Nonrandom distribution of Pseudomonas aeruginosa and Staphylococcus aureus in chronic wounds

Genotypic and Phenotypic Diversity of Staphylococcus aureus Isolates from Cystic Fibrosis Patient Lung Infections and Their Interactions with Pseudomonas aeruginosa

Staphylococcus aureus has recently overtaken Pseudomonas aeruginosa as the most commonly recognized bacterial pathogen that infects the respiratory tracts of individuals with the genetic disease cystic fibrosis (CF) in the United States. Most studies of S. aureus in CF patient lung infections have focused on a few isolates, often exclusively laboratory-adapted strains, and how they are killed by P. aeruginosa Less is known about the diversity of S. aureus CF patient lung isolates in terms of both their virulence and their interaction with P. aeruginosa To begin to address this gap, we recently sequenced 64 clinical S. aureus isolates and a reference isolate, JE2. Here, we analyzed the antibiotic resistance genotypes, sequence types, clonal complexes, spa types, agr types, and presence/absence of other known virulence factor genes of these isolates. We hypothesized that virulence phenotypes of S. aureus, namely, toxin production and the mucoid phenotype, would be lost in these isolates due to adaptation in the CF patient lung. In contrast to these expectations, we found that most isolates can lyse both rabbit and sheep blood (67.7%) and produce polysaccharide (69.2%), suggesting that these phenotypes were not lost during adaptation to the CF lung. We also identified three distinct phenotypic groups of S. aureus based on their survival in the presence of nonmucoid P. aeruginosa laboratory strain PAO1 and its mucoid derivative. Altogether, our work provides greater insight into the diversity of S. aureus isolates from CF patients, specifically the distribution of important virulence factors and their interaction with P. aeruginosa, all of which have implications in patient health.IMPORTANCEStaphylococcus aureus is now the most frequently detected recognized pathogen in the lungs of individuals who have cystic fibrosis (CF) in the United States, followed closely by Pseudomonas aeruginosa When these pathogens are found to coinfect the CF lung, patients have a significantly worse prognosis. While P. aeruginosa has been rigorously studied in the context of bacterial pathogenesis in CF, less is known about S. aureus Here, we present an in-depth study of 64 S. aureus clinical isolates from CF patients, for which we investigated genetic diversity utilizing whole-genome sequencing, virulence phenotypes, and interactions with P. aeruginosa We found that S. aureus isolated from CF lungs are phylogenetically diverse; most retain known virulence factors and vary in their interactions with P. aeruginosa (i.e., they range from being highly sensitive to P. aeruginosa to completely tolerant to it). Deepening our understanding of how S. aureus responds to its environment and other microbes in the CF lung will enable future development of effective treatments and preventative measures against these formidable infections.

The microbiome of diabetic foot ulcers: a comparison of swab and tissue biopsy wound sampling techniques using 16S rRNA gene sequencing

Background

Health-care professionals need to collect wound samples to identify potential pathogens that contribute to wound infection. Obtaining appropriate samples from diabetic foot ulcers (DFUs) where there is a suspicion of infection is of high importance. Paired swabs and tissue biopsies were collected from DFUs and both sampling techniques were compared using 16S rRNA gene sequencing.

Results

Mean bacterial abundance determined using quantitative polymerase chain reaction (qPCR) was significantly lower in tissue biopsies (p = 0.03). The mean number of reads across all samples was significantly higher in wound swabs \documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \Big(\overline{X} $$\end{document}(X¯ = 32,014) compared to tissue (\documentclass[12pt]{minimal} \usepackage{amsmath} \usepackage{wasysym} \usepackage{amsfonts} \usepackage{amssymb} \usepackage{amsbsy} \usepackage{mathrsfs} \usepackage{upgreek} \setlength{\oddsidemargin}{-69pt} \begin{document}$$ \overline{X} $$\end{document}X¯ = 15,256, p = 0.001). Tissue biopsies exhibited greater overall diversity of bacteria relative to swabs (Shannon’s H diversity p = 0.009). However, based on a presence/absence analysis of all paired samples, the frequency of occurrence of bacteria from genera of known and potential pathogens was generally higher in wound swabs than tissue biopsies. Multivariate analysis identified significantly different bacterial communities in swabs compared to tissue (p = 0.001). There was minimal correlation between paired wound swabs and tissue biopsies in the number and types of microorganisms. RELATE analysis revealed low concordance between paired DFU swab and tissue biopsy samples (Rho = 0.043, p = 0.34).

Conclusions

Using 16S rRNA gene sequencing this study identifies the potential for using less invasive swabs to recover high relative abundances of known and potential pathogen genera from DFUs when compared to the gold standard collection method of tissue biopsy.

Efficacy of Lytic Phage Cocktails on Staphylococcus aureus and Pseudomonas aeruginosa in Mixed-Species Planktonic Cultures and Biofilms

The efficacy of phages in multispecies infections has been poorly examined. The in vitro lytic efficacies of phage cocktails AB-SA01, AB-PA01, which target Staphylococcus aureus and Pseudomonas aeruginosa, respectively, and their combination against their hosts were evaluated in S. aureus and P. aeruginosa mixed-species planktonic and biofilm cultures. Green fluorescent protein (GFP)-labelled P. aeruginosa PAO1 and mCherry-labelled S. aureus KUB7 laboratory strains and clinical isolates were used as target bacteria. During real-time monitoring using fluorescence spectrophotometry, the density of mCherry S. aureus KUB7 and GFP P. aeruginosa PAO1 significantly decreased when treated by their respective phage cocktail, a mixture of phage cocktails, and gentamicin. The decrease in bacterial density measured by relative fluorescence strongly associated with the decline in bacterial cell counts. This microplate-based mixed-species culture treatment monitoring through spectrophotometry combine reproducibility, rapidity, and ease of management. It is amenable to high-throughput screening for phage cocktail efficacy evaluation. Each phage cocktail, the combination of the two phage cocktails, and tetracycline produced significant biofilm biomass reduction in mixed-species biofilms. This study result shows that these phage cocktails lyse their hosts in the presence of non-susceptible bacteria. These data support the use of phage cocktails therapy in infections with multiple bacterial species.

Overcoming Multidrug Resistance and Biofilms of Pseudomonas aeruginosa with a Single Dual-Function Potentiator of β-Lactams

Clinicians prescribe hundreds of millions of β-lactam antibiotics to treat the majority of patients presenting with bacterial infections. Patient outcomes are positive unless resistant bacteria, such as Pseudomonas aeruginosa (P. aeruginosa), are present. P. aeruginosa has both intrinsic and acquired antibiotic resistance, making clinical management of infection a real challenge, particularly when these bacteria are sequestered in biofilms. These problems would be alleviated if, upon the initial presentation of bacterial infection symptoms, clinicians were able to administer an antibiotic that kills both susceptible and otherwise resistant bacteria and eradicates biofilms. As the most common class of antibiotics, β-lactams could be used in a new drug if the leading causes of β-lactam antibiotic resistance, permeation barriers from lipopolysaccharide, efflux pumps, and β-lactamase enzymes, were also defeated. Against P. aeruginosa and their biofilms, the potency of β-lactam antibiotics is restored with 600 Da branched polyethylenimine (600 Da BPEI). Checkerboard assays using microtiter plates demonstrate the potentiation of piperacillin, cefepime, Meropenem, and erythromycin antibiotics. Growth curves demonstrate that only a combination of 600 Da BPEI and piperacillin produces growth inhibition against antibiotic resistant P. aeruginosa. Scanning electron microscopy (SEM) was used to confirm that the combination treatment leads to abnormal P. aeruginosa morphology. Data collected with isothermal titration calorimetry and fluorescence spectroscopy demonstrate a mechanism of action in which potentiation at low concentrations of 600 Da BPEI reduces diffusion barriers from lipopolysaccharides without disrupting the outer membrane itself. Coupled with the ability to overcome a reduction in antibiotic activity created by biofilm exopolymers, targeting anionic sites on lipopolysaccharides and biofilm exopolysaccharides with the same compound provides new opportunities to counter the rise of multidrug-resistant infections.

Successful treatment of a unique chronic multi-bacterial scalp infection with N-chlorotaurine, N-bromotaurine and bromamine T

Microbial species can act in synergy to circumvent environmental stress conditions and survive. In addition, biofilms are a serious public-health issue globally and constitute a clinical emergency. Infection persistence, increased morbidity and mortality, and antibiotic resistance are consequences of poly-microbial synergy. Due to inherited complexity and synergy between numerous species, newer antimicrobial agents of increased efficacy and tolerability are needed. In this unique medical case, a chronic (9 year) multi-bacterial scalp infection was differentially diagnosed from other inflammatory skin disorders by prolonged microbiological culture. The bacterial species found seem to have caused lesions of visible biofilm not documented previously in the medical literature. This complicated infection was treated successfully and rapidly with the combined topical application of the active halogen compounds N-chlorotaurine, N-bromotaurine and bromamine T, which is in contrast to the previous failed systemic and topical therapeutic approaches. This study strengthens the case for the use of active halogen compounds against multi-bacterial infections of the skin in the future, without the occurrence of resistance.

Investigation of synovial fluid induced Staphylococcus aureus aggregate development and its impact on surface attachment and biofilm formation

Periprosthetic joint infections (PJIs) are a devastating complication that occurs in 2% of patients following joint replacement. These infections are costly and difficult to treat, often requiring multiple corrective surgeries and prolonged antimicrobial treatments. The Gram-positive bacterium Staphylococcus aureus is one of the most common causes of PJIs, and it is often resistant to a number of commonly used antimicrobials. This tolerance can be partially attributed to the ability of S. aureus to form biofilms. Biofilms associated with the surface of indwelling medical devices have been observed on components removed during chronic infection, however, the development and localization of biofilms during PJIs remains unclear. Prior studies have demonstrated that synovial fluid, in the joint cavity, promotes the development of bacterial aggregates with many biofilm-like properties, including antibiotic resistance. We anticipate these aggregates have an important role in biofilm formation and antibiotic tolerance during PJIs. Therefore, we sought to determine specifically how synovial fluid promotes aggregate formation and the impact of this process on surface attachment. Using flow cytometry and microscopy, we quantified the aggregation of various clinical S. aureus strains following exposure to purified synovial fluid components. We determined that fibrinogen and fibronectin promoted bacterial aggregation, while cell free DNA, serum albumin, and hyaluronic acid had minimal effect. To determine how synovial fluid mediated aggregation affects surface attachment, we utilized microscopy to measure bacterial attachment. Surprisingly, we found that synovial fluid significantly impeded bacterial surface attachment to a variety of materials. We conclude from this study that fibrinogen and fibronectin in synovial fluid have a crucial role in promoting bacterial aggregation and inhibiting surface adhesion during PJI. Collectively, we propose that synovial fluid may have conflicting protective roles for the host by preventing adhesion to surfaces, but by promoting bacterial aggregation is also contributing to the development of antibiotic tolerance.

CCN1 is an opsonin for bacterial clearance and a direct activator of Toll-like receptor signaling

Expression of the matricellular protein CCN1 (CYR61) is associated with inflammation and is required for successful wound repair. Here, we show that CCN1 binds bacterial pathogen-associated molecular patterns including peptidoglycans of Gram-positive bacteria and lipopolysaccharides of Gram-negative bacteria. CCN1 opsonizes methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa and accelerates their removal by phagocytosis and increased production of bactericidal reactive oxygen species in macrophages through the engagement of integrin α_vβ₃. Mice with myeloid-specific Ccn1 deletion and knock-in mice expressing CCN1 unable to bind α_vβ₃ are more susceptible to infection by S. aureus or P. aeruginosa, resulting in increased mortality and organ colonization. Furthermore, CCN1 binds directly to TLR2 and TLR4 to activate MyD88-dependent signaling, cytokine expression and neutrophil mobilization. CCN1 is therefore a pattern recognition receptor that opsonizes bacteria for clearance and functions as a damage-associated molecular pattern to activate inflammatory responses, activities that contribute to wound healing and tissue repair.

CCN1 is a matricellular protein with a variety of functions, including an effect on wound healing and an association with inflammation. Here, the authors identify a possible mechanism by showing that CCN1 mediates the clearance of bacterial infections in mice and activates TLR signalling.

The social life of microbes in chronic infection

Chronic infections place a significant burden on healthcare systems, requiring over $25 billion in treatment annually in the United States alone [1,2]. Notably, the majority of chronic infections, which include cystic fibrosis (CF), chronic wounds, otitis media, periodontitis, urinary tract infections, and osteomyelitis, are considered polymicrobial and are often recalcitrant to antibiotic treatment [1-9]. Although we know that diverse communities of microbes comprise these infections, how microbes interact and the impacts of these interactions on human disease are less understood. Here, we discuss recent advances in our understanding of how bacteria communicate in chronic infection, with a focus on Staphylococcus aureus and Pseudomonas aeruginosa, and we highlight outstanding questions and controversies in the field.

Universal Dermal Microbiome in Human Skin

Human skin microbiota is thought to be unique according to the individual's lifestyle and genetic predisposition. This is true for the epidermal microbiota, while our findings demonstrate that the dermal microbiota is universal between healthy individuals. The preserved dermal microbial community is compositionally unique and functionally distinct to the specific environment in the depth of human skin. It is expected to have direct contact with the immune response of the human host, and research in the communication between host and microbiota should be targeted to this cutaneous compartment. This novel insight into specific microbial adaptation can be used advantageously in the research of chronic disorders and infections of the skin. It can enlighten the alteration between health and disease to the benefit of patients suffering from long-lasting socioeconomic illnesses.

Human skin microbiota has been described as a “microbial fingerprint” due to observed differences between individuals. Current understanding of the cutaneous microbiota is based on sampling the outermost layers of the epidermis, while the microbiota in the remaining skin layers has not yet been fully characterized. Environmental conditions can vary drastically between the cutaneous compartments and give rise to unique communities. We demonstrate that the dermal microbiota is surprisingly similar among individuals and contains a specific subset of the epidermal microbiota. Variability in bacterial community composition decreased significantly from the epidermal to the dermal compartment but was similar among anatomic locations (hip and knee). The composition of the epidermal microbiota was more strongly affected by environmental factors than that of the dermal community. These results indicate a well-conserved dermal community that is functionally distinct from the epidermal community, challenging the current dogma. Future studies in cutaneous disorders and chronic infections may benefit by focusing on the dermal microbiota as a persistent microbial community.

Comparative Analysis of the Host Response in a Rat Model of Deep-Partial and Full-Thickness Burn Wounds With Pseudomonas aeruginosa Infection

Burn wound injury affects soldiers and civilians alike, often resulting in a dynamic, but un-orchestrated, host response that can lead to infection, scarring, and potentially death. To mitigate these factors, it is important to have a clinically relevant model of burn wound infection that can be utilized for advancing burn wound treatments. Our previous reports have demonstrated the ability of Pseudomonas aeruginosa to generate a biofilm infection within a modified Walker-Mason rat burn model of deep-partial (DPT) and full-thickness (FT) burn wounds (10% total body surface area) in male Sprague-Dawley rats (350–450 g). Here, we further define this model with respect to the host response when challenged with P. aeruginosa infection between the two burn types. Following burn injury and immediate surface exposure to P. aeruginosa, inflammation at the local and systemic levels were monitored for an 11 days period. Compared to burn-only groups, infection with P. aeruginosa further promoted local inflammation in both DPT and FT burn wounds, which was evident by enhanced cellular influx (including neutrophils and monocytes), increased levels of several pro-inflammatory cytokines (IL-1β, IL-6, GRO/KC, andMIP-1α), and reduced IL-10. Systemically, only minor changes were seen in circulating white blood cells and cytokines; however, increases in high mobility group box-1 (HMGB-1) and hyaluronan, as well as decreases in fibronectin were noted particularly in FT burns. Compared to the burn-only group, P. aeruginosa infection resulted in sustained and/or higher levels of HMGB-1 and hyaluronan. Combined with our previous work that defined the burn depth and development of P. aeruginosa biofilms within the wound, this study further establishes this model by defining the host response to the burn and biofilm-infection. Furthermore, this characterization shows several similarities to what is clinically seen and establishes this model for future use in the development and testing of novel therapeutics for burn wound treatment at home and on the battlefield.

An in vitro collagen perfusion wound biofilm model; with applications for antimicrobial studies and microbial metabolomics

Background

The majority of in vitro studies of medically relevant biofilms involve the development of biofilm on an inanimate solid surface. However, infection in vivo consists of biofilm growth on, or suspended within, the semi-solid matrix of the tissue, whereby current models do not effectively simulate the nature of the in vivo environment. This paper describes development of an in vitro method for culturing wound associated microorganisms in a system that combines a semi-solid collagen gel matrix with continuous flow of simulated wound fluid. This enables culture of wound associated reproducible steady state biofilms under conditions that more closely simulate the dynamic wound environment. To demonstrate the use of this model the antimicrobial kinetics of ceftazidime, against both mature and developing Pseudomonas aeruginosa biofilms, was assessed. In addition, we have shown the potential application of this model system for investigating microbial metabolomics by employing selected ion flow tube mass spectrometry (SIFT-MS) to monitor ammonia and hydrogen cyanide production by Pseudomonas aeruginosa biofilms in real-time.

Results

The collagen wound biofilm model facilitates growth of steady-state reproducible Pseudomonas aeruginosa biofilms under wound like conditions. A maximum biofilm density of 10¹⁰ cfu slide^− 1 was achieved by 30 h of continuous culture and maintained throughout the remainder of the experiment. Treatment with ceftazidime at a clinically relevant dose resulted in a 1.2–1.6 log reduction in biofilm density at 72 h compared to untreated controls. Treatment resulted in loss of complex biofilm architecture and morphological changes to bacterial cells, visualised using confocal microscopy. When monitoring the biofilms using SIFT-MS, ammonia and hydrogen cyanide levels peaked at 12 h at 2273 ppb (±826.4) and 138 ppb (±49.1) respectively and were detectable throughout experimentation.

Conclusions

The collagen wound biofilm model has been developed to facilitate growth of reproducible biofilms under wound-like conditions. We have successfully used this method to: (1) evaluate antimicrobial efficacy and kinetics, clearly demonstrating the development of antimicrobial tolerance in biofilm cultures; (2) characterise volatile metabolite production by P. aeruginosa biofilms, demonstrating the potential use of this method in metabolomics studies.

Bioengineered Platforms for Chronic Wound Infection Studies: How Can We Make Them More Human-Relevant?

Chronic wound infections are an important cause of delayed wound healing, posing a significant healthcare burden with consequences that include hospitalization, amputation, and death. These infections most often take the form of three-dimensional biofilm communities, which are notoriously recalcitrant to antibiotics and immune clearance, contributing to the chronic wound state. In the chronic wound microenvironment, microbial biofilms interact closely with other key components, including host cellular and matrix elements, immune cells, inflammatory factors, signaling components, and mechanical cues. Intricate relationships between these contributing factors not only orchestrate the development and progression of wound infections but also influence the therapeutic outcome. Current medical treatment for chronic wound infections relies heavily on long-term usage of antibiotics; however, their efficacy and reasons for failure remain uncertain. To develop effective therapeutic approaches, it is essential to better understand the complex pathophysiology of the chronic wound infection microenvironment, including dynamic interactions between various key factors. For this, it is critical to develop bioengineered platforms or model systems that not only include key components of the chronic wound infection microenvironment but also recapitulate interactions between these factors, thereby simulating the infection state. In doing so, these platforms will enable the testing of novel therapeutics, alone and in combinations, providing insights toward composite treatment strategies. In the first section of this review, we discuss the key components and interactions in the chronic wound infection microenvironment, which would be critical to recapitulate in a bioengineered platform. In the next section, we summarize the key features and relevance of current bioengineered chronic wound infection platforms. These are categorized and discussed based on the microenvironmental components included and their ability to recapitulate the architecture, interactions, and outcomes of the infection microenvironment. While these platforms have advanced our understanding of the underlying pathophysiology of chronic wound infections and provided insights into therapeutics, they possess certain insufficiencies that limit their clinical relevance. In the final section, we propose approaches that can be incorporated into these existing model systems or developed into future platforms developed, thus enhancing their biomimetic and translational capabilities, and thereby their human-relevance.

Optimal environmental and culture conditions allow the in vitro coexistence of Pseudomonas aeruginosa and Staphylococcus aureus in stable biofilms

The coexistence between species that occurs in some infections remains hard to achieve in vitro since bacterial fitness differences eventually lead to a single organism dominating the mixed culture. Pseudomonas aeruginosa and Staphylococcus aureus are major pathogens found growing together in biofilms in disease-affected lungs or wounds. Herein, we tested and analyzed different culture media, additives and environmental conditions to support P. aeruginosa and S. aureus coexistence in vitro. We have unraveled the potential of DMEM to support the growth of these two organisms in mature cocultured biofilms (three days old) in an environment that dampens the pH rise. Our conditions use equal initial inoculation ratios of both strains and allow the stable formation of separate S. aureus microcolonies that grow embedded in a P. aeruginosa biofilm, as well as S. aureus biofilm overgrowth when bovine serum albumin is added to the system. Remarkably, we also found that S. aureus survival is strictly dependent on a well-characterized phenomenon of oxygen stratification present in the coculture biofilm. An analysis of differential tolerance to gentamicin and ciprofloxacin treatment, depending on whether P. aeruginosa and S. aureus were growing in mono- or coculture biofilms, was used to validate our in vitro coculture conditions.

Metabolic modelling of chronic wound microbiota predicts mutualistic interactions that drive community composition

AIMS

To identify putative mutualistic interactions driving community composition in polymicrobial chronic wound infections using metabolic modelling.

METHODS AND RESULTS

We developed a 12 species metabolic model that covered 74% of 16S rDNA pyrosequencing reads of dominant genera from 2963 chronic wound patients. The community model was used to predict species abundances averaged across this large patient population. We found that substantially improved predictions were obtained when the model was constrained with genera prevalence data and predicted abundances were averaged over 5000 ensemble simulations with community participants randomly determined according to the experimentally determined prevalences. Staphylococcus and Pseudomonas were predicted to exhibit a strong mutualistic relationship that resulted in community growth rate and diversity simultaneously increasing, suggesting that these two common chronic wound pathogens establish dominance by cooperating with less harmful commensal species. In communities lacking one or both dominant pathogens, other mutualistic relationship including Staphylococcus/Acinetobacter, Pseudomonas/Serratia and Streptococcus/Enterococcus were predicted consistent with published experimental data.

CONCLUSIONS

Mutualistic interactions were predicted to be driven by crossfeeding of organic acids, alcohols and amino acids that could potentially be disrupted to slow chronic wound disease progression.

SIGNIFICANCE AND IMPACT OF THE STUDY

Approximately 2% of the US population suffers from nonhealing chronic wounds infected by a combination of commensal and pathogenic bacteria. These polymicrobial infections are often resilient to antibiotic treatment due to the nutrient-rich wound environment and species interactions that promote community stability and robustness. The simulation results from this study were used to identify putative mutualistic interactions between bacteria that could be targeted to enhance treatment efficacy.

Tissue Oxygenation Changes to Assess Healing in Venous Leg Ulcers Using Near-Infrared Optical Imaging

Objective: Venous leg ulcers (VLUs) comprise 80% of leg ulcers. One of the key parameters that can promote healing of VLUs is tissue oxygenation. To date, clinicians have employed visual inspection of the wound site to determine the healing progression of a wound. Clinicians measure the wound size and check for epithelialization. Imaging for tissue oxygenation changes surrounding the wounds can objectively complement the subjective visual inspection approach. Herein, a handheld noncontact near-infrared optical scanner (NIROS) was developed to measure tissue oxygenation of VLUs during weeks of treatment. Approach: Continuous-wave-based diffuse reflectance measurements were processed using Modified Beer-Lambert's law to obtain changes in tissue oxygenation (in terms of oxy-, deoxy-, total hemoglobin, and oxygen saturation). The tissue oxygenation contrast obtained between the wound and surrounding tissue was longitudinally mapped across weeks of treatment of four VLUs (healing and nonhealing cases). Results: It was observed that wound to background tissue oxygenation contrasts in healing wounds diminished and/or stabilized, whereas in the nonhealing wounds it did not. In addition, in a very slow-healing wound, wound to background tissue oxygenation contrasts fluctuated and did not converge. Innovation: Near-infrared imaging of wounds to assess healing or nonhealing of VLUs from tissue oxygenation changes using a noncontact, handheld, and low-cost imager has been demonstrated for the first time. Conclusion: The tissue oxygenation changes in wound with respect to the surrounding tissue can provide an objective subclinical physiological assessment of VLUs during their treatment, along with the gold-standard visual clinical assessment.

An Equine Wound Model to Study Effects of Bacterial Aggregates on Wound Healing

Objective: Relevant animal models to study effects of bacterial aggregates on wound healing are lacking. We aimed at establishing an equine wound model with bacterial aggregates to investigate the impact of bacterial inoculation on normal (thorax) and impaired (limb) wound healing. Approach: Wounds were created on three limbs and both thorax sides of six horses. Twelve out of 20 wounds per horse were inoculated with 10⁴ Staphylococcus aureus and 10⁵ Pseudomonas aeruginosa on day 4. Healing was monitored until day 27 by clinical assessment, including wound scoring, surface pH measurements, and digital photography for area determination. Biopsies were used for bacterial culture and for peptide nucleic acid fluorescence in situ hybridization to detect bacterial aggregates. Results: Inoculated limb wounds healed slower than noninoculated limb wounds from day 10 onward (p < 0.0001). Inoculated and noninoculated thorax wounds healed equally well and faster than limb wounds. The odds ratio of detecting bacterial aggregates in inoculated limb wounds was 7.1 (2.4-21.0, p = 0.0086) compared with noninoculated limb wounds and 36.2 (3.8-348, p = 0.0018) compared with thorax wounds. Innovation: This equine wound model with bacterial aggregates might be superior to other animal wound models, as both normal and impaired healing can be studied simultaneously. In this model, many aspects of wound healing, including novel treatments, may be studied. Conclusions: The impaired healing observed in inoculated limb wounds may be related to the persistent bacterial aggregates. Both in capability of clearing inoculated bacteria from the wounds and in healing pattern, thorax wounds were superior to limb wounds.

Non-antibiotic antimicrobial interventions and antimicrobial stewardship in wound care

Control of wound infection today relies largely on antibiotics, but the continual emergence of antibiotic-resistant microorganisms threatens a return to the pre-antibiotic era when physicians used antiseptics to prevent and manage infection. Some of those antiseptics are still used today, and others have become available. A diverse variety of non-antibiotic antimicrobial interventions are found on modern formularies. Unlike the mode of action of antibiotics, which affect specific cellular target sites of pathogens, many non-antibiotic antimicrobials affect multiple cellular target sites in a non-specific way. Although this reduces the likelihood of selecting for resistant strains of microorganisms, some have emerged and cross-resistance between antibiotics and antiseptics has been detected. With the prospect of a post-antibiotic era looming, ways to maintain and extend our antimicrobial armamentarium must be found. In this narrative review, current and emerging non-antibiotic antimicrobial strategies will be considered and the need for antimicrobial stewardship in wound care will be explained.

Combinatorial Drug Therapy for Controlling Pseudomonas aeruginosa and Its Association With Chronic Condition of Diabetic Foot Ulcer

Diabetic foot ulcer (DFU) is a major complication of diabetes mellitus, major observations of DFU cases have reported on amputation of foot region, and microbial bioburden during DFU is a major cause that affects healing of the wound regions. Pathogenic microbes are routinely isolated from these wound regions, especially Staphylococcus, Pseudomonas, Klebsiella, and Escherichia coli have been reported, whereas higher prevalence of Pseudomonas species during chronic condition in the deeper part of the wound, when left untreated, leads to gangrene. Multiple drug-resistant Pseudomonas strains are a new threat because of their biofilm-forming ability, making it more potent and incurable. Acyl homoserine lactones (AHL) are a group of signaling molecules that can regulate biofilm growth, and Las and Rhl operon generally work in tandem to initiate biofilm formation by Pseudomonas species. These signaling molecules also initiate virulence factors that correlates upregulation of inflammatory responses, and AHL can be a therapeutic target in order to prevent the efficacy of multiple drug-resistant strains that form biofilm and also can be an alternative solution against control of multiple drug-resistant strains.

Influence of Microbiota on Diabetic Foot Wound in Comparison with Adjacent Normal Skin Based on the Clinical Features

Diabetic foot ulcer (DFU) is a complication experienced by diabetic patients and does not heal well in an altered wound environment. Although diverse microbes in DFU were detected, little is known about their influences on diabetic foot wound (DFW) and the association with the skin microbiota in normal tissue from the same patients according to clinical features. We aimed to analyze the microbiota in normal skin and DFW tissue from the same subject and predict their roles based on clinical features. We analyzed the microbiota in normal skin and DFW tissue from the same subject and compared the associated members of microbiota with clinical parameters. The diversity of skin microbiota was higher than that of DFW tissues, along with compositional differences. In addition, different microbes were associated with clinical features. The proportions of Bacteroidetes, Prevotella, Peptoniphilus, Porphyromonas, and Dialister were higher in the severe groups than of the mild groups, whereas that of Firmicutes was lower in the severe groups. According to wound severity, the microbiota could be related to inflammation, damaging host cell membrane, and pathogenicity through lipopolysaccharide biosynthesis, cellular antigens, and protein digestion metabolism. The predicted DFW microbiota functions according to systemic diabetic status defined by ESRD and HbA1c, differed from those presented by wound severity. Results indicate that the microbiota in normal skin is related to the colonizing microbes in DFW tissue according to clinical features and the different microbes can play important roles in DFW prognosis. This information can be applied to prevent and manage DFW by modulating the microbiota.

Clinical indicators of wound infection and biofilm: reaching international consensus

OBJECTIVE

To achieve international consensus relating to clinical indicators for a chronic wound, wound infection and biofilm presence to inform the development of international clinical guidance for assessing and managing wound infection.

METHOD

An online Delphi consensus process of international key opinion leaders in infection was undertaken. A literature search underpinned the development of issue statements related to terminology, emerging topics and debate in the field of wound infection. Experts participated in three rounds of consensus voting, sharing their opinions and indicating their level of agreement with the issue statements. Votes were calculated using web-based software that implements a nominal group voting methodology previously published by Research and Development/University of California at Los Angeles.

RESULTS

A total of 14 experts took part in the development process. Consensus was reached on clinical indicators of wound chronicity, wound infection and biofilm presence. Agreement was also reached that the term 'critical colonisation' should no longer be used to refer to a stage in the wound infection continuum.

CONCLUSION

Outcomes from the consensus process were used to inform the development of international, evidence-informed guidance on the assessment and treatment of wound infection to promote improved outcomes for people with wounds.

Motility-Independent Formation of Antibiotic-Tolerant Pseudomonas aeruginosa Aggregates

Pseudomonas aeruginosa is a bacterial pathogen that causes severe chronic infections in immunocompromised individuals. This bacterium is highly adaptable to its environments, which frequently select for traits that promote bacterial persistence. A clinically significant temporal adaptation is the formation of surface- or cell-adhered bacterial biofilms that are associated with increased resistance to immune and antibiotic clearance. Extensive research has shown that bacterial flagellar motility promotes formation of such biofilms, whereupon the bacteria subsequently become nonmotile. However, recent evidence shows that antibiotic-tolerant nonattached bacterial aggregates, distinct from surface-adhered biofilms, can form, and these have been reported in the context of lung infections, otitis media, nonhealing wounds, and soft tissue fillers. It is unclear whether the same bacterial traits are required for aggregate formation as for biofilm formation. In this report, using isogenic mutants, we demonstrate that P. aeruginosa aggregates in liquid cultures are spontaneously formed independent of bacterial flagellar motility and independent of an exogenous scaffold. This contrasts with the role of the flagellum to initiate surface-adhered biofilms. Similarly to surface-attached biofilms, these aggregates exhibit increased antibiotic tolerance compared to planktonic cultures. These findings provide key insights into the requirements for aggregate formation that contrast with those for biofilm formation and that may have relevance for the persistence and dissemination of nonmotile bacteria found within chronic clinical infections.IMPORTANCE In this work, we have investigated the role of bacterial motility with regard to antibiotic-tolerant bacterial aggregate formation. Previous work has convincingly demonstrated that P. aeruginosa flagellar motility promotes the formation of surface-adhered biofilms in many systems. In contrast, aggregate formation by P. aeruginosa was observed for nonmotile but not for motile cells in the presence of an exogenous scaffold. Here, we demonstrate that both wild-type P. aeruginosa and mutants that genetically lack motility spontaneously form antibiotic-tolerant aggregates in the absence of an exogenously added scaffold. Additionally, we also demonstrate that wild-type (WT) and nonmotile P. aeruginosa bacteria can coaggregate, shedding light on potential physiological interactions and heterogeneity of aggregates.

Targeting Bacterial Biofilms by the Green Tea Polyphenol EGCG

Bacterial biofilms are multicellular aggregates in which cells are embedded in an extracellular matrix of self-produced biopolymers. Being refractory to antibiotic treatment and host immune systems, biofilms are involved in most chronic infections, and anti-biofilm agents are being searched for urgently. Epigallocatechin-3-gallate (EGCG) was recently shown to act against biofilms by strongly interfering with the assembly of amyloid fibres and the production of phosphoethanolamin-modified cellulose fibrils. Mechanistically, this includes a direct inhibition of the fibre assembly, but also triggers a cell envelope stress response that down-regulates the synthesis of these widely occurring biofilm matrix polymers. Based on its anti-amyloidogenic properties, EGCG seems useful against biofilms involved in cariogenesis or chronic wound infection. However, EGCG seems inefficient against or may even sometimes promote biofilms which rely on other types of matrix polymers, suggesting that searching for 'magic bullet' anti-biofilm agents is an unrealistic goal. Combining molecular and ecophysiological aspects in this review also illustrates why plants control the formation of biofilms on their surfaces by producing anti-amyloidogenic compounds such as EGCG. These agents are not only helpful in combating certain biofilms in chronic infections but even seem effective against the toxic amyloids associated with neuropathological diseases.

Insulin treatment enhances pseudomonas aeruginosa biofilm formation by increasing intracellular cyclic di-GMP levels, leading to chronic wound infection and delayed wound healing

Diabetes-related infections have become challenging and important public health problems in China and around the world. P. aeruginosa plays an important role in diabetic foot infections. As a gram-negative opportunistic pathogen, P. aeruginosa causes recurrent and refractory infections that are characterized by biofilm formation. Previous studies have demonstrated that biofilm-challenged wounds typically take longer to heal than non-biofilm-challenged normal wounds in diabetic mouse models. In the present study, we sought to explore the mechanism via which insulin treatment affects cyclic di-GMP signaling in P. aeruginosa-infected chronic wounds in db/db diabetic mice. We found that the wounds of diabetic mice healed more slowly than those of nondiabetic mice. Moreover, wound healing in diabetic mice treated with insulin exhibited a considerable delay. Peptide nucleic acid-fluorescence in situ hybridization (PNA-FISH) was used to detect biofilms on P. aeruginosa-infected wound tissues. Increased intracellular c-di-GMP levels promoted biofilm formation in wound tissues from nondiabetic mice. Greater biofilm formation was observed in the wounds of insulin-treated diabetic mice than in the wounds of untreated diabetic mice or nondiabetic mice, in both the PAO1/p_lac-yhjH- and PAO1-infected groups. Quantitative RT-PCR indicated that upon infection with PAO1/P_lac-yhjH (the low c-di-GMP expression strain), the expression of IL-4 RNA was significantly higher in diabetic mice treated with insulin than in untreated diabetic mice or nondiabetic mice at each observation time point. Peak expression of IFN-γ occurred earlier in diabetic mice treated with insulin than in untreated diabetic mice with each of the experimental strains. Finally, P. aeruginosa harboring the plasmid pCdrA: gfp ^s was used as a reporter strain to monitor c-di-GMP levels. We found that insulin could promote biofilm formation by increasing intracellular c-di-GMP levels in vitro. Taken together, these data demonstrate that insulin treatment increases intracellular c-di-GMP levels, promotes biofilm formation and prolongs the inflammation period during the healing of infected wounds, resulting in delayed wound healing.

Graphene-based nanomaterials: the promising active agents for antibiotics-independent antibacterial applications

Graphene-based nanomaterials, such as graphene oxide (GO) and reduced graphene oxide (rGO), have shown great potentials in drug delivery and photodynamic/photothermal therapy due to their featured structure and physicochemical properties. In recent years, their antibacterial potentials have also been exploited. The commonly recognized antibacterial mechanisms include sharp edge-mediated cutting effect, oxidative stress and cell entrapment. This antibacterial activity is very important for human health. As we know, infection with the pathogenic bacteria, especially the drug-resistant ones, is a great threat to human lives. Thus, the development of the antibiotics-independent and drug-free antibacterial agents is of great importance and significance. Graphene-based nanomaterials are a kind of such antibacterial agents. An insight into their properties and antibacterial mechanisms is necessary before they are developed into real products. Herein, we provide a comprehensive understanding of the antibacterial application of graphene-based nanomaterials via summarizing their antibacterial activities against some typical microbial species and discussing their unique mechanisms. In addition, the side-effects and problems in using these nanomaterials are also discussed.

Cadexomer iodine effectively reduces bacterial biofilm in porcine wounds ex vivo and in vivo

Biofilms are prevalent in non-healing chronic wounds and implicated in delayed healing. Tolerance to antimicrobial treatments and the host's immune system leave clinicians with limited interventions against biofilm populations. It is therefore essential that effective treatments be rigorously tested and demonstrate an impact on biofilm across multiple experimental models to guide clinical investigations and protocols. Cadexomer iodine has previously been shown to be effective against biofilm in various in vitro models, against methicillin-resistant Staphylococcus aureus biofilm in mouse wounds, and clinically in diabetic foot ulcers complicated by biofilm. Similarities between porcine and human skin make the pig a favoured model for cutaneous wound studies. Two antiseptic dressings and a gauze control were assessed against mature biofilm grown on ex vivo pig skin and in a pig wound model. Significant reductions in biofilm were observed following treatment with cadexomer iodine across both biofilm models. In contrast, silver carboxymethylcellulose dressings had minimal impact on biofilm in the models, with similar results to the control in the ex vivo model. Microscopy and histopathology indicate that the depth of organisms in wound tissue may impact treatment effectiveness. Further work on the promising biofilm efficacy of cadexomer iodine is needed to determine optimal treatment durations against biofilm.

Microbial epidemiology and antimicrobial resistance patterns of wound infection in Ethiopia: a meta-analysis of laboratory-based cross-sectional studies

BACKGROUND

Wound infections are responsible for significant human morbidity and mortality worldwide. Specifically, surgical site infections are the third most commonly reported nosocomial infections accounting approximately a quarter of such infections. This systematic review and meta-analysis is, therefore, aimed to determine microbial profiles cultured from wound samples and their antimicrobial resistance patterns in Ethiopia.

METHODS

Literature search was carried out through visiting electronic databases and indexing services including PubMed, MEDLINE, EMBASE, CINAHL, and Google Scholar. Original records, available online from 2000 to 2018, addressing the research question and written in English were identified and screened. The relevant data were extracted from included studies using a format prepared in Microsoft Excel and exported to STATA 15.0 software for analyses of outcome measures and subgrouping. Der-Simonian-Laird's random effects model was applied for pooled estimation of outcome measures at 95% confidence level. Comprehensive meta-analysis version-3 software was used for assessing publication bias across studies. The study protocol is registered on PROSPERO with reference number ID: CRD42019117638.

RESULTS

A total of 21 studies with 4284 wound samples, 3012 positive wound cultures and 3598 bacterial isolates were included for systematic review and meta-analysis. The pooled culture positivity was found to be 70.0% (95% CI: 61, 79%). Regarding the bacterial isolates recovered, the pooled prevalence of S. aureus was 36% (95% CI: 29, 42%), from which 49% were methicillin resistant strains. The pooled estimate of E. coli isolates was about 13% (95% CI: 10, 16%) followed by P. aeruginosa, 9% (95% CI: 6, 12%), K. pneumoniae, 9% (95% CI: 6, 11%) and P. mirabilis, 8% (95% CI: 5, 11%). Compared to other antimicrobials, S. aureus has showed lower estimates of resistance against ciprofloxacin, 12% (95% CI: 8, 16%) and gentamicin, 13% (95% CI: 8, 18%). E. coli isolates exhibited the highest point estimate of resistance towards ampicillin (P = 84%; 95% CI: 76, 91%). Gentamicin and ciprofloxacin showed relatively lower estimates of resistance with pooled prevalence being 24% (95% CI: 16, 33%) and 27% (95% CI: 16, 37%), respectively. Likewise, P. aeruginosa showed the lowest pooled estimates of resistance against ciprofloxacin (P = 16%; 95% CI: 9, 24%).

CONCLUSION

Generally, the wound culture positivity was found very high indicating the likelihood of poly-microbial contamination. S. aureus is by far the most common bacterial isolate recovered from wound infection. The high estimate of resistance was observed among β-lactam antibiotics in all bacterial isolates. Ciprofloxacin and gentamicin were relatively effective in treating wound infections with poly-microbial etiology.

Current Status of In Vitro Models and Assays for Susceptibility Testing for Wound Biofilm Infections

Biofilm infections have gained recognition as an important therapeutic challenge in the last several decades due to their relationship with the chronicity of infectious diseases. Studies of novel therapeutic treatments targeting infections require the development and use of models to mimic the formation and characteristics of biofilms within host tissues. Due to the diversity of reported in vitro models and lack of consensus, this review aims to provide a summary of in vitro models currently used in research. In particular, we review the various reported in vitro models of Pseudomonas aeruginosa biofilms due to its high clinical impact in chronic wounds and in other chronic infections. We assess advances in in vitro models that incorporate relevant multispecies biofilms found in infected wounds, such as P. aeruginosa with Staphylococcus aureus, and additional elements such as mammalian cells, simulating fluids, and tissue explants in an attempt to better represent the physiological conditions found at an infection site. It is hoped this review will aid researchers in the field to make appropriate choices in their proposed studies with regards to in vitro models and methods.

From molecules to multispecies ecosystems: the roles of structure in bacterial biofilms

Biofilms are communities of sessile microbes that are bound to each other by a matrix made of biopolymers and proteins. Spatial structure is present in biofilms on many lengthscales. These range from the nanometer scale of molecular motifs to the hundred-micron scale of multicellular aggregates. Spatial structure is a physical property that impacts the biology of biofilms in many ways. The molecular structure of matrix components controls their interaction with each other (thereby impacting biofilm mechanics) and with diffusing molecules such as antibiotics and immune factors (thereby impacting antibiotic tolerance and evasion of the immune system). The size and structure of multicellular aggregates, combined with microbial consumption of growth substrate, give rise to differentiated microenvironments with different patterns of metabolism and gene expression. Spatial association of more than one species can benefit one or both species, while distances between species can both determine and result from the transport of diffusible factors between species. Thus, a widespread theme in the biological importance of spatial structure in biofilms is the effect of structure on transport. We survey what is known about this and other effects of spatial structure in biofilms, from molecules up to multispecies ecosystems. We conclude with an overview of what experimental approaches have been developed to control spatial structure in biofilms and how these and other experiments can be complemented with computational work.

Bacteriophage PEV20 and Ciprofloxacin Combination Treatment Enhances Removal of Pseudomonas aeruginosa Biofilm Isolated from Cystic Fibrosis and Wound Patients

Antibiotic resistance in Pseudomonas aeruginosa biofilms necessitates the need for novel antimicrobial therapy with anti-biofilm properties. Bacteriophages (phages) are recognized as an ideal biopharmaceutical for combating antibiotic-resistant bacteria especially when used in combination with antibiotics. However, previous studies primarily focused on using phages against of P. aeruginosa biofilms of laboratory strains. In the present study, biofilms of six P. aeruginosa isolated from cystic fibrosis and wound patients, and one laboratory strain was treated singly and with combinations of anti-Pseudomonas phage PEV20 and ciprofloxacin. Of these strains, three were highly susceptible to the phage, while one was partially resistant and one was completely resistant. Combination treatment with PEV20 and ciprofloxacin enhanced biofilm eradication compared with single treatment. Phage and ciprofloxacin synergy was found to depend on phage-resistance profile of the target bacteria. Furthermore, phage and ciprofloxacin combination formulation protected the lung epithelial and fibroblast cells from P. aeruginosa and promoted cell growth. The results demonstrated that thorough screening of phage-resistance is crucial for designing phage-antibiotic formulation. The addition of highly effective phage could reduce the ciprofloxacin concentration required to combat P. aeruginosa infections associated with biofilm in cystic fibrosis and wound patients.

Effect of Polyhexamethylene Biguanide Solution on Bacterial Load and Biofilm in Venous Leg Ulcers: A Randomized Controlled Trial

PURPOSE

The purpose of this study was to investigate the effect of polyhexamethylene biguanide (PHMB) solution as a wound cleanser on bacterial load and bacterial biofilm in venous leg ulcers.

DESIGN

Randomized controlled trial.

SUBJECTS AND SETTING

The target population was adults attending the dermatology outpatient clinic of the Clinical Hospital of the Federal University of Minas Gerais, Brazil. The sample comprised 44 patients with venous leg ulcers recruited over a 6-month period.

METHODS

Participants were divided into 2 groups: the intervention group had their wounds cleansed with PHMB, and the control group had their wound cleansed with a 0.9% saline solution. Tissue fragments of the wounds were collected for bacteriological analysis; transmission electron microscopy was used to identify the presence of biofilm.

RESULTS

The bacterial load was reduced in both groups compared to baseline values; no significant difference was found when groups were compared. Correlation analysis between wound duration (months), wound area (cm²), necrosis (%), variables, and bacterial count (colony forming units [CFUs]/g) after cleansing showed a significant relationship between area of the wound and CFUs/g (P = .0070, r = 0.51). Transmission electron microscopy revealed the presence of bacterial biofilm in the wounds after cleansing with both solutions.

CONCLUSIONS

The results of this study indicate that both PHMB and saline solution are effective in reducing the bacterial load in venous leg ulcers. However, bacterial biofilm was present after cleansing with both solutions. These findings provide important evidence regarding effectiveness of 2 common wound cleansers on bacterial presence in wounds.

Evaluation of short exposure times of antimicrobial wound solutions against microbial biofilms: from in vitro to in vivo

Objectives

Test the performance of topical antimicrobial wound solutions against microbial biofilms using in vitro, ex vivo and in vivo model systems at clinically relevant exposure times.

Methods

Topical antimicrobial wound solutions were tested under three different conditions: (in vitro) 4% w/v Melaleuca oil, polyhexamethylene biguanide, chlorhexidine, povidone iodine and hypochlorous acid were tested at short duration exposure times for 15 min against 3 day mature biofilms of Staphylococcus aureus and Pseudomonas aeruginosa; (ex vivo) hypochlorous acid was tested in a porcine skin explant model with 12 cycles of 10 min exposure, over 24 h, against 3 day mature P. aeruginosa biofilms; and (in vivo) 4% w/v Melaleuca oil was applied for 15 min exposure, daily, for 7 days, in 10 patients with chronic non-healing diabetic foot ulcers complicated by biofilm.

Results

In vitro assessment demonstrated variable efficacy in reducing biofilms ranging from 0.5 log₁₀ reductions to full eradication. Repeated instillation of hypochlorous acid in a porcine model achieved <1 log₁₀ reduction (0.77 log₁₀, P = 0.1). Application of 4% w/v Melaleuca oil in vivo resulted in no change to the total microbial load of diabetic foot ulcers complicated by biofilm (median log₁₀ microbial load pre-treatment = 4.9 log₁₀ versus 4.8 log₁₀, P = 0.43).

Conclusions

Short durations of exposure to topical antimicrobial wound solutions commonly utilized by clinicians are ineffective against microbial biofilms, particularly when used in vivo. Wound solutions should not be used as a sole therapy and clinicians should consider multifaceted strategies that include sharp debridement as the gold standard.

Monitoring and Molecular Characterization of Staphylococcus aureus Isolated from Chronic Wounds

OBJECTIVE

Researchers analyzed chronic wounds treated with 2% hydrogel to determine whether the presence of methicillin-resistant Staphylococcus aureus (MRSA) is related to the presence of clinical signs of infection.

METHODS

Thirty-five patients were recruited for this descriptive study using a quantitative approach. Staphylococcus aureus was identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry. Antibiotic susceptibility was determined using a disk diffusion test according to Clinical and Laboratory Standards Institute standards. Polymerase chain reaction, pulsed-field gel electrophoresis, and multilocus sequence typing were performed. Statistical analyses were performed using Spearman correlation coefficients for the variables MRSA and clinical signs of infection.

MAIN OUTCOME MEASURES

The identification of MRSA or methicillin-sensitive S aureus (MSSA), presence or absence of an infection in the wound, and molecular characterization of bacteria were measured.

MAIN RESULTS

Of the 35 patients analyzed, 8 (22.9%) were classified as having an infection in their wounds. Spearman ρ indicated a strong positive correlation between the increase in the number of clinical signs of infection and MSSA (P =.84), but only a moderate positive correlation with MRSA (P =.60). The S aureus clonal pattern was unique for each of the major bacteria isolated. Global MRSA sequence-type clones (ST-1 and ST-72) were detected in 2 patients.

CONCLUSIONS

Compared with those colonized by MSSA, chronic wounds colonized by MRSA did not display a strong correlation with the presence of a greater number of clinical signs of infection.

Influence of Laboratory Culture Media on in vitro Growth, Adhesion, and Biofilm Formation of Pseudomonas aeruginosa and Staphylococcus aureus

OBJECTIVE

Pseudomonas aeruginosa and Staphylococcus aureus dual-species biofilm infections are notoriously difficult to manage. This study aimed at investigating the influence of four different culture media on the planktonic growth, adhesion, and biofilm formation of P. aeruginosa and S. aureus.

MATERIALS AND METHODS

We monitored four different culture media including Nutrient Broth, Brain Heart Infusion (BHI) broth, Luria-Bertani broth, and RPMI 1640 medium on the planktonic growth, adhesion, and biofilm formation of P. aeruginosa (ATCC 27853) and S. aureus (ATCC 25923) using MTT assay and scanning electron microscopy (SEM).

RESULTS

The most robust growth of the mono- and dual-species cultures was noted in BHI broth. On the contrary, RPMI 1640 medium promoted maximal initial adhesion of both the mono- and dual-species, but BHI broth fostered the maximal biofilm growth. SEM images showed profuse extracellular polysaccharide production in biofilms, particularly in coculture, in BHI medium.

CONCLUSION

Our data demonstrate that BHI broth, relative to the other tested media, is the most conducive for in vitro evaluation of biofilm and planktonic growth kinetics of these two pathogens, both in mono- and coculture.

Use of next generation sequencing to investigate the microbiota of experimentally induced wounds and the effect of bandaging in horses

Objectives

To use next generation sequencing to characterize the microbiota of horses during healing of skin wounds in two anatomical locations (body and limb) known to present different healing patterns; and to investigate the impact of bandaging on bacterial communities of skin wounds located on the limbs of horses.

Methods

Full-thickness skin wounds were created on the distal extremity of both thoracic limbs and on one lateral mid-thoracic wall of four healthy horses. Limb wounds were randomly assigned to bandaging or not. A full-thickness sample was collected with a biopsy punch from intact thorax and limb skin (T0) and from the margin of one wound per site (thorax, unbandaged limb, bandaged limb) 1 week (T1) and 2 weeks (T2) postoperatively, and at full healing (T3). Thoracic skin samples obtained from three healthy horses were included in the analysis as controls.

Results

Anatomic location (thorax vs. limb) significantly influenced bacterial composition of equine skin and healing wounds. Fusobacterium and Actinobacillus were strongly associated with limb wounds during the initial phases of healing. Bandaging had a significant impact on the microbiota during the healing process. The skin microbiota after healing was more similar to samples from controls, demonstrating the resilience and stability of the environment.

Conclusions

Equine skin microbiota is a rich and stable environment that is disturbed by wounding, but returns to its previous stage after full healing. Anatomic location significantly influences bacterial composition of the equine skin during wound healing. Bandaging has a significant impact on the skin microbiota of horses during the healing process. Results of this study provide new insight for a better understanding of the contribution of bacteria to wound healing in horses and may facilitate the future development of therapeutic strategies using commensal bacteria.

Bacterial Silver Resistance Gained by Cooperative Interspecies Redox Behavior

Silver has emerged as an important therapeutic option for wound infections in recent years due to its broad-spectrum antimicrobial activity. The silver cation (Ag⁺), but not the bulk metal (Ag⁰), is highly toxic for most microorganisms, although resistance due to genetic modification or horizontal gene transfer does occur. Pseudomonas aeruginosa, however, achieves silver resistance by producing the redox-active metabolite pyocyanin that reduces Ag⁺ to nontoxic Ag⁰ Pyocyanin also possesses broad-spectrum antimicrobial activity. Many microbial species reduce pyocyanin, which reduces molecular oxygen to antimicrobial hydrogen peroxide. In this study, it was hypothesized that both Ag⁺ and oxygen would act as competing terminal electron acceptors for pyocyanin, thus acting as a universal microbial protectant from Ag⁺ while avoiding hydrogen peroxide formation. Escherichia coli and Staphylococcus aureus efficiently reduced pyocyanin and generated hydrogen peroxide, while Ag⁺ markedly reduced the amount of hydrogen peroxide produced. Although unable to reduce directly Ag⁺ to Ag⁰ on their own, E. coli and S. aureus did so when pyocyanin was present, resulting in increased survival when exposed to Ag⁺ Coincubation experiments with either E. coli or S. aureus with P. aeruginosa demonstrated increased survival for those species to Ag⁺, but only if pyocyanin was present. These data demonstrate that microorganisms that display no intrinsic silver resistance may survive and proliferate under potentially toxic conditions, provided their environment contains a suitable redox-active metabolite-producing bacterium. Chronic wounds are often polymicrobial in nature, with pyocyanin-producing P. aeruginosa bacteria frequently being present; therefore, redox-based silver resistance may compromise treatment efforts.

Options and Limitations in Clinical Investigation of Bacterial Biofilms

Bacteria can form single- and multispecies biofilms exhibiting diverse features based upon the microbial composition of their community and microenvironment. The study of bacterial biofilm development has received great interest in the past 20 years and is motivated by the elegant complexity characteristic of these multicellular communities and their role in infectious diseases. Biofilms can thrive on virtually any surface and can be beneficial or detrimental based upon the community's interplay and the surface. Advances in the understanding of structural and functional variations and the roles that biofilms play in disease and host-pathogen interactions have been addressed through comprehensive literature searches. In this review article, a synopsis of the methodological landscape of biofilm analysis is provided, including an evaluation of the current trends in methodological research. We deem this worthwhile because a keyword-oriented bibliographical search reveals that less than 5% of the biofilm literature is devoted to methodology. In this report, we (i) summarize current methodologies for biofilm characterization, monitoring, and quantification; (ii) discuss advances in the discovery of effective imaging and sensing tools and modalities; (iii) provide an overview of tailored animal models that assess features of biofilm infections; and (iv) make recommendations defining the most appropriate methodological tools for clinical settings.

Antimicrobial and Antibiofilm Efficacy of Graphene Oxide against Chronic Wound Microorganisms

Chronic wounds represent an increasing problem worldwide. Graphene oxide (GO) has been reported to exhibit strong antibacterial activity toward both Gram-positive and Gram-negative bacteria. The aim of this work was to investigate the in vitro antimicrobial and antibiofilm efficacy of GO against wound pathogens. Staphylococcus aureus PECHA 10, Pseudomonas aeruginosa PECHA 4, and Candida albicans X3 clinical isolates were incubated with 50 mg/liter of GO for 2 and 24 h to evaluate the antimicrobial effect. Optical and atomic force microscopy images were performed to visualize the effect of GO on microbial cells. Moreover, the antibiofilm effect of GO was tested on biofilms, both in formation and mature. Compared to the respective time controls, GO significantly reduced the S. aureus growth both at 2 and 24 h in a time-dependent way, and it displayed a bacteriostatic effect in respect to the GO t = 0; an immediate (after 2 h) slowdown of bacterial growth was detected for P. aeruginosa, whereas a tardive effect (after 24 h) was recorded for C. albicans Atomic force microscopy images showed the complete wrapping of S. aureus and C. albicans with GO sheets, which explains its antimicrobial activity. Moreover, significant inhibition of biofilm formation and a reduction of mature biofilm were recorded for each detected microorganism. The antibacterial and antibiofilm properties of GO against chronic wound microorganisms make it an interesting candidate to incorporate into wound bandages to treat and/or prevent microbial infections.

Staphylococcus aureus biofilms release leukocidins to elicit extracellular trap formation and evade neutrophil-mediated killing

Bacterial biofilms efficiently evade immune defenses, greatly complicating the prognosis of chronic infections. How methicillin-resistant Staphylococcus aureus (MRSA) biofilms evade host immune defenses is largely unknown. This study describes some of the major mechanisms required for S. aureus biofilms to evade the innate immune response and provides evidence of key virulence factors required for survival and persistence of bacteria during chronic infections. Neutrophils are the most abundant white blood cells in circulation, playing crucial roles in the control and elimination of bacterial pathogens. Specifically, here we show that, unlike single-celled populations, S. aureus biofilms rapidly skew neutrophils toward neutrophil extracellular trap (NET) formation through the combined activity of leukocidins Panton-Valentine leukocidin and γ-hemolysin AB. By eliciting this response, S. aureus was able to persist, as the antimicrobial activity of released NETs was ineffective at clearing biofilm bacteria. Indeed, these studies suggest that NETs could inadvertently potentiate biofilm infections. Last, chronic infection in a porcine burn wound model clearly demonstrated that leukocidins are required for "NETosis" and facilitate bacterial survival in vivo.

Role of anaerobes in polymicrobial communities and biofilms complicating diabetic foot ulcers

Infected tissues in the feet of people with diabetes in the form of a diabetic foot ulcer (DFU) present a complex pathology for clinicians to manage. This is partly attributed to the multi-factorial nature of the disease, which may include; altered foot architecture leading to excessive plantar pressures and frictional forces peripheral arterial disease and loss of protective sensation. In addition, to the above co-morbid variables, it is understood that a delayed wound healing state may be perpetuated by the presence of microorganisms residing in the wound tissue. The microbiology of chronic DFUs has often been reported as being polymicrobial. Of growing interest is the presence and potential role of anaerobic microorganisms in the pathology of DFUs and how they may contribute to the infective process or delayed healing. The presence of anaerobes in DFUs has been greatly underestimated, largely due to the limitations of conventional culture methods in identifying them from samples. Advancements in molecular and microscopy techniques have extended our view of the wound microbiome in addition to observing the growth and behaviour (planktonic or biofilm) of microorganisms in situ. This review paper will reflect on the evidence for the role and significance of anaerobes in DFUs and infection. A focus of this review will be to explore recent advancements in molecular genomics and microscopy techniques in order to better assess the roles of anaerobic bacteria in chronic DFUs and in biofilm-based wound care.

Acquisition of resistance to carbapenem and macrolide-mediated quorum sensing inhibition by Pseudomonas aeruginosa via ICETn4371 6385

Pseudomonas aeruginosa can cause life-threatening infections in immunocompromised patients. The first-line agents to treat P. aeruginosa infections are carbapenems. However, the emergence of carbapenem-resistant P. aeruginosa strains greatly compromised the effectiveness of carbapenem treatment, which makes the surveillance on their spreading and transmission important. Here we characterized the full-length genomes of two carbapenem-resistant P. aeruginosa clinical isolates that are capable of producing New Delhi metallo-β-lactamase-1 (NDM-1). We show that bla_NDM-1 is carried by a novel integrative and conjugative element (ICE) ICE_Tn43716385, which also carries the macrolide resistance gene msr(E) and the florfenicol resistance gene floR. By exogenously expressing msr(E) in P. aeruginosa laboratory strains, we show that Msr(E) can abolish azithromycin-mediated quorum sensing inhibition in vitro and anti-Pseudomonas effect in vivo. We conclude that ICEs are important in transmitting carbapenem resistance, and that anti-virulence treatment of P. aeruginosa infections using sub-inhibitory concentrations of macrolides can be challenged by horizontal gene transfer.

Yichen Ding et al. identify a novel integrative and conjugative element that confers Pseudomonas aeruginosa with resistance to carbapenem, the last-resort drug for susceptable Gram-negative bacterial infections. This study also shows how antivirulence treatment for P. aeruginosainfections can be challenged by horizontal gene transfer.

Bacterial Quorum Sensing and Microbial Community Interactions

Many bacteria use a cell-cell communication system called quorum sensing to coordinate population density-dependent changes in behavior. Quorum sensing involves production of and response to diffusible or secreted signals, which can vary substantially across different types of bacteria. In many species, quorum sensing modulates virulence functions and is important for pathogenesis. Over the past half-century, there has been a significant accumulation of knowledge of the molecular mechanisms, signal structures, gene regulons, and behavioral responses associated with quorum-sensing systems in diverse bacteria. More recent studies have focused on understanding quorum sensing in the context of bacterial sociality. Studies of the role of quorum sensing in cooperative and competitive microbial interactions have revealed how quorum sensing coordinates interactions both within a species and between species. Such studies of quorum sensing as a social behavior have relied on the development of "synthetic ecological" models that use nonclonal bacterial populations. In this review, we discuss some of these models and recent advances in understanding how microbes might interact with one another using quorum sensing. The knowledge gained from these lines of investigation has the potential to guide studies of microbial sociality in natural settings and the design of new medicines and therapies to treat bacterial infections.

Biodegradable Nanocomposite Antimicrobials for the Eradication of Multidrug-Resistant Bacterial Biofilms without Accumulated Resistance

Infections caused by multidrug-resistant (MDR) bacteria are a rapidly growing threat to human health, in many cases exacerbated by their presence in biofilms. We report here a biocompatible oil-in-water cross-linked polymeric nanocomposite that degrades in the presence of physiologically relevant biomolecules. These degradable nanocomposites demonstrated broad-spectrum penetration and elimination of MDR bacteria, eliminating biofilms with no toxicity to cocultured mammalian fibroblast cells. Notably, serial passaging revealed that bacteria were unable to develop resistance toward these nanocomposites, highlighting the therapeutic promise of this platform.

Interleukin-26 (IL-26) is a novel anti-microbial peptide produced by T cells in response to staphylococcal enterotoxin

Anti-microbial peptides are produced at outer and inner surfaces by epithelia and innate immune cells in response to bacterial infection. Staphylococcus aureus is an enterotoxin producing, Gram-positive pathogen, which is a major cause of soft tissue infections and life-threatening bacteremia and sepsis. Here we show that (i) skin T cells in chronic wounds infected with S. aureus express interleukin-26 (IL-26) in situ, (ii) staphylococcal enterotoxins (SE) trigger IL-26 expression in T cell lines and primary skin T cells, and (iii) IL-26 triggers death and inhibits biofilm formation and growth of S. aureus. Thus, we provide novel evidence that IL-26 is an anti-microbial peptide produced by T cells in response to SE. Accordingly, we propose that IL-26 producing T cells take part in the innate immune response to SE producing S. aureus and thus play a novel role in the primary innate immune defense in addition to their classical role in adaptive immunity.

Bacterial Aggregates Establish at the Edges of Acute Epidermal Wounds

Objective: The bacterial composition and distribution were evaluated in acute standardized epidermal wounds and uninjured skin by a molecular in situ technology benchmarked to conventional culturing. This was done to reveal whether bacterial biofilm is present in acute wounds. Approach: On the buttock of 26 healthy volunteers, 28 suction blisters were made and de-roofed. Four wounds were biopsied immediately after wounding, whereas the remaining 24 wounds were treated daily with sterile deionized water and covered with a moisture-retaining dressing. On day 4 post-wounding, swabs were obtained for culturing from the wounds and adjacent skin, and the wounds including adjacent skin were excised. Tissue sections were stained with peptide nucleic acid (PNA) fluorescence in situ hybridization (FISH) probes, counterstained by 4',6-diamidino-2-phenylindole, and evaluated by confocal laser scanning microscopy (CLSM). Results: No bacterial aggregates were detected at day 0. At day 4, coagulase-negative staphylococci (CoNS) were the sole bacteria identified by CLSM/PNA-FISH and culturing. CoNS was isolated from 78% of the wound swabs and 48% of the skin swabs. Bacterial aggregates (5-150 μm) were detected by PNA-FISH/CLSM in the split stratum corneum and fibrin deposits at the wound edges and in the stratum corneum and the hair follicles of the adjacent skin. The bacterial aggregates were more common (p = 0.0084) and larger (p = 0.0083) at wound edges than in the adjacent skin. Innovation: Bacterial aggregates can establish in all wound types and may have clinical significance in acute wounds. Conclusion: Bacterial aggregates were observed at the edges of acute epidermal wounds, indicating initiated establishment of a biofilm.