Strategies for the prevention of microbial biofilm formation on silicone rubber voice prostheses

A double-blind randomized clinical trial of inflammatory cytokine and pepsin levels in the saliva of patients with voice prostheses

BACKGROUND

Tracheoesophageal speech is one of the most effective method used for voice rehabilitation after laryngectomy. The main limitation is the need for periodic voice prothesis (VP) replacements. The process of developing VP usage complications is still unexplored. The aim of this study was to assess the level of cytokines (IL-1β, IL-6, IL-8, IL-10, TNFα) and pepsin in saliva as potential factors reducing VP longevity.

METHODS

Prospective double-blind randomized clinical trial was conducted (NCT04268459). Patients were randomly divided into two groups depending on VP replacement regimen (regular-every 3 months, or irregular-when complications occur). Levels of IL-1β, IL-6, IL-8, IL-10, TNFα, and pepsin in saliva samples (fasting and after eating) of laryngectomized patients were measured using ELISA tests.

RESULTS

Fifty-two patients (26 in both groups) with control group (7 patients) participated in the study. The level of IL-1β, IL-6, IL-8, IL-10, TNFα, and pepsin did not differ according to regularity of VP replacements (p = 0.301-0.801). IL-6 levels were significantly higher when VP complications occurs (p = 0.012).

CONCLUSIONS

The saliva components were not significantly different depending on the frequency of VP replacements. IL-6 plays an important role in the development of VP use complications.

Silicones for Maxillofacial Prostheses and Their Modifications in Service

The biomedical applications of silicones are countless due to their outstanding properties. In dentistry, silicone for maxillofacial and plastic surgery has become indispensable, from both physiological and aesthetic points of view. In this mini-review, silicone materials for dentistry and facial prostheses are discussed, focusing on their properties and alterations when exposed for long periods to different environments. A significant number of studies reported in the literature have been conducted in vitro, mimicking some of the main degradative factors which have been identified as triggers for discoloration and deterioration of the mechanical properties. Among these, in artificial aging and accelerated natural aging studies, UV radiation is considered the most important. Other weathering factors, biological contamination, and disinfection agents may have dramatic effects as well. Several general properties of silicones are described at the beginning, with a focus on biocompatibility, cross-linking mechanisms, and applications in dentistry and maxillofacial prosthetics. We discuss the ongoing cross-linking and/or possible exudation after manufacturing, which also affects the stability of the prosthesis over time, and possibly the patient. Next, the main environmental factors that affect the prostheses in service are presented, including the role of cigarettes smoke, which has been discussed very little so far. A few aspects, such as biofilm formation, its negative effects, and proposed solutions to overcome this phenomenon regarding silicones, are also described. We conclude by proposing a set of topics for future research and development based on the gaps that have been identified in the literature. Although silicones are probably irreplaceable in maxillofacial prosthetics, improvements in terms of base materials, additives, surface treatments, and maintenance are possible and necessary for long-lasting and safer prostheses.

Development of iodine based sustained release antimicrobial coatings for polyurethane voice prostheses

Voice prostheses are known to fail in few weeks to several months of implantation due to the clogging mainly caused by microbial biofilm formation, which is a cause of concern. Iodine is a known broad-spectrum biocide and is reported to easily form complexes with various polymers. For long term device disinfection, strong iodine complexation that offers sustained iodine release for a prolonged period is essential. The present research work deals with the synthesis of a poly(methyl methacrylate-n-butyl acrylate-N-vinyl-2-pyrrolidone) (poly[MMA-BA-NVP]) tercopolymer through free radical polymerization for surface coating thermoplastic polyurethane (TPU) based voice prostheses. The NVP content in the tercopolymer was varied from 20% to 50% to optimise iodine loading and subsequent release. Base TPU coated with the tercopolymer was treated with 4% aqueous iodine solution at room temperature (28 ± 3 °C) for two hours. It was observed that the tercopolymer containing 35% N-vinyl-2-pyrrolidone (NVP), 32.5% methyl methacrylate (MMA) and 32.5% butyl acrylate (nBA) gave a stable coating on TPUs together with sustained iodine release for a prolonged period. Furthermore, the tercopolymer coated and iodine loaded TPUs exhibited excellent antimicrobial activity against Candida albicans, Staphylococcus aureus and Escherichia coli.

Surface Engineering Strategies to Enhance the In Situ Performance of Medical Devices Including Atomic Scale Engineering

Decades of intense scientific research investigations clearly suggest that only a subset of a large number of metals, ceramics, polymers, composites, and nanomaterials are suitable as biomaterials for a growing number of biomedical devices and biomedical uses. However, biomaterials are prone to microbial infection due to Escherichia coli (E. coli), Staphylococcus aureus (S. aureus), Staphylococcus epidermidis (S. epidermidis), hepatitis, tuberculosis, human immunodeficiency virus (HIV), and many more. Hence, a range of surface engineering strategies are devised in order to achieve desired biocompatibility and antimicrobial performance in situ. Surface engineering strategies are a group of techniques that alter or modify the surface properties of the material in order to obtain a product with desired functionalities. There are two categories of surface engineering methods: conventional surface engineering methods (such as coating, bioactive coating, plasma spray coating, hydrothermal, lithography, shot peening, and electrophoretic deposition) and emerging surface engineering methods (laser treatment, robot laser treatment, electrospinning, electrospray, additive manufacturing, and radio frequency magnetron sputtering technique). Atomic-scale engineering, such as chemical vapor deposition, atomic layer etching, plasma immersion ion deposition, and atomic layer deposition, is a subsection of emerging technology that has demonstrated improved control and flexibility at finer length scales than compared to the conventional methods. With the advancements in technologies and the demand for even better control of biomaterial surfaces, research efforts in recent years are aimed at the atomic scale and molecular scale while incorporating functional agents in order to elicit optimal in situ performance. The functional agents include synthetic materials (monolithic ZnO, quaternary ammonium salts, silver nano-clusters, titanium dioxide, and graphene) and natural materials (chitosan, totarol, botanical extracts, and nisin). This review highlights the various strategies of surface engineering of biomaterial including their functional mechanism, applications, and shortcomings. Additionally, this review article emphasizes atomic scale engineering of biomaterials for fabricating antimicrobial biomaterials and explores their challenges.

Assessment of Ceragenins in Prevention of Damage to Voice Prostheses Caused by Candida Biofilm Formation

This study aimed to investigate the potential application of ceragenins (CSAs) as new candidacidal agents to prevent biofilm formation on voice prostheses (VPs). The deterioration of the silicone material of VPs is caused by biofilm growth on the device which leads to frequent replacement procedures and sometimes serious complications. A significant proportion of these failures is caused by Candida species. We found that CSAs have significant candidacidal activities in vitro (MIC; MFC; MBIC), and they effectively eradicate species of yeast responsible for VP failure. Additionally, in our in vitro experimental setting, when different Candida species were subjected to CSA-13 and CSA-131 during 25 passages, no tested Candida strain showed the significant development of resistance. Using liquid chromatography–mass spectrometry (LC-MS), we found that VP immersion in an ethanol solution containing CSA-131 results in silicon impregnation with CSA-131 molecules, and in vitro testing revealed that fungal biofilm formation on such VP surfaces was inhibited by embedded ceragenins. Future in vivo studies will validate the use of ceragenin-coated VP for improvement in the life quality and safety of patients after a total laryngectomy.

Synthesis and Characterization of Cationic Dendrimer-PDMS Hybrids

A modular strategy for the synthesis of dendron-linear polymer hybrids comprised of a flexible polydimethylsiloxane (PDMS) midblock with cationic 2,2-bis(hydroxymethyl)propionic acid (bis-MPA) dendron end groups is developed. The invention of a scalable methodology to access quaternary ammonium carboxylate building blocks and their direct use in esterification chemistry enables rapid access to cationic bis-MPA dendrons. The convergent click coupling of highly charged dendrons to hydrophobic PDMS chain-ends gives a 12-membered family of hybrids that are comprised of different dendron generations (G1-3) and quaternary ammonium alkyl chain lengths (C4 , C8 , C12 , C16 ). This provides a library of materials with variable hydrophobicity, charge density, and chain-end valency. The physical behavior of the dendron-linear PDMS hybrid copolymers significantly changes after introduction of the cationic dendron end-groups and leads to soft-solid materials as a result of inhibited chain mobility. These PDMS-dendron hybrids are expected to behave as surface-active antimicrobial additives in bulk cross-linked silicone systems.

Review of probiotic use in otolaryngology

OBJECTIVE

Probiotics have garnered considerable attention as an intervention for various conditions common to otolaryngology. The purpose of this review is to evaluate the current literature to offer recommendations about the safety and efficacy of probiotic management in otolaryngologic conditions.

STUDY DESIGN

Narrative review.

METHODS

PubMed and Google Scholar were queried using pertinent keywords to retrieve relevant studies with particular focus in the recent 5 years. All abstracts were assessed and studies, reviews and meta-analyses achieving evaluation of probiotic therapies or characterization of microbiome changes were included for further review. Studies were categorized by condition or anatomic region across various subspecialties. Key data parameters were extracted and evaluated across studies and treatment types.

RESULTS

Strong evidence exists for the use probiotic agents to improve symptoms for allergic rhinitis, chronic rhinosinusitis and certain dental conditions. Despite promising results, further investigation is needed to evaluate and optimize probiotic delivery for mitigating otitis media, oropharyngeal inflammation and upper respiratory tract infections. Preclinical studies suggest that probiotics may potentially offer benefit for voice prosthesis maintenance, wound healing and mitigation of oral dysplasia.

CONCLUSION

Probiotic therapies may offer clinical benefit in a variety of contexts within the field of otolaryngology, especially for short-term relief of certain inflammatory conditions of the oral cavity, auditory and nasal cavities. Further investigation is warranted for evaluation of long-term outcomes and pathogenic deterrence.

Preparation of medical hydrophilic and antibacterial silicone rubber via surface modification

Bacterial adhesion of medical indwelling devices shortens their service life and brings about infections in patients. The combination of hydrophilic and antibacterial modifications can not only kill the bacteria in contact with the surface, but also avoid the adhesion of dead bacteria. From this view, with a self-made quaternary ammonium salt and a zwitterion as the modifiers, a modified silicone rubber, SR-g-(DMAPS-co-QA), was prepared via random co-grafting. The static water angle test and antibacterial assays proved the enhancement of both the hydrophilicity and antibacterial activity. In addition, compared with the unmodified silicone rubber, after 7 days of co-cultivation in E. coli suspension, SR-g-(DMAPS-co-QA) demonstrated good resistance to biofilm formation. Furthermore, to simulate the real situation, its antibacterial effect in dynamic flow condition was measured, confirming that SR-g-(DMAPS-co-QA) still maintained good antibacterial performance after a 48 hour cyclic flow of E. coli bacterial suspension.

Surface modification of silicone rubber to enhance hydrophilicity and antibacterial effect.

Evaluation of the Potential of Biofilm Formation of Bifidobacterium longum subsp. infantis and Lactobacillus reuteri as Competitive Biocontrol Agents Against Pathogenic and Food Spoilage Bacteria

This study proposes to exploit the in vivo metabolism of two probiotics (Bifidobacterium longum subsp. infantis and Lactobacillus reuteri) which, upon adhesion on a solid surface, form a biofilm able to control the growth of pathogenic and food spoilage bacteria. The results showed that pathogenic cell loads were always lower in presence of biofilm (6.5-7 log CFU/cm2) compared to those observed in its absence. For Escherichia coli O157:H7, a significant decrease (>1-2 logarithmic cycles) was recorded; for Listeria monocytogenes, Staphylococcus aureus, and Salmonella enterica, cell load reductions ranged from 0.5 to 1.5 logarithmic cycles. When tested as active packaging, the biofilm was successfully formed on polypropylene, polyvinyl chloride, greaseproof paper, polyethylene and ceramic; the sessile cellular load ranged from 5.77 log CFU/cm2 (grease-proof paper) to 6.94 log CFU/cm2 (polyethylene, PE). To test the potential for controlling the growth of spoilage microorganisms in food, soft cheeses were produced, inoculated with L. monocytogenes and Pseudomonas fluorescens, wrapped in PE pellicles with pre-formed biofim, packed both in air and under vacuum, and stored at 4 and 15 °C: an effective effect of biofilms in slowing the decay of the microbiological quality was recorded.

Biosurfactants of Lactobacillus helveticus for biodiversity inhibit the biofilm formation of Staphylococcus aureus and cell invasion

Aim: This study aimed to evaluate the differences of biosurfactants produced by two Lactobacillus helveticus strains against the biofilm formation of Staphylococcus aureus in vitro and in vivo. Materials & methods: Scanning electron microscopy, Real time-quantitative PCR (RT-qPCR) and cell assay were used to analyze the inhibiting effect of biosurfactants against biofilm formation. Results & conclusion: Results showed that the biosurfactants have anti-adhesive and inhibiting effects on biofilm formation in vivo and in vitro. The biofilm-formative genes and autoinducer-2 signaling regulated these characteristics, and the biosurfactant L. helveticus 27170 is better than that of 27058. Host cell adhesion and invasion results indicated that the biosurfactants L. helveticus prevented the S. aureus invading the host cell, which may be a new strategy to eliminate biofilms.

Medical-Grade Silicone Coated with Rhamnolipid R89 Is Effective against Staphylococcus spp. Biofilms

Staphylococcus aureus and Staphylococcus epidermidis are considered two of the most important pathogens, and their biofilms frequently cause device-associated infections. Microbial biosurfactants recently emerged as a new generation of anti-adhesive and anti-biofilm agents for coating implantable devices to preserve biocompatibility. In this study, R89 biosurfactant (R89BS) was evaluated as an anti-biofilm coating on medical-grade silicone. R89BS is composed of homologues of the mono- (75%) and di-rhamnolipid (25%) families, as evidenced by mass spectrometry analysis. The antimicrobial activity against Staphylococcus spp. planktonic and sessile cells was evaluated by microdilution and metabolic activity assays. R89BS inhibited S. aureus and S. epidermidis growth with minimal inhibitory concentrations (MIC₉₉) of 0.06 and 0.12 mg/mL, respectively and dispersed their pre-formed biofilms up to 93%. Silicone elastomeric discs (SEDs) coated by R89BS simple adsorption significantly counteracted Staphylococcus spp. biofilm formation, in terms of both built-up biomass (up to 60% inhibition at 72 h) and cell metabolic activity (up to 68% inhibition at 72 h). SEM analysis revealed significant inhibition of the amount of biofilm-covered surface. No cytotoxic effect on eukaryotic cells was detected at concentrations up to 0.2 mg/mL. R89BS-coated SEDs satisfy biocompatibility requirements for leaching products. Results indicate that rhamnolipid coatings are effective anti-biofilm treatments and represent a promising strategy for the prevention of infection associated with implantable devices.

Isolation and characterization of kurstakin and surfactin isoforms produced by Enterobacter cloacae C3 strain

In this work, the extraction, structural analysis, and identification as well as antimicrobial, anti-adhesive, and antibiofilm activities of lipopeptides produced by Enterobacter cloacae C3 strain were studied. A combination of chromatographic and spectroscopic techniques offers opportunities for a better characterization of the biosurfactant structure. Thin layer chromatography (TLC) and HPLC for amino acid composition determination are used. Efficient spectroscopic techniques have been utilized for investigations on the biochemical structure of biosurfactants, such as Fourier transform infrared (FT-IR) spectroscopy and mass spectrometry analysis. This is the first work describing the production of different isoforms belonging to kurstakin and surfactin families by E cloacae strain. Three kurstakin homologues differing by the fatty acid chain length from C₁₀ to C₁₂ were detected. The spectrum of lipopeptides belonging to surfactin family contains various isoforms differing by the fatty acid chain length as well as the amino acids at positions four and seven. Lipopeptide C3 extract exhibited important antibacterial activity against Gram-positive and Gram-negative bacteria, antifungal activity, and interesting anti-adhesive and disruptive properties against biofilm formation by human pathogenic bacterial strains: Salmonella typhimurium, Klebsiella pneumoniae, Staphylococcus aureus, Bacillus cereus, and Candida albicans.

Intraosseous metal implants in orthopedics: A review

Metal implants are biomaterials widely used in orthopedics. They are both used in osteosynthesis and arthroplasty. Their mechanical properties, biocompatibility and resistance to corrosion make them a widely used option in orthopedics. Alloys are the most commonly used metals in orthopedics. As far as physical traumas are concerned, implants such as screws, plates and/or nails are used for osteosynthesis as they ensure the stability of the fractured area and contribute to bone healing. Prostheses are used in arthroplasty to restore joint function for as long as possible. Contact between bone and the prosthesis induces bone remodeling at the interface between metal and bone even if the metal is recognized as biocompatible. Upon time, the interface between the metal implant and the bony tissue is continuously modified and adapted. Hip prosthesis is a typical example of intraosseous metal implant whose bone/implant interface has been extensively studied. Metal can be altered in vivo by different mechanisms including corrosion and fretting. An altered torque friction leads to wear debris that accumulate in the peri-prosthetic tissues causing metallosis.

Bacterial biofilm formation on implantable devices and approaches to its treatment and prevention

In living organisms, biofilms are defined as complex communities of bacteria residing within an exopolysaccharide matrix that adheres to a surface. In the clinic, they are typically the cause of chronic, nosocomial, and medical device-related infections. Due to the antibiotic-resistant nature of biofilms, the use of antibiotics alone is ineffective for treating biofilm-related infections. In this review, we present a brief overview of concepts of bacterial biofilm formation, and current state-of-the-art therapeutic approaches for preventing and treating biofilms. Also, we have reviewed the prevalence of such infections on medical devices and discussed the future challenges that need to be overcome in order to successfully treat biofilms using the novel technologies being developed.

Unveiling the fate of adhering bacteria to antimicrobial surfaces: expression of resistance-associated genes and macrophage-mediated phagocytosis

Since most antibacterial coatings reported to fight biomaterial-associated infections (BAI) fail in completely preventing bacterial colonization, it is crucial to know the impact of that small fraction of adhered bacteria in BAI recrudescence. This study aims to understand the fate of Staphylococcus aureus able to adhere to an antimicrobial coating previously developed, in terms of potential development of bacterial resistance and their macrophage-mediated phagocytosis. Antimicrobial coating comprised the co-immobilization of Palm peptide and DNase I onto polydimethylsiloxane. Expression of genes associated to resistance and virulence mechanisms showed that cells in contact with antimicrobial surfaces for a long period of 30 days, exhibit genes equally or less expressed, as compared to cells recovered from control surfaces. Recovered cells also exhibit the same susceptibility patterns, which strengthens the evidence of no resistance development. Remarkably, cells adhered to modified surfaces shows a reduced metabolic activity upon vancomycin treatment unlike the cells found on control surfaces, which can be identified as a clinical opportunity for prophylactically administration after implant surgery. Furthermore, results highlight that functionalization of PDMS with Palm and DNase I should not compromise the action of host immune cells. The overall results reinforce the potential of this antimicrobial strategy to fight BAI.

Use of design of experiments to optimize the production of microbial probiotic biofilms

Here, we describe the production of a probiotic biofilm through three intermediate steps: (1) measurement of the adhesion capacity of 15 probiotic strains to evaluate their tendency to form biofilm on different surfaces (stainless steel, glass, and polycarbonate); (2) evaluation of the effects of pH, temperature, cellular growth phase, agitation, and presence of surfactants on probiotic biofilm formation (BF) through the Design of Experiments (DoE) approach; (3) study of the effects of pH, temperature and surfactants concentration on probiotic BF using the Central Composite Design. Finally, we show that biofilms pre-formed by selected probiotics can delay the growth of pathogens, such as Listeria monocytogenes chosen as model organism. Among the tested strains, Bifidobacterium infantis DSM20088 and Lactobacillus reuteri DSM20016 were found to be as the probiotics able to ensure the greatest adhesion (over 6 Log CFU cm2) to the surfaces tested in a very short time (<24 h). Cellular growth phase and agitation of the medium were factors not affecting BF, pH exerted a very bland effect and a greater tendency to adhesion was observed when the temperature was about 30 °C. The results obtained in the last experimental phase suggest that our probiotic biofilms can be used as an efficient mean to delay the growth of L. monocytogenes: the λ phase length, in fact, was longer in samples containing probiotic biofilms (0.30-1.02 h) against 0.08 h observed in the control samples. A reduction of the maximum cell load was also observed (6.99-7.06 Log CFU mL-1 against about 8 Log CFU mL-1 observed in the control samples).

Biofilm in voice prosthesis: A prospective cohort study and laboratory tests using sonication and SEM analysis

OBJECTIVE

The objective of the study was to compare the biofilm growing pattern and its morphological extent on silicone and a teflon-like material using a sonication process and a Scanning Electron Microscope (SEM).

DESIGN

A prospective cohort study and a laboratory study.

SETTING

Otolaryngology -Head and Neck surgery Department and the Microbiology Institute.

PARTICIPANTS

The participants included fifteen laryngectomised patients with phonatory prostheses, which were removed because of device failure, and two different kinds of phonatory prostheses from the laboratory (Provox 2 and ActiValve) that were artificially colonised by Candida albicans.

MAIN OUTCOME MEASURES

Tracheo-oesophageal puncture (TEP) is currently considered the gold standard for post-laryngectomy voice rehabilitation. "Leakage" represents the most common cause of substitution and is generated by biofilm colonisation of the prosthesis by mixed mycotic and bacterial agents. New biomaterials have been developed that are deemed to be more resistant to the colonisation of micro-organisms and material deformation.

RESULTS

The devices showed colonisation by mixed bacterial flora (Staphylococci 13%, Streptococci 9%, and Haemophilus influenzae 5%) and by yeasts (Candida albicans 12%). Moreover, we observed a different distribution of biofilm layers in Provox ActiValve (22.56%) compared to Provox 2 (56.82%) after experimental colonisation by the previously isolated Candida strain.

CONCLUSION

Resident microbiological species from the upper airways unavoidably colonise the polymer surfaces, and no strategies have been effective except for the manipulation of the chemical-physical properties of the device's polymer. Our study confirms that Provox ActiValve, which is made with a fluoroplastic material (teflon-like), is less subject to in vitro colonisation by Candida, and thus showed a higher clinical resistance to biofilm and a longer lifespan. The sonication seems to significantly improve the knowledge of bacterial and mycotic flora in biofilm colonisation. The design of a device for the daily cleaning capable to reach and brush the oesophageal flange of the prosthesis preserving the valve mechanism could represent a practical and simple help in this still unsolved problem.

Efficacy of carboxymethyl chitosan against Candida tropicalis and Staphylococcus epidermidis monomicrobial and polymicrobial biofilms

Polymicrobial biofilms with fungi and bacteria are the leading cause for the failure of medical devices and related infections. In this study, antibiofilm activities of carboxymethyl chitosan (CM-chitosan) on monomicrobial and polymicrobial biofilms of Staphylococcus epidermidis and Candida tropicalis in vitro were evaluated. CM-chitosan was effective as a sole agent, inhibiting both monomicrobial and polymicrobial biofilms in microplates and also on the silicone surface in short- and long-term periods. Biofilm architecture was investigated by scanning electron microscopy and confocal laser scanning microscopy was used to examine living/dead organisms within biofilm. CM-chitosan inhibited planktonic growth as well as adhesion. Further biofilm formation was inhibited by CM-chitosan added at 90min or 12h after biofilm initiation. CM-chitosan may serve as a possible antibiofilm agent to limit monomicrobial and polymicrobial biofilm.

Inhibition of mixed fungal and bacterial biofilms on silicone by carboxymethyl chitosan

Mixed biofilms with fungi and bacteria are the leading cause for the failure of medical silicone devices, such as voice prostheses in laryngectomy. In this study, we determined the effect of carboxymethyl chitosan (CM-chitosan) on mixed biofilm formation of fungi and bacteria on silicone which is widely used for construction of medical devices. Mixed biofilm formations were inhibited 72.87% by CM-chitosan. Furthermore, CM-chitosan significantly decreased the metabolic activity of the biofilms using 2, 3-bis (2-methoxy-4-nitro-5-sulfo-phenyl)-2H-tetrazolium-5 carboxanilide (XTT) reduction assay. The examination using confocal laser scanning microscopy and scanning electron microscope confirmed that CM-chitosan inhibited the mixed biofilm and damaged the cells. Effects of CM-chitosan on different stages of biofilms were also evaluated. CM-chitosan inhibited the adhesion of fungi and bacteria with an efficiency of >90%. It prevented biofilm formation at efficiencies of 69.86%, 50.88% and 46.58% when CM-chitosan was added at 90min, 12h and 24h after biofilm initiation, respectively. Moreover, CM-chitosan inhibited Candida yeast-to-hyphal transition. CM-chitosan was not only able to inhibit the metabolic activity of biofilms, but also active upon the establishment and development of biofilm. Therefore, CM-chitosan may serve as a possible antibiofilm agent to limit biofilm formation on voice prostheses.

Bio-Inspired Coating Strategies for the Immobilization of Polymyxins to Generate Contact-Killing Surfaces

Microbial colonization of indwelling devices remains a major concern in modern healthcare. Developing approaches to prevent biomaterial-associated infections (BAI) is, therefore, in great demand. This study aimed to immobilize two antimicrobial peptides (polymyxins B and E) onto polydimethylsiloxane (PDMS) using two polydopamine (pDA)-based approaches: the conventional two-step method involving the deposition of a pDA layer to which biomolecules are immobilized, and a one-step method where peptides are dissolved together with dopamine before its polymerization. Surface characterization confirms the immobilization of polymyxins onto PDMS at a non-toxic concentration. Immobilization of polymyxins using a one-step pDA-based approach is able to prevent Pseudomonas aeruginosa adhesion and kill a significant fraction of the adherent ones. Living cells adhered to these modified surfaces exhibit the same susceptibility pattern as cells adhered to unmodified surfaces, highlighting no resistance development. Results suggest that polymyxins immobilization holds a great potential as an additional antimicrobial functionality in the design of biomaterials.

Antibiofilm activity of carboxymethyl chitosan on the biofilms of non-Candida albicans Candida species

Although most cases of candidiasis have been attributed to Candida albicans, non-C. albicans Candida species have been isolated in increasing numbers in patients. In this study, we determined the inhibition of carboxymethyl chitosan (CM-chitosan) on single and mixed species biofilm of non-albicans Candida species, including Candida tropicalis, Candida parapsilosis, Candida krusei and Candida glabrata. Biofilm by all tested species in microtiter plates were inhibited nearly 70%. CM-chitosan inhibited mixed species biofilm in microtiter plates and also on medical materials surfaces. To investigate the mechanism, the effect of CM-chitosan on cell viability and biofilm growth was employed. CM-chitosan inhibited Candida planktonic growth as well as adhesion. Further biofilm formation was inhibited with CM-chitosan added at 90min, 12h or 24h after biofilm initiation. CM-chitosan was not only able to inhibit the metabolic activity of Candida cells, but was also active upon the establishment and the development of biofilms.

Vibratory stimulus reduces in vitro biofilm formation on tracheoesophageal voice prostheses

OBJECTIVES/HYPOTHESIS

Demonstrate that biofilm formation will be reduced on tracheoesophageal prostheses when vibratory stimulus is applied, compared to controls receiving no vibratory stimulus, in a dynamic in vitro model of biofilm accumulation simulating the interface across the tracheoesophageal puncture site.

STUDY DESIGN

Prospective, randomized, controlled, crossover in university laboratory.

METHODS

Ex vivo tracheoesophageal prostheses were obtained from university-affiliated speech language pathologists at Indiana University School of Medicine, Indianapolis. Prostheses demonstrating physical integrity and an absence of gross biofilm accumulation were utilized. Sixteen prostheses were cleansed and sterilized prior to random placement by length in two modified Robbins devices arranged in parallel. Each device was seeded with a polymicrobial oral flora on day 1 and received basal artificial salivary flow continuously with three growth medium meals daily. One device was randomly selected for vibratory stimulus, and 2 minutes of vibration was applied to each prosthesis before and after meals for 5 days. The prostheses were explanted and sonicated, and the biofilm cultured for enumeration. This process was repeated after study arm crossover.

RESULTS

Tracheoesophageal prostheses in the dynamic model receiving vibratory stimulus demonstrated reduced gross biofilm accumulation and a significant biofilm colony forming unit per milliliter reduction of 5.56-fold compared to nonvibratory controls (P < 0.001). Significant reductions were observed within length subgroups.

CONCLUSION

Application of vibratory stimulus around meal times significantly reduces biofilm accumulation on tracheoesophageal prostheses in a dynamic in vitro model. Further research using this vibratory stimulus method in vivo will be required to determine if reduced biofilm accumulation correlates with longer device lifespan.

LEVEL OF EVIDENCE

NA Laryngoscope, 126:2752-2757, 2016.

Pseudomonas aeruginosa biofilm disruption using microbial surfactants

AIMS

To establish the ability of the rhamnolipids biosurfactants from Pseudomonas aeruginosa, in the presence and absence of caprylic acid and ascorbic acid, to disrupt bacterial biofilms, compared with the anionic alkyl sulphate surfactant Sodium dodecyl sulphate (SDS).

METHODS AND RESULTS

Pseudomonas aeruginosa ATCC 15442 biofilms were disrupted by rhamnolipids at concentrations between 0·5 and 0·4 g l(-1) and with SDS at 0·8 g l(-1) . The combination of rhamnolipids 0·4 g l(-1) and caprylic acid at 0·1 g l(-1) showed a remarkable effect on biofilm disruption and cell killing. After 30 min of treatment most of the biofilm was disrupted and cell viability was significantly reduced. Neither caprylic acid nor ascorbic acid has any effect on biofilm disruption at 0·1 g l(-1) . SDS is an effective antimicrobial agent; however, in the presence of caprylic acid its effect was neutralized.

CONCLUSIONS

The results show that rhamnolipids at low concentration in the presence of caprylic acid are promising molecules for inhibition/disruption of biofilms formed by Ps. aeruginosa ATCC 15442.

SIGNIFICANCE AND IMPACT OF THE STUDY

The disruption of biofilms has major significance in many industrial and domestic cleaning applications and in medical situations.

Device Life of Two Generations of Provox Voice Prostheses

Background:

Tracheoesophageal voice prostheses are invaluable for speech rehabilitation in patients who have received total laryngectomy, but device failure impedes communication and creates psychosocial and financial burdens. This study compares the Provox 2 and Provox Vega voice prostheses on the parameter of device life.

Methods:

This was a retrospective observational study of 21 patients with 181 device replacements at an academic tertiary care medical center. Disparity in device life and factors that may influence device life were analyzed.

Results:

The mean device life for Provox 2, at 115.6 days (SE = 5.8), was longer than for Provox Vega, at 65.1 days (SE = 7.5) ( P < .001).

Conclusions:

Device longevity was greater for Provox 2 over Provox Vega. These results will facilitate the design of prospective studies to assess reasons for variations in device life between patients and device types.

Bacterial adherence and biofilm formation on medical implants: a review

Biofilms are a complex group of microbial cells that adhere to the exopolysaccharide matrix present on the surface of medical devices. Biofilm-associated infections in the medical devices pose a serious problem to the public health and adversely affect the function of the device. Medical implants used in oral and orthopedic surgery are fabricated using alloys such as stainless steel and titanium. The biological behavior, such as osseointegration and its antibacterial activity, essentially depends on both the chemical composition and the morphology of the surface of the device. Surface treatment of medical implants by various physical and chemical techniques are attempted in order to improve their surface properties so as to facilitate bio-integration and prevent bacterial adhesion. The potential source of infection of the surrounding tissue and antimicrobial strategies are from bacteria adherent to or in a biofilm on the implant which should prevent both biofilm formation and tissue colonization. This article provides an overview of bacterial biofilm formation and methods adopted for the inhibition of bacterial adhesion on medical implants.

Candida biofilm formation on voice prostheses

Laryngopharyngeal malignancy is treated with radiotherapy and/or surgery. When total laryngectomy is required, major laryngeal functions (phonation, airway control, swallowing and coughing) are affected. The insertion of a silicone rubber voice prosthesis in a surgically created tracheoesophageal puncture is the most effective method for voice rehabilitation. Silicone, as is the case with other synthetic materials such as polymethylmethacrylate, polyurethane, polyvinyl chloride, polypropylene and polystyrene, has the propensity to become rapidly colonized by micro-organisms (mainly Candida albicans) forming a biofilm, which leads to the failure of the devices. Silicone is used within voice prosthetic devices because of its flexible properties, which are essential for valve function. Valve failure, as well as compromising speech, may result in aspiration pneumonia, and repeated valve replacement may lead to either tract stenosis or insufficiency. Prevention and control of biofilm formation are therefore crucial for the lifespan of the prosthesis and promotion of tracheoesophageal tissue and lung health. To date, the mechanisms of biofilm formation on voice prostheses are not fully understood. Further studies are therefore required to identify factors influencing Candida biofilm formation. This review describes the factors known to influence biofilm formation on voice prostheses and current strategies employed to prolong their life by interfering with microbial colonization.

[A review of the complications and candida colonization associated with voice rehabilitation using a voice prosthesis]

Between December 2004 and December 2011, we have used the indwelling voice prosthesis for voice rehabilitation in 28 patients after total laryngectomy in our department. To clarify both the complications and safety of voice reconstruction using a voice prosthesis, and the occurrence of candida colonization, we conducted a retrospective study with a review of the Japanese literature. Twenty-six patients who were observed over a period of more than six months at our hospital were enrolled in this study. We examined the interval of prosthesis replacement, types and frequency of complications, candida colonization, and clinical outcomes. The median follow-up time postoperatively was 28.8 months (range 8.1-95.7). The average interval of prosthesis replacement was 147 days (4.9 months). Complications occurred in 14 patients (54%), and 6 patients (23%) of whom were hospitalized. The main complications were periprosthetic leakage, increased granulation around the tracheoesophageal shunt and stenosis of the trachea stoma. There were no significant differences in the frequency of complications in the background factor of the patients as far as age (p = 0.495), radiation therapy (p = 0.686) or reconstruction time (p = 0.257) were concerned. Candida species was detected in 81% of the specimens which we submitted to a culture test and confirmed the pseudohyphae which comfirmed the pathogenicity from the histopathological examination. Moreover, radiation therapy was significantly associated with the detection of candida (p = 0.004). Permanent closure of the tracheoesophageal shunt for periprosthetic leakage was required in one patient, but we were able to deal with the other complications. No patient experienced any life-threatening complications and all are safely using the prostheses. It has been reported that complications will occur over the long-term, thus careful follow-up is necessary.

Chemical modification of polyvinyl chloride and silicone elastomer in inhibiting adhesion of Aeromonas hydrophila

Disease-causing bacteria of the genus Aeromonas are able to adhere to pipe materials, colonizing the surfaces and forming biofilms in water distribution systems. The aim of our research was to study how the modification of materials used commonly in the water industry can reduce bacterial cell attachment. Polyvinyl chloride and silicone elastomer surfaces were activated and modified with reactive organo-silanes by coupling or co-crosslinking silanes with the native material. Both the native and modified surfaces were tested using the bacterial strain Aeromonas hydrophila, which was isolated from the Polish water distribution system. The surface tension of both the native and modified surfaces was measured. To determine cell viability and bacterial adhesion two methods were used, namely plate count and luminometry. Results were expressed in colony-forming units (c.f.u.) and in relative light units (RLU) per cm(2). Almost all the chemically modified surfaces exhibited higher anti-adhesive and anti-microbial properties in comparison to the native surfaces. Among the modifying agents examined, poly[dimethylsiloxane-co-(N,N-dimethyl-N-n-octylammoniopropyl chloride) methylsiloxane)] terminated with hydroxydimethylsilyl groups (20 %) in silicone elastomer gave the most desirable results. The surface tension of this modifier, was comparable to the non-polar native surface. However, almost half of this value was due to the result of polar forces. In this case, in an adhesion analysis, only 1 RLU cm(-2) and less than 1 c.f.u. cm(-2) were noted. For the native gumosil, the results were 9,375 RLU cm(-2) and 2.5 × 10(8) c.f.u. cm(-2), respectively. The antibacterial activity of active organo-silanes was associated only with the carrier surface because no antibacterial compounds were detected in liquid culture media, in concentrations that were able to inhibit cell growth.

A comparison of effects of broad-spectrum antibiotics and biosurfactants on established bacterial biofilms

Current antibiofilm solutions based on planktonic bacterial physiology have limited efficacy in clinical and occasionally environmental settings. This has prompted a search for suitable alternatives to conventional therapies. This study compares the inhibitory properties of two biological surfactants (rhamnolipids and a plant-derived surfactant) against a selection of broad-spectrum antibiotics (ampicillin, chloramphenicol and kanamycin). Testing was carried out on a range of bacterial physiologies from planktonic and mixed bacterial biofilms. Rhamnolipids (Rhs) have been extensively characterised for their role in the development of biofilms and inhibition of planktonic bacteria. However, there are limited direct comparisons with antimicrobial substances on established biofilms comprising single or mixed bacterial strains. Baseline measurements of inhibitory activity using planktonic bacterial assays established that broad-spectrum antibiotics were 500 times more effective at inhibiting bacterial growth than either Rhs or plant surfactants. Conversely, Rhs and plant biosurfactants reduced biofilm biomass of established single bacterial biofilms by 74-88 and 74-98 %, respectively. Only kanamycin showed activity against biofilms of Bacillus subtilis and Staphylococcus aureus. Broad-spectrum antibiotics were also ineffective against a complex biofilm of marine bacteria; however, Rhs and plant biosurfactants reduced biofilm biomass by 69 and 42 %, respectively. These data suggest that Rhs and plant-derived surfactants may have an important role in the inhibition of complex biofilms.

Yeast Colonization of Voice Prostheses: Pilot Study Investigating Effect of a Bovine Milk Product Containing Anti—Candida Albicans Immunoglobulin A Antibodies on Yeast Colonization and Valve Leakage

Objectives:

Our goals were to determine whether a bovine milk product containing anti– Candida albicans immunoglobulin A antibodies (“immune milk”) could reduce the adherence of C albicans to voice prosthesis silicone in vitro, and whether administration of the milk could reduce C albicans colonization and voice prosthesis damage in vivo.

Methods:

An in vitro assay of C albicans attachment to silicone was developed with radiolabeled C albicans. A pilot crossover in vivo trial, over 3 periods of 3 months, was also undertaken for 4 patients with voice prostheses, comparing daily administrations of immune milk and a control milk product. The prosthesis valves were replaced at each change-over and were assessed for wet weight of removable biofilm, yeast numbers in removable biofilm, valve leakage, and valve damage.

Results:

Immune milk inhibited C albicans adherence to silicone in vitro. However, in a small clinical pilot study, this effect was not replicated.

Conclusions:

There is scope to further investigate the topical use of immune milk for management of voice prosthesis biofilms.

Inhibition of bacterial adhesion on medical devices

Microbial infections resulting from bacterial adhesion to biomaterial surfaces have been observed on almost all medical devices. Biofilm infections pose a number of clinical challenges due to their resistance to immune defence mechanisms and antimicrobials, and, regardless of the sophistication of the implant, all medical devices are susceptible to microbial colonisation and infection. Research efforts are currently directed towards eliminating or reducing infection of medical devices. Strategies to prevent biofilm formation include physiochemical modification of the biomaterial surface to create anti-adhesive surfaces, incorporation of antimicrobial agents into medical device polymers, mechanical design alternatives, and release of antibiotics. Nevertheless, the success of these alternatives has been modest, mainly due to the various environments into which devices are placed and the diversity of ways in which organisms can colonise surfaces. Biosurfactants have been reported as a promising strategy as they effectively inhibit bacterial adhesion and retard biofilm formation, and are thus potentially useful as a new generation of anti-adhesive and antimicrobial coatings for medical devices.

Biofilms on tracheoesophageal voice prostheses: a confocal laser scanning microscopy demonstration of mixed bacterial and yeast biofilms

The aim of this study was to demonstrate the presence of yeast and bacterial biofilms on the surface of tracheoesophageal voice prostheses (TVPs) by a double-staining technique with confocal laser scanning microscopy (CLSM). Biofilms of 12 removed TVPs were visualized by scanning electron microscopy, then stained with ConA-FITC and propidium iodide for CLSM. Microbial identification was by partial 16S rRNA gene analysis and ITS-2 sequence analysis. Microbial biofilms on the TVPs consisted of bacteria and filamentous cells. Bacterial cells were attached to the filamentous and unicellular yeast cells, thus forming a network. Sequence analyses of six voice prostheses identified the presence of a variety of bacterial and yeast species. In vivo studies showed that Klebsiella oxytoca and Micrococcus luteus efficiently attached to Candida albicans. CLSM with double fluorescence staining can be used to demonstrate biofilm formations composed of a mixture of yeast and bacterial cells on the surface of TVPs.