Comparison of quantification methods illustrates reduced Pseudomonas aeruginosa activity on nanorough polyvinyl chloride

Antimicrobial Solutions for Endotracheal Tubes in Prevention of Ventilator-Associated Pneumonia

Ventilator-associated pneumonia is one of the most frequently encountered hospital infections and is an essential issue in the healthcare field. It is usually linked to a high mortality rate and prolonged hospitalization time. There is a lack of treatment, so alternative solutions must be continuously sought. The endotracheal tube is an indwelling device that is a significant culprit for ventilator-associated pneumonia because its surface can be colonized by different types of pathogens, which generate a multispecies biofilm. In the paper, we discuss the definition of ventilator-associated pneumonia, the economic burdens, and its outcomes. Then, we present the latest technological solutions for endotracheal tube surfaces, such as active antimicrobial coatings, passive coatings, and combinatorial methods, with examples from the literature. We end our analysis by identifying the gaps existing in the present research and investigating future possibilities that can decrease ventilator-associated pneumonia cases and improve patient comfort during treatment.

Antimicrobial materials for endotracheal tubes: A review on the last two decades of technological progress

Ventilator-associated pneumonia (VAP) is an unresolved problem in nosocomial settings, remaining consistently associated with a lack of treatment, high mortality, and prolonged hospital stay. The endotracheal tube (ETT) is the major culprit for VAP development owing to its early surface microbial colonization and biofilm formation by multiple pathogens, both critical events for VAP pathogenesis and relapses. To combat this matter, gradual research on antimicrobial ETT surface coating/modification approaches has been made. This review provides an overview of the relevance and implications of the ETT bioburden for VAP pathogenesis and how technological research on antimicrobial materials for ETTs has evolved. Firstly, certain main VAP attributes (definition/categorization; outcomes; economic impact) were outlined, highlighting the issues in defining/diagnosing VAP that often difficult VAP early- and late-onset differentiation, and that generate misinterpretations in VAP surveillance and discrepant outcomes. The central role of the ETT microbial colonization and subsequent biofilm formation as fundamental contributors to VAP pathogenesis was then underscored, in parallel with the uncovering of the polymicrobial ecosystem of VAP-related infections. Secondly, the latest technological developments (reported since 2002) on materials able to endow the ETT surface with active antimicrobial and/or passive antifouling properties were annotated, being further subject to critical scrutiny concerning their potentialities and/or constraints in reducing ETT bioburden and the risk of VAP while retaining/improving the safety of use. Taking those gaps/challenges into consideration, we discussed potential avenues that may assist upcoming advances in the field to tackle VAP rampant rates and improve patient care. STATEMENT OF SIGNIFICANCE: The use of the endotracheal tube (ETT) in patients requiring mechanical ventilation is associated with the development of ventilator-associated pneumonia (VAP). Its rapid surface colonization and biofilm formation are critical events for VAP pathogenesis and relapses. This review provides a comprehensive overview on the relevance/implications of the ETT biofilm in VAP, and on how research on antimicrobial ETT surface coating/modification technology has evolved over the last two decades. Despite significant technological advances, the limited number of gathered reports (46), highlights difficulty in overcoming certain hurdles associated with VAP (e.g., persistent colonization/biofilm formation; mechanical ventilation duration; hospital length of stay; VAP occurrence), which makes this an evolving, complex, and challenging matter. Challenges and opportunities in the field are discussed.

Antimicrobial Coating: Tracheal Tube Application

Ventilator-associated pneumonia (VAP) is a common and serious nosocomial infection in mechanically ventilated patients, increasing mortality, prolonging the patient length of stay, and increasing costs. In recent years, extensive studies on ventilator-associated pneumonia have shown that tracheal intubation plays an essential role in the pathogenesis of VAP, with the primary mechanism being the rapid colonization of the tracheal intubation surface by microbiota. Antibiotics do not combat microbial airway colonization, and antimicrobial coating materials offer new ideas to solve this problem. This paper reviews the current research progress on the role of endotracheal tube (ET) biofilms in the pathogenesis of VAP and antimicrobial coating materials.

Effects of different sterilization methods on surface characteristics and biofilm formation on zirconia in vitro

OBJECTIVE

The current laboratory study was to investigate the effect of different sterilization treatments on surface characteristics of zirconia, and biofilm formation on zirconia surface after exposure to these sterilization treatments.

METHODS

Commercially available zirconia discs (Cerconbase, Degu-Dent, Hanau, Germany) were prepared and polished to the same value of surface roughness. The discs were treated with one of the following sterilization methods steam autoclave sterilization, dry heat sterilization, ultraviolet C (UVC) irradiation, and gamma (γ) ray irradiation. The characteristics of zirconia surfaces were evaluated by scanning electron microscopy (SEM), surface roughness, surface free energy (SFE), X-ray photoelectron spectroscopy (XPS), and X-ray diffraction (XRD) measurements. Then, Staphylococcus aureus (S.a.) and Porphyromonas gingivalis (P.g.) bacteria were used and cultured on the respective sterilized zirconia surfaces. The amount of biofilm formation on zirconia surface was quantified by colony forming unit (CFU) counts.

RESULTS

Significant modifications were detected on the colour and SFE of zirconia. The colour of zirconia samples after UVC irradiation became light yellow whilst dark brown colour was observed after gamma ray irradiation. Moreover, UVC and gamma ray irradiation increased the hydrophilicity of zirconia surface. Overall, dry heat sterilized samples showed the significantly lowest amount of bacteria growth on zirconia, while UVC and gamma ray irradiation resulted in the highest.

SIGNIFICANCE

It is evident that various sterilization methods could change the surface which contribute to different biofilm formation and colour on zirconia.

Lipase degradation of plasticized polyvinyl chloride endotracheal tube surfaces to create nanoscale features

Polyvinyl chloride (PVC) endotracheal tubes (ETTs) nanoetched with a fungal lipase have been shown to reduce bacterial growth and biofilm formation and could be an inexpensive solution to the complex problem of ventilator-associated pneumonia (VAP). Although bacterial growth and colonization on these nanoetched materials have been well characterized, little is known about the mechanism by which the fungal lipase degrades the PVC and, thus, alters its properties to minimize bacteria functions. This study used X-ray photoelectron spectroscopy (XPS) and attenuated total reflectance Fourier transform infrared spectroscopy (ATR-FTIR) to better describe the surface chemistry of both unetched and lipase nanoetched PVC ETT. ATR-FTIR analysis of the unetched and treated surfaces showed a similar presence of a plasticizer. This was confirmed by XPS analysis, which showed an increase of carbon and the presence of oxygen on both unetched and nanoetched surfaces. A quantitative comparison of the FTIR spectra revealed significant correlations (Pearson’s correlation, R=0.997 [R²=0.994, P<0.001]) between the unetched and nanomodified PVC ETT spectra, demonstrating similar surface chemistry. This analysis showed no shifting or widening of the bands in the spectra and no significant changes in the intensity of the infrared peaks due to the degradation of the plasticizer by the fungal lipase. In contrast, results from this study did demonstrate significantly increased nanoscale surface features on the lipase etched compared to non-etched PVC ETTs. This led to a change in surface energetics, which altered ion adsorption to the ETTs. Thus, these results showed that PVC surfaces nanoetched with a 0.1% lipase solution for 48 hours have no significant change on surface chemistry but do significantly increase nanoscale surface roughness and alters ion adsorption, which suggests that the unique properties of these materials, including their previously reported ability to decrease bacterial adhesion and growth, are due to the changes in the degree of the nanoscale roughness, not changes in their surface chemistry.

SEM Analysis of Surface Impact on Biofilm Antibiotic Treatment

The aim of this work was to use scanning electron microscopy (SEM) to investigate the effect of ampicillin treatment on Escherichia coli biofilms formed on two surface materials with different properties, silicone (SIL) and glass (GLA). Epifluorescence microscopy (EM) was initially used to assess biofilm formation and killing efficiency on both surfaces. This technique showed that higher bacterial colonization was obtained in the hydrophobic SIL than in the hydrophilic GLA. It has also shown that higher biofilm inactivation was attained for GLA after the antibiotic treatment (7-log reduction versus 1-log reduction for SIL). Due to its high resolution and magnification, SEM enabled a more detailed analysis of the antibiotic effect on biofilm cells, complementing the killing efficiency information obtained by EM. SEM micrographs revealed that ampicillin-treated cells have an elongated form when compared to untreated cells. Additionally, it has shown that different materials induced different levels of elongation on cells exposed to antibiotic. Biofilms formed on GLA showed a 37% higher elongation than those formed on SIL. Importantly, cell elongation was related to viability since ampicillin had a higher bactericidal effect on GLA-formed biofilms. These findings raise the possibility of using SEM for understanding the efficacy of antimicrobial treatments by observation of biofilm morphology.

Decreased Pseudomonas aeruginosa biofilm formation on nanomodified endotracheal tubes: a dynamic lung model

Ventilator-associated pneumonia (VAP) is a serious complication of mechanical ventilation that has been shown to be associated with increased mortality rates and medical costs in the pediatric intensive care unit. Currently, there is no cost-effective solution to the problems posed by VAP. Endotracheal tubes (ETTs) that are resistant to bacterial colonization and that inhibit biofilm formation could provide a novel solution to the problems posed by VAP. The objective of this in vitro study was to evaluate differences in the growth of Pseudomonas aeruginosa on unmodified polyvinyl chloride (PVC) ETTs and on ETTs etched with a fungal lipase, Rhizopus arrhizus, to create nanoscale surface features. These differences were evaluated using an in vitro model of the pediatric airway to simulate a ventilated patient in the pediatric intensive care unit. Each experiment was run for 24 hours and was supported by computational models of the ETT. Dynamic conditions within the ETT had an impact on the location of bacterial growth within the tube. These conditions also quantitatively affected bacterial growth especially within the areas of tube curvature. Most importantly, experiments in the in vitro model revealed a 2.7 log reduction in the number (colony forming units/mL) of P. aeruginosa on the nanoroughened ETTs compared to the untreated PVC ETTs after 24 hours. This reduction in total colony forming units/mL along the x-axis of the tube was similar to previous studies completed for Staphylococcus aureus. Thus, this dynamic study showed that lipase etching can create surface features of nanoscale roughness on PVC ETTs that decrease bacterial attachment of P. aeruginosa without the use of antibiotics and may provide clinicians with an effective and inexpensive tool to combat VAP.

The potential role of nano- and micro-technology in the management of critical illnesses

In recent years nanomedicine has become an attractive concept for the targeted delivery of therapeutic and diagnostic compounds to injured or inflamed organs. Nanoscale drug delivery systems have the ability to improve the pharmacokinetics and increase the biodistribution of therapeutic agents to target organs, thereby resulting in improved efficacy and reduced drug toxicity. These systems are exploited for therapeutic purposes to carry the drug in the body in a controlled manner from the site of administration to the therapeutic target. The mortality in many of the critical illnesses such as sepsis and acute respiratory distress syndrome continues to remain high despite of an increased understanding of the molecular pathogenesis of these diseases. Several promising targets that have been identified as potential therapies for these devastating diseases have been limited because of difficulty with delivery systems. In particular, delivery of peptides, proteins, and miRNAs to the lung is an ongoing challenge. Hence, it is an attractive strategy to test potential targets by employing nanotechnology. Here some of the novel nanomedicine approaches that have been proposed and studied in recent years to facilitate the delivery of therapeutic agents in the setting of critical illnesses such as acute respiratory distress syndrome, sepsis and ventilator associated pneumonia are reviewed.

Escherichia coli adhesion, biofilm development and antibiotic susceptibility on biomedical materials

The aim of this work was to test materials typically used in the construction of medical devices regarding their influence in the initial adhesion, biofilm development and antibiotic susceptibility of Escherichia coli biofilms. Adhesion and biofilm development was monitored in 12-well microtiter plates containing coupons of different biomedical materials--silicone (SIL), stainless steel (SS) and polyvinyl chloride (PVC)--and glass (GLA) as control. The susceptibility of biofilms to ciprofloxacin and ampicillin was assessed, and the antibiotic effect in cell morphology was observed by scanning electron microscopy. The surface hydrophobicity of the bacterial strain and materials was also evaluated from contact angle measurements. Surface hydrophobicity was related with initial E. coli adhesion and subsequent biofilm development. Hydrophobic materials, such as SIL, SS, and PVC, showed higher bacterial colonization than the hydrophilic GLA. Silicone was the surface with the greatest number of adhered cells and the biofilms formed on this material were also less susceptible to both antibiotics. It was found that different antibiotics induced different levels of elongation on E. coli sessile cells. Results revealed that, by affecting the initial adhesion, the surface properties of a given material can modulate biofilm buildup and interfere with the outcome of antimicrobial therapy. These findings raise the possibility of fine-tuning surface properties as a strategy to reach higher therapeutic efficacy.

Multi-scale strategy to eradicate Pseudomonas aeruginosa on surfaces using solid lipid nanoparticles loaded with free fatty acids

Infections are both frequent and costly in hospitals around the world, leading to longer hospital stays, overuse of antibiotics, and excessive costs to the healthcare system. Moreover, antibiotic resistant organisms, such as Pseudomonas aeruginosa are increasing in frequency, leading to 1.7 million infections per year in USA hospitals, and 99,000 deaths, both due to the evolution of antibiotic resistance and the formation of biofilms on medical devices. In particular, respiratory infections are costly, deadly to 4.5 million persons per year worldwide, and can spread to the lungs through the placement of endotracheal tubing. In this study, towards a reduction in infections, solid lipid nanoparticles were formulated from free fatty acids, or natural lipophilic constituents found in tissues of the body. A strategy was developed to target infections by producing coatings made of non-toxic chemistries lauric acid and oleic acid delivered by core-shell solid lipid nanoparticles that act against bacteria by multiple mechanisms at the nanoscale, including disruption of bacteria leading to DNA release, and reducing the adhesion of dead bacteria to ~1%. This is the first such study to explore an anti-infection surface relying on these multi-tier strategies at the nanoscale.

Activities of tobramycin and polymyxin E against Pseudomonas aeruginosa biofilm-coated medical grade endotracheal tubes

Indwelling medical devices have become a major source of nosocomial infections, especially Pseudomonas aeruginosa infections, which remain the most common cause of ventilator-associated pneumonia (VAP) in neonates and children. Using medical grade polyvinyl chloride endotracheal tubes (ETTs), the activity of tobramycin and polymyxin E was quantified in a simulated prevention and treatment static time-kill model using biofilm-forming P. aeruginosa. The model simulated three clinical conditions: (i) planktonic bacteria grown in the presence of antibiotics (tobramycin and polymyxin E) without ETTs, (ii) planktonic bacteria grown in the presence of P. aeruginosa, antibiotic, and ETTs (simulating prevention), and (iii) a 24-h-formed P. aeruginosa biofilm grown on ETTs prior to antibiotic exposure (simulating treatment). In the model simulating "prevention" (conditions 1 and 2 above), tobramycin alone or in combination with polymyxin E was more bactericidal than polymyxin E alone at 24 h using a concentration of greater than 2 times the MIC. However, after a 24-h-old biofilm was allowed to form on the ETTs, neither monotherapy nor combination therapy over 24 h exhibited bactericidal or bacteriostatic effects. Against the same pathogens, tobramycin and polymyxin E, alone or in combination, exhibited bactericidal activity prior to biofilm attachment to the ETTs; however, no activity was observed once biofilm formed on ETTs. These findings support surveillance culturing to identify pathogens for a rapid and targeted approach to therapy, especially when P. aeruginosa is a potential pathogen.

Reduced adhesion of Staphylococcus aureus to ZnO/PVC nanocomposites

In hospitals and clinics worldwide, medical device surfaces have become a rapidly growing source of nosocomial infections. In particular, patients requiring mechanical ventilation (and, thus, intubation with an endotracheal tube) for extended lengths of time are faced with a high probability of contracting ventilator-associated pneumonia. Once inserted into the body, the endotracheal tube provides a surface to which bacteria can adhere and form a biofilm (a robust, sticky matrix that provides protection against the host immune system and antibiotic treatment). Adding to the severity of this problem is the spread of bacterial genetic tolerance to antibiotics, in part demonstrated by the recent and significant increase in the prevalence of methicillin-resistant Staphylococcus aureus. To combat these trends, different techniques in biomaterial design must be explored. Recent research has shown that nanomaterials (materials with at least one dimension less than 100 nm) may have the potential to prevent or disrupt bacterial processes that lead to infections. In this study, polyvinyl chloride (PVC) taken from a conventional endotracheal tube was embedded with varying concentrations of zinc oxide (ZnO) nanoparticles. S. aureus biofilms were then grown on these nanocomposite surfaces during a 24-hour culture. Following this, biofilms were removed from the surfaces and the number of colony forming units present was assessed. Bacterial proliferation on the samples embedded with the highest concentration of ZnO nanoparticles was 87% less when compared to the control, indicating that this technique is effective at reducing biofilm formation on PVC surfaces without the use of antibiotics.

Effects of different sterilization techniques and varying anodized TiO₂ nanotube dimensions on bacteria growth

Infection of titanium (Ti)-based orthopedic implants is a growing problem due to the ability of bacteria to develop a resistance to today's antibiotics. As an attempt to develop a new strategy to combat bacteria functions, Ti was anodized in the present study to possess different diameters of nanotubes. It is reported here for the first time that Ti anodized to possess 20 nm tubes then followed by heat treatment to remove fluorine deposited from the HF anodization electrolyte solution significantly reduced both S. aureus and S. epidermidis growth compared to unanodized Ti controls. It was further found that the sterilization method used for both anodized nanotubular Ti and conventional Ti played an important role in the degree of bacteria growth on these substrates. Overall, UV light and ethanol sterilized samples decreased bacteria growth, while autoclaving resulted in the highest amount of bacteria growth. In summary, this study indicated that through a simple and inexpensive process, Ti can be anodized to possess 20 nm tubes that no matter how sterilized (UV light, ethanol soaking, or autoclaving) reduces bacteria growth and, thus, shows great promise as an antibacterial implant material.

Decreased Staphylococcus aureus biofilm formation on nanomodified endotracheal tubes: a dynamic airway model

Ventilator-associated pneumonia (VAP) is a serious and costly clinical problem. Specifically, receiving mechanical ventilation for over 24 hours increases the risk of VAP and is associated with high morbidity, mortality, and medical costs. Cost-effective endotracheal tubes (ETTs) that are resistant to bacterial infections could help prevent this problem. The objective of this study was to determine differences in the growth of Staphylococcus aureus on nanomodified and unmodified polyvinyl chloride (PVC) ETTs under dynamic airway conditions simulating a ventilated patient. PVC ETTs were modified to have nanometer surface features by soaking them in Rhizopus arrhisus, a fungal lipase. Twenty-four-hour experiments (supported by computational models) showed that airflow conditions within the ETT influenced both the location and the concentration of bacterial growth on the ETTs, especially within areas of tube curvature. More importantly, experiments revealed a 1.5 log reduction in the total number of S. aureus on the novel nanomodified ETTs compared with the conventional ETTs after 24 hours of airflow. This dynamic study showed that lipase etching can create nanorough surface features on PVC ETTs that suppress S. aureus growth, and thus may provide clinicians with an effective and inexpensive tool to combat VAP.

Superhydrophobic, nanotextured polyvinyl chloride films for delaying Pseudomonas aeruginosa attachment to intubation tubes and medical plastics

Bacterial attachment onto the surface of polymers in medical devices such as polyvinyl chloride (PVC) is influenced by the physicochemical properties of the polymer, including its surface hydrophobicity and roughness. In this study, to prevent biofilm formation onto PVC devices, the PVC surface was modified using a combination of solvent (tetrahydrofuran) and non-solvents (i.e. ethanol and methanol). The surface of unmodified PVC was smooth and relatively hydrophobic (water contact angle (CA)=80°). Ethanol-treated PVCs revealed the presence of micron-sized particulates and porous structures as the concentration of ethanol was increased. Surface hydrophobicity (measured in terms of CA) increased from 73° to 150° as the ethanol concentration increased from 15% to 35% (v/v). In general, methanol-treated PVCs were more hydrophilic compared to those treated with ethanol. The colonization of Pseudomonas aeruginosa PAO1 onto unmodified PVC surface was rapid, and individual bacterial cells could be seen after 6h incubation. On the surface of treated PVC, the secretion of extracellular matrix layers was evident at 18 h and P. aeruginosa PAO1 start to form microcolonies at 24h of incubation. The initial attachment of P. aeruginosa PAO1 was delayed to 18 and 24h, respectively in the PVCs treated with 25% (v/v) and 35% (v/v) ethanol. It can be concluded that the treatment used in this study to prepare superhydrophobic PVC surface prevented the colonization of bacteria up to 24h after culture.

Fructose-enhanced reduction of bacterial growth on nanorough surfaces

Patients on mechanical ventilators for extended periods of time often face the risk of developing ventilator-associated pneumonia. During the ventilation process, patients incapable of breathing are intubated with polyvinyl chloride (PVC) endotracheal tubes (ETTs). PVC ETTs provide surfaces where bacteria can attach and proliferate from the contaminated oropharyngeal space to the sterile bronchoalveolar area. To overcome this problem, ETTs can be coated with antimicrobial agents. However, such coatings may easily delaminate during use. Recently, it has been shown that changes in material topography at the nanometer level can provide antibacterial properties. In addition, some metabolites, such as fructose, have been found to increase the efficiency of antibiotics used to treat Staphylococcus aureus (S. aureus) infections. In this study, we combined the antibacterial effect of nanorough ETT topographies with sugar metabolites to decrease bacterial growth and biofilm formation on ETTs. We present for the first time that the presence of fructose on the nanorough surfaces decreases the number of planktonic S. aureus bacteria in the solution and biofilm formation on the surface after 24 hours. We thus envision that this method has the potential to impact the future of surface engineering of biomaterials leading to more successful clinical outcomes in terms of longer ETT lifetimes, minimized infections, and decreased antibiotic usage; all of which can decrease the presence of antibiotic resistant bacteria in the clinical setting.