Medical Device-associated Infections Research Articles

Staphylococcus epidermidis biofilms with higher proportions of dormant bacteria induce a lower activation of murine macrophages.

Staphylococcus epidermidis is an opportunistic pathogen and, due to its ability to establish biofilms, is a leading causative agent of indwelling medical device-associated infection. The presence of high amounts of dormant bacteria is a hallmark of biofilms, making them more tolerant to antimicrobials and to the host immune response. We observed that S. epidermidis biofilms grown in excess glucose accumulated high amounts of viable but non-culturable (VBNC) bacteria, as assessed by their low ratio of culturable bacteria over the number of viable bacteria. This effect, which was a consequence of the accumulation of acidic compounds due to glucose metabolism, was counteracted by high extracellular levels of calcium and magnesium added to the culture medium allowing modulation of the proportions of VBNC bacteria within S. epidermidis biofilms. Using bacterial inocula obtained from biofilms with high and low proportions of VBNC bacteria, their stimulatory effect on murine macrophages was evaluated in vitro and in vivo. The inoculum enriched in VBNC bacteria induced in vitro a lower production of tumour necrosis factor alpha, interleukin-1 and interleukin-6 by bone-marrow-derived murine macrophages and, in vivo, a lower stimulatory effect on peritoneal macrophages, assessed by increased surface expression of Gr1 and major histocompatibility complex class II molecules. Overall, these results show that environmental conditions, such as pH and extracellular levels of calcium and magnesium, can induce dormancy in S. epidermidis biofilms. Moreover, they show that bacterial suspensions enriched in dormant cells are less inflammatory, suggesting that dormancy can contribute to the immune evasion of biofilms.

Staphylococcus epidermidis device-related infections: pathogenesis and clinical management

Abstract Staphylococcus epidermidis, the most frequently isolated coagulase-negative staphylococcus, is the leading cause of infection related to implanted medical devices (IMDs). This is directly related to its capability to establish multilayered, highly structured biofilms on artificial surfaces. At present, conventional systemic therapies using standard antimicrobial agents represent the main strategy to treat and prevent medical device-associated infections. However, device-related infections are notoriously difficult to treat and bacteria within biofilm communities on the surface of IMDs frequently outlive treatment, and removal of the medical device is often required for successful therapy. Importantly, major advances in this research area have been made, leading to a greater understanding of the complexities of biofilm formation of S. epidermidis and resulting in significant developments in the treatment and prevention of infections related to this member of the coagulase-negative group of staphylococci. This review will examine the pathogenesis of the clinically significant S. epidermidis and provide an overview of the conventional and emerging antibiofilm approaches in the management of medical device-associated infections related to this important nosocomial pathogen.

Effect of corrosion rate and surface energy of silver coatings on bacterial adhesion

Many studies suggest a strong antimicrobial activity of silver coatings. The biocidal activity of silver is related to the biologically active silver ion released from silver coatings. However, no studies have been reported on the effect of surface energy of silver coatings on antibacterial performance. In this paper, three silver coatings with various corrosion rates and surface energies were prepared on stainless steel plates using AgNO 3 based electroless plating solutions. The corrosion rate and surface energy of the silver coatings were characterized with CorrTest Electrochemistry Workstation and Dataphysics OCA-20 contact angle analyzer, respectively. The antibacterial performance of the silver coatings was evaluated with Pseudomonas aeruginosa PA01, which frequently causes medical device-associated infections. The experimental results showed that surface energy had significant influence on initial bacterial adhesion at low corrosion rate. The extended DLVO theory was used to explain the bacterial adhesion behavior.

Influence of reducers on nanostructure and surface energy of silver coatings and bacterial adhesion

Abstract The high incidence of infections caused by the use of implanted biomedical devices has a severe impact on human health and health care costs. Many studies suggest a strong antimicrobial activity of silver-coated medical devices. However no studies have been reported on the effect of surface energy of silver coatings on bacterial adhesion. In this paper, 4 types of silver coatings with various surface energies were prepared on stainless steel plates using AgNO 3 based electroless plating solutions with four different reducing agents, formaldehyde, hydrazine, glucose and potassium sodium tartrate tetrahydrate, respectively. The morphology and surface energy of the silver coatings were characterized with an Atomic Force Microscope and a Dataphysics OCA-20 contact angle analyzer, respectively. The anti-bacterial performance of the silver coatings was evaluated with Pseudomonas aeruginosa PA01, which frequently causes medical device-associated infections. The experimental results showed that bacterial adhesion decreased with the total surface energy of the coatings decreasing, but decreased with the electron donor component increasing. All the silver coatings performed much better than stainless steel in reducing bacterial attachment. The extended DLVO theory was used to explain bacterial adhesion behavior.

Influence of interaction energy between Si‐doped diamond‐like carbon films and bacteria on bacterial adhesion under flow conditions

Diamond-like carbon (DLC) films, especially modified DLC films with doped elements as biomaterials for medical devices have been attracting great interest. In this article, the bacterial adhesion behavior on DLC films, Si-doped DLC films, and stainless steel 316L was investigated with Pseudomonas aeruginosa ATCC 33347, which frequently causes medical device-associated infections. This was done under laminar flow conditions in a flow chamber at 37 degrees C. The contact angles of the coatings and the biofilm were measured. Polar liquids of distilled water and ethylene glycol, and apolar liquid of diiodomethane were used as a probe for surface free energy calculations. The electron donor component gamma(-) of surface energy of Si-doped DLC films increased with increasing the silicon content in the DLC films. The experimental results showed that the surface energy of the coatings and the interaction energy between the coatings and bacteria in water had significant influences on bacterial adhesion. The extended DLVO theory was used to explain the adhesion behavior.

<I>Staphylococcus epidermidis</I> device-related infections: pathogenesis and clinical management

Staphylococcus epidermidis, the most frequently isolated coagulase-negative staphylococcus, is the leading cause of infection related to implanted medical devices (IMDs). This is directly related to its capability to establish multilayered, highly structured biofilms on artificial surfaces. At present, conventional systemic therapies using standard antimicrobial agents represent the main strategy to treat and prevent medical device-associated infections. However, device-related infections are notoriously difficult to treat and bacteria within biofilm communities on the surface of IMDs frequently outlive treatment, and removal of the medical device is often required for successful therapy. Importantly, major advances in this research area have been made, leading to a greater understanding of the complexities of biofilm formation of S. epidermidis and resulting in significant developments in the treatment and prevention of infections related to this member of the coagulase-negative group of staphylococci. This review will examine the pathogenesis of the clinically significant S. epidermidis and provide an overview of the conventional and emerging antibiofilm approaches in the management of medical device-associated infections related to this important nosocomial pathogen.

Reduction of bacterial adhesion on ion-implanted stainless steel surfaces

The high incidence of infections caused by the use of biomedical devices has a severe impact on human health. An approach to reduce the complications is to modify the surface properties of biomedical devices. In this paper, stainless steel disks were implanted with N +, O + and SiF 3 +, respectively, by an ion implantation technique. The surface properties of the ion-implanted surfaces were characterized, including their surface chemical composition, roughness, topography, wettability and surface energy. Bacterial adhesion of Staphylococcus epidermidis and Staphylococcus aureus, which frequently cause medical device-associated infections was evaluated. The experimental results showed that these implanted stainless steels, particularly SiF 3 + implanted stainless steel performed much better than untreated stainless steel control on reducing bacterial attachment.

Synergistic Activity of Dispersin B and Cefamandole Nafate in Inhibition of Staphylococcal Biofilm Growth on Polyurethanes

Antibiotic therapies to eradicate medical device-associated infections often fail because of the ability of sessile bacteria, encased in their exopolysaccharide matrix, to be more drug resistant than planktonic organisms. In the last two decades, several strategies to prevent microbial adhesion and biofilm formation on the surfaces of medical devices, based mainly on the use of antiadhesive, antiseptic, and antibiotic coatings on polymer surfaces, have been developed. More recent alternative approaches are based on molecules able to interfere with quorum-sensing phenomena or to dissolve biofilms. Interestingly, a newly purified beta-N-acetylglucosaminidase, dispersin B, produced by the gram-negative periodontal pathogen Actinobacillus actinomycetemcomitans, is able to dissolve mature biofilms produced by Staphylococcus epidermidis as well as some other bacterial species. Therefore, in this study, we developed new polymeric matrices able to bind dispersin B either alone or in combination with an antibiotic molecule, cefamandole nafate (CEF). We showed that our functionalized polyurethanes could adsorb a significant amount of dispersin B, which was able to exert its hydrolytic activity against the exopolysaccharide matrix produced by staphylococcal strains. When microbial biofilms were exposed to both dispersin B and CEF, a synergistic action became evident, thus characterizing these polymer-dispersin B-antibiotic systems as promising, highly effective tools for preventing bacterial colonization of medical devices.

Bacterial adhesion on ion-implanted stainless steel surfaces

Stainless steel disks were implanted with N +, O + and SiF 3 +, respectively at the Surrey Ion Beam Centre. The surface properties of the implanted surfaces were analyzed, including surface chemical composition, surface topography, surface roughness and surface free energy. Bacterial adhesion of Pseudomonas aeruginosa, Staphylococcus epidermidis and Staphylococcus aureus, which frequently cause medical device-associated infections was evaluated under static condition and laminar flow condition. The effect of contact time, growth media and surface properties of the ion-implanted steels on bacterial adhesion was investigated. The experimental results showed that SiF 3 +-implanted stainless steel performed much better than N +-implanted steel, O +-implanted steel and untreated stainless steel control on reducing bacterial attachment under identical experimental conditions.

Evaluation of bacterial adhesion on Si-doped diamond-like carbon films

Diamond-like carbon (DLC) films as biomaterial for medical devices have been attracting great interest due to their excellent properties such as hardness, low friction and chemical inertness. It has been demonstrated that the properties of DLC films can be further improved by the addition of silicon into DLC films, such as thermal stability, compressive stress, etc. However no research work on anti-bacterial properties of silicon-doped diamond-like carbon films has been reported. In this paper the surface physical and chemical properties of Si-doped diamond-like carbon films with various Si contents on 316 stainless steel substrate prepared by a magnetron sputtering technique were investigated, including surface topography, surface chemistry, the sp 3/sp 2 ratio, contact angle, surface free energy, etc. Bacterial adhesion to Si-doped DLC films was evaluated with Pseudomonas aeruginosa, Staphylococcus epidermidis and Staphylococcus aureus which frequently cause medical device-associated infections. The experimental results showed that bacterial adhesion decreased with increasing the silicon content in the films. All the Si-doped DLC films performed much better than stainless steel 316L on reducing bacterial attachment.

Microbial interactions in Staphylococcus epidermidis biofilms

Medical device-associated infections, most frequently caused by coagulase-negative staphylococci, especially Staphylococcus epidermidis, are of increasing importance in modern medicine. The formation of adherent, multilayered bacterial biofilms is the most important factor in the pathogenesis of these infections, which regularly fail to respond to appropriate antimicrobial therapy. Progress in elucidating the factors functional in elaboration of S. epidermidis biofilms and the regulation of their expression with a special emphasis on the role of quorum sensing are reviewed. Significant progress has been made in recent years, which provides the rationale for developing better preventive, therapeutic and diagnostic measures.

Genetics and genomics of Candida albicans biofilm formation

Biofilm formation by the opportunistic fungal pathogen Candida albicans is a complex process with significant consequences for human health: it contributes to implanted medical device-associated infections. Recent advances in gene expression profiling and genetic analysis have begun to clarify the mechanisms that govern C. albicans biofilm development and acquisition of unique biofilm phenotypes. Such studies have identified candidate adhesin genes, and have revealed that biofilm drug resistance is multifactorial. Newly defined cell-cell communication pathways also have profound effects on biofilm formation. Future challenges include the elucidation of the structure and function of the extracellular exopolymeric substance that surrounds biofilm cells, and the extension of in vitro biofilm observations to newly developed in vivo biofilm models.

Biofilm Formation in Medical Device-Related Infection

Medical device-associated infections, most frequently caused by coagulase-negative staphylococci, especially Staphylococcus epidermidis, are of increasing importance in modern medicine. Regularly, antimicrobial therapy fails without removal of the implanted device. The most important factor in the pathogenesis of medical device-associated staphylococcal infections is the formation of adherent, multilayered bacterial biofilms. There is urgent need for an increased understanding of the functional factors involved in biofilm formation, the regulation of their expression, and the interaction of those potential virulence factors in device related infection with the host. Significant progress has been made in recent years which may ultimately lead to new rational approaches for better preventive, therapeutic, and diagnostic measures.

Suppression of Drug‐Resistant Staphylococcal Infections by the Quorum‐Sensing Inhibitor RNAIII‐Inhibiting Peptide

Staphylococcus aureus and S. epidermidis are major causes of infection related to biofilm formed on indwelling medical devices. Such infections are common causes of morbidity and mortality and, because of biofilm resistance to antibiotics, are difficult to treat. The RNAIII-inhibiting peptide (RIP) (YSPWTNF-NH2) inhibits the pathogenesis of staphylococci by disrupting bacterial cell-cell communication (known as "quorum sensing"). Using a vascular-graft rat model, we show that RIP, applied locally and systemically, can completely inhibit drug-resistant S. aureus and S. epidermidis biofilms. The present study provides the first direct demonstration that interfering with cell-cell communication by use of a quorum-sensing inhibitor can eliminate medical device-associated staphylococcal infections. We suggest that medical devices could be coated with RIP to prevent infections, including those by antibiotic-resistant staphylococcal strains.

Furanones as potential anti-bacterial coatings on biomaterials

A major barrier to the long-term use of medical devices is development of infection. Staphylococcus epidermidis is one of the most common bacterial isolates from these infections with biofilm formation being their main virulence factor. Currently, antibiotics are used as the main form of therapy. However with the emergence of staphylococcal resistance, this form of therapy is fast becoming ineffective. In this study, the ability of a novel furanone antimicrobial compound to inhibit S. epidermidis adhesion and slime production on biomaterials was assessed. Furanones were physically adsorbed to various biomaterials and bacterial load determined using radioactivity. Slime production was assessed using a colorimetric method. Additionally, the effect of the furanone coating on material surface characteristics such as hydrophobicity and surface roughness was also investigated. The results of this study indicated that there was no significant change in the material characteristics after furanone coating. Bacterial load on all furanone-coated materials was significantly reduced ( p<0.001) as was slime production ( p<0.001). There is a potential for furanone-coated biomaterials to be used to reduce medical device-associated infections.

Polymer Designs to Control Biofilm Growth on Medical Devices

Indwelling and temporary medical delivery devices (i.e. catheters) are increasingly used in hospital settings, providing clinicians with useful tools to administer nutrients, draw blood samples and deliver drugs. However, they can often put patients at risk for local or systemic infections, including bloodstream infections and endocarditis. Microorganisms readily adhere to the surfaces and colonize them by forming a slimy layer of biofilm. Bacteria growing in biofilms exhibit an increased antibiotic resistance in comparison with planktonic cells. Consequently the antibiotic treatment of these medical device-associated infections frequently fails. Detechment resulting in the formation of microemboli is a further biofilm related complication. Since infections often involve increased morbidity and morality, prolonged hospitalization and additional medical costs, various strategies to prevent biofilm formation on implanted medical devices have been developed over the last two decades. In this paper we review and discuss the most significant experimental approaches to inhibit bacterial adhesion and growth on these devices.

Minimal attachment killing (MAK): a versatile method for susceptibility testing of attached biofilm-positive and -negative Staphylococcus epidermidis.

Due to its ability to attach to polymeric surfaces Staphylococcus epidermidis is a common pathogen in chronic, medical device-associated infections. Attached S. epidermidis displays reduced susceptibility against a variety of antimicrobial substances, and little correlation between standard susceptibility test results and clinical outcome of antibiotic treatment is observed. In this study we established a new, versatile, and easy method of antimicrobial susceptibility testing for attached Staphylococcus epidermidis, suitable for both biofilm-negative and biofilm-positive attached bacteria using readily available equipment. For three biofilm-positive wild-type strains and their biofilm-negative mutants minimal attachment killing concentrations (MAK) of penicillin, oxacillin, vancomycin, and gentamicin were determined. Depending on strain and investigated antibiotics, a heterogeneous MAK (MAK(hetero)) could be differentiated from a homogeneous resistance (MAK(homo)), favoring a model of few persisters within attached cells under antibiotic treatment. For the biofilm-negative mutants, a lower MAK(homo) was detected than for the corresponding wild types for some of the tested antibiotics, which probably resulted from higher bacterial inocula of wild-type strains, whereas the MAK(hetero) were comparable for mutants and wild types for most of the tested antibiotics and strains. These data indicate that biofilm formation is not a necessary prerequisite for persistence of attached S. epidermidis cells under antibiotic treatment, which could explain therapeutic failure in foreign body-associated infections due to biofilm-negative S. epidermidis isolates. The highly individual resistance phenotypes of the investigated strains with different antibiotics suggests that MAK determination could help to predict the therapeutic outcome of foreign body-associated infections with both biofilm-positive and biofilm-negative S. epidermidis.

Biofilm formation by Staphylococcus epidermidis depends on functional RsbU, an activator of the sigB operon: differential activation mechanisms due to ethanol and salt stress.

Staphylococcus epidermidis is a common pathogen in medical device-associated infections. Its major pathogenetic factor is the ability to form adherent biofilms. The polysaccharide intercellular adhesin (PIA), which is synthesized by the products of the icaADBC gene cluster, is essential for biofilm accumulation. In the present study, we characterized the gene locus inactivated by Tn917 insertions of two isogenic, icaADBC-independent, biofilm-negative mutants, M15 and M19, of the biofilm-producing bacterium S. epidermidis 1457. The insertion site was the same in both of the mutants and was located in the first gene, rsbU, of an operon highly homologous to the sigB operons of Staphylococcus aureus and Bacillus subtilis. Supplementation of Trypticase soy broth with NaCl (TSB(NaCl)) or ethanol (TSB(EtOH)), both of which are known activators of sigB, led to increased biofilm formation and PIA synthesis by S. epidermidis 1457. Insertion of Tn917 into rsbU, a positive regulator of alternative sigma factor sigma(B), led to a biofilm-negative phenotype and almost undetectable PIA production. Interestingly, in TSB(EtOH), the mutants were enabled to form a biofilm again with phenotypes similar to those of the wild type. In TSB(NaCl), the mutants still displayed a biofilm-negative phenotype. No difference in primary attachment between the mutants and the wild type was observed. Similar phenotypic changes were observed after transfer of the Tn917 insertion of mutant M15 to the independent and biofilm-producing strain S. epidermidis 8400. In 11 clinical S. epidermidis strains, a restriction fragment length polymorphism of the sigB operon was detected which was independent of the presence of the icaADBC locus and a biofilm-positive phenotype. Obviously, different mechanisms are operative in the regulation of PIA expression in stationary phase and under stress induced by salt or ethanol.

17] Methods for studying biofilms produced by staphylococcus epidermidis

Publisher Summary This chapter discusses the methods for studying biofilms produced by Staphylococcus epidermidis . Coagulase-negative staphylococci, in particular Staphylococcus epidermidis, once regarded as harmless skin commensals or contaminants of clinical material, are now accepted as major nosocomial pathogens. These bacteria are the most common cause of medical device-associated infection, especially if host immunity is depressed because of underlying disease or treatment with immunosuppressive drugs. Common types of device-associated infection include prosthetic valve endocarditis, infections of intravascular devices, peritonitis associated with continuous ambulatory peritoneal dialysis, central venous shunt infections, and bacteremia. Bloodstream infection with coagulase-negative staphylococci is also common in low birth weight newborns requiring intensive care. One of the problems encountered when examining the literature on biofilm production by S. epidermidis is the plethora of methods and approaches that have been used to investigate the interaction among the bacteria and glass or plastic surfaces. This chapter begins with an overview of methods that have been used to study biofilm formation by staphylococci. Methods for assaying early attachment and mature biofilm are described. Deceptively simple, these methods require careful attention to detail in order to obtain meaningful results. An attempt is made to discuss the problems associated with differences in methodology among research groups, by presenting methodology that is accepted by a majority of investigators.

18] Methods to detect and analyze phenotypic variation in biofilm-forming staphylococci

Publisher Summary This chapter discusses the methods to detect and analyze phenotypic variation in biofilm-forming staphylococci. Staphylococci are the most common cause of medical device-associated infections, especially in immunocompromised patients. The pathogenesis of these infections is favored by the ability of certain Staphylococcus epidermidis and Staphylococcus aureus strains to express a slimy matrix, in which the bacteria becomes embedded and forms thick, multilayered biofilms on smooth surfaces. Staphylococcus aureus and S. epidermidis clinical isolates are known to vary in a wide range of phenotypic properties. Thus, it has been shown that cells from a single parental clone can differ in terms of growth rate, exoprotein production, antibiotic susceptibility, and adhesion. It has been suggested that this phenotypic variation might contribute to the successful adaptation of the bacteria to environmental changes. With respect to S. epidermidis , it was shown that the majority of the clinical S. epidermidis isolates grow in multicellular clusters and that the removal of these biofilms (for example, by antibiotics) is difficult. Therefore, it is assumed that staphylococcal biofilm formation represents an advantage for the bacteria that contributes considerably to pathogenesis. However, numerous studies give evidence that S. epidermidis has a strong capacity to vary biofilm expression. Thus, it was observed that within a S. epidermidis biofilm population biofilm-negative variants are currently released. This chapter describes the detection and genetic analysis of these biofilm-negative variants. It shows the application of the 16S rRNA in situ hybridization technique for the detection of staphylococci grown in biofilms, and in infected tissues.