to or around the biological tissue to remove any remaining antibiotic at the site of infection. For example, the suction component may be configured to apply a vacuum of at least -50 mmHg to the biological tissue for about 30 minutes. The flushing component may be configured to deliver a flushing fluid to the biological tissue to wash / flush any remaining antibiotic from the site of infection.

[0100] Also disclosed herein are kits for treating localized infections in living tissue of a human patient. The kits may include at least one antibiotic, a therapeutic delivery system and / or perfusion device configured to locally perfuse (inject and aspirate) a series of doses of the at least one antibiotic, and instructions for administering a daily dose of the at least one antibiotic at a concentration above the MBEC level of the at least one antibiotic for the localized infection. It is further contemplated that the instructions may include procedures for administering the at least one antibiotic according to any of the methods disclosed herein. In some examples, the kits may include two or more antibiotics, a therapeutic delivery system and / or perfusion device, and instructions for administering two or more antibiotics, wherein at least one of the antibiotics is at a concentration above the MBEC level of the at least one antibiotic for the localized infection. The kits may include three or more antibiotics, a therapeutic delivery system and / or perfusion device, and instructions for administering two or more antibiotics, wherein at least one of the antibiotics is at a concentration above the MBEC level of the at least one antibiotic for the localized infection.

[0101] In another embodiment, the kit may include a first antibiotic combination of two or more antibiotics, a second antibiotic combination of two or more antibiotics, a therapeutic delivery system and / or a perfusion device, and instructions for administering the first antibiotic combination and / or the second antibiotic combination, wherein at least one of the antibiotics in the first or second antibiotic combination is at a concentration above the MBEC level of the at least one antibiotic for the localized infection. In some examples, the therapeutic delivery system and / or perfusion device is configured to locally administer via perfusion to living tissue a daily dose of greater than 3,500 mg of vancomycin or daptomycin and / or locally administer via perfusion a daily dose of greater than 150 mg of tobramycin.

[0102] In some examples, the one or more, two or more, or three or more antibiotics may be selected from vancomycin, daptomycin, tobramycin, and / or any antibiotic known in the art. In some examples, the antibiotics may be provided in undiluted form in a vial or other container. The end user can then combine the one or more antibiotics with saline or other biocompatible fluid at a desired concentration in one or more fluid reservoirs when ready to administer the antibiotic(s). In other examples, the antibiotics may be provided in saline and stored in a fluid reservoir, such as a bag. In various embodiments, a kit may include one or more antibiotics and any combination of a therapy delivery system, a perfusion device, a fluid reservoir, any other components necessary for the therapy delivery system or perfusion device to function properly, and instructions for administering the antibiotic(s). In some cases, the kit may be provided separately to the end user, with individual components of the kit arriving at the end user at different times and then assembled by the end user prior to administration to a patient.

[0103] 7A-7B show examples of a therapy delivery system 100 and perfusion device 107 that can provide controlled delivery of one or more antibiotics to a treatment site 102 (e.g., an infection in a periprosthetic space, a bone segment, or a wound area). The therapy delivery system 100 and perfusion device 107, in whole or in part, may be included in a kit. Generally, the therapy delivery system 100 can include a (portable) disposable device that allows adjustment of the distance between the therapy delivery system 100 and a patient's treatment site 102 (e.g., a patient suffering from an infection treatable with fluid perfusion). In the example illustrated in FIG. 7A, the therapy delivery system 100 provides perfusion to a treatment site 102 (e.g., a joint space or a bone segment) that includes an perfusable volume. The system 100 can include a fluid delivery system 104A, a fluid collection system 104B, and a control system 106. The fluid delivery system 104A can include one or more fluid reservoirs 108A, B. In some examples, one or more fluid reservoirs 108A,B may contain one or more antibiotics provided by the kit. For example, fluid reservoir 108A may contain a first antibiotic, such as tobramycin in a saline solution, and fluid reservoir 108B may contain a second antibiotic, such as vancomycin or daptomycin in a saline solution. Fluid collection system 104B may include one or more collection fluid canisters 109.

[0104] In some examples, the control system 106 may control the flow of fluid from the fluid reservoirs 108A, B to the treatment site 102 and / or draw fluid from the treatment site 102 to the fluid recovery system 104B. For example, the control system 106 may include one or more of a vacuum source, a pump, or any other means for moving fluid through the system 100. In some examples, one means for moving fluid may be used for both infusing and withdrawing fluid from the treatment site 102. In other examples, one means may be used for infusing and another means for withdrawing. The system may be configured to deliver fluid percutaneously to a perfusion device positioned within the treatment area (e.g., infected tissue and / or infected joints, such as the hip, knee, shoulder, wrist, or ankle). Although not shown, one or more other medical devices may assist, coordinate with, and / or operate in parallel with the therapy delivery system 100 to provide therapy to the patient (including the treatment site 102).

[0105] In certain examples, the perfusion device 107 can be configured to fluidly couple to the therapy delivery system 100, as illustrated in FIG. 7A. The therapy delivery system 100 can also be coupled to a syringe or another manual component for delivery and withdrawal of fluid from the treatment site. In some embodiments, the perfusion device 107 can have a porous component 103. The porous component 103 of the perfusion device 107 can be configured to fill spaces and / or openings in the treatment site and allow fluid exiting the tubing to flow through the porous component 103 and into the treatment site 102.

[0106] The treatment system 100 may be configured to fluidly couple to a perfusion device 107 that may provide controlled delivery of fluid (e.g., antibiotics, saline, local anesthetic) to a treatment site 102 (e.g., an infected joint such as a knee or hip) during, for example, an I&D, DAIR, Double DAIR, or another procedure described elsewhere herein, or other types of healing, including wound and perioperative healing.

[0107] By way of example context, therapy delivery system 100 may be used to deliver one or more antibiotics to an infected joint (e.g., hip, knee, shoulder, wrist, ankle) or any type of biological tissue that can be treated using controlled fluid irrigation. Examples of treatments include periprosthetic joint infection treatment protocols such as debridement, antibiotic and implant retention (DAIR) and exchange arthroplasty, irrigation of surgical incisions and traumatic wounds, or irrigation for osteomyelitis and septic arthritis. While the present application may be described in the context of a particular treatment site (e.g., an infected joint) and its connections to that site, it should be noted that other treatment sites are contemplated, and the manner in which the system interfaces with these various sites may vary.

[0108] 7A-7B, the fluid delivery system 104A includes two or more fluid reservoirs 108A, 108B.

[0109] Each of the fluid reservoirs 108A, 108B may have a specific volume and may store a specific fluid type to be delivered during a respective treatment phase. The contents of the fluid reservoirs may be switched so that a first antibiotic is stored in either the first fluid reservoir 108B or the second fluid reservoir 108A, and a second antibiotic is stored in either the second fluid reservoir 108A or the first fluid reservoir 108B. The fluid reservoirs may, in some examples, contain a combination of antibiotics. The fluid reservoirs may be provided as part of a kit or may be provided separately and combined with one or more antibiotics of the kit prior to use.

[0110] For example, the first fluid reservoir 108A may contain or store a first fluid, which may include an antibiotic (e.g., a first antibiotic), such as tobramycin, or a combination of first antibiotics. The first fluid may be delivered from the first fluid reservoir 108A to the treatment site 102 according to a respective fluid delivery protocol. The fluid delivery protocol may be included in the kit's instructions. The protocol may define the concentration of the first antibiotic, the volume of the first antibiotic fluid to be delivered, the duration of antibiotic fluid delivery, and a pre-delivery vacuum, which may be performed at a set pressure (e.g., -125 mmHg) for a set vacuum time period (e.g., approximately 30 minutes). The volume of the first antibiotic fluid delivered to the treatment site 102 may be set in the range of 6 mL to 500 mL, for example, 50 mL. In some implementations, approximately 80 mg of tobramycin sulfate in 50 mL of 0.9% sodium chloride is delivered in approximately 30 to 60 seconds for a total soak of two hours within a single 24-hour period. The delivery of the first fluid volume can be controlled with an accuracy of ± approximately 5 mL to 10 mL. In some applications, delivery of the first antibiotic fluid is followed by a soaking protocol to allow the treatment site 102 to soak in the delivered fluid. The duration of the first antibiotic fluid soaking protocol can be one to three hours, for example, about two hours. The first antibiotic fluid can be removed from the treatment site 102 by the fluid collection system 104B before the second fluid is delivered to the treatment site 102. The duration of the first antibiotic fluid removal from the treatment site 102 can be approximately 30 minutes.

[0111] The second fluid reservoir 108B may store a second fluid, which may include an antibiotic (e.g., a second antibiotic) such as vancomycin or daptomycin, or a second antibiotic combination. The volume of the second fluid delivered to the treatment site 102 over a period of time may be set between 500 mL and 1500 mL, for example, in the range of 1200 mL. This may vary depending on the total volume of the second antibiotic fluid delivered, the length of the period, and the total time for delivery, soaking, and removal of the first fluid. For example, in a 24-hour period in which the delivery, soaking, and removal of the first fluid were 2 hours, the duration of delivery of the second fluid may be approximately 22 hours. The delivery of the second antibiotic fluid volume may be controlled with an accuracy of ± approximately 5 mL. Delivery of the second antibiotic fluid is followed by a soaking protocol that allows the treatment site 102 to soak in the delivered fluid. The duration of the second antibiotic fluid soaking protocol may be between 15 and 45 minutes, for example, approximately 30 minutes. The second fluid may be removed from the treatment site 102 by the fluid recovery system 104B. The duration of the second fluid removal from the treatment site 102 may be approximately 30 minutes. In some applications, multiple cycles of delivery, soaking, and removal of the second antibiotic fluid are repeated before the first fluid is subsequently delivered to the treatment site 102. For example, the treatment protocol may be repeated over multiple (e.g., 5, 6, 7) days, with the first antibiotic fluid being delivered once to soak the treatment area 102 each day, and after removal of the first fluid, multiple cycles of delivery, soaking, and removal of the second antibiotic fluid being repeated to complete the 24-hour treatment protocol. For example, on day 1, the treatment site 102 and system may be primed, and a vacuum may be established in the system, such as by a pump. After seal checks and confirmation in the system, the first fluid may be delivered and allowed to soak as described above. After removal of the first fluid, the second fluid may be delivered and allowed to soak, then removed multiple times (e.g., 20-23 times) for the remainder of Day 1. At the start of Day 2 (e.g., 24 hours after the start of treatment), the canister and / or one or more reservoir bags may be replaced and the seal verified. A pretreatment vacuum cycle may be initiated prior to the start of delivery and soaking of the first fluid.After removal of the first fluid, the second fluid is delivered and allowed to soak, and then may be removed multiple times (e.g., 20-23 times) for the remainder of day 2. This one-day protocol may be repeated for up to about 7 days, about 10 days, about 14 days, or any period for which treatment is desired.

[0112] The fluid collection system 104B can direct fluid from the treatment site 102 to the collection fluid canister 109. In some examples, the control system 106 can create a vacuum within the collection fluid canister 109 to remove fluid from the treatment site 102 to the collection fluid canister 109. For example, a pump can be activated by the control system 106 to create a vacuum within at least the collection fluid canister 109. In other examples, a vacuum pressure source, a syringe, gravity, a pump, or any other mechanism for moving fluid into or out of the treatment site 102 is contemplated. The collection fluid canister 109 can include a single-use canister having a known volume (e.g., 2000 mL). The collection fluid canister 109 collects antibiotic solution or other fluids (e.g., wound exudate) that accumulate during vacuum-induced drainage of fluid from the treatment site 102. The material of the canister 109 is preferably translucent or transparent so that during use the user can assess the level of contents within the canister 109. The material of the canister 109 is also preferably capable of holding a vacuum at the maximum vacuum level without deforming or restricting flow. [Example]

[0113] Example 1: Serum concentrations of vancomycin and tobramycin administered by perfusion Irrigation of vancomycin and tobramycin within the manufacturer's recommended systemic dose range for the treatment of periprosthetic joint infection (PJI) has been clinically studied. For 7 days after the first stage of a two-stage exchange arthroplasty procedure, a daily dose of 2.6 g of vancomycin at a concentration of 2,500 mcg / mL and a daily dose of 80 mg of tobramycin at a concentration of 1,600 mcg / mL were administered by irrigation to the infected joint. The serum concentration levels of vancomycin and tobramycin in this study were well below the safe serum concentrations of each antibiotic. The serum concentrations of vancomycin over a 7-day period in 37 human subjects who received intermittent local irrigation of 50 cc of vancomycin at a concentration of 2,500 mcg / mL are shown in Figure 6. Each dose was administered hourly, soaked into the joint (knee or hip) for 30 minutes, and aspirated by applying a −125 mmHg vacuum to the joint for 30 minutes before repeating the hourly cycle for 21.5 hours per day.

[0114] Peak serum concentrations of tobramycin over 7 days in 37 human clinical study subjects receiving daily local irrigation of 50 cc at a concentration of 1,600 mcg / mL were minimal and below the limit of detection in most subjects. Each dose was administered once daily, immersed in the joint (knee or hip) for 120 minutes, and aspirated by applying a -125 mmHg vacuum to the joint for 30 minutes before repeating the hourly vancomycin irrigation cycle for the remaining 21.5 hours of the day.

[0115] Example 2: Tobramycin and vancomycin against preformed biofilms Eradication of preformed biofilms from six clinically relevant strains using tobramycin and vancomycin was demonstrated using a modified BEST Assay. TM The device was evaluated using the BEST Assay TM The device and protocol were developed to perform high-throughput testing of medical devices. TMThe method quantitatively measures microbial colonization on and around medical devices. The protocol presented herein was designed to evaluate the efficacy of tobramycin and vancomycin treatment against pre-formed biofilms to determine their feasibility as a treatment for prosthetic joints infected with established biofilms.

[0116] Specifically, this study was conducted to determine the antibiofilm efficacy of a 2-hour treatment with tobramycin followed by 30-minute alternating treatments of vancomycin / rest treatments given for 1 day or repeated for 7 days against Pseudomonas aeruginosa, Escherichia coli, Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), and Staphylococcus epidermidis.

[0117] In the first test (code B in the table below), tobramycin was administered in the challenge medium at a concentration of 1,600 μg / mL and contacted with the biofilm for 2 hours, followed by vancomycin in the challenge medium at a concentration of 2,500 μg / mL and contacted with the biofilm for 22 hours. In the second test (code C in the table below), tobramycin was administered in the challenge medium at a concentration of 1,600 μg / mL and contacted with the biofilm for 2 hours, followed by vancomycin in the challenge medium at a concentration of 2,500 μg / mL in 30-minute pulses over 22 hours. Table 1 provides a description of the samples and contact times. The challenge medium contained 20% TSB made up in saline (0.9% NaCl) for S. aureus, S. epidermidis, and E. faecalis, and 10% TSB made up in saline (0.9% NaCl) for E. coli and P. aeruginosa. [Table 1]

[0118] BEST Assay TMThe plates were assembled using hydroxyapatite-coated polyurethane / acrylate coupons measuring 8 mm x 15 mm. TM Plates were either standard or contained three ports in each well to allow for the addition / removal of challenge medium. Antimicrobial treatment was administered for 1 or 7 days.

[0119] BEST Assay TM Device setup: The study was conducted as two separate challenges (one per time point): a 1-day challenge was conducted first, and data from the 1-day challenge were used to modify the challenge settings before proceeding to the 7-day challenge.

[0120] Subculture, inoculum preparation, and biofilm formation: Using frozen stocks (approximately -80°C), the first subculture of the above microorganisms was streaked onto TSA plates. The plates were incubated at 37±2°C for 20±4.0 hours and then stored wrapped in parafilm at approximately 4°C until needed. From the first subculture plate, a second subculture plate was streaked as above and used within 32 hours. From the second subculture plate, a single colony was picked and used to inoculate approximately 10 mL of sterile TSB. The liquid culture was incubated on a rotary shaker (110±10 rpm) at 37±2°C for 20±2.0 hours.

[0121] The overnight culture was diluted in biofilm growth medium (100% TSB). This was designated the inoculum and quantified by serial dilution and spot plating. The inoculated plates were incubated at 37 ± 2°C and counted after approximately 16–24 h of incubation. Data were evaluated as total CFU recovered per device.

[0122] Add 2 mL of inoculum to a 24-well plate containing the BEST Assay TMThe cells were added to the appropriate wells of the device, and the entire device was placed on a rotary shaker (110±10 rpm) and incubated at 37±2° C. for 24±2 hours.

[0123] Challenge: After 24 hours of incubation, the coupons were rinsed once with 2.5 mL / well saline for 30 seconds. The coupons were then transferred to either 2.5 mL / well tobramycin (at the concentrations listed in Table 1) or 2.5 mL / well challenge medium and incubated for 2 hours ± 10 minutes at 37 ± 2°C without shaking. After 2 hours of incubation, the coupons were rinsed once with 2.5 mL / well saline for 30 seconds. The coupons were transferred to either 2.5 mL / well vancomycin (at the concentrations listed in Table 1) or 2.5 mL challenge medium and the time was recorded. Standard BEST Assay TM Plates were incubated at 37±2° C. for 22±1 hours without shaking.

[0124] Modified BEST Assay TM For plates, use tubing connected to a vacuum pump and two multi-channel peristaltic pumps. TM The device was attached. The vacuum pump and peristaltic pump were controlled using Labview. Every 30 minutes, the vacuum pump removed the medium in each well of the device, and then the peristaltic pump immediately replaced the medium with either antibiotic solution or rinse solution. This was done every 30 minutes for a total of 22±1 hours. For challenges carried out over one day, the above process was repeated once a day (every 24±1 hour). Biofilm Recovery:

[0125] Biofilm Recovery: The coupon samples were rinsed once with 2.5 mL of sterile saline. The coupons were placed in 2.5 mL of DE neutralizing broth.

[0126] The coupons were sonicated for 30 minutes. After sonication, the coupons were transferred to 2.5 mL of TSB and incubated at 37 ± 2°C for 24 ± 2 hours, and evaluated for the presence or absence of growth (+ / -) based on the development of turbidity. After sonication, the recovered suspension was serially diluted and spot-plated onto TSA. The inoculated plates were incubated at 37 ± 2°C and counted after approximately 16-24 hours of incubation. Data were evaluated as total CFU recovered per device. Log 10 The reduction was compared to the counts in the control sample.

[0127] Because the number of viable bacteria recovered from the test coupons was expected to be low, a membrane filtration step was incorporated to count the attached organisms. The remaining recovery solution was filtered through a 0.45 μm filter membrane. Additional saline was added to ensure the recovery solution completely covered the membrane. The filters were placed on TSA plates, incubated at 37 ± 2°C, and counted after 16–24 hours. All CFU on the filter plates were counted.

[0128] result: Tables 3a and 3b summarize the results of daily dosing with static tobramycin and vancomycin (code B from Table 1) and pulsed vancomycin (code C from Table 1) compared to the control (code A). Tables 4a and 4b summarize the comparison of daily dosing with code C and code B. The results show that pulsing vancomycin resulted in a similar log reduction compared to static vancomycin dosing, with both dosing methods achieving a Log reduction of greater than 4.0 for most biofilms compared to the growth control. 10 This results in a decrease. [Table 2] [Table 3] [Table 4] [Table 5]

[0129] Tables 5a and 5b summarize the results of 7-day dosing with static tobramycin and vancomycin (code B from Table 1) and pulsed vancomycin (code C from Table 1) compared to the control (code A). Tables 4a and 4b summarize the comparison of code C and code B for 7-day dosing. The results show that pulsing vancomycin resulted in a similar log reduction compared to static vancomycin dosing, with both dosing methods achieving a Log reduction of greater than 4.0 for most biofilms compared to the growth control. 10 This results in a decrease. [Table 6] [Table 7] [Table 8] [Table 9]

[0130] Example 3: Tobramycin and vancomycin / daptomycin for eradicating pre-formed biofilms Eradication of preformed biofilms from six clinically relevant strains using tobramycin and vancomycin / daptomycin was evaluated using the MBEC Assay® device. The MBEC Assay® device consists of a 96-peg lid and a corresponding receiver plate with 96 individual wells with a maximum working volume of 200 μL. Biofilms were established on the pegs under batch conditions with gentle mixing (i.e., no nutrient flow into or out of individual wells), resulting in the formation of 96 nearly identical biofilms. The ability of antimicrobial combinations to eliminate preformed biofilms was determined by treating these preformed biofilms with the antimicrobial agents and quantifying the cells remaining on the pegs. Log 10 Reductions were calculated relative to a growth control consisting of challenge medium without added antimicrobial agent.

[0131] Specifically, this study was conducted to determine the antibiofilm effects of treatment with various concentrations of tobramycin and vancomycin / daptomycin against Staphylococcus epidermidis, Staphylococcus aureus, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa. Various concentrations of tobramycin (1,600 μg / mL to 40,000 μg / mL) were contacted with the biofilm for approximately 2 hours, followed by various concentrations of either vancomycin or daptomycin (2,500 μg / mL to 50,000 μg / mL) for approximately 11 hours. Table 7 provides a description of the samples and contact times. [Table 10]

[0132] Subculture, inoculum preparation, and biofilm formation: Using cryogenic stocks (approximately -80°C), first subcultures of each of the microorganisms listed above were streaked onto TSA plates. Plates were incubated at 37±2°C for 20±4.0 hours, then wrapped in parafilm and stored at approximately 4°C until needed. From the first subculture plate, second subculture plates were streaked as described above and used within 32 hours. From the second subculture plate, a single colony was picked and used to inoculate 10-50 mL of sterile growth medium. Liquid cultures were incubated at 37±2°C for 20±2.0 hours on a rotating shaker (110±10 rpm).

[0133] The overnight culture was diluted in biofilm growth medium (100% TSB). This was referred to as the inoculum and was quantified by serial dilution and spot plating. 150 μL of the inoculum was added to the appropriate wells of a 96-well plate, and the MBEC Assay® lid was placed on the plate. 150 μL of sterile water was added to all remaining wells. The entire apparatus was placed on a rotating shaker (110 ± 10 rpm) and incubated at 37 ± 2 °C for 24 ± 2 hours.

[0134] Calling Plates: A total of six MBEC Assay® plates were used (one uncoated and two HA-coated per time point), including 13- and 24-hour challenge.

[0135] To prepare the MBEC Assay® first challenge plate and first tobramycin challenge using a sterile 96-well microtiter plate, the following was performed under sterile conditions: 200 μL of sterile challenge medium containing tobramycin at the concentrations listed in Table 7 was added to the appropriate wells of the 96-well plate. Some wells received 200 μL of sterile challenge medium without antibiotic. The medium concentration (i.e., 10% or 20% TSB) matched that used on the rest of the plate. Some wells received 200 μL of sterile challenge medium containing 1,600 μg / mL tobramycin.

[0136] The biofilm-bearing MBEC Assay® lids were transferred to a new plate containing 200 μL of saline per well for 30-60 seconds, and the control pegs were snapped off and placed in 200 μL of D / E recovery medium for recovery. The lids were then transferred to the tobramycin challenge plate in an unsealed pouch containing moist paper towels to maintain humidity and incubated at 37 ± 2°C for 2 hours ± 15 minutes without shaking.

[0137] An MBEC Assay® second challenge plate was prepared for the first vancomycin or daptomycin challenge. 200 μL of sterile challenge medium containing the desired antibiotic (vancomycin or daptomycin) at the concentration listed in Table 7 was added to the appropriate wells of the 96-well plate. Some wells received 200 μL of sterile challenge medium without antibiotic. The medium concentration (i.e., 10% or 20% TSB) matched that used on the rest of the plate. Some wells received 200 μL of sterile challenge medium containing 2,500 μg / mL vancomycin or 2,500 μg / mL daptomycin.

[0138] The biofilm-bearing MBEC Assay® lids were transferred to a new plate containing 200 μL of saline per well for 30–60 seconds. The lids were then transferred to a vancomycin or daptomycin challenge plate in an unsealed bag containing moist paper towels to maintain humidity and incubated at 37 ± 2°C for 11 ± 0.5 hours without shaking. After this incubation, the 13-hour challenged plate was collected, while the 24-hour challenged plate continued for further incubation. After the 11-hour incubation, the biofilm-bearing MBEC Assay® lids were transferred to a new plate containing 200 μL of saline per well for 30–60 seconds. The biofilm-bearing MBEC Assay® lids were transferred to a new plate containing 200 μL of sterile challenge medium without antibiotics per well in an unsealed bag containing moist paper towels to maintain humidity and incubated at 37 ± 2°C for 11 ± 2 hours without shaking. After this incubation, the 24-hour challenged plates were harvested.

[0139] Biofilm Log 10 Decrease: After the desired challenge time, the amount of biofilm remaining on the pegs was determined. The MBEC Assay® lids were rinsed in sterile saline for 30 seconds by transferring each lid to three consecutive 96-well base plates containing 200 μL of saline. The Assay® lids were transferred to a collection plate containing 200 μL of collection medium per well. The devices were sonicated for 30 ± 5 minutes. After sonication, the recovered CFUs were quantified by serial dilution and spot plating.

[0140] Plates were incubated at 37±2°C and counted after 16-24 hours of incubation, after which the plates were further incubated for approximately 20 hours and counted again. Data were expressed as Log 10The log reduction was calculated as CFU / PEG compared to the growth control. 100 μL of 100% TSB was added to each well of the recovery plate and incubated at 37 ± 2°C for approximately 15 hours for the 13-hour time point and 24 ± 2 hours for the 24-hour time point. After incubation, 10 μL from each well was spotted onto a TSA plate and incubated at 37 ± 2°C for 16–24 hours and assessed for the presence or absence of growth (+ / -).

[0141] result: Table 8a summarizes the LogR and % kill results for various concentrations of tobramycin and vancomycin against P. aeruginosa. Table 8b summarizes the LogR and % kill results for various concentrations of tobramycin and daptomycin against P. aeruginosa. [Table 11] [Table 12]

[0142] Table 9a shows a summary of the LogR and % kill results for various concentrations of tobramycin and vancomycin against E. coli. Table 9b shows a summary of the LogR and % kill results for various concentrations of tobramycin and daptomycin against E. coli. [Table 13] [Table 14]

[0143] Table 10a shows a summary of the LogR and % kill results for various concentrations of tobramycin and vancomycin against S. epidermidis. Table 10b shows a summary of the LogR and % kill results for various concentrations of tobramycin and daptomycin against S. epidermidis. [Table 15] [Table 16]

[0144] Table 11a shows a summary of the LogR and % kill results for various concentrations of tobramycin and vancomycin against Enterococcus faecalis. Table 11b shows a summary of the LogR and % kill results for various concentrations of tobramycin and daptomycin against Enterococcus faecalis. [Table 17] [Table 18]

[0145] Table 12a shows a summary of the LogR and % kill results for various concentrations of tobramycin and vancomycin against Staphylococcus aureus. Table 12b shows a summary of the LogR and % kill results for various concentrations of tobramycin and daptomycin against Staphylococcus aureus. [Table 19] [Table 20]

[0146] Table 13a shows a summary of the LogR and % kill results for various concentrations of tobramycin and vancomycin against Staphylococcus aureus (MRSA). Table 13b shows a summary of the LogR and % kill results for various concentrations of tobramycin and daptomycin against Staphylococcus aureus (MRSA). [Table 21] [Table 22]

[0147] Definition: In various embodiments, the description is provided with reference to the drawings. However, certain embodiments may be practiced without one or more of these specific details or in combination with other known methods and configurations. In this description, numerous specific details, such as specific doses, fixed dose combinations, and concentrations, are presented to provide a thorough understanding of the present invention. In other instances, specific doses, fixed dose combinations, and concentrations are not described in particular detail to avoid unnecessarily obscuring the description. References throughout this specification to "doses," "fixed dose ratios," "concentrations," and the like, mean that a particular method or described feature is included in at least one novel method of treatment. Thus, the appearance of phrases such as "a method of treatment" in various places throughout this specification does not necessarily refer to the same method of treatment. Furthermore, specific antibiotics, doses, fixed dose combinations, ratios, and concentrations may be combined in any suitable manner in one or more novel methods of treatment.

[0148] Where a range of values ​​is provided, each value between the upper and lower limits of that range is specifically contemplated and described herein.

[0149] As used herein, the term "about" refers to a range of values ​​that includes the specified value and that one of ordinary skill in the art would consider reasonably similar to the specified value. In embodiments, "about" refers to within a standard deviation using measurements generally accepted in the art. In embodiments, "about" refers to a range that spans + / - 10% of the specified value and may include the specified value. For example, endpoints may be within 10%, 8%, 5%, 3%, 2%, or 1% of the recited value. Furthermore, for convenience and brevity, a numerical range of "about 50 mg / mL to about 80 mg / mL" should also be understood to provide support for the range "50 mg / mL to 80 mg / mL." Endpoints may be based on variability permitted by appropriate regulatory agencies, such as the FDA, USP, etc.

[0150] As used herein, the term "substantially" means a value that one of ordinary skill in the art would consider significantly greater than the specified value. In some embodiments, "substantially" means at least 25% more than the specified value, or at least 125% of the specified value.

[0151] As used herein, the terms "safe" and "recommended" mean recommended by a medical authority, such as a manufacturer, the FDA, or other similar regulatory body. In some instances, the maximum dose or serum level may be based on peer-reviewed medical literature (e.g., Rybak et al., "Therapeutic Monitoring of Vancomycin in Adult Patients: A Consensus Review of the American Society of Health-System Pharmacists, the Infections Diseases Society of America, and the Society of Infectious Diseases Pharmacists," ASHP Therapeutic Position Statements, pp. 685-700, 2009) or recommended by a professional medical organization or association. In additional instances, the maximum recommended daily systemic dose and / or maximum safe serum concentration may be provided on the label or instructions for use of a particular antibiotic.

[0152] As used herein, the terms "maximum recommended daily dose," "maximum recommended daily systemic dose," and "maximum recommended systemic daily dose" may be used interchangeably. In some instances, the systemic daily dose may be the daily dose administered by IV.

[0153] While this specification contains many specific details, these should not be construed as limitations on the scope of what is or may be claimed, but rather as descriptions of features specific to particular methods. Some methods described herein may be practiced in combination in a single method. Conversely, various features described in the context of a single method may be practiced individually, separately in multiple methods, or in any suitable subcombination of novel methods. Furthermore, while a method may be described herein as including a particular combination of antibiotics, dosages, or concentrations, and even originally claimed as such, one or more features from the claimed combination may, in some cases, be omitted from the combination, and the claimed combination may be intended as a subcombination or a variation of the subcombination. Similarly, although the sequential administration of multiple antibiotics is described herein in a particular order or for a particular duration, this should not be construed as requiring that the method be performed in a particular sequential order or for a particular duration, or that all elements of the sequence be performed, to achieve the desired results. Only a few examples and methods are disclosed. Variations, modifications, and enhancements to the described and other methods may be made based on what is disclosed.

[0154] In the above description and claims, phrases such as "at least one" or "one or more" may be followed by a connected list of one or more elements, antibiotics, combinations, doses, or concentrations. The term "and / or" may also appear in lists of two or more such elements. Unless otherwise implicitly or explicitly contradicted by the context in which it is used, such phrases are intended to mean any of the listed elements individually, or any of the listed elements in combination with any of the other listed elements. For example, the phrases "at least one of A and B," "one or more of A and B," and "A and / or B" are intended to mean "A only, B only, or a combination of A and B," respectively. A similar interpretation is intended for lists containing more than two items. For example, the phrases "at least one of A, B, and C," "one or more of A, B, and C," and "A, B, and / or C" are intended to mean "A only, B only, C only, a combination of A and B, a combination of A and C, a combination of B and C, or a combination of A, B, and C," respectively.

[0155] Use of the term "based on" above and in the claims is intended to mean "based at least in part on," thereby allowing for unrecited features or elements.

[0156] As used herein, the terms "comprises," "comprising," "containing," "having," and the like may have the meanings ascribed to them in U.S. patent law, and may also mean "includes," "including," and the like, and are generally construed as open-ended terms. The terms "consisting of" or "consists of" are closed-ended terms and include only those components, structures, steps, etc. specifically recited in conjunction with the term, and in accordance with U.S. patent law. "Consisting essentially of" or "consists essentially of" have the meanings generally ascribed to them by U.S. patent law. In particular, this term is generally open-ended, except to permit the inclusion of additional items, materials, components, steps, or elements that do not materially affect the basic and novel characteristics or function of the item(s) with which it is used. For example, trace elements that are present in a composition but do not affect the properties or characteristics of the composition are permitted to be present under the expression "consisting essentially of," even if they are not explicitly listed in the list of items following the term "consisting essentially of." When open-ended terms such as "comprising" or "including" are used herein, it is understood that direct support for the phrase "consisting essentially of" as well as the phrase "consisting of" should also be provided, as if explicitly stated, and vice versa.

[0157] As used herein, first, second, third, etc. are used to characterize and distinguish various antibiotics. The use of numerical terms may be used to distinguish one antibiotic from another. The use of such numerical terms does not imply a sequence or order unless clearly indicated by context. Such numerical references may be used interchangeably without departing from the teachings of the embodiments and variations herein.

[0158] The inventions disclosed herein may be packaged in a single package of multiple antibiotics, or may be packaged together in multiple packages of antibiotic combinations for use individually or together, and such use may be administered simultaneously, sequentially, cyclically, or consecutively (in a particular sequence which may include repeated use of one or more individual or combination antibiotics) according to specific instructions.

[0159] All methods described herein may be performed in any suitable order unless otherwise indicated herein or clearly contradicted by context. The use of any and all examples or exemplary language (e.g., "such as") provided herein is intended merely to better clarify the invention and does not impose a limitation on the scope of any claims. No language in the specification should be construed as indicating any non-claimed element essential to the practice of the invention.

[0160] Implementation Embodiment 1: A method of treating a localized infection in a human patient, said method comprising topically administering a solution to said human patient at a dose substantially exceeding the maximum recommended daily systemic dose of at least one antimicrobial agent within a 24 hour period, wherein said solution provides a peak or trough serum concentration within said 24 hour period that is less than or equal to a maximum safe level of serum concentration of said at least one antimicrobial agent.

[0161] Embodiment 2: The method of embodiment 1, wherein said local administration comprises one or more perfusions of said local infection with said at least one antimicrobial agent.

[0162] Embodiment 3: The method of embodiment 2, wherein irrigating the localized infection comprises immersing the localized site of infection in the at least one antimicrobial agent and then aspirating the at least one antimicrobial agent from the localized site of infection.

[0163] Embodiment 4: The method of embodiment 3, wherein the immersion is for about 10 minutes to about 180 minutes.

[0164] Embodiment 5: The method of embodiment 4, wherein the soaking is for about 30 minutes to about 120 minutes.

[0165] Embodiment 6: The method described in embodiment 3, wherein the perfusion is performed at least twice within 24 hours.

[0166] Embodiment 7: The method described in embodiment 3, wherein the perfusion is performed at least 5 times within 24 hours.

[0167] Embodiment 8: The method described in embodiment 3, wherein the perfusion is performed at least 10 times within a 24 hour period.

[0168] Embodiment 9: The method described in embodiment 3, wherein the perfusion is performed at least 15 times within a 24 hour period.

[0169] Embodiment 10: The method described in embodiment 3, wherein the perfusion is performed at least 20 times within a 24 hour period.

[0170] Embodiment 11: The method of embodiment 1, wherein the dose of the at least one antibacterial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antibacterial agent by at least 125%.

[0171] Embodiment 12: The method of embodiment 1, wherein the dose of the at least one antibacterial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antibacterial agent by at least 150%.

[0172] Embodiment 13: The method of embodiment 1, wherein the dose of the at least one antibacterial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antibacterial agent by at least 175%.

[0173] Embodiment 14: The method of embodiment 1, wherein the dose of the at least one antibacterial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antibacterial agent by at least 200%.

[0174] Embodiment 15: The method of embodiment 1, wherein the at least one antibacterial agent is an antibiotic.

[0175] Embodiment 16: The method of embodiment 15, wherein the at least one antibiotic is an aminoglycoside.

[0176] Embodiment 17: The method of embodiment 15, wherein the at least one antibiotic is a glycopeptide.

[0177] Embodiment 18: The method according to embodiment 17, wherein the at least one antibiotic is vancomycin.

[0178] Embodiment 19: The method of embodiment 18, wherein the dose of vancomycin administered locally is at least 3,000 mg within 24 hours.

[0179] Embodiment 20: The method of embodiment 18, wherein the dose of locally administered vancomycin is at least 6,000 mg within 24 hours.

[0180] Embodiment 21: The method of embodiment 18, wherein the dose of vancomycin administered locally is at least 12,000 mg within 24 hours.

[0181] Embodiment 22: The method of embodiment 18, wherein the dose of locally administered vancomycin is at least 24,000 mg within 24 hours.

[0182] Embodiment 23: The method of embodiment 18, wherein the daily dose of locally administered vancomycin is 3,000 to 50,000 mg in 24 hours and the trough serum concentration of vancomycin is less than 30 mcg / mL.

[0183] Embodiment 24: The method of embodiment 23, wherein the trough serum concentration of vancomycin is less than 20 mcg / mL.

[0184] Embodiment 25: The method of embodiment 23, wherein the trough serum concentration of vancomycin is less than 10 mcg / mL.

[0185] Embodiment 26: The method of embodiment 18, wherein the maximum safe level of trough serum concentration of vancomycin is 25 mcg / mL.

[0186] Embodiment 27: The method of embodiment 18, wherein the local administration comprises perfusing the local infection with vancomycin two or more times within a 24-hour period.

[0187] Embodiment 28: The method of embodiment 27, wherein irrigating the localized infection comprises immersing the localized infection in vancomycin followed by aspirating the vancomycin from the site of the localized infection.

[0188] Embodiment 29: The method of embodiment 18, wherein the local infection comprises an unidentified pathogen.

[0189] Embodiment 30: The method of embodiment 18, wherein said localized infection is polymicrobial.

[0190] Embodiment 31: The method described in embodiment 18, wherein the site of local infection is a local wound.

[0191] Embodiment 32: The method of embodiment 31, wherein the local wound is a diabetic ulcer.

[0192] Embodiment 33: The method of embodiment 18, wherein the site of local infection is a traumatic wound.

[0193] Embodiment 34: The method of embodiment 33, wherein the traumatic wound comprises an implanted medical device.

[0194] Embodiment 35: The method described in embodiment 18, wherein the site of local infection is a surgical incision.

[0195] Embodiment 36: The method of embodiment 18, wherein the site of local infection is a subcutaneous surgical wound.

[0196] Embodiment 37: The method of embodiment 36, wherein the subcutaneous surgical wound comprises an implanted medical device.

[0197] Embodiment 38: The method of embodiment 37, wherein the implanted medical device is an orthopedic implant.

[0198] Embodiment 39: The method described in embodiment 38, wherein the orthopedic implant is a joint replacement prosthesis.

[0199] Embodiment 40: The method of embodiment 16, wherein the aminoglycoside is tobramycin.

[0200] Embodiment 41: The method according to embodiment 40, wherein the dose of locally administered tobramycin is at least 100 mg within 24 hours.

[0201] Embodiment 42: The method according to embodiment 40, wherein the dose of locally administered tobramycin is at least 200 mg within 24 hours.

[0202] Embodiment 43: The method according to embodiment 40, wherein the dose of locally administered tobramycin is at least 400 mg within 24 hours.

[0203] Embodiment 44: The method according to embodiment 40, wherein the daily dose of tobramycin is at least 800 mg within a 24-hour period.

[0204] Embodiment 45: The method of embodiment 40, wherein the daily dose of tobramycin is 100 to 1,000 mg / day and the peak serum concentration of tobramycin is less than 10 mcg / mL.

[0205] Embodiment 46: The method of embodiment 40, wherein the peak serum concentration of tobramycin is less than 9 mcg / mL.

[0206] Embodiment 47: The method of embodiment 40, wherein the peak serum concentration of tobramycin is less than 6 mcg / mL.

[0207] Embodiment 48: The method of embodiment 40, wherein the peak serum concentration of tobramycin is less than 3 mcg / mL.

[0208] Embodiment 49: The method of embodiment 40, wherein the peak serum concentration of tobramycin is below the limit of detection in a clinical test for serum concentrations of tobramycin.

[0209] Embodiment 50: The method of embodiment 1, wherein the at least one antibiotic comprises two antibiotics.

[0210] Embodiment 51: The method of embodiment 50, wherein the two antibiotics comprise vancomycin and tobramycin.

[0211] Embodiment 52: The method of embodiment 51, wherein the two antibiotics are administered sequentially.

[0212] Embodiment 53: The method of embodiment 52, wherein vancomycin is administered topically every hour for 20-22 hours within a 24-hour period, the vancomycin being soaked for about 30 minutes followed by suction for about 30 minutes, and tobramycin is administered topically once for about 2 hours within a 24-hour period.

[0213] Embodiment 54: The method of embodiment 51, wherein the concentration of locally administered vancomycin is 3,000 mcg / mL to 50,000 mcg / mL and the concentration of locally administered tobramycin is 2,000 mcg / mL to 40,000 mcg / mL. .

[0214] Embodiment 55: The method of embodiment 51, wherein the topical administration is provided for 1 to 10 days.

[0215] Embodiment 56: The method according to embodiment 51, wherein vancomycin and tobramycin are administered in a fixed dose ratio of 6:1 to 150:1.

[0216] Embodiment 57: The method according to embodiment 51, wherein the dose of vancomycin is at least 3,000 mg within 24 hours or the dose of tobramycin is at least 100 mg within 24 hours.

[0217] Embodiment 58: The method according to embodiment 51, wherein the dose of vancomycin is at least 6,000 mg within 24 hours or the dose of tobramycin is at least 200 mg within 24 hours.

[0218] Embodiment 59: The method according to embodiment 51, wherein the dose of vancomycin is at least 12,000 mg within 24 hours or the dose of tobramycin is at least 400 mg within 24 hours.

[0219] Embodiment 60: The method of embodiment 51, wherein the daily dose of vancomycin within 24 hours is 3,000 to 50,000 mg, or the daily dose of tobramycin within 24 hours is 100 to 4,000 mg, and the trough serum concentration of vancomycin is less than 30 mcg / mL and the peak serum concentration of tobramycin is less than 10 mcg / mL.

[0220] Embodiment 61: A method of treating a localized infection in a human patient, comprising topically administering to said human patient a local administration concentration of at least one antibacterial agent that exceeds the maximum recommended concentration of the at least one antibacterial agent, and providing a peak or trough serum concentration that is less than the maximum safe serum concentration of said at least one antibacterial agent.

[0221] Embodiment 62: The method of embodiment 61, wherein the local administration comprises irrigating the local infection by immersing the local infection in at least one antibacterial agent and aspirating the at least one antibacterial agent after a period of time.

[0222] Embodiment 63: The method described in embodiment 62, wherein the at least one antibacterial agent is vancomycin.

[0223] Embodiment 64: The method of embodiment 62, wherein the concentration of vancomycin is at least 3,000 mcg / mL.

[0224] Embodiment 65: The method of embodiment 62, wherein the concentration of locally administered vancomycin is 3,000 to 50,000 mcg / mL and the trough serum concentration is less than 30 mcg / mL.

[0225] Embodiment 66: The method described in embodiment 62, wherein the at least one antibacterial agent is tobramycin.

[0226] Embodiment 67: The method of embodiment 66, wherein the concentration of locally administered tobramycin is at least 100 mcg / mL.

[0227] Embodiment 68: The method of embodiment 66, wherein the concentration of locally administered tobramycin is 100 to 40,000 mcg / mL and the peak serum concentration is less than 10 mcg / mL.

[0228] Embodiment 69: The method of embodiment 62, wherein the at least one antibacterial agent comprises vancomycin and tobramycin.

[0229] Embodiment 70: The method of embodiment 69, wherein the concentration of locally administered vancomycin is at least 3,000 mcg / mL or the concentration of locally administered tobramycin is at least 100 mcg / mL.

[0230] Embodiment 71: The method of embodiment 69, wherein the concentration of locally administered vancomycin is 3,000 to 50,000 mcg / mL, or the concentration of locally administered tobramycin is 100 to 40,000 mcg / mL, and the trough serum concentration of vancomycin is less than 30 mcg / mL and the peak serum concentration of tobramycin is less than 10 mcg / mL.

[0231] Embodiment 72: A method of treating a musculoskeletal infection in a human patient, comprising administering at least one antibacterial agent to said human patient at a local administration concentration that exceeds the minimum biofilm eradicating concentration (MBEC) of said at least one antibacterial agent, and providing a peak or trough serum concentration of said at least one antibacterial agent that is less than the maximum safe serum concentration of said at least one antibacterial agent.

[0232] Embodiment 73: The method described in embodiment 72, wherein the MBEC comprises a concentration of the at least one antibacterial agent that reduces by more than 99.999% the number of colony forming units (CFU's) of a specific microorganism that has formed a biofilm for at least 24 hours during the period in which the at least one antibacterial agent is topically administered to the local infection.

[0233] Embodiment 74: The method described in embodiment 73, wherein the microorganism is one or more of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococcus (VRE), Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa.

[0234] Embodiment 75: The method of embodiment 72, wherein the at least one antibacterial agent comprises a glycopeptide and an aminoglycoside.

[0235] Embodiment 76: The method of embodiment 75, wherein the glycopeptide comprises vancomycin and the aminoglycoside comprises tobramycin.

[0236] Embodiment 77: The method of embodiment 76, wherein the concentration of locally administered vancomycin is at least 3,000 mcg / mL and the concentration of locally administered tobramycin is at least 100 mcg / mL.

[0237] Embodiment 78: The method of embodiment 76, wherein the concentration of locally administered vancomycin is 3,000 to 50,0000 mcg / mL, the concentration of locally administered tobramycin is 100 to 40,000 mcg / mL, the peak serum concentration of tobramycin is less than 10 mcg / mL, and the trough serum concentration of vancomycin is 30 mcg / mL.

[0238] Embodiment 79: A method of treating a localized infection in a human patient, comprising topically administering to said human patient, within a 24 hour period, a total dose of a first antibiotic that substantially exceeds the maximum recommended systemic daily dose, and providing a peak or trough serum concentration within said 24 hour period that is less than or equal to the maximum safe serum concentration of said first antibiotic.

[0239] Embodiment 80: A method of treating a localized infection in a human patient in need thereof, comprising locally administering to said human patient, within a 24-hour period, a total dose of a first antibiotic that substantially exceeds the maximum recommended daily systemic dose and a total dose of a second antibiotic that substantially exceeds the maximum recommended daily dose, and providing a peak or trough serum concentration within said 24-hour period that is less than or equal to the maximum recommended safe serum concentration of either the first antibiotic or the second antibiotic.

[0240] Embodiment 81: A method of treating a localized infection in a human patient, comprising topically administering to said human patient, within a 24-hour period, a total dose of at least two antibiotics that substantially exceeds the maximum recommended daily systemic dose of each of said at least two antibiotics, and providing a peak or trough serum concentration within said 24-hour period that is less than or equal to the maximum safe serum concentration of each of said at least two antibiotics.

[0241] Embodiment 82: A method of treating living tissue in a human patient, comprising locally administering to said human patient, within a 24 hour period, a total dose of at least one therapeutic agent that substantially exceeds the maximum recommended systemic daily dose of the at least one therapeutic agent, and providing a peak or trough serum concentration of the at least one therapeutic agent that is less than or equal to the maximum safe serum concentration.

[0242] Embodiment 83: A method of treating a localized infection in a living tissue of a human patient, comprising locally administering to said human patient, within said 24-hour period, a total dose of at least one antibiotic of greater than 3,000 mg in said 24-hour period.

[0243] Embodiment 84: A method of treating a localized infection in a human patient, comprising topically administering to said human patient a total dose of greater than 3,000 mg / day of vancomycin within a 24-hour period.

[0244] Embodiment 85: The method of embodiment 84, wherein the total dose of vancomycin in the 24 hour period is at least 6,000 mg / day.

[0245] Embodiment 86: The method of embodiment 84, wherein the total dose of vancomycin in the 24 hour period is at least 12,000 mg / day.

[0246] Embodiment 87: The method of embodiment 84, wherein the total dose of vancomycin administered locally in 24 hours is at least 24,000 mg / day.

[0247] Embodiment 88: A method of treating a localized infection in a human patient, comprising topically administering to said human patient, within said 24-hour period, a total dose of tobramycin of greater than 100 mg in said 24-hour period.

[0248] Embodiment 89: The method of embodiment 88, wherein the dose of tobramycin in the 24 hours is at least 200 mg.

[0249] Embodiment 90: The method of embodiment 88, wherein the dose of tobramycin in said 24 hours is at least 400 mg.

[0250] Embodiment 91: The method of embodiment 88, wherein the dose of tobramycin in the 24 hours is at least 800 mg.

[0251] Embodiment 92: A kit for treating a topical infection in a human patient, comprising: At least one antibiotic; a therapeutic delivery system and / or an irrigation device configured to locally irrigate a localized infection with at least one dose of at least one antibiotic; and instructions for administering at least one dose of said at least one antibiotic; Kit including:

[0252] Embodiment 93: A kit described in embodiment 92, wherein the at least one antibiotic is vancomycin.

[0253] Embodiment 94: The kit described in embodiment 92, wherein the therapeutic delivery system and / or perfusion device is configured to locally administer a total dose of vancomycin of more than 3,000 mg in 24 hours.

[0254] Embodiment 95: A kit described in embodiment 92, wherein the at least one antibiotic is tobramycin.

[0255] Embodiment 96: The kit described in embodiment 92, wherein the therapeutic delivery system and / or perfusion device is configured to locally administer a total dose of more than 100 mg of tobramycin in 24 hours.

[0256] Embodiment 97: A kit described in embodiment 92, wherein the kit comprises at least two antibiotics, and at least one antibiotic is at a concentration that exceeds the minimum biofilm eradicating concentration (MBEC) of the at least one antibiotic.

[0257] Embodiment 98: A kit described in embodiment 97, wherein the at least one antibiotic comprises vancomycin and tobramycin.

[0258] Embodiment 99: A kit described in embodiment 97, wherein the at least two antibiotics comprise daptomycin and tobramycin.

[0259] Embodiment 100: A kit described in embodiment 92, wherein the at least one antibiotic is provided in a fluid reservoir.

[0260] Embodiment 101: A method for treating a localized infection in a human patient, comprising locally administering to said human patient two or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of said at least one antibiotic for the localized infection.

[0261] Embodiment 102: The method described in embodiment 101, comprising locally administering five or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of the at least one antibiotic for the local infection.

[0262] Embodiment 103: The method described in embodiment 101, comprising locally administering 10 or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of the at least one antibiotic for the local infection.

[0263] Embodiment 104: The method described in embodiment 101, comprising locally administering 20 or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of at least one antibiotic for the local infection.

[0264] Embodiment 105: The method described in embodiment 101, wherein the at least one antibiotic comprises two or more antibiotics.

[0265] Embodiment 106: The method of embodiment 105, wherein the two or more antibiotics are selected from the group consisting of vancomycin, daptomycin, and tobramycin.

[0266] Embodiment 107: The method described in embodiment 105, wherein the number of CFUs in the local infection is reduced by at least 3 logs, 4 logs, 5 logs or 6 logs within 7 days.

[0267] Embodiment 108: The method described in embodiment 105, wherein more than 99% of the CFUs of the local infection are killed within 7 days.

[0268] Embodiment 109: The method described in embodiment 105, wherein more than 99% of the CFUs of the local infection are killed within 7 days.

[0269] Embodiment 110: The method described in embodiment 105, wherein the number of CFUs in the local infection is reduced by at least 3 logs, 4 logs, 5 logs or 6 logs within 3 days.

[0270] Embodiment 111: The method described in embodiment 105, wherein more than 99% of the CFUs of the local infection are killed within 3 days.

[0271] Embodiment 112: The method described in embodiment 105, wherein more than 99% of the CFUs of the local infection are killed within 3 days.

[0272] Embodiment 113: The method described in embodiment 98, wherein the number of CFUs in the local infection is reduced by at least 3 logs, 4 logs, 5 logs or 6 logs within 24 hours.

[0273] Embodiment 114: The method described in embodiment 105, wherein more than 99% of the CFUs of the local infection are killed within 24 days.

[0274] Embodiment 115: The method described in embodiment 105, wherein more than 99% of the CFUs of the local infection are killed within 24 days.

[0275] Embodiment 116: A method of treating a localized infection in a human patient, comprising topically administering at least one antibiotic to said human patient two or more times within a 24-hour period, wherein the AUC / MBEC at the site of the localized infection is maintained for at least 5 hours per day.

[0276] Embodiment 117: The method described in embodiment 116, wherein the AUC / MBEC is maintained for at least 10 hours per day.

[0277] Embodiment 118: The method described in embodiment 116, wherein the AUC / MBEC is maintained for at least 20 hours per day.

[0278] Embodiment 119: A method for treating a localized infection in a human patient, comprising topically administering to the human patient, over a period of two or more days, at least on a first day, at least one antibiotic at a concentration above the MBEC for the at least one antibiotic for the localized infection and at least one antibiotic that is less than the concentration of the at least one antibiotic on said first day, wherein the concentration of the at least one antibiotic on a later day is above the minimum inhibitory concentration of the at least one antibiotic for the localized infection.

[0279] Embodiment 120: The method described in embodiment 119, wherein the period of two or more days is a period of 5 to 7 days and the at least first day is 1 to 3 days.

[0280] Embodiment 121: A method of treating a localized infection in a human patient in need thereof, comprising administering by local perfusion to said human patient at a dose of at least 25 mg of vancomycin at a concentration of 3,000 mcg / mL or greater, and providing a trough serum concentration in said patient of less than 30 mcg / mL for 24 hours following administration.

[0281] Embodiment 122: A method of treating a localized infection in a human patient in need thereof, comprising administering by local perfusion a dosage of vancomycin and tobramycin to said human patient, wherein said dosage is Vancomycin at a concentration of 3,000 mcg / mL or greater, at a dose of at least 50 mg; and containing at least a 50 mg dose of tobramycin at a concentration of 2,000 mcg / mL or greater; wherein said administration provides said patient with a trough serum concentration of vancomycin that is less than 30 mcg / mL and a peak serum concentration of tobramycin that is less than 10 mcg / mL over a 24-hour period following administration.

[0282] Embodiment 123: A method for treating a localized infection in a human patient, comprising: identifying at least one microorganism within the localized infection; and 1. A method comprising topically administering to the human patient two or more antibiotics, wherein at least one of the antibiotics is administered at a concentration above the MBEC level of the at least one antibiotic for the at least one microorganism.

[0283] Embodiment 124: The method described in embodiment 123, wherein the microorganism is one or more of Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa, and the two or more antibiotics are vancomycin and tobramycin.

[0284] Embodiment 125: The method described in embodiment 123, wherein the microorganism is methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococcus (VRE) and the two or more antibiotics are daptomycin and tobramycin.

[0285] Embodiment 126: The method described in embodiment 123, wherein the at least one microorganism is identified by clinical testing of a sample from the local infection site.

[0286] Embodiment 127: The method described in embodiment 123, wherein the number of CFUs in the local infection is reduced by at least 4 logs within 7 days of administration.

[0287] Embodiment 128: The method described in embodiment 127, wherein the number of CFUs in the local infection is reduced by 5 logs or more, 6 logs or more, or 7 logs or more within 7 days of administration.

[0288] Embodiment 129: The method described in embodiment 123, wherein more than 99% of the CFU of the local infection are killed within 7 days of administration.

[0289] Embodiment 130: The method described in embodiment 129, wherein more than 99.9% of the CFUs of the local infection are killed within 7 days of administration.

[0290] Embodiment 131: The method described in embodiment 123, wherein the number of CFUs in the local infection is reduced by 4 logs within 24 hours of administration.

[0291] Embodiment 132: The method described in embodiment 131, wherein the number of CFUs in the local infection is reduced by 5 logs or more, 6 logs or more, or 7 logs or more within 24 hours of administration.

[0292] Embodiment 133: The method described in embodiment 123, wherein more than 99% of the CFU of the local infection are killed within 24 hours of administration.

[0293] Embodiment 134: The method described in embodiment 133, wherein more than 99.9% of the CFUs of the local infection are killed within 24 hours of administration.

[0294] Embodiment 135: A method for treating a localized infection in a human patient, comprising: topically administering to said human patient two or more antibiotics, wherein at least one of said antibiotics is administered at a concentration that exceeds the MBEC of said at least one antibiotic against at least one microorganism; during said administering, identifying at least one microorganism within said localized infection; and after identifying the at least one microorganism, switching at least one of the antibiotics to a different antibiotic.

[0295] Embodiment 136: The method described in embodiment 135, wherein the at least one microorganism is identified by clinical examination of a sample from the local infection site.

[0296] Embodiment 137: The method described in embodiment 135, wherein the number of CFUs in the local infection is reduced by at least 4 logs within 7 days of administration.

[0297] Embodiment 138: The method described in embodiment 135, wherein the number of CFUs in the local infection is reduced by 5 logs or more, 6 logs or more, or 7 logs or more within 7 days of administration.

[0298] Embodiment 139: The method described in embodiment 135, wherein more than 99% of the CFU of the local infection are killed within 7 days of administration.

[0299] Embodiment 140: The method described in embodiment 139, wherein more than 99.9% of the CFUs of the local infection are killed within 7 days of administration.

[0300] Embodiment 141: The method described in embodiment 135, wherein the number of CFUs in the local infection is reduced by 4 logs or more within 24 hours of administration.

[0301] Embodiment 142: The method described in embodiment 141, wherein the number of CFUs in the local infection is reduced by 5 logs or more, 6 logs or more, or 7 logs or more within 24 hours of administration.

[0302] Embodiment 143: The method described in embodiment 135, wherein more than 99% of the CFUs of the local infection are killed within 24 hours of administration.

[0303] Embodiment 144: The method described in embodiment 143, wherein more than 99.9% of the CFUs of the local infection are killed within 24 hours of administration.

[0304] Embodiment 145: A method for treating a localized infection in a human patient, comprising: topically administering to said human patient two or more antibiotics, wherein at least one of said antibiotics is administered at a concentration above the MBEC level of said at least one antibiotic for at least one microorganism; during said administering, identifying at least one microorganism within said localized infection; and after identifying the at least one microorganism, switching at least one of the antibiotics to a different antibiotic.

[0305] Embodiment 146: The method of embodiment 145, wherein the second antibiotic combination results in an improvement in at least one identified microorganism of 0.5 log or more, 1 log or more, 1.5 log or more, 2.0 log or more, 2.5 log or more, 3.0 log or more, 3.5 log or more, or 4.0 log or more compared to the first antibiotic combination against the identified microorganism.

[0306] Embodiment 147: The method described in embodiment 145, wherein the at least one microorganism is identified by clinical examination of a sample from the local infection site.

[0307] Embodiment 148: The method described in embodiment 145, wherein the number of CFUs in the local infection is reduced by at least 4 logs within 7 days of administration of the second antibiotic combination.

[0308] Embodiment 149: The method described in embodiment 148, wherein within 7 days of administration of the second antibiotic combination, the number of CFUs in the localized infection is reduced by 5 logs or more, 6 logs or more, or 7 logs or more.

[0309] Embodiment 150: The method described in embodiment 145, wherein more than 99% of the CFU of the local infection are killed within 7 days of administration of the second antibiotic combination.

[0310] Embodiment 151: The method described in embodiment 145, wherein more than 99.9% of the CFUs of the local infection are killed within 7 days of administration of the second antibiotic combination.

[0311] Embodiment 152: The method described in embodiment 145, wherein the number of CFUs in the local infection is reduced by 4 logs or more within 24 hours of administration of the second antibiotic combination.

[0312] Embodiment 153: The method described in embodiment 152, wherein the number of CFUs in the topical administration is reduced by 5 logs or more, 6 logs or more, or 7 logs or more within 24 hours of administration of the second antibiotic combination.

[0313] Embodiment 154: The method described in embodiment 145, wherein more than 99% of the CFU of the local infection are killed within 24 hours of administration of the second antibiotic combination.

[0314] Embodiment 155: The method described in embodiment 145, wherein more than 99.9% of the CFUs of the local infection are killed within 24 hours of administration of the second antibiotic combination.

Claims

1. 1. A method of treating a localized infection in a human patient, said method comprising topically administering a solution to said human patient within a 24-hour period at a dose substantially exceeding a maximum recommended daily systemic dose of at least one antimicrobial agent, wherein said solution provides a peak or trough serum concentration within said 24-hour period that is less than or equal to a maximum safe level of serum concentration of said at least one antimicrobial agent.

2. 10. The method of claim 1, wherein the local administration comprises one or more perfusions of the local infection with the at least one antimicrobial agent.

3. 3. The method of claim 2, wherein irrigating the localized infection comprises immersing the localized site of infection in the at least one antimicrobial agent and then aspirating the at least one antimicrobial agent from the localized site of infection.

4. 4. The method of claim 3, wherein the soaking is for about 10 minutes to about 180 minutes.

5. 5. The method of claim 4, wherein the soaking is for about 30 minutes to about 120 minutes.

6. 4. The method of claim 3, wherein the perfusion is performed at least twice within a 24-hour period.

7. 4. The method of claim 3, wherein the perfusion is performed at least five times within a 24-hour period.

8. 4. The method of claim 3, wherein the perfusion is performed at least 10 times within a 24-hour period.

9. 4. The method of claim 3, wherein the perfusion is performed at least 15 times within a 24-hour period.

10. 4. The method of claim 3, wherein the perfusion is performed at least 20 times within a 24-hour period.

11. 10. The method of claim 1, wherein the dose of the at least one antimicrobial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antimicrobial agent by at least 125%.

12. 10. The method of claim 1, wherein the dose of the at least one antimicrobial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antimicrobial agent by at least 150%.

13. 10. The method of claim 1, wherein the dose of the at least one antimicrobial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antimicrobial agent by at least 175%.

14. 10. The method of claim 1, wherein the dose of the at least one antimicrobial agent administered locally within a 24-hour period exceeds the maximum recommended daily systemic dose of the at least one antimicrobial agent by at least 200%.

15. The method of claim 1 , wherein the at least one antimicrobial agent is an antibiotic.

16. 16. The method of claim 15, wherein the at least one antibiotic is an aminoglycoside.

17. 16. The method of claim 15, wherein the at least one antibiotic is a glycopeptide.

18. 18. The method of claim 17, wherein the at least one antibiotic is vancomycin.

19. 19. The method of claim 18, wherein the dose of vancomycin administered locally is at least 3,000 mg within a 24-hour period.

20. 19. The method of claim 18, wherein the dose of vancomycin administered locally is at least 6,000 mg within a 24-hour period.

21. 19. The method of claim 18, wherein the dose of vancomycin administered locally is at least 12,000 mg within a 24-hour period.

22. 19. The method of claim 18, wherein the dose of vancomycin administered locally is at least 24,000 mg within a 24-hour period.

23. 19. The method of claim 18, wherein the daily dose of locally administered vancomycin is 3,000 to 30,000 mg in a 24-hour period and the trough serum concentration of vancomycin is less than 30 mcg / mL.

24. 24. The method of claim 23, wherein the vancomycin trough serum concentration is less than 20 mcg / mL.

25. 24. The method of claim 23, wherein the vancomycin trough serum concentration is less than 10 mcg / mL.

26. 19. The method of claim 18, wherein the maximum safe level of vancomycin trough serum concentration is 25 mcg / mL.

27. 20. The method of claim 18, wherein the local administration comprises perfusing the local infection with vancomycin two or more times within a 24-hour period.

28. 28. The method of claim 27, wherein irrigating the localized infection comprises immersing the localized infection in vancomycin and subsequently aspirating the vancomycin from the site of the localized infection.

29. 19. The method of claim 18, wherein the localized infection comprises an unidentified pathogen.

30. 19. The method of claim 18, wherein the localized infection is polymicrobial.

31. 19. The method of claim 18, wherein the site of local infection is a local wound.

32. 32. The method of claim 31, wherein the topical wound is a diabetic ulcer.

33. 19. The method of claim 18, wherein the site of local infection is a traumatic wound.

34. 34. The method of claim 33, wherein the traumatic wound comprises an implanted medical device.

35. 19. The method of claim 18, wherein the site of localized infection is a surgical incision.

36. 19. The method of claim 18, wherein the site of local infection is a subcutaneous surgical wound.

37. 37. The method of claim 36, wherein the subcutaneous surgical wound contains an implanted medical device.

38. 38. The method of claim 37, wherein the implanted medical device is an orthopedic implant.

39. 39. The method of claim 38, wherein the orthopedic implant is a joint replacement prosthesis.

40. 17. The method of claim 16, wherein the aminoglycoside is tobramycin.

41. 41. The method of claim 40, wherein the dose of locally administered tobramycin is at least 100 mg within a 24 hour period.

42. 41. The method of claim 40, wherein the dose of locally administered tobramycin is at least 200 mg within a 24 hour period.

43. 41. The method of claim 40, wherein the dose of locally administered tobramycin is at least 400 mg within a 24 hour period.

44. 41. The method of claim 40, wherein the daily dose of tobramycin is at least 800 mg within a 24-hour period.

45. 41. The method of claim 40, wherein the daily dose of tobramycin is 100-1,000 mg / day and the peak serum concentration of tobramycin is less than 10 mcg / mL.

46. 41. The method of claim 40, wherein the peak serum concentration of tobramycin is less than 9 mcg / mL.

47. 41. The method of claim 40, wherein the peak serum concentration of tobramycin is less than 6 mcg / mL.

48. 41. The method of claim 40, wherein the peak serum concentration of tobramycin is less than 3 mcg / mL.

49. 41. The method of claim 40, wherein the peak serum concentration of tobramycin is below the limit of detection in a clinical assay for serum concentration of tobramycin.

50. 10. The method of claim 1, wherein the at least one antibiotic comprises two antibiotics.

51. 51. The method of claim 50, wherein the two antibiotics comprise vancomycin and tobramycin.

52. 52. The method of claim 51, wherein the two antibiotics are administered sequentially.

53. 53. The method of claim 52, wherein vancomycin is administered topically every hour for 20-22 hours within a 24-hour period, the vancomycin being soaked for about 30 minutes followed by suction for about 30 minutes, and tobramycin is administered topically once for about 2 hours within a 24-hour period.

54. 52. The method of claim 51, wherein the concentration of locally administered vancomycin is from 3,000 mcg / mL to 30,000 mcg / mL and the concentration of locally administered tobramycin is from 2,000 mcg / mL to 20,000 mcg / mL.

55. 52. The method of claim 51, wherein the topical administration is provided for 1 to 10 days.

56. 52. The method of claim 51, wherein the vancomycin and tobramycin are administered in a fixed dose ratio of 6:1 to 150:

1.

57. 52. The method of claim 51, wherein the dose of vancomycin is at least 3,000 mg within a 24-hour period or the dose of tobramycin is at least 100 mg within a 24-hour period.

58. 52. The method of claim 51, wherein the dose of vancomycin is at least 6,000 mg within a 24-hour period or the dose of tobramycin is at least 200 mg within a 24-hour period.

59. 52. The method of claim 51, wherein the dose of vancomycin is at least 12,000 mg within a 24-hour period or the dose of tobramycin is at least 400 mg within a 24-hour period.

60. 52. The method of claim 51, wherein the daily dose of vancomycin within 24 hours is between 3,000 and 30,000 mg, or the daily dose of tobramycin within 24 hours is between 100 and 1,000 mg, and the trough serum concentration of vancomycin is less than 30 mcg / mL and the peak serum concentration of tobramycin is less than 10 mcg / mL.

61. 1. A method of treating a localized infection in a human patient, comprising: topically administering to the human patient a localized administration concentration of at least one antibacterial agent that exceeds a maximum recommended concentration of the at least one antibacterial agent; and providing a peak or trough serum concentration of the at least one antibacterial agent that is less than a maximum safe serum concentration of the at least one antibacterial agent.

62. 62. The method of claim 61, wherein the local administration comprises irrigating the local infection by immersing the local infection in at least one antimicrobial agent and aspirating the at least one antimicrobial agent after a period of time.

63. 63. The method of claim 62, wherein the at least one antibacterial agent is vancomycin.

64. 63. The method of claim 62, wherein the concentration of vancomycin is at least 3,000 mcg / mL.

65. 63. The method of claim 62, wherein the concentration of locally administered vancomycin is 3,000-30,000 mcg / mL and the trough serum concentration is less than 30 mcg / mL.

66. 63. The method of claim 62, wherein the at least one antibacterial agent is tobramycin.

67. 67. The method of claim 66, wherein the concentration of locally administered tobramycin is at least 100 mcg / mL.

68. 67. The method of claim 66, wherein the concentration of locally administered tobramycin is 100-40,000 mcg / mL and the peak serum concentration is less than 10 mcg / mL.

69. 63. The method of claim 62, wherein the at least one antibacterial agent comprises vancomycin and tobramycin.

70. 70. The method of claim 69, wherein the concentration of locally administered vancomycin is at least 3,000 mcg / mL or the concentration of locally administered tobramycin is at least 100 mcg / mL.

71. 70. The method of claim 69, wherein the concentration of locally administered vancomycin is 3,000 to 50,000 mcg / mL, or the concentration of locally administered tobramycin is 100 to 40,000 mcg / mL, and the trough serum concentration of vancomycin is less than 30 mcg / mL and the peak serum concentration of tobramycin is less than 10 mcg / mL.

72. 1. A method of treating a musculoskeletal infection in a human patient, comprising administering at least one antimicrobial agent to the human patient at a local administration concentration that exceeds a minimum biofilm eradicating concentration (MBEC) of the at least one antimicrobial agent, and providing a peak or trough serum concentration of the at least one antimicrobial agent that is less than a maximum safe serum concentration of the at least one antimicrobial agent.

73. 73. The method of claim 72, wherein the MBEC comprises a concentration of the at least one antimicrobial agent that reduces by more than 99.999% the number of colony forming units (CFU's) of a particular microorganism that formed a biofilm for at least 24 hours during the period in which the at least one antimicrobial agent is topically administered to the local infection.

74. 74. The method of claim 73, wherein the microorganism is one or more of Staphylococcus aureus, methicillin-resistant Staphylococcus aureus (MRSA), vancomycin-resistant enterococci (VRE), Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa.

75. 73. The method of claim 72, wherein the at least one antibacterial agent comprises a glycopeptide and an aminoglycoside.

76. 76. The method of claim 75, wherein the glycopeptide comprises vancomycin and the aminoglycoside comprises tobramycin.

77. 77. The method of claim 76, wherein the concentration of locally administered vancomycin is at least 3,000 mcg / mL and the concentration of locally administered tobramycin is at least 100 mcg / mL.

78. 77. The method of claim 76, wherein the concentration of locally administered vancomycin is 3,000 to 50,0000 mcg / mL, the concentration of locally administered tobramycin is 100 to 40,000 mcg / mL, the peak serum concentration of tobramycin is less than 10 mcg / mL, and the trough serum concentration of vancomycin is 30 mcg / mL.

79. 1. A method of treating a localized infection in a human patient, comprising locally administering to said human patient, within a 24-hour period, a total dose of a first antibiotic that substantially exceeds a maximum recommended systemic daily dose, and providing a peak or trough serum concentration within said 24-hour period that is less than or equal to a maximum safe serum concentration of said first antibiotic.

80. 1. A method of treating a localized infection in a human patient in need thereof, comprising locally administering to said human patient, within a 24-hour period, a total dose of a first antibiotic that substantially exceeds a maximum recommended daily systemic dose and a total dose of a second antibiotic that substantially exceeds a maximum recommended daily dose, and providing peak or trough serum concentrations within said 24-hour period that are less than or equal to a maximum recommended safe serum concentration of either the first antibiotic or the second antibiotic.

81. 1. A method of treating a localized infection in a human patient, comprising topically administering to the human patient, within a 24-hour period, a total dose of at least two antibiotics that substantially exceeds a maximum recommended daily systemic dose of each of the at least two antibiotics, and providing a peak or trough serum concentration within the 24-hour period that is less than or equal to a maximum safe serum concentration of each of the at least two antibiotics.

82. 1. A method of treating living tissue in a human patient, comprising locally administering to said human patient, within a 24 hour period, a total dose of at least one therapeutic agent that substantially exceeds the maximum recommended systemic daily dose of the at least one therapeutic agent, and providing a peak or trough serum concentration of the at least one therapeutic agent that is less than or equal to the maximum safe serum concentration.

83. 1. A method of treating a localized infection in a living tissue of a human patient, comprising locally administering to said human patient, within said 24-hour period, a total dose of at least one antibiotic that exceeds 3,000 mg in said 24-hour period.

84. 1. A method of treating a localized infection in a human patient, comprising topically administering to said human patient a total dose of vancomycin greater than 3,000 mg / day within a 24 hour period.

85. 85. The method of claim 84, wherein the total dose of vancomycin in the 24 hour period is at least 6,000 mg / day.

86. 85. The method of claim 84, wherein the total dose of vancomycin in the 24 hour period is at least 12,000 mg / day.

87. 85. The method of claim 84, wherein the total dose of vancomycin administered topically in a 24-hour period is at least 24,000 mg / day.

88. 1. A method of treating a localized infection in a human patient, comprising topically administering to said human patient, within said 24-hour period, a total dose of tobramycin greater than 100 mg in said 24-hour period.

89. 89. The method of claim 88, wherein the dose of tobramycin in the 24 hour period is at least 200 mg.

90. 89. The method of claim 88, wherein the dose of tobramycin in the 24 hour period is at least 400 mg.

91. 89. The method of claim 88, wherein the dose of tobramycin in the 24 hour period is at least 800 mg.

92. 1. A kit for treating a topical infection in a human patient, comprising: at least one antibiotic; a therapeutic delivery system and / or an irrigation device configured to locally irrigate a localized infection with at least one dose of at least one antibiotic; and instructions for administering at least one dose of said at least one antibiotic; Kit including:

93. 93. The kit of claim 92, wherein the at least one antibiotic is vancomycin.

94. 93. The kit of claim 92, wherein the therapeutic delivery system and / or perfusion device is configured to locally administer a total dose of vancomycin greater than 3,000 mg in 24 hours.

95. 93. The kit of claim 92, wherein the at least one antibiotic is tobramycin.

96. 93. The kit of claim 92, wherein the therapeutic delivery system and / or perfusion device is configured to locally administer a total dose of tobramycin of greater than 100 mg in 24 hours.

97. 93. The kit of claim 92, wherein the kit comprises at least two antibiotics, at least one antibiotic at a concentration that exceeds the minimum biofilm eradicating concentration (MBEC) of the at least one antibiotic.

98. 98. The kit of claim 97, wherein the at least two antibiotics comprise vancomycin and tobramycin.

99. 98. The kit of claim 97, wherein the at least two antibiotics comprise daptomycin and tobramycin.

100. 93. The kit of claim 92, wherein the at least one antibiotic is provided in a fluid reservoir.

101. 1. A method for treating a localized infection in a human patient, comprising locally administering to the human patient two or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of said at least one antibiotic for the localized infection.

102. 102. The method of claim 101, comprising locally administering five or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of the at least one antibiotic for the localized infection.

103. 102. The method of claim 101, comprising locally administering 10 or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of the at least one antibiotic for the localized infection.

104. 102. The method of claim 101, comprising locally administering 20 or more doses of at least one antibiotic within a 24 hour period at a concentration above the MBEC level of the at least one antibiotic for the localized infection.

105. 102. The method of claim 101, wherein the at least one antibiotic comprises two or more antibiotics.

106. 106. The method of claim 105, wherein the two or more antibiotics are selected from the group consisting of vancomycin, daptomycin, and tobramycin.

107. 106. The method of claim 105, wherein the number of CFUs in the localized infection is reduced by at least 3 logs within 7 days.

108. 108. The method of claim 107, wherein the number of CFUs in the localized infection is reduced by at least 4 logs within 7 days.

109. 108. The method of claim 107, wherein the number of CFUs in the localized infection is reduced by at least 5 logs within 7 days.

110. 106. The method of claim 105, wherein greater than 99% of the CFUs of the localized infection are killed within 7 days.

111. 111. The method of claim 110, wherein greater than 99.9% of the CFUs of the localized infection are killed within 7 days.

112. 106. The method of claim 105, wherein the number of CFUs in the localized infection is reduced by at least 3 logs within 3 days.

113. 113. The method of claim 112, wherein the number of CFUs in the localized infection is reduced by at least 4 logs within 3 days.

114. 113. The method of claim 112, wherein the number of CFUs in the localized infection is reduced by at least 5 logs within 3 days.

115. 106. The method of claim 105, wherein greater than 99% of the CFU of the localized infection are killed within 3 days.

116. 116. The method of claim 115, wherein greater than 99.9% of the CFUs of the localized infection are killed within 3 days.

117. 106. The method of claim 105, wherein the number of CFUs in the local infection is reduced by at least 3 logs within 24 hours.

118. 118. The method of claim 117, wherein the number of CFUs in the localized infection is reduced by at least 4 logs within 24 hours.

119. 118. The method of claim 117, wherein the number of CFUs in the local infection is reduced by at least 5 logs within 24 hours.

120. 106. The method of claim 105, wherein greater than 99% of the CFUs of the localized infection are killed within 24 hours.

121. 121. The method of claim 120, wherein greater than 99.9% of the CFUs of the localized infection are killed within 24 hours.

122. 1. A method of treating a localized infection in a human patient, comprising topically administering at least one antibiotic to said human patient two or more times within a 24-hour period, wherein the AUC / MBEC at the site of the localized infection is maintained for at least five hours per day.

123. 123. The method of claim 122, wherein the AUC / MBEC is maintained for at least 10 hours per day.

124. 123. The method of claim 122, wherein the AUC / MBEC is maintained for at least 20 hours per day.

125. 1. A method for treating a localized infection in a human patient, comprising topically administering to the human patient, over a period of two or more days, at least on a first day, at least one antibiotic at a concentration that is greater than the MBEC for the localized infection of the at least one antibiotic and less than the concentration of the at least one antibiotic on the first day, wherein the concentration of the at least one antibiotic on a subsequent day is greater than the minimum inhibitory concentration for the at least one antibiotic for the localized infection.

126. 126. The method of claim 125, wherein the period of two or more days is a period of 5 to 7 days, and the at least first day is 1 to 3 days.

127. A method for treating a localized infection in a human patient in need thereof, comprising administering by local perfusion to the human patient at least a 25 mg dose of vancomycin at a concentration of 3,000 mcg / mL or greater, and providing a trough serum concentration in the patient of less than 30 mcg / mL for 24 hours after administration.

128. 1. A method of treating a localized infection in a human patient in need thereof, comprising administering to said human patient by local perfusion a dosage of vancomycin and tobramycin, wherein said dosage comprises: a dose of at least 50 mg of vancomycin at a concentration of 3,000 mcg / mL or greater; and comprising at least a 50 mg dose of tobramycin at a concentration of 2,000 mcg / mL or greater; wherein said administration provides said patient with a trough serum concentration of vancomycin that is less than 30 mcg / mL and a peak serum concentration of tobramycin that is less than 10 mcg / mL over a 24-hour period following administration.

129. 1. A method of treating a topical infection in a human patient, comprising: identifying at least one microorganism within the localized infection; and 10. A method comprising topically administering to the human patient two or more antibiotics, wherein at least one of the antibiotics is administered at a concentration that exceeds the MBEC level of the at least one antibiotic for the at least one microorganism.

130. 130. The method of claim 129, wherein the microorganism is one or more of Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, and Pseudomonas aeruginosa, and the two or more antibiotics are vancomycin and tobramycin.

131. 130. The method of claim 129, wherein the microorganism is methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococcus (VRE), and the two or more antibiotics are daptomycin and tobramycin.

132. 130. The method of claim 129, wherein the at least one microorganism is identified by clinical testing of a sample from the localized infection site.

133. 130. The method of claim 129, wherein the number of CFUs in the localized infection is reduced by at least 4 logs within 7 days of administration.

134. 134. The method of claim 133, wherein the number of CFUs in the localized infection is reduced by 5 log or more, 6 log or more, or 7 log or more within 7 days of administration.

135. 130. The method of claim 129, wherein greater than 99% of the CFUs in the localized infection are killed within 7 days of administration.

136. 136. The method of claim 135, wherein greater than 99.9% of the CFUs in the localized infection are killed within 7 days of administration.

137. 130. The method of claim 129, wherein the number of CFUs in the localized infection is reduced by 4 logs within 24 hours of administration.

138. 138. The method of claim 137, wherein the number of CFUs in the localized infection is reduced by 5 log or more, 6 log or more, or 7 log or more within 24 hours of administration.

139. 130. The method of claim 129, wherein greater than 99% of the CFUs in the localized infection are killed within 24 hours of administration.

140. 140. The method of claim 139, wherein greater than 99.9% of the CFUs in the localized infection are killed within 24 hours of administration.

141. 1. A method of treating a topical infection in a human patient, comprising: topically administering to said human patient two or more antibiotics, wherein at least one of said antibiotics is administered at a concentration above the MBEC of said at least one antibiotic against at least one microorganism; during said administering, identifying at least one microorganism within said localized infection; and after identifying the at least one microorganism, switching at least one of the antibiotics to a different antibiotic.

142. 142. The method of claim 141, wherein the at least one microorganism is identified by clinical testing of a sample from the local infection site.

143. 142. The method of claim 141, wherein the number of CFUs in the localized infection is reduced by at least 4 logs within 7 days of administration.

144. 144. The method of claim 143, wherein the number of CFUs in the localized infection is reduced by 5 log or more, 6 log or more, or 7 log or more within 7 days of administration.

145. 142. The method of claim 141, wherein greater than 99% of the CFUs in the localized infection are killed within 7 days of administration.

146. 146. The method of claim 145, wherein greater than 99.9% of the CFUs in the localized infection are killed within 7 days of administration.

147. 142. The method of claim 141, wherein the number of CFUs in the localized infection is reduced by 4 logs or more within 24 hours of administration.

148. 148. The method of claim 147, wherein the number of CFUs in the localized infection is reduced by 5 log or more, 6 log or more, or 7 log or more within 24 hours of administration.

149. 142. The method of claim 141, wherein greater than 99% of the CFUs in the localized infection are killed within 24 hours of administration.

150. 150. The method of claim 149, wherein greater than 99.9% of the CFUs in the localized infection are killed within 24 hours of administration.

151. 1. A method of treating a localized infection in a human patient, comprising: topically administering to the human patient a first antibiotic combination comprising two or more antibiotics; identifying at least one microorganism in the localized infection; and switching at least one of the antibiotics to provide a second antibiotic combination; and administering to the human patient the second antibiotic combination comprising two or more antibiotics, wherein the second antibiotic combination reduces the log 100% or greater reduction in the at least one identified microorganism compared to the first antibiotic combination against the identified microorganism. １０ A method that results in an increase in reduction (LogR).

152. 152. The method of claim 151, wherein the second antibiotic combination results in an improvement in the at least one identified microorganism of 0.5 log or more, 1 log or more, 1.5 log or more, 2.0 log or more, 2.5 log or more, 3.0 log or more, 3.5 log or more, or 4.0 log or more compared to the first antibiotic combination against the identified microorganism.

153. 152. The method of claim 151, wherein the at least one microorganism is identified by clinical testing of a sample from the local infection site.

154. 152. The method of claim 151, wherein the number of CFUs in the localized infection is reduced by at least 4 logs within 7 days of administration of the second antibiotic combination.

155. 155. The method of claim 154, wherein within 7 days of administration of the second antibiotic combination, the number of CFUs in the localized infection is reduced by 5 log or more, 6 log or more, or 7 log or more.

156. 152. The method of claim 151, wherein greater than 99% of the CFUs in the localized infection are killed within 7 days of administration of the second antibiotic combination.

157. 152. The method of claim 151, wherein greater than 99.9% of the CFUs in the localized infection are killed within 7 days of administration of the second antibiotic combination.

158. 152. The method of claim 151, wherein the number of CFUs in the localized infection is reduced by 4 logs or more within 24 hours of administration of the second antibiotic combination.

159. 159. The method of claim 158, wherein the number of CFUs of the topically administered second antibiotic combination is reduced by 5 log or more, 6 log or more, or 7 log or more within 24 hours of administration.

160. 152. The method of claim 151, wherein greater than 99% of the CFUs in the localized infection are killed within 24 hours of administration of the second antibiotic combination.

161. 152. The method of claim 151, wherein greater than 99.9% of the CFUs in the localized infection are killed within 24 hours of administration of the second antibiotic combination.

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