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Abstract
Candida albicans is among the most prevalent fungal species of the human microbiota and asymptomatically colonizes healthy individuals. However, it is also an opportunistic pathogen that can cause severe, and often fatal, bloodstream infections. The medical impact of C. albicans typically depends on its ability to form biofilms, which are closely packed communities of cells that attach to surfaces, such as tissues and implanted medical devices. In this Review, we provide an overview of the processes involved in the formation of C. albicans biofilms and discuss the core transcriptional network that regulates biofilm development. We also consider some of the advantages that biofilms provide to C. albicans in comparison with planktonic growth and explore polymicrobial biofilms that are formed by C. albicans and certain bacterial species.
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52
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Rijkschroeff P, Loos BG, Nicu EA. Impaired polymorphonuclear neutrophils in the oral cavity of edentulous individuals. Eur J Oral Sci 2017; 125:371-378. [PMID: 28833699 PMCID: PMC5601278 DOI: 10.1111/eos.12367] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/28/2017] [Indexed: 12/29/2022]
Abstract
Oral health is characterized by functional oral polymorphonuclear neutrophils (oPMNs). Edentulism might be associated with a loss of oPMNs because these cells enter the oral cavity primarily through the gingival crevices. The main aim of this study was to investigate the numbers of oPMNs in rinse samples obtained from edentulous (n = 21) and dentate (n = 20) subjects. A second study aim was to investigate possible differences between oPMNs and peripheral blood polymorphonuclear neutrophils (cPMNs). Apoptosis/necrosis and cell-activation markers (CD11b, CD63 and CD66b) were analyzed using flow cytometry. Reactive oxygen species (ROS) production was determined either without stimulation (constitutive) or in response to 10 μM phorbol myristate acetate or Fusobacterium nucleatum. The edentulous subjects presented with lower oPMN counts and higher percentages of apoptotic/necrotic oPMNs compared with dentate subjects. Furthermore, oPMNs from edentulous donors expressed low levels of all three activation markers and low constitutive ROS. In contrast, oPMNs from dentate subjects expressed high levels of all three activation markers and a higher level of constitutive ROS than cPMNs. When challenged, oPMNs from edentulous subjects showed no upregulation in ROS production, whereas oPMNs from dentate subjects retained their ability to respond to stimulation. The functional characteristics of cPMNs were comparable between edentulous and dentate subjects. This study demonstrates that despite having functional cPMNs, edentulous subjects have low oPMN numbers that are functionally impaired.
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Affiliation(s)
- Patrick Rijkschroeff
- Department of PeriodontologyAcademic Centre for Dentistry AmsterdamAmsterdamthe Netherlands
| | - Bruno G. Loos
- Department of PeriodontologyAcademic Centre for Dentistry AmsterdamAmsterdamthe Netherlands
| | - Elena A. Nicu
- Department of PeriodontologyAcademic Centre for Dentistry AmsterdamAmsterdamthe Netherlands
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53
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Barker JC, Khansa I, Gordillo GM. A Formidable Foe Is Sabotaging Your Results: What You Should Know about Biofilms and Wound Healing. Plast Reconstr Surg 2017; 139:1184e-1194e. [PMID: 28445380 DOI: 10.1097/prs.0000000000003325] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
LEARNING OBJECTIVES After reading this article, the participant should be able to: 1. Describe biofilm pathogenesis as it relates to problem wounds. 2. Understand the preclinical and clinical evidence implicating biofilm in problem wounds. 3. Explain the diagnostic and treatment challenges that biofilms create for problem wounds. 4. Demonstrate a basic understanding of emerging strategies aimed at counteracting these processes. SUMMARY Biofilm represents a protected mode of growth for bacteria, allowing them to evade standard diagnostic techniques and avoid eradication by standard therapies. Although only recently discovered, biofilm has existed for millennia and complicates nearly every aspect of medicine. Biofilm impacts wound healing by allowing bacteria to evade immune responses, prolonging inflammation and disabling skin barrier function. It is important to understand why problem wounds persist despite state-of-the-art treatment, why they are difficult to accurately diagnose, and why they recur. The aim of this article is to focus on current gaps in knowledge related to problem wounds, specifically, biofilm infection.
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Affiliation(s)
- Jenny C Barker
- Columbus, Ohio.,From the Department of Plastic Surgery, Comprehensive Wound Center, The Ohio State University
| | - Ibrahim Khansa
- Columbus, Ohio.,From the Department of Plastic Surgery, Comprehensive Wound Center, The Ohio State University
| | - Gayle M Gordillo
- Columbus, Ohio.,From the Department of Plastic Surgery, Comprehensive Wound Center, The Ohio State University
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54
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Basaraba RJ, Ojha AK. Mycobacterial Biofilms: Revisiting Tuberculosis Bacilli in Extracellular Necrotizing Lesions. Microbiol Spectr 2017; 5:10.1128/microbiolspec.TBTB2-0024-2016. [PMID: 28597824 PMCID: PMC7875192 DOI: 10.1128/microbiolspec.tbtb2-0024-2016] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Indexed: 12/18/2022] Open
Abstract
Under detergent-free in vitro conditions, Mycobacterium tuberculosis, the etiological agent of tuberculosis in humans, spontaneously forms organized multicellular structures called biofilms. Moreover, in vitro biofilms of M. tuberculosis are more persistent against antibiotics than their single-cell planktonic counterparts, thereby raising questions about the occurrence of biofilms in the host tissues and their significance in persistence during chemotherapy of tuberculosis. In this article, we present arguments that extracellular M. tuberculosis in necrotizing lesions likely grows as biofilms.
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Affiliation(s)
- Randall J Basaraba
- College of Veterinary Medicine and Biomedical Sciences, Colorado State University, Fort Collins, Co 80524
| | - Anil K Ojha
- Wadsworth Center, NY State Department of Health and University at Albany, Albany, NY 12208
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55
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Abstract
Candida albicans is the most common human fungal pathogen causing diseases ranging from mucosal to systemic infections. As a commensal, C. albicans asymptomatically colonizes mucosal surfaces; however, any disruption in the host environment or under conditions of immune dysfunction, C. albicans can proliferate and invade virtually any site in the host. The ability of this highly adaptable fungal species to transition from commensal to pathogen is due to a repertoire of virulence factors. Specifically, the ability to switch morphology and form biofilms are properties central to C. albicans pathogenesis. In fact, the majority of C. albicans infections are associated with biofilm formation on host or abiotic surfaces such as indwelling medical devices, which carry high morbidity and mortality. Significantly, biofilms formed by C. albicans are inherently tolerant to antimicrobial therapy and therefore, the susceptibility of Candida biofilms to the current therapeutic agents remains low. The aim of this review is to provide an overview of C. albicans highlighting some of the diverse biofilm-associated diseases caused by this opportunistic pathogen and the animal models available to study them. Further, the classes of antifungal agents used to combat these resilient infections are discussed along with mechanisms of drug resistance.
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56
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Hirschfeld J, Roberts HM, Chapple ILC, Parčina M, Jepsen S, Johansson A, Claesson R. Effects of Aggregatibacter actinomycetemcomitans leukotoxin on neutrophil migration and extracellular trap formation. J Oral Microbiol 2016; 8:33070. [PMID: 27834173 PMCID: PMC5103672 DOI: 10.3402/jom.v8.33070] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2016] [Revised: 09/26/2016] [Accepted: 10/04/2016] [Indexed: 12/12/2022] Open
Abstract
Background Aggressive periodontitis is associated with the presence of Aggregatibacter actinomycetemcomitans, a leukotoxin (Ltx)-producing periodontal pathogen. Ltx has the ability to lyse white blood cells including neutrophils. Objectives This study was aimed at investigating the interactions between neutrophils and Ltx with regard to the chemotactic properties of Ltx and the release of neutrophil extracellular traps (NETs). Methods Neutrophils from healthy blood donors were isolated and incubated for 30 min and 3 h with increasing concentrations of Ltx (1, 10, and 100 ng/mL) as well as with A. actinomycetemcomitans strains (NCTC 9710 and HK 1651) producing different levels of Ltx. Formation of NETs and cell lysis were assessed by microscopy, fluorescence-based assays, and measurement of released lactate dehydrogenase. Neutrophil migration in response to different Ltx gradients was monitored by real-time video microscopy, and image analysis was performed using ImageJ software. Results Although Ltx (10 and 100 ng/mL) and the leukotoxic A. actinomycetemcomitans strain HK 1651 lysed some neutrophils, other cells were still capable of performing NETosis in a concentration-dependent manner. Low doses of Ltx and the weakly leukotoxic strain NCTC 9710 did not lead to neutrophil lysis, but did induce some NETosis. Furthermore, all three concentrations of Ltx enhanced random neutrophil movement; however, low directional accuracy was observed compared with the positive control (fMLP). Conclusions The results indicate that Ltx acts both as a neutrophil activator and also causes cell death. In addition, Ltx directly induces NETosis in neutrophils prior to cell lysis. In future studies, the underlying pathways involved in Ltx-meditated neutrophil activation and NETosis need to be investigated further.
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Affiliation(s)
- Josefine Hirschfeld
- Periodontal Research Group, Birmingham Dental School & Hospital, Birmingham, United Kingdom.,Department of Periodontology, Operative and Preventive Dentistry, University Hospital Bonn, Bonn, Germany;
| | - Helen M Roberts
- Periodontal Research Group, Birmingham Dental School & Hospital, Birmingham, United Kingdom
| | - Iain L C Chapple
- Periodontal Research Group, Birmingham Dental School & Hospital, Birmingham, United Kingdom
| | - Marijo Parčina
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital Bonn, Bonn, Germany
| | - Søren Jepsen
- Department of Periodontology, Operative and Preventive Dentistry, University Hospital Bonn, Bonn, Germany
| | - Anders Johansson
- Section Molecular Periodontology, Department of Odontology, Umeå University, Umeå, Sweden
| | - Rolf Claesson
- Section Oral Microbiology, Department of Odontology, Umeå University, Umeå, Sweden
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57
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Oral polymorphonuclear neutrophil characteristics in relation to oral health: a cross-sectional, observational clinical study. Int J Oral Sci 2016; 8:191-8. [PMID: 27515277 PMCID: PMC5113092 DOI: 10.1038/ijos.2016.23] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/03/2016] [Indexed: 12/31/2022] Open
Abstract
Polymorphonuclear neutrophils (PMNs) have a major role in the innate immune system. However, little is known about PMN contribution in relation to oral health. The objective of this study was to investigate the numbers and functional characteristics of oral PMNs (oPMNs) compared with circulatory PMNs (cPMNs). Oral rinse and venous blood samples were obtained from 268 systemically and orally healthy volunteers in a cross-sectional observational study. PMN counts, cell cycle analysis and cellular activation state were investigated. Also, reactive oxygen species (ROS) production was analyzed, with and without bacterial stimulation (Fusobacterium nucleatum). In males, 1.2 × 106±1.0 × 106 oPMNs were collected, and showed a tendency to correlate with the levels of gingival bleeding (r=0.215, P=0.008). Comparable oPMNs counts were found among females (1.0 × 106±0.7 × 106). More late-stage apoptotic/necrotic cells were found among the oPMNs (53.1%) compared with the cPMNs (8.5% P<0.001). Without additional stimulation, oPMNs were more activated than cPMNs, as indicated by higher expression of CD11b, CD63 and CD66b, and higher constitutive ROS levels (P<0.001). Notably, in response to bacterial stimulation, oPMNs released comparable ROS levels as cPMNs (P=0.042). In conclusion, this study provides data on viable oPMNs showing high levels of activation in orally and systemically healthy individuals, free of apparent caries lesions and periodontal disease. These data suggests that although the oPMNs are in a more mature stage of their life cycle compared with the cPMNs, oPMNs are still responsive to stimulation, which indicates their functional potential and possible contribution to a healthy oral ecosystem.
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58
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The role of biofilm on orthopaedic implants: the "Holy Grail" of post-traumatic infection management? Eur J Trauma Emerg Surg 2016; 42:411-416. [PMID: 27262848 DOI: 10.1007/s00068-016-0694-1] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2016] [Accepted: 05/30/2016] [Indexed: 12/21/2022]
Abstract
The development of post-traumatic infection is potentially a limb threatening condition. The orthopaedic trauma literature lags behind the research performed by our arthroplasty colleagues on the topic of implant-related infections. Surgical site infections in the setting of a recent ORIF are notoriously hard to eradicate due to biofilm formation around the implant. This bacteria-friendly, dynamic, living pluri-organism structure has the ability to morph and adapt to virtually any environment with the aim to maintain the causative organism alive. The challenges are twofold: establishing an accurate diagnosis with speciation/sensitivity and eradicating the infection. Multiple strategies have been researched to improve diagnostic accuracy, to prevent biofilm formation on orthopaedic implants, to mobilize/detach or weaken the biofilm or to target specifically bacteria embedded in the biofilm. The purpose of our paper is to review the patho-physiology of this mysterious pluri-cellular structure and to summarize some of the most pertinent research performed to improve diagnostic and treatment strategies in biofilm-related infections.
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Konstantinidis T, Kambas K, Mitsios A, Panopoulou M, Tsironidou V, Dellaporta E, Kouklakis G, Arampatzioglou A, Angelidou I, Mitroulis I, Skendros P, Ritis K. Immunomodulatory Role of Clarithromycin in Acinetobacter baumannii Infection via Formation of Neutrophil Extracellular Traps. Antimicrob Agents Chemother 2016; 60:1040-8. [PMID: 26643338 PMCID: PMC4750671 DOI: 10.1128/aac.02063-15] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/23/2015] [Indexed: 12/29/2022] Open
Abstract
Macrolide antibiotics have been shown to act as immunomodulatory molecules in various immune cells. However, their effect on neutrophils has not been extensively investigated. In this study, we investigated the role of macrolide antibiotics in the generation of neutrophil extracellular traps (NETs). By assessing ex vivo and in vivo NET formation, we demonstrated that clarithromycin is able to induce NET generation both in vitro and in vivo. Clarithromycin utilizes autophagy in order to form NETs, and these NETs are decorated with antimicrobial peptide LL-37. Clarithromycin-induced NETs are able to inhibit Acinetobacter baumannii growth and biofilm formation in an LL-37-dependent manner. Additionally, LL-37 antimicrobial function depends on NET scaffold integrity. Collectively, these data expand the knowledge on the immunomodulatory role of macrolide antibiotics via the generation of LL-37-bearing NETs, which demonstrate LL-37-dependent antimicrobial activity and biofilm inhibition against A. baumannii.
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Affiliation(s)
- Theocharis Konstantinidis
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Konstantinos Kambas
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Alexandros Mitsios
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Maria Panopoulou
- Laboratory of Microbiology, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Victoria Tsironidou
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Erminia Dellaporta
- Gastrointestinal Endoscopy Unit, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Georgios Kouklakis
- Gastrointestinal Endoscopy Unit, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Athanasios Arampatzioglou
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Iliana Angelidou
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece
| | - Ioannis Mitroulis
- Department of Clinical Pathobiochemistry and Institute for Clinical Chemistry and Laboratory Medicine, Faculty of Medicine, Technische Universität Dresden, Dresden, Germany
| | - Panagiotis Skendros
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece First Department of Internal Medicine, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
| | - Konstantinos Ritis
- Laboratory of Molecular Hematology, Department of Medicine, Democritus University of Thrace, Alexandroupolis, Greece First Department of Internal Medicine, Democritus University of Thrace, University General Hospital of Alexandroupolis, Alexandroupolis, Greece
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60
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Lovati AB, Romanò CL, Bottagisio M, Monti L, De Vecchi E, Previdi S, Accetta R, Drago L. Modeling Staphylococcus epidermidis-Induced Non-Unions: Subclinical and Clinical Evidence in Rats. PLoS One 2016; 11:e0147447. [PMID: 26796958 PMCID: PMC4721651 DOI: 10.1371/journal.pone.0147447] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 01/03/2016] [Indexed: 01/20/2023] Open
Abstract
S. epidermidis is one of the leading causes of orthopaedic infections associated with biofilm formation on implant devices. Open fractures are at risk of S. epidermidis transcutaneous contamination leading to higher non-union development compared to closed fractures. Although the role of infection in delaying fracture healing is well recognized, no in vivo models investigated the impact of subclinical low-grade infections on bone repair and non-union. We hypothesized that the non-union rate is directly related to the load of this commonly retrieved pathogen and that a low-grade contamination delays the fracture healing without clinically detectable infection. Rat femurs were osteotomized and stabilized with plates. Fractures were infected with a characterized clinical-derived methicillin-resistant S. epidermidis (103, 105, 108 colony forming units) and compared to uninfected controls. After 56 days, bone healing and osteomyelitis were clinically assessed and further evaluated by micro-CT, microbiological and histological analyses. The biofilm formation was visualized by scanning electron microscopy. The control group showed no signs of infection and a complete bone healing. The 103 group displayed variable response to infection with a 67% of altered bone healing and positive bacterial cultures, despite no clinical signs of infection present. The 105 and 108 groups showed severe signs of osteomyelitis and a non-union rate of 83–100%, respectively. The cortical bone reaction related to the periosteal elevation in the control group and the metal scattering detected by micro-CT represented limitations of this study. Our model showed that an intra-operative low-grade S. epidermidis contamination might prevent the bone healing, even in the absence of infectious signs. Our findings also pointed out a dose-dependent effect between the S. epidermidis inoculum and non-union rate. This pilot study identifies a relevant preclinical model to assess the role of subclinical infections in orthopaedic and trauma surgery and to test specifically designed diagnostic, prevention and therapeutic strategies.
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Affiliation(s)
- Arianna Barbara Lovati
- Cell and Tissue Engineering Laboratory, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
- * E-mail:
| | - Carlo Luca Romanò
- Dipartimento di Chirurgia Ricostruttiva e delle Infezioni Osteo-articolari, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Marta Bottagisio
- Cell and Tissue Engineering Laboratory, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
- Department of Veterinary Science and Public Health, University of Milan, Milan, Italy
| | - Lorenzo Monti
- Orthopaedics and Traumatology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Elena De Vecchi
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Sara Previdi
- Laboratory of Cancer Cachexia AIRC Start-Up, Oncology Department, Mario Negri Institute for Pharmacological Research, Milan, Italy
| | - Riccardo Accetta
- Orthopaedics and Traumatology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
| | - Lorenzo Drago
- Laboratory of Clinical Chemistry and Microbiology, IRCCS Galeazzi Orthopaedic Institute, Milan, Italy
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
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61
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Marcinkiewicz J, Stręk P, Strus M, Głowacki R, Ciszek-Lenda M, Zagórska-Świeży K, Gawda A, Tomusiak A. Staphylococcus epidermidis and biofilm-associated neutrophils in chronic rhinosinusitis. A pilot study. Int J Exp Pathol 2016; 96:378-86. [PMID: 26765504 DOI: 10.1111/iep.12156] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2015] [Accepted: 09/16/2015] [Indexed: 11/26/2022] Open
Abstract
A key role of bacterial biofilm in the pathogenesis of chronic rhinosinusitis (CRS) with (CRSwNP) and without nasal polyps (CRSsNP) is commonly accepted. However, the impact of some bacterial species isolated from inflamed sinus mucosa on biofilm formation is unclear. In particular, the role of Staphylococcus epidermidis as aetiological agents of CRS is controversial. Moreover, the effect of biofilm formation on neutrophil infiltration and activity in CRSwNP calls for explanation. In this study, biofilms were found in three of 10 patients (mean age = 46 ± 14) with CRS undergoing endoscopic sinus surgery by means of scanning electron microscopy. Unexpectedly, S. epidermidis was the primary isolated bacteria and was also found to be present in all biofilm-positive mucosa specimens, indicating its pivotal role in the pathogenesis of severe chronic infections associated with biofilm formation. We have also measured the activity of myeloperoxidase (MPO), the most abundant neutrophil enzyme, to demonstrate the presence of neutrophils in the samples tested. Our present results show that the level of MPO in CRS associated with biofilm is lower than that without biofilm. It may suggest either a low number of neutrophils or the presence of a type of neutrophils with compromised antimicrobial activity, described as biofilm-associated neutrophils (BAN). Finally, we conclude that further studies with a large number of CRS cases should be performed to establish the association between S. epidermidis and other frequently isolated bacterial species from paranasal sinuses, with the severity of CRS, biofilm formation and the infiltration of BAN.
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Affiliation(s)
| | - Paweł Stręk
- Department of Otorhinolaryngology, Jagiellonian University Medical College, Krakow, Poland
| | - Magdalena Strus
- Chair of Microbiology, Jagiellonian University Medical College, Krakow, Poland
| | - Roman Głowacki
- Department of Otorhinolaryngology, Jagiellonian University Medical College, Krakow, Poland
| | - Marta Ciszek-Lenda
- Chair of Immunology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Anna Gawda
- Chair of Immunology, Jagiellonian University Medical College, Krakow, Poland
| | - Anna Tomusiak
- Chair of Microbiology, Jagiellonian University Medical College, Krakow, Poland
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