Attenuation of Residual Antibiotics Using Vitamin C in Homograft Heart Valves
-
Ellen Sepanian
,
Orkideh Olang
,
Mohsen Heydari
,
Seyed Amirhosein Tavakoli
,
Seyed Kazem Hosseini
,
Hamid Goodarzi
,
Alireza Heidary Rouchi
Abstract
Objective: The removal of residual antibiotics from whole homograft tissues after disinfection is a matter of concern. To avoid bacteriostasis, which causes falsely negative culture results, we investigated the effectiveness of a novel method applicable to whole homografts.
Methods: Thirty homografts, assessed as unsuitable for transplantation, were obtained from 24 deceased donors. Fourteen days after freezing, each homograft was thawed and divided lengthwise into 2 halves, with one serving as an unexposed control and the other as an exposed sample. Exposure was conducted using 400 µg/mL vitamin C. Five-step microbiological assays were performed using direct tissue samples and cryopreservation solution after thawing. The presence of residual antibiotics in tissue homogenates and cryopreservation solution was assessed by an agar diffusion test on seeded plates with 8 virulent strains. The effect of the intervention was determined by comparing the inhibition zones of exposed and unexposed tissue homogenates.
Results: Blood culture results from all donors were negative. The initial contamination rate was 13.3%, and the isolates were not detected after disinfection. Thawed tissues that were not exposed to vitamin C all yielded negative culture results, whereas one tissue sample exposed to vitamin C had a positive result (Pantoea eucrina). The diameter of the inhibition zone in seeded plates was 14.4% smaller with tissue exposed to vitamin C than that of controls (P=0.021).
Conclusion: The retention of antibiotics and carryover effect are unavoidable. Vitamin C can break down antimicrobial molecules and produce soluble by-products, which leads to a diminished amount of residual antimicrobials and a higher probability of detecting microorganisms in post-disinfection cultures.
1. Gall KL, Smith SE, Willmette CA, O'Brien MF. Allograft heart valve viability and valve-processing variables. Ann Thorac Surg.1998; 65(4): 1032-38.
2. Heng WL, Albrecht H, Chiappini P, Lim YP, Manning L. International heart valve bank survey: a review of processing practices and activity outcomes. J Transplant. 2013;2013:163150.
3. Greenwald MA, Kuehnert MJ, Fishman JA. Infectious disease transmission during organ and tissue transplantation. Emerg Infect Dis. 2012; 18(8): e1.
4. Fishman JA, Greenwald MA, Grossi PA. Transmission of infection with human allografts: essential considerations in donor screening. Clin Infect Dis. 2012; 55(5): 720-7.
5. Dashti-Khavidaki S, Dabardani F, Mahdavi-Mazdeh M, Ravanasa E, Hosseini SK. Efficacy of decontamination protocol by antimicrobial treatment in Iranian Tissue Bank (ITB). Cell Tissue Bank. 2015; 16(3): 381-8.
6. Germain M, Strong DM, Dowling G, Mohr J, Duong A, Garibaldi A, et al. Disinfection of human cardiac valve allografts in tissue banking: systematic review report. Cell Tissue Bank. 2016; 17(4):593-601.
7. Gall K, Smith S, Willmette C, Wong M, O’Brien M. Allograft heart valve sterilization: a six-year in-depth analysis of a twenty-five-year experience with low-dose antibiotics. J Thorac Cardiovasc Surg.1995;110(3): 680-7.
8. Tabaku M, Jashari R, Carton HF, Du Verger A, Van Hoeck B, Vanderkelen A. Processing of cardiovascular allografts: effectiveness of European Homograft Bank (EHB) antimicrobial treatment (cool decontamination protocol with low concentration of antibiotics). Cell Tissue Bank. 2004; 5(4): 261-6.
9. Jashari R, Tabaku M, Van Hoeck B, Cochez C, Callant M, Vanderkelen A. Decontamination of heart valve and arterial allografts in the European Homograft Bank (EHB): comparison of two different antibiotic cocktails in low temperature. Cell Tissue Bank. 2007; 8(4): 247-255.
10. Germain M, Thibault L, Jacques A, Tremblay J, Bourgeois R. Heart valve homograft decontamination with antibiotics: impact of the temperature of incubation on efficacy. Cell Tissue Bank. 2010; 11(2): 197-204.
11. Heng WL, Lim CH, Tan BH, Chlebicki MP, Ling Lee WH, Seck T, et al. From penicillin-streptomycin to amikacin-vancomycin: antibiotic decontamination of cardiovascular homografts in Singapore. PLoS One. 2012;7(12): e51605.
12. Leeming JP, Lovering AM, Hunt CJ. Residual antibiotics in allograft heart valve tissue samples following antibiotic disinfection. J Hosp Infect. 2005;60(3): 231-234.
13. Jashari R, Faucon F, Van Hoeck B, De Glas S, Fan Y, Vandenbulcke S. Determination of residual antibiotics in cryopreserved heart valve allografts. Transfus Med Hemother. 2011;38(6): 379-386.
14. Soo A, Healy DG, El-Bashier H, Shaw S, Wood AE. Quality control in homograft valve processing: when to screen for microbiological contamination? Cell Tissue Bank.2011;12(3): 185-90.
15. Buzzi M, Guarino A, Gatto C, Manara S, Dainese L, Polvani G, et al. Residual antibiotics in decontaminated human cardiovascular tissues intended for transplantation and risk of falsely negative microbiological analyses. PLoS One. 2014;9(11): e112679.
16. Agnihotri AK, McGiffin DC, Galbraith AJ, O’Brien MF. The prevalence of infective endocarditis after aortic valve replacement. J Thorac Cardiovasc Surg. 1995; 110(6):1708-1728.
17. Eastlund T. Bacterial infection transmitted by human tissue allograft transplantation. Cell Tissue Bank. 2006; 7(3):147-66.
18. Mallick TK, Mosquera A, Zinderman CE, St Martin L, Wise RP. Reported infections after human tissue transplantation before and after new Food and Drug Administration (FDA) regulations, United States, 2001 through June, 2010. Cell Tissue Bank. 2012; 13 (2):259-67.
19. Gatto C, Giurgola L, D’ Amato Tothova J. A suitable and efficient procedure for the removal of decontaminating antibiotics from tissue allografts. Cell Tissue Bank. 2013;14(1):107-15.
20. Mitteregger D, Barousch W, Nehr M, Kundi M, Zeitlinger M, Makristathis A, et al. Neutralization of antimicrobial substances in new BacT/ Alert+FA and FN Plus blood cultures bottles. J Clin Microbiol. 2013; 51(5): 1534-40.
21. Heidary Rouchi A, Radmehr H, Tavakoli SA, Jafarzadeh Kashi TS, Mahdavi-Mazdeh M. Iranian homograft heart valves: assessment of durability and late outcome. Cell Tissue Bank. 2016; 17(4):603-610.
22. Weller PF, Adkinson NF, Feldweg AM. Vancomycin hypersensitivity. UpToDate; 2017. [Topic 2083, Version 9.0].
23. Kane RS, Glink PT, Champan RG, McDonald JC, Jensen PK, Gao H, et al. Basicity of the amino groups of the aminoglycoside amikacin using capillary electrophoresis and coupled CE-MS-MS techniques. Anal Chem.2001;73(16): 4028-36.
24. Johnson JLH and Yalkowsky SH. Reformulation of a new vancomycin analog: an example of the importance of buffer species and strength. AAPS PharmSciTech.2006;7(1):E33-7.
25. Jia Z, O'Mara ML, Zuegg J, Cooper MA, Mark AE. Vancomycin: ligand recognition, dimerization and super-complex formation. The FEBS Journal. 2013; 280(5): 1294-1307.doi: 10.1111/febs.12121.
26. Assary RS, Atesin AC, Li Z, Curtiss LA, Marks TJ. Reaction pathways and energetics of etheric C-O bond cleavage catalyzed by lanthanide triflates. ACS Catal. 2013;3(9):1908-14.
27. Golubitskii GB, Budko EV, Basova EM, Kostarnoi AV, Ivanov VM. Stability of ascorbic acid in aqueous and aqueous-organic solutions for quantitative determination. J Anal Chem. 2007;62(8):742-7.
28. Kadkhodaee M, Khastar H, Faghihi M, Ghaznavi R, Zahmatkesh M. Effects of co-supplementation of vitamins E and C on gentamicin-induced nephrotoxicity in rat. Exp Physiol. 2005; 90(4): 571-576.
29. Ocak S, Gorur S, Hakverdi S, Celik S, Erdogan S. Protective effects of caffeic acid phenethyl ester, vitamin C, vitamin E and N-Acetylcysteine on vancomycin-induced nephrotoxicity in rats. Basic Clin Pharmacol. 2007; 100(5):328-333.
30. Yousef JM, Chen G, Hill PA, Nation RL, Li J. Ascorbic acid protects against the nephrotoxicity and apoptosis caused by colistin and affects its pharmacokinetics. J Antimicrob Chemother. 2012; 67(2):452-459.
31. Akhundi S, Lee YR, Perry GK, Fike DS, Mnjoyan S. Nephrotoxicity in recipients of vancomycin vs. vancomycin with vitamin C. Int J Med Pharm. 2015; 3(2):1-15.
32. Heidary Rouchi A, Tavakoli SA, Mahdavi-Mazdeh M. Iranian homograft tissue processing. Glob Cardiol Sci Pract. 2016; 2016(1): e201607.
33. Pruss A and Mönig HJ. Current standards in tissue banking. ISBT Sci Ser. 2010; 5(n1): 148-54.
34. Balouiri M, Sadiki M, Ibnsouda SK. Method for in vitro evaluating antimicrobial activity: a review. J Pharm Anal. 2016; 6(2):71-9.
35. Zimmer BL, Carpenter DE, Esparza G, Alby K, Bhatnagar A, Ferrell AL, et al. Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically. Clinical and Laboratory Standards Institute (CLSI) Document M07. 12th Edition; 2024.
36. Lane DJ. 16S/23S rRNA sequencing. In: Stackebrandt E, Goodfellow M, eds. Nucleic Acid techniques in bacterial systematic. New York: John Wiley and Sons; 1991. p. 115-75.
37. Altschul SF, Gish W, Miller W, Myers EW, Lipman DJ. Basic local alignment search tool. J Mol Biol.1990;215 (3): 403-10.
38. Adeolu M, Alnajar S, Naushad S, Gupta RS. Genome-based phylogeny and taxonomy of the ‘Enterobacteriales’: proposal for Enterobacterales ord. nov. divided into the families Enterobacteriaceae, Erwiniaceae fam. nov., Pectobacteriaceae fam. nov., Yersiniaceae fam. nov., Hafniaceae fam. nov., Morganellaceae fam. nov., and Budviciaceae fam. nov. Int J Syst Evol Microbiol. 2016; 66(12):5575-99.
39. Saksenborg Kolle I, Vinter-Jansen L, Nielsen ME, Nilsen HL. Pantoea eucrina: Catheter-Related Bloodstream Infection in a Woman with Short Bowel Syndrom. Clin Case Rep, 2025;13(2):e70103.
40. Brady CL, Cleenwerck I, Venter SN, Engelbeen K, De Vos P, Coutinho PA. Emended description of the genus Pantoea, description of four species from human clinical samples, Pantoea septica sp. nov., Pantoea eucrina sp. nov., Pantoea brenneri sp. nov. and Pantoea conspicua sp. nov., and transfer of Pectobacterium cypripedii (Hori 1911) Brenner et al. 1973 emend. Hauben et al. 1998 to the genus as Pantoea cypripedii comb. nov. Int J Syst Evol Microbiol.2010;60(10): 2430-40.
2. Heng WL, Albrecht H, Chiappini P, Lim YP, Manning L. International heart valve bank survey: a review of processing practices and activity outcomes. J Transplant. 2013;2013:163150.
3. Greenwald MA, Kuehnert MJ, Fishman JA. Infectious disease transmission during organ and tissue transplantation. Emerg Infect Dis. 2012; 18(8): e1.
4. Fishman JA, Greenwald MA, Grossi PA. Transmission of infection with human allografts: essential considerations in donor screening. Clin Infect Dis. 2012; 55(5): 720-7.
5. Dashti-Khavidaki S, Dabardani F, Mahdavi-Mazdeh M, Ravanasa E, Hosseini SK. Efficacy of decontamination protocol by antimicrobial treatment in Iranian Tissue Bank (ITB). Cell Tissue Bank. 2015; 16(3): 381-8.
6. Germain M, Strong DM, Dowling G, Mohr J, Duong A, Garibaldi A, et al. Disinfection of human cardiac valve allografts in tissue banking: systematic review report. Cell Tissue Bank. 2016; 17(4):593-601.
7. Gall K, Smith S, Willmette C, Wong M, O’Brien M. Allograft heart valve sterilization: a six-year in-depth analysis of a twenty-five-year experience with low-dose antibiotics. J Thorac Cardiovasc Surg.1995;110(3): 680-7.
8. Tabaku M, Jashari R, Carton HF, Du Verger A, Van Hoeck B, Vanderkelen A. Processing of cardiovascular allografts: effectiveness of European Homograft Bank (EHB) antimicrobial treatment (cool decontamination protocol with low concentration of antibiotics). Cell Tissue Bank. 2004; 5(4): 261-6.
9. Jashari R, Tabaku M, Van Hoeck B, Cochez C, Callant M, Vanderkelen A. Decontamination of heart valve and arterial allografts in the European Homograft Bank (EHB): comparison of two different antibiotic cocktails in low temperature. Cell Tissue Bank. 2007; 8(4): 247-255.
10. Germain M, Thibault L, Jacques A, Tremblay J, Bourgeois R. Heart valve homograft decontamination with antibiotics: impact of the temperature of incubation on efficacy. Cell Tissue Bank. 2010; 11(2): 197-204.
11. Heng WL, Lim CH, Tan BH, Chlebicki MP, Ling Lee WH, Seck T, et al. From penicillin-streptomycin to amikacin-vancomycin: antibiotic decontamination of cardiovascular homografts in Singapore. PLoS One. 2012;7(12): e51605.
12. Leeming JP, Lovering AM, Hunt CJ. Residual antibiotics in allograft heart valve tissue samples following antibiotic disinfection. J Hosp Infect. 2005;60(3): 231-234.
13. Jashari R, Faucon F, Van Hoeck B, De Glas S, Fan Y, Vandenbulcke S. Determination of residual antibiotics in cryopreserved heart valve allografts. Transfus Med Hemother. 2011;38(6): 379-386.
14. Soo A, Healy DG, El-Bashier H, Shaw S, Wood AE. Quality control in homograft valve processing: when to screen for microbiological contamination? Cell Tissue Bank.2011;12(3): 185-90.
15. Buzzi M, Guarino A, Gatto C, Manara S, Dainese L, Polvani G, et al. Residual antibiotics in decontaminated human cardiovascular tissues intended for transplantation and risk of falsely negative microbiological analyses. PLoS One. 2014;9(11): e112679.
16. Agnihotri AK, McGiffin DC, Galbraith AJ, O’Brien MF. The prevalence of infective endocarditis after aortic valve replacement. J Thorac Cardiovasc Surg. 1995; 110(6):1708-1728.
17. Eastlund T. Bacterial infection transmitted by human tissue allograft transplantation. Cell Tissue Bank. 2006; 7(3):147-66.
18. Mallick TK, Mosquera A, Zinderman CE, St Martin L, Wise RP. Reported infections after human tissue transplantation before and after new Food and Drug Administration (FDA) regulations, United States, 2001 through June, 2010. Cell Tissue Bank. 2012; 13 (2):259-67.
19. Gatto C, Giurgola L, D’ Amato Tothova J. A suitable and efficient procedure for the removal of decontaminating antibiotics from tissue allografts. Cell Tissue Bank. 2013;14(1):107-15.
20. Mitteregger D, Barousch W, Nehr M, Kundi M, Zeitlinger M, Makristathis A, et al. Neutralization of antimicrobial substances in new BacT/ Alert+FA and FN Plus blood cultures bottles. J Clin Microbiol. 2013; 51(5): 1534-40.
21. Heidary Rouchi A, Radmehr H, Tavakoli SA, Jafarzadeh Kashi TS, Mahdavi-Mazdeh M. Iranian homograft heart valves: assessment of durability and late outcome. Cell Tissue Bank. 2016; 17(4):603-610.
22. Weller PF, Adkinson NF, Feldweg AM. Vancomycin hypersensitivity. UpToDate; 2017. [Topic 2083, Version 9.0].
23. Kane RS, Glink PT, Champan RG, McDonald JC, Jensen PK, Gao H, et al. Basicity of the amino groups of the aminoglycoside amikacin using capillary electrophoresis and coupled CE-MS-MS techniques. Anal Chem.2001;73(16): 4028-36.
24. Johnson JLH and Yalkowsky SH. Reformulation of a new vancomycin analog: an example of the importance of buffer species and strength. AAPS PharmSciTech.2006;7(1):E33-7.
25. Jia Z, O'Mara ML, Zuegg J, Cooper MA, Mark AE. Vancomycin: ligand recognition, dimerization and super-complex formation. The FEBS Journal. 2013; 280(5): 1294-1307.doi: 10.1111/febs.12121.
26. Assary RS, Atesin AC, Li Z, Curtiss LA, Marks TJ. Reaction pathways and energetics of etheric C-O bond cleavage catalyzed by lanthanide triflates. ACS Catal. 2013;3(9):1908-14.
27. Golubitskii GB, Budko EV, Basova EM, Kostarnoi AV, Ivanov VM. Stability of ascorbic acid in aqueous and aqueous-organic solutions for quantitative determination. J Anal Chem. 2007;62(8):742-7.
28. Kadkhodaee M, Khastar H, Faghihi M, Ghaznavi R, Zahmatkesh M. Effects of co-supplementation of vitamins E and C on gentamicin-induced nephrotoxicity in rat. Exp Physiol. 2005; 90(4): 571-576.
29. Ocak S, Gorur S, Hakverdi S, Celik S, Erdogan S. Protective effects of caffeic acid phenethyl ester, vitamin C, vitamin E and N-Acetylcysteine on vancomycin-induced nephrotoxicity in rats. Basic Clin Pharmacol. 2007; 100(5):328-333.
30. Yousef JM, Chen G, Hill PA, Nation RL, Li J. Ascorbic acid protects against the nephrotoxicity and apoptosis caused by colistin and affects its pharmacokinetics. J Antimicrob Chemother. 2012; 67(2):452-459.
31. Akhundi S, Lee YR, Perry GK, Fike DS, Mnjoyan S. Nephrotoxicity in recipients of vancomycin vs. vancomycin with vitamin C. Int J Med Pharm. 2015; 3(2):1-15.
32. Heidary Rouchi A, Tavakoli SA, Mahdavi-Mazdeh M. Iranian homograft tissue processing. Glob Cardiol Sci Pract. 2016; 2016(1): e201607.
33. Pruss A and Mönig HJ. Current standards in tissue banking. ISBT Sci Ser. 2010; 5(n1): 148-54.
34. Balouiri M, Sadiki M, Ibnsouda SK. Method for in vitro evaluating antimicrobial activity: a review. J Pharm Anal. 2016; 6(2):71-9.
35. Zimmer BL, Carpenter DE, Esparza G, Alby K, Bhatnagar A, Ferrell AL, et al. Methods for dilution antimicrobial susceptibility tests for bacteria that grow aerobically. Clinical and Laboratory Standards Institute (CLSI) Document M07. 12th Edition; 2024.
36. Lane DJ. 16S/23S rRNA sequencing. In: Stackebrandt E, Goodfellow M, eds. Nucleic Acid techniques in bacterial systematic. New York: John Wiley and Sons; 1991. p. 115-75.
37. Altschul SF, Gish W, Miller W, Myers EW, Lipman DJ. Basic local alignment search tool. J Mol Biol.1990;215 (3): 403-10.
38. Adeolu M, Alnajar S, Naushad S, Gupta RS. Genome-based phylogeny and taxonomy of the ‘Enterobacteriales’: proposal for Enterobacterales ord. nov. divided into the families Enterobacteriaceae, Erwiniaceae fam. nov., Pectobacteriaceae fam. nov., Yersiniaceae fam. nov., Hafniaceae fam. nov., Morganellaceae fam. nov., and Budviciaceae fam. nov. Int J Syst Evol Microbiol. 2016; 66(12):5575-99.
39. Saksenborg Kolle I, Vinter-Jansen L, Nielsen ME, Nilsen HL. Pantoea eucrina: Catheter-Related Bloodstream Infection in a Woman with Short Bowel Syndrom. Clin Case Rep, 2025;13(2):e70103.
40. Brady CL, Cleenwerck I, Venter SN, Engelbeen K, De Vos P, Coutinho PA. Emended description of the genus Pantoea, description of four species from human clinical samples, Pantoea septica sp. nov., Pantoea eucrina sp. nov., Pantoea brenneri sp. nov. and Pantoea conspicua sp. nov., and transfer of Pectobacterium cypripedii (Hori 1911) Brenner et al. 1973 emend. Hauben et al. 1998 to the genus as Pantoea cypripedii comb. nov. Int J Syst Evol Microbiol.2010;60(10): 2430-40.
| Files | ||
| Issue | Vol 21 No 1 (2026) | |
| Section | Original Article(s) | |
| DOI | https://doi.org/10.18502/jthc.v21i1.21277 | |
| Keywords | ||
| Homograft Heart Valve Residual Antibiotics Decontamination Vitamin C | ||
| Rights and permissions | |
|
This work is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License. |
How to Cite
1.
Sepanian E, Olang O, Heydari M, Tavakoli SA, Hosseini SK, Goodarzi H, Heidary Rouchi A. Attenuation of Residual Antibiotics Using Vitamin C in Homograft Heart Valves. Res Heart Yield Transl Med. 2026;21(1):1-11.
