Abstract
Our aim was to demonstrate that biofilm formation in a clinical strain of methicillin-resistant Staphylococcus aureus (MRSA) can be enhanced by environment exposure in an endotracheal tube (ETT) and to determine how it is affected by systemic treatment and atmospheric conditions. Second, we aimed to assess biofilm production dynamics after extubation. We prospectively analyzed 70 ETT samples obtained from pigs randomized to be untreated (controls, n = 20), or treated with vancomycin (n = 32) or linezolid (n = 18). A clinical MRSA strain (MRSA-in) was inoculated in pigs to create a pneumonia model, before treating with antibiotics. Tracheally intubated pigs with MRSA severe pneumonia, were mechanically ventilated for 69 ± 16 hours. All MRSA isolates retrieved from ETTs (ETT-MRSA) were tested for their in vitro biofilm production by microtiter plate assay. In vitro biofilm production of MRSA isolates was sequentially studied over the next 8 days post-extubation to assess biofilm capability dynamics over time. All experiments were performed under ambient air (O2) or ambient air supplemented with 5% CO2. We collected 52 ETT-MRSA isolates (placebo N = 19, linezolid N = 11, and vancomycin N = 22) that were clonally identical to the MRSA-in. Among the ETT-MRSA isolates, biofilm production more than doubled after extubation in 40% and 50% under 5% CO2 and O2, respectively. Systemic antibiotic treatment during intubation did not affect this outcome. Under both atmospheric conditions, biofilm production for MRSA-in was at least doubled for 9 ETT-MRSA isolates, and assessment of these showed that biofilm production decreased progressively over a 4-day period after extubation. In conclusion, a weak biofilm producer MRSA strain significantly enhances its biofilm production within an ETT, but it is influenced by the ETT environment rather than by the systemic treatment used during intubation or by the atmospheric conditions used for bacterial growth.
Highlights
Intubation with an endotracheal tube (ETT) is a routine procedure that is applied to 40%–50% of patients admitted to intensive care units (ICUs)[1]
Other factors may play a role in ETT-biofilm formation we focused on three of them related with the clinical management of ICU patients such as: the endotracheal tube, the systemic antimicrobial treatment and atmospheric conditions that can vary between different ventilatory patterns applied to critical patients
61% and 71% of the methicillin-resistant Staphylococcus aureus (MRSA) isolates from within the ETTs showed a significant increase in biofilm production compared with the MRSA strain (MRSA-in) under O2 (2.02 [0.63–3.02], p < 0.001) and 5% CO2 (1.40 [0.57–2.39], p = 0.007), respectively (Fig. 1)
Summary
Intubation with an endotracheal tube (ETT) is a routine procedure that is applied to 40%–50% of patients admitted to intensive care units (ICUs)[1]. When covered by secretions or cell debris, microorganisms from the stomach or oropharynx[2] can rapidly colonize the ETT by directly or indirectly adhering to its surface[3,4]. Experiments were performed under ambient air (O2) and under ambient air supplemented with 5% CO2 (5% CO2) to assess the influence of atmospheric conditions on biofilm formation This reflected the clinical scenario where different proportion of gases can be applied during the mechanical ventilation of intubated patients[26]. Other factors may play a role in ETT-biofilm formation we focused on three of them related with the clinical management of ICU patients such as: the endotracheal tube, the systemic antimicrobial treatment and atmospheric conditions that can vary between different ventilatory patterns applied to critical patients
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