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Miar S, Gonzales G, Dion G, Ong JL, Malka R, Bizios R, Branski RC, Guda T. Electrospun composite-coated endotracheal tubes with controlled siRNA and drug delivery to lubricate and minimize upper airway injury. Biomaterials 2024; 309:122602. [PMID: 38768544 DOI: 10.1016/j.biomaterials.2024.122602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 04/25/2024] [Accepted: 05/02/2024] [Indexed: 05/22/2024]
Abstract
Endotracheal Tubes (ETTs) maintain and secure a patent airway; however, prolonged intubation often results in unintended injury to the mucosal epithelium and inflammatory sequelae which complicate recovery. ETT design and materials used have yet to adapt to address intubation associated complications. In this study, a composite coating of electrospun polycaprolactone (PCL) fibers embedded in a four-arm polyethylene glycol acrylate matrix (4APEGA) is developed to transform the ETT from a mechanical device to a dual-purpose device capable of delivering multiple therapeutics while preserving coating integrity. Further, the composite coating system (PCL-4APEGA) is capable of sustained delivery of dexamethasone from the PCL phase and small interfering RNA (siRNA) containing polyplexes from the 4APEGA phase. The siRNA is released rapidly and targets smad3 for immediate reduction in pro-fibrotic transforming growth factor-beta 1 (TGFϐ1) signaling in the upper airway mucosa as well as suppressing long-term sequelae in inflammation from prolonged intubation. A bioreactor was used to study mucosal adhesion to the composite PCL-4APEGA coated ETTs and investigate continued mucus secretory function in ex vivo epithelial samples. The addition of the 4APEGA coating and siRNA delivery to the dexamethasone delivery was then evaluated in a swine model of intubation injury and observed to restore mechanical function of the vocal folds and maintain epithelial thickness when observed over 14 days of intubation. This study demonstrated that increase in surface lubrication paired with surface stiffness reduction significantly decreased fibrotic behavior while reducing epithelial adhesion and abrasion.
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Affiliation(s)
- Solaleh Miar
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, USA; Department of Civil, Environmental, and Biomedical Engineering, University of Hartford, West Hartford, CT, USA.
| | - Gabriela Gonzales
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, USA.
| | - Gregory Dion
- Department of Otolaryngology-Head and Neck Surgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Joo L Ong
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, USA.
| | - Ronit Malka
- Department of Otolaryngology - Head and Neck Surgery, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA.
| | - Rena Bizios
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, USA.
| | - Ryan C Branski
- Departments of Rehabilitation Medicine and Otolaryngology-Head and Neck Surgery, NYU Grossman School of Medicine, New York, NY, USA.
| | - Teja Guda
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, USA; Department of Cell Systems and Anatomy, University of Texas Health San Antonio, San Antonio, TX, USA.
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Gonzales G, Malka R, Marinelli L, Lee CM, Miar S, Cook S, Dion GR, Guda T. Endotracheal tubes with dexamethasone eluting electrospun coating improve tissue mechanical function after upper airway injury. Sci Rep 2024; 14:2821. [PMID: 38308093 PMCID: PMC10837152 DOI: 10.1038/s41598-024-53328-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 01/31/2024] [Indexed: 02/04/2024] Open
Abstract
Corticosteroid-eluting endotracheal tubes (ETTs) were developed and employed in a swine laryngotracheal injury model to maintain airway patency and provide localized drug delivery to inhibit fibrotic scarring. Polycaprolactone (PCL) fibers with or without dexamethasone were electrospun onto the ETT surface PCL-only coated ETTs and placed in native airways of 18 Yorkshire swine. Regular and dexamethasone-PCL coated ETTs were placed in airways of another 18 swine injured by inner laryngeal mucosal abrasion. All groups were evaluated after 3, 7 and 14 days (n = 3/treatment/time). Larynges were bisected and localized stiffness determined by normal indentation, then sequentially matched with histological assessment. In the native airway, tissue stiffness with PCL-only ETT placement increased significantly from 3 to 7 days (p = 0.0016) and 3 to 14 days (p < 0.0001) while dexamethasone-PCL ETT placement resulted in stiffness decreasing from 7 to 14 days (p = 0.031). In the injured airway, localized stiffness at 14 days was significantly greater after regular ETT placement (23.1 ± 0.725 N/m) versus dexamethasone-PCL ETTs (17.10 ± 0.930 N/m, p < 0.0001). Dexamethasone-loaded ETTs were found to reduce laryngotracheal tissue stiffening after simulated intubation injury compared to regular ETTs, supported by a trend of reduced collagen in the basement membrane in injured swine over time. Findings suggest localized corticosteroid delivery allows for tissue stiffness control and potential use as an approach for prevention and treatment of scarring caused by intubation injury.
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Affiliation(s)
- Gabriela Gonzales
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
| | - Ronit Malka
- Department of Otolaryngology - Head and Neck Surgery, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Lisa Marinelli
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Christine M Lee
- Department of Pathology and Area Laboratory Services, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Solaleh Miar
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA
- Department of Civil, Environmental, and Biomedical Engineering, University of Hartford, West Hartford, CT, 06117, USA
| | - Stacy Cook
- Department of Otolaryngology - Head and Neck Surgery, Brooke Army Medical Center, JBSA, Fort Sam Houston, TX, 78234, USA
| | - Gregory R Dion
- Department of Otolaryngology - Head and Neck Surgery, University of Cincinnati College of Medicine, University of Cincinnati Medical Center, 231 Albert Sabin Way, Cincinnati, OH, 45267, USA.
| | - Teja Guda
- Department of Biomedical Engineering and Chemical Engineering, The University of Texas at San Antonio, 1 UTSA Circle, San Antonio, TX, 78249, USA.
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Ni BY, Jin HP, Wu W. Therapeutic effects of deep pharyngeal electrical stimulation combined with modified masako maneuver on aspiration in patients with stroke. NeuroRehabilitation 2024; 54:391-398. [PMID: 38607771 DOI: 10.3233/nre-240005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/14/2024]
Abstract
BACKGROUND Stroke patients often experience difficulty swallowing. OBJECTIVE To assist in the improvement of dysphagia symptoms by introducing a novel approach to the treatment of patients with post-stroke aspiration. METHODS A total of 60 patients with post-stroke aspiration were enrolled and divided into an experimental group (n = 30) and a control group (n = 30). The control group received standard treatment, sham intraoral stimulation, and the Masako maneuver, while the experimental group was administered standard treatment, deep pharyngeal electrical stimulation (DPES), and a modified Masako maneuver. Changes in their Functional Oral Intake Scale (FOIS) and Rosenbek scale scores were observed. RESULTS The FOIS scores of both groups increased significantly after treatment (p < 0.01, respectively). The Rosenbek scale scores of both groups decreased significantly after treatment, with the experimental group scoring significantly lower than the control group (1.01±0.09 vs. 2.30±0.82) (p < 0.05). After treatment, the overall response rate in the experimental group (93.33%) was significantly higher than that in the control group (83.33%) (p < 0.001). CONCLUSION In terms of effectively improving dysphagia in aspiration patients after stroke, DPES combined with modified Masako maneuver is clinically recommended.
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Affiliation(s)
- Bo-Ye Ni
- Department of Rehabilitation, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hua-Ping Jin
- Department of Rehabilitation, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Wei Wu
- Department of Rehabilitation, The First Affiliated Hospital of Soochow University, Suzhou, China
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Meng X, Xiong H, Ji F, Gao X, Han L, Wu Z, Jia L, Ren J. Facile surface treatment strategy to generate dense lysozyme layer on ultra-high molecular weight polyethylene enabling inhibition of bacterial biofilm formation. Colloids Surf B Biointerfaces 2023; 225:113243. [PMID: 36893665 DOI: 10.1016/j.colsurfb.2023.113243] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 02/14/2023] [Accepted: 03/03/2023] [Indexed: 03/07/2023]
Abstract
Medical plastics such as those found in endotracheal tubes are widely used in intensive care units for the treatment of critically ill patients. Although commonplace in hospital environment, these catheters are at a high risk of bacterial contamination and have been found responsible for numerous health-care-associated infections. Antimicrobial coatings that can prevent harmful bacterial growth are required to reduce the occurrence of such infections. In this study, we introduce a facile surface treatment strategy that could form antimicrobial coatings on the surface of average medical plastics. The strategy involves treatment of activated surfaces with lysozyme, a natural antimicrobial enzyme presenting in human lacrimal gland secretions which is widely used for wound healing. Using ultra-high molecular weight polyethylene (UHMWPE) as the representative surface, oxygen/argon plasma treatment for 3 min led to the increase of surface roughness and the generation of negatively charged groups, with the zeta potential measured as -94.5 mV at pH 7. The activated surface could accommodate lysozyme with a density of up to 0.3 nmol/cm2 through electrostatic interaction. Antimicrobial activity of the resulting surface (UHMWPE@Lyz) was characterized with Escherichia coli and Pseudomonas sp. strains, and the treated surface significantly inhibited the bacterial colonization and the formation of biofilm compared to the untreated UHMWPE. This method of constructing an effective lysozyme-based antimicrobial coating is a generally applicable, simple and fast process for surface treatment with no adverse solvent and wastes involved.
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Affiliation(s)
- Xiao Meng
- Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116023, PR China
| | - Hao Xiong
- Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116023, PR China
| | - Fangling Ji
- Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116023, PR China
| | - Xiaorong Gao
- Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116023, PR China
| | - Lulu Han
- Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116023, PR China
| | - Zhenlin Wu
- School of Optoelectronic Engineering and Instrumentation Science, Dalian University of Technology, Dalian 116023, PR China
| | - Lingyun Jia
- Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116023, PR China
| | - Jun Ren
- Liaoning Key Laboratory of Molecular Recognition and Imaging, School of Bioengineering, Dalian University of Technology, Dalian 116023, PR China.
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Alves D, Grainha T, Pereira MO, Lopes SP. Antimicrobial materials for endotracheal tubes: A review on the last two decades of technological progress. Acta Biomater 2023; 158:32-55. [PMID: 36632877 DOI: 10.1016/j.actbio.2023.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 12/21/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
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.
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Affiliation(s)
- Diana Alves
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
| | - Tânia Grainha
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
| | - Maria Olívia Pereira
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
| | - Susana Patrícia Lopes
- CEB - Centre of Biological Engineering, University of Minho, 4710-057 Braga, Portugal; LABBELS - Associate Laboratory, Braga/Guimarães, Portugal.
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Yadav D, Wairagu PM, Kwak M, Jin JO, Jin JO. Nanoparticle-Based Inhalation Therapy for Pulmonary Diseases. Curr Drug Metab 2022; 23:882-896. [PMID: 35927812 DOI: 10.2174/1389200223666220803103039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/04/2022] [Accepted: 04/29/2022] [Indexed: 01/05/2023]
Abstract
The lung is exposed to various pollutants and is the primary site for the onset of various diseases, including infections, allergies, and cancers. One possible treatment approach for such pulmonary diseases involves direct administration of therapeutics to the lung so as to maintain the topical concentration of the drug. Particles with nanoscale diameters tend to reach the pulmonary region. Nanoparticles (NPs) have garnered significant interest for applications in biomedical and pharmaceutical industries because of their unique physicochemical properties and biological activities. In this article, we describe the biological and pharmacological activities of NPs as well as summarize their potential in the formulation of drugs employed to treat pulmonary diseases. Recent advances in the use of NPs in inhalation chemotherapy for the treatment of lung diseases have also been highlighted.
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Affiliation(s)
- Dhananjay Yadav
- Department of Life Science, Yeungnam University, Gyeongsan 38541, South Korea
| | - Peninah M Wairagu
- Department of Biochemistry and Biotechnology, The Technical University of Kenya, Nairobi, Kenya
| | - Minseok Kwak
- Department of Chemistry, Pukyong National University, Busan 48513, Korea
| | - Jun-O Jin
- Department of Microbiology, University of Ulsan College of Medicine, Seoul 05505, Korea
| | - Jun-O Jin
- Department of Biotechnology, ITM University, Gwalior, Madhya Pradesh, 474011, India.,Research Institute of Cell Culture, Yeungnam University, Gyeongsan 38541, Korea
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Application of Nanomaterials in the Prevention, Detection, and Treatment of Methicillin-Resistant Staphylococcus aureus (MRSA). Pharmaceutics 2022; 14:pharmaceutics14040805. [PMID: 35456638 PMCID: PMC9030647 DOI: 10.3390/pharmaceutics14040805] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 01/27/2023] Open
Abstract
Due to differences in geographic surveillance systems, chemical sanitization practices, and antibiotic stewardship (AS) implementation employed during the COVID-19 pandemic, many experts have expressed concerns regarding a future surge in global antimicrobial resistance (AMR). A potential beneficiary of these differences is the Gram-positive bacteria MRSA. MRSA is a bacterial pathogen with a high potential for mutational resistance, allowing it to engage various AMR mechanisms circumventing conventional antibiotic therapies and the host’s immune response. Coupled with a lack of novel FDA-approved antibiotics reaching the clinic, the onus is on researchers to develop alternative treatment tools to mitigate against an increase in pathogenic resistance. Mitigation strategies can take the form of synthetic or biomimetic nanomaterials/vesicles employed in vaccines, rapid diagnostics, antibiotic delivery, and nanotherapeutics. This review seeks to discuss the current potential of the aforementioned nanomaterials in detecting and treating MRSA.
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Seitz A, Baker JE, Levinsky NC, Morris MC, Edwards MJ, Gulbins E, Blakeman TC, Rodriquez D, Branson RD, Goodman M. Antimicrobial coating prevents ventilator-associated pneumonia in a 72 hour large animal model. J Surg Res 2021; 267:424-431. [PMID: 34229130 DOI: 10.1016/j.jss.2021.05.046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Revised: 04/22/2021] [Accepted: 05/27/2021] [Indexed: 12/26/2022]
Abstract
BACKGROUND The primary goal of this study was to demonstrate that endotracheal tubes coated with antimicrobial lipids plus mucolytic or antimicrobial lipids with antibiotics plus mucolytic would significantly reduce pneumonia in the lungs of pigs after 72 hours of continuous mechanical ventilation compared to uncoated controls. MATERIALS AND METHODS Eighteen female pigs were mechanically ventilated for up to 72 hours through uncoated endotracheal tubes, endotracheal tubes coated with the antimicrobial lipid, octadecylamine, and the mucolytic, N-acetylcysteine, or tubes coated with octadecylamine, N-acetylcysteine, doxycycline, and levofloxacin (6 pigs per group). No exogenous bacteria were inoculated into the pigs, pneumonia resulted from the pigs' endogenous oral flora. Vital signs were recorded every 15 minutes and arterial blood gas measurements were obtained for the duration of the experiment. Pigs were sacrificed either after completion of 72 hours of mechanical ventilation or just prior to hypoxic arrest. Lungs, trachea, and endotracheal tubes were harvested for analysis to include bacterial counts of lung, trachea, and endotracheal tubes, lung wet and dry weights, and lung tissue for histology. RESULTS Pigs ventilated with coated endotracheal tubes were less hypoxic, had less bacterial colonization of the lungs, and survived significantly longer than pigs ventilated with uncoated tubes. Octadecylamine-N-acetylcysteine-doxycycline-levofloxacin coated endotracheal tubes had less bacterial colonization than uncoated or octadecylamine-N-acetylcysteine coated tubes. CONCLUSION Endotracheal tubes coated with antimicrobial lipids plus mucolytic and antimicrobial lipids with antibiotics plus mucolytic reduced bacterial colonization of pig lungs after prolonged mechanical ventilation and may be an effective strategy to reduce ventilator-associated pneumonia.
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Affiliation(s)
- Aaron Seitz
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio.
| | - Jennifer E Baker
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Nick C Levinsky
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Mackenzie C Morris
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael J Edwards
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Erich Gulbins
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio; Department of Molecular Biology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas C Blakeman
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Dario Rodriquez
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Richard D Branson
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Michael Goodman
- Department of Surgery, College of Medicine, University of Cincinnati, Cincinnati, Ohio
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Avoiding ventilator-associated pneumonia: Curcumin-functionalized endotracheal tube and photodynamic action. Proc Natl Acad Sci U S A 2020; 117:22967-22973. [PMID: 32868444 DOI: 10.1073/pnas.2006759117] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Hospital-acquired infections are a global health problem that threatens patients' treatment in intensive care units, causing thousands of deaths and a considerable increase in hospitalization costs. The endotracheal tube (ETT) is a medical device placed in the patient's trachea to assist breathing and delivering oxygen into the lungs. However, bacterial biofilms forming at the surface of the ETT and the development of multidrug-resistant bacteria are considered the primary causes of ventilator-associated pneumonia (VAP), a severe hospital-acquired infection for significant mortality. Under these circumstances, there has been a need to administrate antibiotics together. Although necessary, it has led to a rapid increase in bacterial resistance to antibiotics. Therefore, it becomes necessary to develop alternatives to prevent and combat these bacterial infections. One possibility is to turn the ETT itself into a bactericide. Some examples reported in the literature present drawbacks. To overcome those issues, we have designed a photosensitizer-containing ETT to be used in photodynamic inactivation (PDI) to avoid bacteria biofilm formation and prevent VAP occurrence during tracheal intubation. This work describes ETT's functionalization with curcumin photosensitizer, as well as its evaluation in PDI against Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli A significant photoinactivation (up to 95%) against Gram-negative and Gram-positive bacteria was observed when curcumin-functionalized endotracheal (ETT-curc) was used. These remarkable results demonstrate this strategy's potential to combat hospital-acquired infections and contribute to fighting antimicrobial resistance.
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10
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Ozcelik B, Pasic P, Sangwan P, Be CL, Glattauer V, Thissen H, Boulos RA. Evaluation of the Novel Antimicrobial BCP3 in a Coating for Endotracheal Tubes. ACS OMEGA 2020; 5:10288-10296. [PMID: 32426585 PMCID: PMC7226855 DOI: 10.1021/acsomega.9b04178] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Accepted: 04/03/2020] [Indexed: 06/11/2023]
Abstract
Ventilator-associated pneumonia (VAP) is a highly common hospital-acquired infection affecting people that require mechanical ventilation. The endotracheal tube (ETT) used during the ventilation process provides a surface that can allow bacterial colonization and biofilm formation, which can lead to VAP. Although various approaches, including ETT design and material selection, as well as antimicrobial coatings have been employed to minimize adverse events, VAP remains a significant unresolved clinical issue. In this study, we have utilized a novel styrylbenzene-based antimicrobial (BCP3) in a simple and robust coating that allows its long-term release at an effective level. BCP3 was applied onto PVC ETT segments blended together with poly(lactic-co-glycolic acid) via a facile dip-coating process with controlled loadings. In vitro studies demonstrated concentration-dependent release of BCP3 from the coatings for at least 31 days. Bacterial assays using major VAP culprits, Staphylococcus aureus and Pseudomonas aeruginosa, demonstrated significant growth inhibition, with a stronger effect on S. aureus. Despite its ability to inhibit bacterial growth, BCP3 showed no cytotoxicity toward mammalian (L929) fibroblasts, which makes it attractive from a clinical perspective. The coating procedure was successfully translated to coat the entire ETTs, making it highly amenable for large-scale manufacturing.
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Affiliation(s)
- Berkay Ozcelik
- Commonwealth Scientific
and Industrial Research Organisation (CSIRO) Manufacturing, Clayton, Victoria 3168, Australia
| | - Paul Pasic
- Commonwealth Scientific
and Industrial Research Organisation (CSIRO) Manufacturing, Clayton, Victoria 3168, Australia
| | - Parveen Sangwan
- Commonwealth Scientific
and Industrial Research Organisation (CSIRO) Manufacturing, Clayton, Victoria 3168, Australia
| | - Cheang Ly Be
- Commonwealth Scientific
and Industrial Research Organisation (CSIRO) Manufacturing, Clayton, Victoria 3168, Australia
| | - Veronica Glattauer
- Commonwealth Scientific
and Industrial Research Organisation (CSIRO) Manufacturing, Clayton, Victoria 3168, Australia
| | - Helmut Thissen
- Commonwealth Scientific
and Industrial Research Organisation (CSIRO) Manufacturing, Clayton, Victoria 3168, Australia
| | - Ramiz A. Boulos
- Boulos
& Cooper Pharmaceuticals Pty. Ltd. 16/45 Delawney Street, Balcatta, Western Australia 6021, Australia
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11
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Green fabrication of anti-bacterial biofilm layer on endotracheal tubing using silver nanoparticles embedded in polyelectrolyte multilayered film. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2019; 101:53-63. [DOI: 10.1016/j.msec.2019.03.061] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Revised: 02/26/2019] [Accepted: 03/18/2019] [Indexed: 02/07/2023]
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12
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Barnes M, Feit C, Grant TA, Brisbois EJ. Antimicrobial polymer modifications to reduce microbial bioburden on endotracheal tubes and ventilator associated pneumonia. Acta Biomater 2019; 91:220-234. [PMID: 31022549 DOI: 10.1016/j.actbio.2019.04.042] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2018] [Revised: 04/16/2019] [Accepted: 04/18/2019] [Indexed: 12/26/2022]
Abstract
Hospital associated infections (HAIs), infections acquired by patients during care in a hospital, remain a prevalent issue in the healthcare field. These infections often occur with the use of indwelling medical devices, such as endotracheal tubes (ETTs), that can result in ventilator-associated pneumonia (VAP). When examining the various routes of infection, VAP is associated with the highest incidence, rate of morbidity, and economic burden. Although ETTs are essential for the survival of patients requiring mechanical ventilation, their use comes with complications. The presence of an ETT in the airway impairs physiological host defense mechanisms for clearance of pathogens and provides a platform for oropharynx microorganism transport to the sterile tracheobronchial network. Antibiotics are administered to treat lower respiratory infections; however, they are not always effective and consequently can result in increased antibiotic resistance. Prophylactic approaches by altering the surface of ETTs to prevent the establishment and growth of bacteria have exhibited promising results. In addition, passive surface modifications that prevent bacterial establishment and growth, or active coatings that possess a bactericidal effect have also proven effective. In this review we aim to highlight the importance of preventing biofilm establishment on indwelling medical devices, focusing on ETTs. We will investigate successful antimicrobial modifications to ETTs and the future avenues that will ultimately decrease HAIs and improve patient care. STATEMENT OF SIGNIFICANCE: Infections that occur with indwelling medicals devices remain a constant concern in the medical field and can result in hospital-acquired infections. Specifically, ventilator associated pneumonia (VAP) occurs with the use of an endotracheal tube (ETT). Infections often require use of antibiotics and can result in patient mortality. Our review includes a summary of the recent collective work of antimicrobial ETT modifications and potential avenues for further investigations in an effort to reduce VAP associated with ETTs. Polymer modifications with antibacterial nature have been developed and tested; however, a focus on ETTs is lacking and clinical availability of new antimicrobial ETT devices is limited. Our collective work shows the successful and prospective applications to the surfaces of ETTs that can support researchers and physicians to create safer medical devices.
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Caratto V, Ball L, Sanguineti E, Insorsi A, Firpo I, Alberti S, Ferretti M, Pelosi P. Antibacterial activity of standard and N-doped titanium dioxide-coated endotracheal tubes: an in vitro study. Rev Bras Ter Intensiva 2018; 29:55-62. [PMID: 28444073 PMCID: PMC5385986 DOI: 10.5935/0103-507x.20170009] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2016] [Accepted: 01/09/2017] [Indexed: 11/28/2022] Open
Abstract
Objective The aim of this study was to assess the antibacterial activity against
Staphylococcus aureus and Pseudomonas
aeruginosa of two nanoparticle endotracheal tube coatings with
visible light-induced photocatalysis. Methods Two types of titanium dioxide nanoparticles were tested: standard anatase
(TiO2) and N-doped TiO2 (N-TiO2).
Nanoparticles were placed on the internal surface of a segment of commercial
endotracheal tubes, which were loaded on a cellulose acetate filter; control
endotracheal tubes were left without a nanoparticle coating. A bacterial
inoculum of 150 colony forming units was placed in the endotracheal tubes
and then exposed to a fluorescent light source (3700 lux, 300-700 nm
wavelength) for 5, 10, 20, 40, 60 and 80 minutes. Colony forming units were
counted after 24 hours of incubation at 37°C. Bacterial inactivation was
calculated as the percentage reduction of bacterial growth compared to
endotracheal tubes not exposed to light. Results In the absence of light, no relevant antibacterial activity was shown against
neither strain. For P. aeruginosa, both coatings had a
higher bacterial inactivation than controls at any time point (p <
0.001), and no difference was observed between TiO2 and
N-TiO2. For S. aureus, inactivation was
higher than for controls starting at 5 minutes for N-TiO2 (p =
0.018) and 10 minutes for TiO2 (p = 0.014); inactivation with
N-TiO2 was higher than that with TiO2 at 20
minutes (p < 0.001), 40 minutes (p < 0.001) and 60 minutes (p <
0.001). Conclusions Nanosized commercial and N-doped TiO2 inhibit bacterial growth
under visible fluorescent light. N-TiO2 has higher antibacterial
activity against S. aureus compared to TiO2.
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Affiliation(s)
- Valentina Caratto
- Dipartimento di Chimica e Chimica Industriale, Università degli Studi di Genova, Genova, Italy.,Istituto CNR SPIN - Genova, Italy
| | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Elisa Sanguineti
- Dipartimento di Chimica e Chimica Industriale, Università degli Studi di Genova, Genova, Italy.,Istituto CNR SPIN - Genova, Italy.,Dipartimento di Scienze della Terra, dell'Ambiente e della Vita, Università degli Studi di Genova, Genova, Italy
| | - Angelo Insorsi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Iacopo Firpo
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Stefano Alberti
- Dipartimento di Chimica e Chimica Industriale, Università degli Studi di Genova, Genova, Italy
| | - Maurizio Ferretti
- Dipartimento di Chimica e Chimica Industriale, Università degli Studi di Genova, Genova, Italy.,Istituto CNR SPIN - Genova, Italy
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
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Fernández-Barat L, Torres A. Biofilms in ventilator-associated pneumonia. Future Microbiol 2016; 11:1599-1610. [DOI: 10.2217/fmb-2016-0040] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Biofilms develop rapidly following endotracheal intubation and represent a persistent source of unnecessary pathogens in the critically ill patient. Overall, the imbalance in the lung microbiome caused by an endotracheal tube and its role in biofilm formation and in ventilator-associated pneumonia is still unclear. Although endotracheal tube–biofilm preventive measures are being tested, no outcome impact has ever been demonstrated, and therefore no approach has been clinically recommended. Nonetheless, an accurate description of the actual biofilm morphology in vivo could be useful to implement effective preventive measures. The combined use of in vitro biofilm models, in vivo animal models and clinical research is vitally important to the attainment of a comprehensive understanding of biofilms in ventilator-associated pneumonia in the near future.
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Affiliation(s)
- Laia Fernández-Barat
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universtitat de Barcelona (UB), Barcelona, Spain
| | - Antoni Torres
- Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (Ciberes), Institut d’Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Universtitat de Barcelona (UB), Barcelona, Spain
- Unidad de cuidados Intensivos respiratorios (UVIR), Servicio de Neumología, Hospital Clínic, Barcelona, Spain
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Abstract
PURPOSE OF REVIEW Lower respiratory tract infections remain one of the leading causes of death in the world. Recently, the introduction of molecular methods based on DNA sequencing and microarrays for the identification of nonculturable microorganisms and subspecies variations has challenged the previous 'one bug - one disease' paradigm, providing us with a broader view on human microbial communities and their role in the development of infectious diseases. The purpose of this review is to describe recent understanding of the role of microbiome and bacterial biofilm in the development of lung infections, and, at the same time, to present new areas of research opportunities. RECENT FINDINGS The review describes recent literature in cystic fibrosis patients, chronic obstructive pulmonary disease patients, and literature in mechanically ventilated patients that helped to elucidate the role of microbiome and biofilm formation in the development of pneumonia. SUMMARY The characterization of the human microbiome and biofilms has changed our understanding of lower respiratory tract infections. More comprehensive, sensitive, and fast methods for bacterial, fungal, and viral detection are warranted to establish the colonization of the lower respiratory tract in healthy individuals and sick patients. Future research might explore the global bacterial, fungal, and viral pulmonary ecosystems and their interdependence to target novel preventive approaches and therapeutic strategies in chronic and acute lung infections.
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Gross JH, Giraldez-Rodriguez LA, Klein AM. Bacterial Laryngotracheitis and Associated Upper Airway Obstruction. Ann Otol Rhinol Laryngol 2015; 124:1002-5. [DOI: 10.1177/0003489415592161] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Iatrogenic laryngotracheal stenosis (LTS) continues to be a known complication of indwelling endotracheal tubes (ETTs). It is well established that secondary scar formation caused by inflammation and mucosal injury are the main mechanisms by which stenosis occurs. Additionally, there are reports of bacterial colonization of ETTs and its potential association with tracheal scar formation. We describe 4 cases of patients with history of intubation and/or tracheostomy and presumed LTS that improved with the management of concurrent bacterial laryngotracheitis. Methods: A retrospective case series of 4 subjects initially diagnosed at a tertiary care center with posterior glottic or subglottic stenosis and positive bacterial laryngotracheal cultures was performed. Results: All 4 patients with presumed LTS had culture-proven bacterial growth isolated from the laryngotrachea and were treated with adjunct antibiotics. In the first 3 cases, complete resolution of upper airway obstruction was achieved. The fourth patient had notable improvement in her airway status without the need for additional surgical intervention. Conclusion: This case series suggests that bacterial growth within the airway may play a larger role in adult postintubation airway injury. Those patients presenting with concern for LTS and symptoms suspicious for an ongoing bacterial infection may benefit from adjunct antibiotic therapy.
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Affiliation(s)
- Jennifer H. Gross
- Department of Otolaryngology, Washington University School of Medicine, Saint Louis, Missouri, USA
| | | | - Adam M. Klein
- Department of Otolaryngology—Head and Neck Surgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Loo CY, Lee WH, Young PM, Cavaliere R, Whitchurch CB, Rohanizadeh R. Implications and emerging control strategies for ventilator-associated infections. Expert Rev Anti Infect Ther 2015; 13:379-93. [DOI: 10.1586/14787210.2015.1007045] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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18
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May RM, Hoffman MG, Sogo MJ, Parker AE, O'Toole GA, Brennan AB, Reddy ST. Micro-patterned surfaces reduce bacterial colonization and biofilm formation in vitro: Potential for enhancing endotracheal tube designs. Clin Transl Med 2014; 3:8. [PMID: 24739529 PMCID: PMC3996152 DOI: 10.1186/2001-1326-3-8] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2013] [Accepted: 03/10/2014] [Indexed: 12/20/2022] Open
Abstract
Background Ventilator-associated pneumonia (VAP) is a leading hospital acquired infection in intensive care units despite improved patient care practices and advancements in endotracheal tube (ETT) designs. The ETT provides a conduit for bacterial access to the lower respiratory tract and a substratum for biofilm formation, both of which lead to VAP. A novel microscopic ordered surface topography, the Sharklet micro-pattern, has been shown to decrease surface attachment of numerous microorganisms, and may provide an alternative strategy for VAP prevention if included on the surface of an ETT. To evaluate the feasibility of this micro-pattern for this application, the microbial range of performance was investigated in addition to biofilm studies with and without a mucin-rich medium to simulate the tracheal environment in vitro. Methods The top five pathogens associated with ETT-related pneumonia, Methicillin-Resistant Staphylococcus aureus (MRSA), Pseudomonas aeruginosa, Klebsiella pneumonia, Acinetobacter baumannii, and Escherichia coli, were evaluated for attachment to micro-patterned and un-patterned silicone surfaces in a short-term colonization assay. Two key pathogens, MRSA and Pseudomonas aeruginosa, were evaluated for biofilm formation in a nutrient rich broth for four days and minimal media for 24 hours, respectively, on each surface type. P. aeruginosa was further evaluated for biofilm formation on each surface type in a mucin-modified medium mimicking tracheal mucosal secretions. Results are reported as percent reductions and significance is based on t-tests and ANOVA models of log reductions. All experiments were replicated at least three times. Results Micro-patterned surfaces demonstrated reductions in microbial colonization for a broad range of species, with up to 99.9% (p < 0.05) reduction compared to un-patterned controls. Biofilm formation was also reduced, with 67% (p = 0.12) and 52% (p = 0.05) reductions in MRSA and P. aeruginosa biofilm formation, respectively. Further, a 58% (p < 0.01) reduction was demonstrated on micro-patterned surfaces for P. aeruginosa biofilms under clinically-simulated conditions when compared to un-patterned controls. Conclusions This engineered micro-pattern reduces the colonization and biofilm formation of key VAP-associated pathogens in vitro. Future application of this micro-pattern on endotracheal tubes may prevent or prolong the onset of VAP without the need for antimicrobial agents.
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Affiliation(s)
- Rhea M May
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
| | - Matthew G Hoffman
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
| | - Melinda J Sogo
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
| | - Albert E Parker
- Center for Biofilm Engineering, and the Department of Mathematical Sciences, Montana State University, Bozeman, MT, USA
| | | | - Anthony B Brennan
- Department of Materials Science and Engineering, University of Florida, Gainesville, FL, USA
| | - Shravanthi T Reddy
- Sharklet Technologies, Inc., Aurora, 12635 E. Montview Blvd. Suite 155, CO 80045 Aurora, CO USA
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Tolstov AL. Production and Physicochemical Characteristics of Silver-Containing Polyurethane Systems. THEOR EXP CHEM+ 2014. [DOI: 10.1007/s11237-014-9336-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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De Souza PR, De Andrade D, Cabral DB, Watanabe E. Endotracheal tube biofilm and ventilator-associated pneumonia with mechanical ventilation. Microsc Res Tech 2014; 77:305-12. [PMID: 24519948 DOI: 10.1002/jemt.22344] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 12/20/2013] [Accepted: 01/24/2014] [Indexed: 11/06/2022]
Abstract
OBJECTIVE To analyze biofilm on internal and external surfaces of endotracheal tubes after their use in critical care patients, and to produce evidence of association between use of the tube, presence of biofilm, and the occurrence of pneumonia. METHODS This was a clinical study performed at the Intensive Care Unit of an emergency hospital in the interior of São Paulo state, Brazil. Data collection involved 30 endotracheal tubes used on adult patients for a period of ≥48 h of mechanical ventilation for scanning electron microscopy. RESULTS Analysis of the biofilm on the 30 tubes by scanning electron microscopy showed various abiotic and biotic structures, predominantly on the internal surface, such as: fibrin network, erythrocytes, leukocytes, cocci, bacilli, and molds, among others. The intubation period of the endotracheal tube for ≥8 days represented one of the risk factors for ventilator-associated pneumonia (RR 7.41, P < 0.001). CONCLUSIONS The presence of the endotracheal tube permits microbial colonization, overall contributing to the development of biofilm and the occurrence of pneumonia.
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Boyer A, Clouzeau B, Bui HN, Vargas F, Hilbert G, Gruson D. Nouvelles techniques pour lutter contre le biofilm de la sonde d’intubation. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-013-0689-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Abstract
Silver has been used for centuries. Today, silver and silver nanoparticles (AgNPs) are used in a wide range of healthcare, food industry, domiciliary applications, and are commonly found in hard surface materials and textiles. Such an extensive use raises questions about its safety, environmental toxicity and the risks associated with microbial resistance and cross-resistance. If the mechanisms of antimicrobial action of ionic silver (Ag+) have been studied, there is little understanding of AgNPs interactions with microorganisms. There have been excellent reviews on the bacterial resistance mechanisms to silver, but there is a paucity of information on resistance to AgNPs. Silver toxicity and accumulation in the environment has been studied and there is a better understanding of silver concentration and species in different environmental compartments. However, owing to the increased applications of silver and AgNPs, questions remain about the presence and consequences of AgNPs in the environment. This review provides an historical perspective of silver usage, an overview of applications, and combined information of microbial resistance and toxicity. Owing the evidence provided in this review, a call for a better understanding and control of silver usage, and for tighter regulations of silver and AgNPs usage is proposed.
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Affiliation(s)
- Jean-Yves Maillard
- Cardiff School of Pharmacy and Pharmaceutical Sciences, Cardiff University , Cardiff , UK
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Li X, Yuan Q, Wang L, Du L, Deng L. Silver-coated endotracheal tube versus non-coated endotracheal tube for preventing ventilator-associated pneumonia among adults: a systematic review of randomized controlled trials. J Evid Based Med 2012; 5:25-30. [PMID: 23528117 DOI: 10.1111/j.1756-5391.2012.01165.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To compare the effects of using silver-coated endotracheal tube (ETT) versus non-coated ETT on the incidence of ventilator-associated pneumonia (VAP) and mortality in adult patients. METHOD We searched MEDLINE, the Cochrane Library, EMBASE, and the Chinese Biomedical Literature Database from inception to June 30, 2011. We also retrieved the reference lists of included studies and reviews. Randomized controlled trials (RCTs) comparing silver-coated ETTs versus non-coated ETTs were included. We pooled the results using a random-effect model and conducted subgroup analyses and sensitivity analyses to address the heterogeneity between studies. RESULTS We identified two eligible RCTs with a total of 1630 participants. The studies were of high quality according to Cochrane Collaboration's tool for assessing risk of bias. Compared with non-coated ETTs, silver-coated ETTs resulted in lower incidence of VAP (RR=0.64, 95% CI 0.43 to 0.96), device-related adverse events (RR=0.53, 95% CI 0.32 to 0.88), and microbiologic burden (≥10,000 CFU/mL: 0.64, 0.48 to 0.86; ≥100,000 CFU/mL: 0.62, 0.43 to 0.89). However, there was no significant difference in total mortality (RR=1.14, 95% CI 0.99 to 1.30). CONCLUSION The limited evidence from meta-analysis of two RCTs showed that using silver-coated ETTs reduced the incidence of VAP, microbiologic burden, and device-related adverse events among adult patients. Additional rigorous randomized trials are needed to confirm these findings.
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Affiliation(s)
- Xiao Li
- Chinese Cochrane Centre/ Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu 610041, China
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Abstract
PURPOSE OF REVIEW The endotracheal tube (ETT) is the main avenue leading to airway contamination and subsequent ventilator-associated pneumonia (VAP) during mechanical ventilation. A number of modifications to the ETT are available, aimed at reducing the incidence of VAP. We review here available systems and devices, and clinical data regarding their efficacy. RECENT FINDINGS Three main modifications of ETTs have been developed: coating with antimicrobials, adding a suction channel for the removal of oro-pharyngeal secretions, and modifying the design of the cuff. Each of these interventions has been shown to limit bacterial colonization of the distal airways and to decrease the incidence of VAP. Data on their ultimate effect on related clinical outcomes are still lacking. SUMMARY Modifications of ETTs aimed at decreasing the onset of VAP show promising results. However, the lack of a significant effect on outcomes prompts us to use caution before recommending their widespread use.
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Cairns S, Thomas JG, Hooper SJ, Wise MP, Frost PJ, Wilson MJ, Lewis MAO, Williams DW. Molecular analysis of microbial communities in endotracheal tube biofilms. PLoS One 2011; 6:e14759. [PMID: 21423727 PMCID: PMC3056660 DOI: 10.1371/journal.pone.0014759] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Accepted: 10/30/2010] [Indexed: 11/22/2022] Open
Abstract
Background Ventilator-associated pneumonia is the most prevalent acquired infection of patients on intensive care units and is associated with considerable morbidity and mortality. Evidence suggests that an improved understanding of the composition of the biofilm communities that form on endotracheal tubes may result in the development of improved preventative strategies for ventilator-associated pneumonia. Methodology/Principal Findings The aim of this study was to characterise microbial biofilms on the inner luminal surface of extubated endotracheal tubes from ICU patients using PCR and molecular profiling. Twenty-four endotracheal tubes were obtained from twenty mechanically ventilated patients. Denaturing gradient gel electrophoresis (DGGE) profiling of 16S rRNA gene amplicons was used to assess the diversity of the bacterial population, together with species specific PCR of key marker oral microorganisms and a quantitative assessment of culturable aerobic bacteria. Analysis of culturable aerobic bacteria revealed a range of colonisation from no growth to 2.1×108 colony forming units (cfu)/cm2 of endotracheal tube (mean 1.4×107 cfu/cm2). PCR targeting of specific bacterial species detected the oral bacteria Streptococcus mutans (n = 5) and Porphyromonas gingivalis (n = 5). DGGE profiling of the endotracheal biofilms revealed complex banding patterns containing between 3 and 22 (mean 6) bands per tube, thus demonstrating the marked complexity of the constituent biofilms. Significant inter-patient diversity was evident. The number of DGGE bands detected was not related to total viable microbial counts or the duration of intubation. Conclusions/Significance Molecular profiling using DGGE demonstrated considerable biofilm compositional complexity and inter-patient diversity and provides a rapid method for the further study of biofilm composition in longitudinal and interventional studies. The presence of oral microorganisms in endotracheal tube biofilms suggests that these may be important in biofilm development and may provide a therapeutic target for the prevention of ventilator-associated pneumonia.
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Affiliation(s)
- Scott Cairns
- University Hospital of Wales, Cardiff, United Kingdom
| | - John Gilbert Thomas
- West Virginia University, Morgantown, West Virginia, United States of America
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Impact of silver-containing wound dressings on bacterial biofilm viability and susceptibility to antibiotics during prolonged treatment. Antimicrob Agents Chemother 2010; 54:5120-31. [PMID: 20855737 DOI: 10.1128/aac.00825-10] [Citation(s) in RCA: 98] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
The long-term antimicrobial efficacy of silver dressings against bacterial biofilms was investigated in a 7-day treatment in vitro model where the protein-rich medium was refreshed daily in order to mimic the conditions found in a wound bed. The use of plate-to-plate transfer assays demonstrated measurable differences in the effectiveness of several silver dressings on the viability of biofilm bacteria and their susceptibility to antibiotics. Whereas after the first day of treatment, all dressings used resulted in a significant reduction in the number of viable cells in the biofilms and disruption of the biofilm colonies, during prolonged treatment, the efficacy of dressings with hydrophilic base materials diminished with daily transfers, and bacterial populations recovered. For dressings with hydrophobic base materials, the level of efficacy correlated with the silver species loaded. Biofilm bacteria, which survived the initial silver treatment, were susceptible to tobramycin, ciprofloxacin, and trimethoprim-sulfamethoxazole, in contrast to untreated biofilms, which were highly tolerant to the same antibiotics. This acquired susceptibility was unaffected by the longevity of pretreatment with the silver dressings but depended on the dressing used. The antimicrobial efficacy of the dressings correlated with the type of the dressing base material and silver species loaded.
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Lorente L, Blot S, Rello J. New issues and controversies in the prevention of ventilator-associated pneumonia. Am J Respir Crit Care Med 2010; 182:870-6. [PMID: 20448095 DOI: 10.1164/rccm.201001-0081ci] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
In the past 2 years, American, Canadian, and European scientific societies have published their new evidence-based guidelines for ventilator-associated pneumonia (VAP) prevention. However, these guidelines did not review some potentially useful strategies, such as the use of an endotracheal tube with an ultrathin cuff membrane, an endotracheal tube with a low-volume/low-pressure cuff, a device for continuous monitoring of the endotracheal tube cuff pressure, a device to remove biofilm from the inner site of the endotracheal tube, and saline instillation before tracheal suctioning. Only a few guidelines analyze the time of tracheostomy, and so no firm recommendations can be made regarding its importance. In addition, the guidelines diverge on the use of heat and moisture exchangers or heated humidifiers and on the use of an endotracheal tube coated with antimicrobial agents. The current review focuses on measures of VAP prevention for which there is no clear recommendation, or the use of which is controversial. A review of the literature suggests that the use of an endotracheal tube with an ultrathin and tapered-shape cuff membrane and coated in antimicrobial agents may reduce the risk of VAP. These features offer an attractive way to optimize the VAP prevention capacity of endotracheal tubes with a lumen for subglottic secretion drainage. We believe that early tracheostomy should be considered, based on the length reduction of mechanical ventilation and intensive care unit stay, reduction of mortality, and on patient comfort, although early tracheostomy has not yet been shown to favorably impact the incidence of VAP. We believed that heat and moisture exchangers should be considered based on the benefits in terms of cost savings. More research is necessary to clarify the role of continuous cuff pressure monitoring, removal of biofilm formation in the endotracheal tubes, and routine saline instillation before tracheal suctioning.
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Affiliation(s)
- Leonardo Lorente
- Intensive Care Unit, Hospital Universitario de Canarias, La Laguna, Tenerife, Spain
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Afessa B, Shorr AF, Anzueto AR, Craven DE, Schinner R, Kollef MH. Association Between a Silver-Coated Endotracheal Tube and Reduced Mortality in Patients With Ventilator-Associated Pneumonia. Chest 2010; 137:1015-21. [DOI: 10.1378/chest.09-0391] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
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30
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Niederman MS. Fighting Vampires and Ventilator-Associated Pneumonia. Chest 2010; 137:1007-1009. [DOI: 10.1378/chest.10-0063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
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Activity of a silver-coated endotracheal tube in preclinical models of ventilator-associated pneumonia and a study after extubation*. Crit Care Med 2010; 38:1135-40. [DOI: 10.1097/ccm.0b013e3181cd12b8] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Abstract
PURPOSE OF REVIEW Ventilator-associated pneumonia (VAP) is the most serious and controversial of the infections of the critically ill patient. The accuracy of standard methods of diagnosis remains under constant scrutiny, and at the same time there is increasing debate about whether it is a preventable disease. This review focuses on the pathophysiology of respiratory tract infection in the ventilated patient, and how the latest advances have grown from our current understanding of its pathogenesis. RECENT FINDINGS Data from many recent investigations have focused on the role of proximal airway infection, ventilator-associated tracheobronchitis (VAT), in respiratory tract infection. The goals of recent trials include reducing the morbidity associated with the progression of airway colonization to VAT or with the progression of VAT to VAP. Continuous subglottic secretion suctioning, innovative types of endotracheal tubes and targeted therapy for VAT in recent investigations have shown promise in improving clinical outcomes in the critically ill patient. However, even with diligent attention to all the modifiable risk factors for respiratory infection, complete elimination of VAT and VAP remains unlikely. As long as a patient requires an endotracheal tube that disturbs airway integrity, host defenses will be impaired, and resistant virulent organisms that result from our liberal use of systemic antibiotics will continue to challenge critical care specialists. SUMMARY This review will focus on: the current understanding of the pathogenesis of VAT and VAP, modifiable risk factors and new approaches to treatment, and bacterial resistance challenges.
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Antonelli M, Azoulay E, Bonten M, Chastre J, Citerio G, Conti G, De Backer D, Lemaire F, Gerlach H, Groeneveld J, Hedenstierna G, Macrae D, Mancebo J, Maggiore SM, Mebazaa A, Metnitz P, Pugin J, Wernerman J, Zhang H. Year in review in Intensive Care Medicine, 2008: I. Brain injury and neurology, renal failure and endocrinology, metabolism and nutrition, sepsis, infections and pneumonia. Intensive Care Med 2008; 35:30-44. [PMID: 19066847 PMCID: PMC7094904 DOI: 10.1007/s00134-008-1371-6] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 12/01/2008] [Indexed: 12/16/2022]
Affiliation(s)
- Massimo Antonelli
- Department of Intensive Care and Anesthesiology, Policlinico Universitario A. Gemelli, Università Cattolica del Sacro Cuore, Largo A. Gemelli, 8, 00168, Rome, Italy.
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Lisboa T, Kollef MH, Rello J. Prevention of VAP: the whole is more than the sum of its parts. Intensive Care Med 2008; 34:985-7. [DOI: 10.1007/s00134-008-1101-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2008] [Accepted: 01/07/2008] [Indexed: 10/22/2022]
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Internally coated endotracheal tubes with silver sulfadiazine in polyurethane to prevent bacterial colonization: a clinical trial. Intensive Care Med 2008; 34:1030-7. [PMID: 18418571 DOI: 10.1007/s00134-008-1100-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2007] [Accepted: 03/05/2008] [Indexed: 10/22/2022]
Abstract
OBJECTIVE Coated medical devices have been shown to reduce catheter-related infections. We coated endotracheal tubes (ETT) with silver sulfadiazine (SSD), and tested them in a clinical study to assess the feasibility, safety, and efficacy of preventing bacterial colonization. DESIGN A prospective, randomized clinical trial, phase I-II. SETTING Academic intensive care unit (ICU). PARTICIPANTS Forty-six adult patients expected to need 12-24 h of intubation were randomized into two groups. INTERVENTIONS Patients were randomized to be intubated with a standard non-coated ETT (St-ETT, n=23; control group), or with a SSD-coated ETT (SSD-ETT, n=23). MEASUREMENTS AND RESULTS Coating with SSD prevented bacterial colonization of the ETT (frequency of colonization: SSD-ETT 0/23, St-ETT 8/23; p<0.01). No organized bacterial biofilm could be identified on the lumen of any ETT; however, SSD was associated with a thinner mucus layer (in the SSD-ETT secretion deposits ranged from 0 to 200 microm; in the St-ETT deposits ranged between 50 and 700 microm). No difference was observed between the two groups in the tracheobronchial brush samples (frequency of colonization: SSD-ETT 0/23, St-ETT 2/23; p=0.48). No adverse reactions were observed with the implementation of the novel device. CONCLUSION SSD-ETT can be safely used in preventing bacterial colonization and narrowing of the ETT in patients intubated for up to 24 h (mean intubation time 16 h).
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