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Edward EA, El Shehawy MR, Abouelfetouh A, Aboulmagd E. Prevalence of different virulence factors and their association with antimicrobial resistance among Pseudomonas aeruginosa clinical isolates from Egypt. BMC Microbiol 2023; 23:161. [PMID: 37270502 DOI: 10.1186/s12866-023-02897-8] [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: 11/16/2022] [Accepted: 05/17/2023] [Indexed: 06/05/2023] Open
Abstract
BACKGROUND Emergence of multi-drug resistant Pseudomonas aeruginosa, coupled with the pathogen's versatile virulence factors, lead to high morbidity and mortality rates. The current study investigated the potential association between the antibiotic resistance and the production of virulence factors among P. aeruginosa clinical isolates collected from Alexandria Main University Hospital in Egypt. We also evaluated the potential of the phenotypic detection of virulence factors to reflect virulence as detected by virulence genes presence. The role of alginate in the formation of biofilms and the effect of ambroxol, a mucolytic agent, on the inhibition of biofilm formation were investigated. RESULTS A multi-drug resistant phenotype was detected among 79.8% of the isolates. The most predominant virulence factor was biofilm formation (89.4%), while DNase was least detected (10.6%). Pigment production was significantly associated with ceftazidime susceptibility, phospholipase C production was significantly linked to sensitivity to cefepime, and DNase production was significantly associated with intermediate resistance to meropenem. Among the tested virulence genes, lasB and algD showed the highest prevalence rates (93.3% and 91.3%, respectively), while toxA and plcN were the least detected ones (46.2% and 53.8%, respectively). Significant association of toxA with ceftazidime susceptibility, exoS with ceftazidime and aztreonam susceptibility, and plcH with piperacillin-tazobactam susceptibility was observed. There was a significant correlation between alkaline protease production and the detection of algD, lasB, exoS, plcH and plcN; pigment production and the presence of algD, lasB, toxA and exoS; and gelatinase production and the existence of lasB, exoS and plcH. Ambroxol showed a high anti-biofilm activity (5% to 92%). Quantitative reverse transcriptase polymerase chain reaction showed that alginate was not an essential matrix component in P. aeruginosa biofilms. CONCLUSIONS High virulence coupled with the isolates' multi-drug resistance to commonly used antimicrobials would increase morbidity and mortality rates among P. aeruginosa infections. Ambroxol that displayed anti-biofilm action could be suggested as an alternative treatment option, yet in vivo studies are required to confirm these findings. We recommend active surveillance of antimicrobial resistance and virulence determinant prevalence for better understanding of coregulatory mechanisms.
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Affiliation(s)
- Eva A Edward
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt.
| | - Marwa R El Shehawy
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
| | - Alaa Abouelfetouh
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alamein International University, Alamein, Egypt
| | - Elsayed Aboulmagd
- Department of Microbiology and Immunology, Faculty of Pharmacy, Alexandria University, Alexandria, Egypt
- College of Pharmacy, Arab Academy for Science, Technology and Maritime, Alamein Branch, Alamein, Egypt
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Balducci E, Papi F, Capialbi DE, Del Bino L. Polysaccharides' Structures and Functions in Biofilm Architecture of Antimicrobial-Resistant (AMR) Pathogens. Int J Mol Sci 2023; 24:ijms24044030. [PMID: 36835442 PMCID: PMC9965654 DOI: 10.3390/ijms24044030] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Revised: 02/13/2023] [Accepted: 02/14/2023] [Indexed: 02/19/2023] Open
Abstract
Bacteria and fungi have developed resistance to the existing therapies such as antibiotics and antifungal drugs, and multiple mechanisms are mediating this resistance. Among these, the formation of an extracellular matrix embedding different bacterial cells, called biofilm, is an effective strategy through which bacterial and fungal cells are establishing a relationship in a unique environment. The biofilm provides them the possibility to transfer genes conferring resistance, to prevent them from desiccation and to impede the penetration of antibiotics or antifungal drugs. Biofilms are formed of several constituents including extracellular DNA, proteins and polysaccharides. Depending on the bacteria, different polysaccharides form the biofilm matrix in different microorganisms, some of them involved in the first stage of cells' attachment to surfaces and to each other, and some responsible for giving the biofilm structure resistance and stability. In this review, we describe the structure and the role of different polysaccharides in bacterial and fungal biofilms, we revise the analytical methods to characterize them quantitatively and qualitatively and finally we provide an overview of potential new antimicrobial therapies able to inhibit biofilm formation by targeting exopolysaccharides.
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Affiliation(s)
| | | | - Daniela Eloisa Capialbi
- GSK, 53100 Siena, Italy
- Department of Biotechnology, Chemistry and Pharmacy, University of Siena, 53100 Siena, Italy
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Li S, Kuok KI, Ji X, Xu A, Yin H, Zheng J, Tan H, Wang R. Supramolecular Modulation of Antibacterial Activity of Ambroxol by Cucurbit[7]uril. Chempluschem 2021; 85:679-683. [PMID: 32253831 DOI: 10.1002/cplu.202000119] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2020] [Revised: 03/24/2020] [Indexed: 12/14/2022]
Abstract
Supramolecular encapsulation by cucurbit[7]uril (CB[7]) was recently demonstrated to provide a simple and efficient method for antibacterial activity regulation of antibiotics. In this work, CB[7] was shown to form binary host-guest complex with ambroxol hydrochloride (ABX), a clinical mucokinetic and expectorant drug, which was reported to exhibit certain antibacterial activity. 1 H NMR titration and isothermal titration calorimetry experiment results suggested that the 4-hydroxyl cyclohexylamine group of ABX was included inside the CB[7] cavity, with a binding constant Ka of (6.69±0.11)×105 M-1 in phosphate buffered saline (PBS) solution, thermodynamically driven by both enthalpy change (ΔH=-12.2 kJ/mol) and entropy change (TΔS=21.1 kJ/mol). More importantly, ABX's inhibitory activity (MIC50 ) against bacillary strains towards Pseudomonas aeruginosa and Escherichia coli strains was decreased from (5.11±0.31)×10-6 M-1 and (2.63±0.34)×10-5 M-1 to zero upon encapsulation by CB[7], and was subsequently recovered to almost its original activity when a competitive guest, amantadine hydrochloride, for disassembling CB[7]-ABX complex, was added, suggesting that the antibacterial activity of ABX could be readily "turned off/on" upon its complexation and decomplexation with CB[7].
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Affiliation(s)
- Shengke Li
- School of Materials Science and Engineering, Nanjing University of Science and Technology, Nanjing, 210094, P. R. China
| | - Kit Ieng Kuok
- State Key Laboratory of Quality Research in Chinese Medicine Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, 999078, Macau, P. R. China
| | - Xia Ji
- Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, 999078, Macau, P. R. China
| | - Anni Xu
- School of Materials Science and Engineering, Nanjing University of Science and Technology, Nanjing, 210094, P. R. China
| | - Hang Yin
- State Key Laboratory of Quality Research in Chinese Medicine Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, 999078, Macau, P. R. China
| | - Jun Zheng
- Faculty of Health Sciences, University of Macau, Avenida da Universidade, Taipa, 999078, Macau, P. R. China
| | - Huaping Tan
- School of Materials Science and Engineering, Nanjing University of Science and Technology, Nanjing, 210094, P. R. China
| | - Ruibing Wang
- State Key Laboratory of Quality Research in Chinese Medicine Institute of Chinese Medical Sciences, University of Macau, Avenida da Universidade, Taipa, 999078, Macau, P. R. China
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Kantar A, Klimek L, Cazan D, Sperl A, Sent U, Mesquita M. An overview of efficacy and safety of ambroxol for the treatment of acute and chronic respiratory diseases with a special regard to children. Multidiscip Respir Med 2020; 15:511. [PMID: 32269775 PMCID: PMC7137760 DOI: 10.4081/mrm.2020.511] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 02/14/2020] [Indexed: 12/20/2022] Open
Abstract
Introduction: Ambroxol (2-amino-3,5-dibromo-N-[trans-4-hydroxycyclohexyl]benzylamine), an over-the-counter product, is a mucoactive agent and has been used widely to treat both acute and chronic respiratory diseases since 1978. This review aims to provide an overview of the clinical evidence available on the use of ambroxol in children with acute and chronic respiratory diseases. Data for this review were obtained from both published and unpublished clinical studies, and real-world evidence studies. Although conducted prior to the introduction of Good Clinical Practice (GCP), these studies, representing almost 1,300 pediatric patients, report strong clinical outcomes following the use of ambroxol in pediatric patients. Furthermore, efficacy findings were consistent irrespective of age, including for patients as young as 1 month old. Additionally, the majority of studies found ambroxol to be well tolerated in children. Taken together, the clinical evidence for ambroxol shows treatment effects that offer significant benefits to pediatric patients for its licensed use as a secretolytic therapy in acute and chronic bronchopulmonary disorders associated with abnormal mucus secretion and impaired mucus transport. The findings from this review indicate that ambroxol, for its intended over-the-counter indications, is both efficacious and well tolerated in children and that the favorable benefit/risk profile of ambroxol reported in adults extends to the pediatric population, starting from early infancy, with acute and chronic respiratory diseases.
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Affiliation(s)
- Ahmad Kantar
- Pediatric Cough and Asthma Center, Istituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
| | - Ludger Klimek
- Wiesbaden Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Dorotheea Cazan
- Maria Hilf Kliniken, Department of Otorhinolaryngology, Head and Neck Surgery, University Hospital Aachen, Mönchengladbach, Germany
| | - Annette Sperl
- Wiesbaden Center for Rhinology and Allergology, Wiesbaden, Germany
| | - Ulrike Sent
- Medical Advisor CHC GSA, Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany
| | - Margarida Mesquita
- Global Medical Lead CHC, Sanofi-Aventis Deutschland GmbH, Frankfurt am Main, Germany
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Cazan D, Klimek L, Sperl A, Plomer M, Kölsch S. Safety of ambroxol in the treatment of airway diseases in adult patients. Expert Opin Drug Saf 2018; 17:1211-1224. [PMID: 30372367 DOI: 10.1080/14740338.2018.1533954] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
INTRODUCTION Ambroxol is a widely used secretolytic and mucoactive over-the-counter agent primarily used to treat respiratory diseases associated with viscid mucus. Following post-marketing reports of hypersensitivity reactions and severe cutaneous adverse reactions (SCARs) possibly linked to ambroxol, the European Union's Pharmacovigilance Risk Assessment Committee (PRAC) initiated in April 2014 a review of the safety of ambroxol in all its registered indications, which was finalized in 2016. Areas covered: Here, we evaluate the clinical safety of ambroxol and provide an expert opinion on the benefit-risk balance of ambroxol in the treatment of adult patients with bronchopulmonary diseases. The evidence for this review is derived from clinical trials of ambroxol that were provided to the PRAC by the marketing authorization holders of ambroxol-containing medicines. Expert opinion: Clinical experience accumulated from randomized clinical trials and observational studies suggests that ambroxol is a safe and well-tolerated treatment of bronchopulmonary diseases, with a well-balanced and favorable benefit-risk profile. All reported adverse events were mild and self-limiting, and the risk of SCARs with ambroxol is low. Further investigations could address the safety and efficacy of ambroxol in pediatric lung diseases and in additional therapeutic indications, such as biofilm-dependent airway disease and lysosomal storage disorders.
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Affiliation(s)
- Dorotheea Cazan
- a Department of Otorhinolaryngology, Head and Neck Surgery, Sleep Disorders Center , University Hospital Mannheim , Mannheim , Germany
| | - Ludger Klimek
- b Wiesbaden Center for Rhinology and Allergology , Wiesbaden , Germany
| | - Annette Sperl
- b Wiesbaden Center for Rhinology and Allergology , Wiesbaden , Germany
| | - Manuel Plomer
- c Global Medical Affairs , Sanofi Aventis Deutschland GmbH , Frankfurt am Main , Germany
| | - Stephan Kölsch
- c Global Medical Affairs , Sanofi Aventis Deutschland GmbH , Frankfurt am Main , Germany
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Polymorphonuclear Leukocytes or Hydrogen Peroxide Enhance Biofilm Development of Mucoid Pseudomonas aeruginosa. Mediators Inflamm 2018; 2018:8151362. [PMID: 30116152 PMCID: PMC6079396 DOI: 10.1155/2018/8151362] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Revised: 03/13/2018] [Accepted: 04/16/2018] [Indexed: 01/05/2023] Open
Abstract
Pseudomonas aeruginosa is an opportunistic pathogenic bacterium involved in many human infections, including pneumonia, diabetic foot ulcers, and ventilator-associated pneumonia. P. aeruginosa cells usually undergo mucoid conversion during chronic lung infection in patients with cystic fibrosis (CF) and resist destruction by polymorphonuclear leukocytes (PMNs), which release free oxygen radicals (ROS), such as H2O2. PMNs are the main leucocytes in the CF sputum of patients who are infected with P. aeruginosa, which usually forms biofilms. Here, we report that PMNs or H2O2 can promote biofilm formation by mucoid P. aeruginosa FRD1 with the use of the hanging-peg method. The mucoid strain infecting CF patients overproduces alginate. In this study, PMNs and H2O2 promoted alginate production, and biofilms treated with PMNs or H2O2 exhibited higher expression of alginate genes. Additionally, PMNs increased the activity of GDP-mannose dehydrogenase, which is the key enzyme in alginate biosynthesis. Our results demonstrate that PMNs or H2O2 can enhance mucoid P. aeruginosa biofilms.
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7
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[More than expectorant: new scientific data on ambroxol in the context of the treatment of bronchopulmonary diseases]. MMW Fortschr Med 2017. [PMID: 28643291 DOI: 10.1007/s15006-017-9805-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ambroxol has been established for decades in the treatment of acute and chronic respiratory diseases. In 2015, the European Medicines Agency reassessed the clinical benefit-risk ratio of the drug. OBJECTIVE What new scientific data on ambroxol, which are relevant to the treatment of bronchopulmonary diseases, are available? METHOD The review is based on a systematic literature research in medline with the search term "ambroxol" during the publication period 2006-2015. Non-relevant publications were excluded manually. RESULTS AND CONCLUSIONS Ambroxol is still intensively researched. The traditional indication as an expectorant is confirmed. But there is also an ever better understanding of the various mechanisms of action as well as the ever more exact modeling of the structures under investigation. New fields of application are conceivable, e. g. in patients with severe pulmonary disease who undergo surgery or who are in intensive care, as an adjuvant in anti-infective therapies, especially in infections with biofilm-producing pathogens, or in rare diseases such as lysosomal storage diseases. However, final evidence of the clinical relevance in these fields of application is still missing.
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Li X, Zhao Y, Huang X, Yu C, Yang Y, Sun S. Ambroxol Hydrochloride Combined with Fluconazole Reverses the Resistance of Candida albicans to Fluconazole. Front Cell Infect Microbiol 2017; 7:124. [PMID: 28439502 PMCID: PMC5383865 DOI: 10.3389/fcimb.2017.00124] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Accepted: 03/27/2017] [Indexed: 12/24/2022] Open
Abstract
In this study, we found that ambroxol hydrochloride (128 μg/mL) exhibits synergistic antifungal effects in combination with fluconazole (2 μg/mL) against resistant planktonic Candida albicans (C. albicans) cells. This combination also exhibited synergistic effects against resistant C. albicans biofilms in different stages (4, 8, and 12 h) according to the microdilution method. In vitro data were further confirmed by the success of this combination in treating Galleria mellonella infected by resistant C. albicans. With respect to the synergistic mechanism, our result revealed that ambroxol hydrochloride has an effect on the drug transporters of resistant C. albicans, increasing the uptake and decreasing the efflux of rhodamine 6G, a fluorescent alternate of fluconazole. This is the first study to investigate the in vitro and in vivo antifungal effects, as well as the possible synergistic mechanism of ambroxol hydrochloride in combination with fluconazole against resistant C. albicans. The results show the potential role for this drug combination as a therapeutic alternative to treat resistant C. albicans and provide insights into the development of antifungal targets and new antifungal agents.
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Affiliation(s)
- Xiuyun Li
- School of Pharmaceutical Sciences, Shandong UniversityJinan, China
| | - Yuanhao Zhao
- Pharmaceutical Department, Qianfoshan Hospital Affiliated to Shandong UniversityJinan, China
| | - Xin Huang
- Pharmaceutical Department, Qianfoshan Hospital Affiliated to Shandong UniversityJinan, China
| | - Cuixiang Yu
- Respiration Medicine, Qianfoshan Hospital Affiliated to Shandong UniversityJinan, China
| | - Yilei Yang
- Pharmaceutical Department, Qianfoshan Hospital Affiliated to Shandong UniversityJinan, China
| | - Shujuan Sun
- Pharmaceutical Department, Qianfoshan Hospital Affiliated to Shandong UniversityJinan, China
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Wang W, Yu J, He Y, Wang Z, Li F. Ambroxol inhibits mucoid conversion ofPseudomonas aeruginosaand contributes to the bactericidal activity of ciprofloxacin against mucoidP. aeruginosabiofilms. APMIS 2016; 124:611-8. [DOI: 10.1111/apm.12542] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Accepted: 03/23/2016] [Indexed: 11/26/2022]
Affiliation(s)
- Wenlei Wang
- Department of PICU; Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Chongqing China
| | - Jialin Yu
- Department of Neonatology; Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Chongqing China
| | - Yu He
- Department of Neonatology; Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Chongqing China
| | - Zhengli Wang
- Department of Neonatology; Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Chongqing China
| | - Fang Li
- Department of Neonatology; Children's Hospital of Chongqing Medical University; Ministry of Education Key Laboratory of Child Development and Disorders; Key Laboratory of Pediatrics in Chongqing; Chongqing International Science and Technology Cooperation Center for Child Development and Disorders; Chongqing China
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Zhang P, Shao Z, Jin W, Duan D. Comparative characterization of two GDP-mannose dehydrogenase genes from Saccharina japonica (Laminariales, Phaeophyceae). BMC PLANT BIOLOGY 2016; 16:62. [PMID: 26956020 PMCID: PMC4782291 DOI: 10.1186/s12870-016-0750-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 02/27/2016] [Indexed: 05/26/2023]
Abstract
BACKGROUND Saccharina japonica is an important commercial brown seaweed, its main product is alginate, which is used in food, textile and by the cosmetic and pharmaceutical industries. GDP-mannose dehydrogenase (GMD) is the key enzyme involved in the synthesis of alginate. However, little is known about GMD in S. japonica. Here we report comparative biochemical analysis of two GMD genes in S. japonica. RESULTS Two GMD genes from S. japonica (Sjgmd1, Sjgmd2) were cloned. The open reading frame lengths of Sjgmd1, Sjgmd2 are 963 bp and 948 bp, respectively. Alignment analysis showed that the two SjGMD sequences shared 79.38 % identity. Both proteins possess the GGxCLPKDV and GxGxVG sequence motifs characteristic of the short-chain dehydrogenase/reductase superfamily. The optimum temperatures for SjGMDs were 30 °C (SjGMD1) and 20 °C (SjGMD2), and the optimum pH values were 8.0 (SjGMD1) and 8.25 (SjGMD2). Kinetic analysis demonstrated the Km values for the substrate GDP-mannose were 289 μM (SjGMD1) and 177 μM (SjGMD2), and the Km values for the cofactor NAD(+) were 139 μM (SjGMD1) and 195 μM (SjGMD2). The metal iron Zn(2+) is a potent inhibitor of SjGMD1 and SjGMD2. Real-time PCR analysis showed that heat and desiccation treatments resulted in a significant increase in Sjgmd1 and Sjgmd2 transcript abundance, suggesting that the SjGMDs are directly involved in the acclimitisation of S. japonica to abiotic stresses. CONCLUSION Our work identified two novel genes encoding GMD in S. japonica, comparatively characterized their structural characteristics and enzyme kinetics, and revealed the function of GMD in the stress adaptability of S. japonica. The knowledge obtained here enriched our understanding of the alginate synthesis mechanism in S. japonica, and may promote further research on functional differences between GMD genes.
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Affiliation(s)
- Pengyan Zhang
- Key Laboratory of Experimental Marine Biology, Institute of Oceanology, Chinese Academy of Sciences, Qingdao, 266071, China.
- Laboratory for Marine Biology and Biotechnology, Qingdao National Laboratory for Marine Science and Technology, Qingdao, 266071, China.
- University of Chinese Academy of Sciences, Beijing, 100049, China.
| | - Zhanru Shao
- Key Laboratory of Experimental Marine Biology, Institute of Oceanology, Chinese Academy of Sciences, Qingdao, 266071, China.
- Laboratory for Marine Biology and Biotechnology, Qingdao National Laboratory for Marine Science and Technology, Qingdao, 266071, China.
| | - Weihua Jin
- Key Laboratory of Experimental Marine Biology, Institute of Oceanology, Chinese Academy of Sciences, Qingdao, 266071, China.
- Laboratory for Marine Biology and Biotechnology, Qingdao National Laboratory for Marine Science and Technology, Qingdao, 266071, China.
| | - Delin Duan
- Key Laboratory of Experimental Marine Biology, Institute of Oceanology, Chinese Academy of Sciences, Qingdao, 266071, China.
- Laboratory for Marine Biology and Biotechnology, Qingdao National Laboratory for Marine Science and Technology, Qingdao, 266071, China.
- State Key Laboratory of Seaweed Bioactive Substances, Qingdao, 266400, China.
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Wang Z, Xiang Q, Yang T, Li L, Yang J, Li H, He Y, Zhang Y, Lu Q, Yu J. Autoinducer-2 of Streptococcus mitis as a Target Molecule to Inhibit Pathogenic Multi-Species Biofilm Formation In Vitro and in an Endotracheal Intubation Rat Model. Front Microbiol 2016; 7:88. [PMID: 26903968 PMCID: PMC4744849 DOI: 10.3389/fmicb.2016.00088] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2015] [Accepted: 01/18/2016] [Indexed: 11/13/2022] Open
Abstract
Streptococcus mitis (S. mitis) and Pseudomonas aeruginosa (P. aeruginosa) are typically found in the upper respiratory tract of infants. We previously found that P. aeruginosa and S. mitis were two of the most common bacteria in biofilms on newborns' endotracheal tubes (ETTs) and in their sputa and that S. mitis was able to produce autoinducer-2 (AI-2), whereas P. aeruginosa was not. Recently, we also found that exogenous AI-2 and S. mitis could influence the behaviors of P. aeruginosa. We hypothesized that S. mitis contributes to this interspecies interaction and that inhibition of AI-2 could result in inhibition of these effects. To test this hypothesis, we selected PAO1 as a representative model strain of P. aeruginosa and evaluated the effect of S. mitis as well as an AI-2 analog (D-ribose) on mono- and co-culture biofilms in both in vitro and in vivo models. In this context, S. mitis promoted PAO1 biofilm formation and pathogenicity. Dual-species (PAO1 and S. mitis) biofilms exhibited higher expression of quorum sensing genes than single-species (PAO1) biofilms did. Additionally, ETTs covered in dual-species biofilms increased the mortality rate and aggravated lung infection compared with ETTs covered in mono-species biofilms in an endotracheal intubation rat model, all of which was inhibited by D-ribose. Our results demonstrated that S. mitis AI-2 plays an important role in interspecies interactions with PAO1 and may be a target for inhibition of biofilm formation and infection in ventilator-associated pneumonia.
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Affiliation(s)
- Zhengli Wang
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Qingqing Xiang
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Ting Yang
- Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical Disorders Chongqing, China
| | - Luquan Li
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Jingli Yang
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Hongong Li
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Yu He
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Yunhui Zhang
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Qi Lu
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
| | - Jialin Yu
- Department of Neonatology, Children's Hospital of Chongqing Medical UniversityChongqing, China; Ministry of Education Key Laboratory of Child Development and Disorders - Chongqing Key Laboratory of Pediatrics - China International Science and Technology Cooperation Base of Child Development and Critical DisordersChongqing, China
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Cheng C, Du L, Yu J, Lu Q, He Y, Ran T. Ciprofloxacin plus erythromycin or ambroxol ameliorates endotracheal tube-associated Pseudomonas aeruginosa biofilms in a rat model. Pathol Res Pract 2015; 211:982-8. [PMID: 26601615 DOI: 10.1016/j.prp.2015.10.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2015] [Revised: 09/27/2015] [Accepted: 10/02/2015] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND OBJECTIVE Pseudomonas aeruginosa is a multi-drug resistant bacterium, with its biofilm-growing mucoid (alginate-producing) strains being particularly resistant. As atomized drug administration is a common practice in pediatric patients, we compared the effect of inhalational therapy with erythromycin plus ciprofloxacin, with that of ambroxol plus ciprofloxacin, against biofilm producing strains of P. aeruginosa. RESULTS Both combined treatment regimens were associated with a significant reduction in bacterial counts in endotracheal (ET) tubes and lungs, as compared to that observed with ambroxol and erythromycin monotherapies (P<0.05). Ciprofloxacin plus ambroxol appeared to have a higher efficacy than ciprofloxacin plus erythromycin, both in lowering bacterial counts (P<0.05) and in disrupting the structural integrity of biofilm. Histopathological changes in the lungs were milder in the two combined treatment groups, as compared to that in groups treated with single drugs. CONCLUSION Erythromycin or ambroxol in combination with ciprofloxacin could eliminate P. aeruginosa biofilms. When combined with ciprofloxacin, ambroxol outperformed erythromycin in eradicating P. aeruginosa biofilm.
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Affiliation(s)
- Chen Cheng
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Lizhong Du
- The Children's Hospital, Zhejiang University School of Medicine, China
| | - Jialin Yu
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China.
| | - Qi Lu
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Yu He
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
| | - Tao Ran
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China
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Synergy of ambroxol with vancomycin in elimination of catheter-related Staphylococcus epidermidis biofilm in vitro and in vivo. J Infect Chemother 2015; 21:808-15. [PMID: 26423688 DOI: 10.1016/j.jiac.2015.08.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 08/04/2015] [Accepted: 08/25/2015] [Indexed: 12/13/2022]
Abstract
Central venous catheters are widely used in neonatal intensive care units (NICUs) nowadays. The commonest cause of catheter-related bloodstream infections (CRBSIs) is coagulase-negative staphylococci (CoNS). Ambroxol, an active metabolite of bromhexine, exhibits antimicrobial activity against strains producing biofilm and enhances the bactericidal effect of some antibiotic by breaking the structure of biofilm. In this study, we aimed to determine the effect of ambroxol with vancomycin on the biofilm of Staphylococcus epidermidis (S. epidermidis) in vitro and in vivo. In the in vitro study, the biofilm of S. epidermidis was assessed by XTT reduction assay and analysed by confocal laser scanning microscopy (CLSM). In the in vivo study, a rabbit model of CRBSIs was created by intravenous intubation with a tube covered with S. epidermidis biofilm. The rabbits received one of the following four treatments by means of antibiotic lock therapy: normal heparin, ambroxol, vancomycin, or vancomycin plus ambroxol each for 3 days. The microstructure of the biofilm was assessed by scanning electron microscopy (SEM). The number of bacterial colonies in the organs (liver, heart, and kidney) and on the intravenous tubes was measured on agar plates. Pathological changes in the organs (liver, heart, and kidney) were observed with Hematoxylin-Eosin staining. The ambroxol exhibits significant efficacy to potentiate the bactericidal effect of vancomycin on S. epidermidis biofilm both in vitro and in vivo. The antibiotic lock therapy using a combination of ambroxol and vancomycin reveals a high ability to eradicate S. epidermidis biofilms in vivo. These results provide the basis of a useful anti-infection strategy for the treatment of CRBSIs.
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Masák J, Čejková A, Schreiberová O, Rezanka T. Pseudomonas biofilms: possibilities of their control. FEMS Microbiol Ecol 2014; 89:1-14. [PMID: 24754832 DOI: 10.1111/1574-6941.12344] [Citation(s) in RCA: 75] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2014] [Revised: 04/02/2014] [Accepted: 04/08/2014] [Indexed: 12/15/2022] Open
Abstract
Genus Pseudomonas includes a large number of species that can be encountered in biotechnological processes as well as in the role of serious human or plant pathogens. Pseudomonads easily form biofilms on various types of surfaces. The biofilm phenotype is characterized by an increased resistance to environmental influences including resistance to antibiotics and other disinfectants, causing a number of problems in health care, food industry, and other areas. Considerable attention is therefore paid to the possibilities of eradication/destruction of pseudomonads biofilms both in terms of understanding the mechanisms of biofilm formation and at the level of finding suitable antibiofilm tools applicable in practice. The first part of this review is devoted to an overview of the regulatory mechanisms that are directly or indirectly involved in the formation of biofilm. The most effective approaches to suppressing the formation of biofilm that do not cause the development of resistance are based on the application of substances that interfere with the regulatory molecules or block the appropriate regulatory mechanisms involved in biofilm development by the cells. Pseudomonads biofilm formation is, similar to other microorganisms, a sophisticated process with many regulatory elements. The suppression of this process therefore also requires multiple antibiofilm tools.
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Affiliation(s)
- Jan Masák
- Department of Biotechnology, Institute of Chemical Technology Prague, Prague 6, Czech Republic
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15
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Cataldi M, Sblendorio V, Leo A, Piazza O. Biofilm-dependent airway infections: a role for ambroxol? Pulm Pharmacol Ther 2013; 28:98-108. [PMID: 24252805 DOI: 10.1016/j.pupt.2013.11.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2013] [Revised: 10/31/2013] [Accepted: 11/11/2013] [Indexed: 11/16/2022]
Abstract
Biofilms are a key factor in the development of both acute and chronic airway infections. Their relevance is well established in ventilator associated pneumonia, one of the most severe complications in critically ill patients, and in cystic fibrosis, the most common lethal genetic disease in Caucasians. Accumulating evidence suggests that biofilms could have also a role in chronic obstructive pulmonary disease and their involvement in bronchiectasis has been proposed as well. When they grow in biofilms, microorganisms become multidrug-resistant. Therefore the treatment of biofilm-dependent airway infections is problematic. Indeed, it still largely based on measures aiming to prevent the formation of biofilms or remove them once that they are formed. Here we review recent evidence suggesting that the mucokinetic drug ambroxol has specific anti-biofilm properties. We also discuss how additional pharmacological properties of this drug could be beneficial in biofilm-dependent airway infections. Specifically, we review the evidence showing that: 1-ambroxol exerts anti-inflammatory effects by inhibiting at multiple levels the activity of neutrophils, and 2-it improves mucociliary clearance by interfering with the activity of airway epithelium ion channels and transporters including sodium/bicarbonate and sodium/potassium/chloride cotransporters, cystic fibrosis transmembrane conductance regulator and aquaporins. As a whole, the data that we review here suggest that ambroxol could be helpful in biofilm-dependent airway infections. However, considering the limited clinical evidence available up to date, further clinical studies are required to support the use of ambroxol in these diseases.
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Affiliation(s)
- M Cataldi
- Division of Pharmacology, Department of Neuroscience, Reproductive and Odontostomatologic Sciences, Federico II University of Naples, Via Pansini 5, 80131 Napoli, Italy.
| | - V Sblendorio
- Division of Pharmacology, Department of Neuroscience, Reproductive and Odontostomatologic Sciences, Federico II University of Naples, Via Pansini 5, 80131 Napoli, Italy
| | - A Leo
- Department of Health Sciences, University Magna Græcia of Catanzaro, University Campus "Salvatore Venuta", Viale Europa, I-88100 Catanzaro, Italy
| | - O Piazza
- University of Salerno, Via Allende, 84081 Baronissi, Italy
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Rene HD, José MSJ, Isela SNR, Claudio CR. Effects of ambroxol onCandida albicansgrowth and biofilm formation. Mycoses 2013; 57:228-32. [DOI: 10.1111/myc.12147] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Revised: 08/22/2013] [Accepted: 09/14/2013] [Indexed: 01/01/2023]
Affiliation(s)
- Hernandez-Delgadillo Rene
- Facultad de Ciencias Biológicas; Instituto de Biotecnologia; Universidad Autonoma de Nuevo Leon, UANL; Monterrey Nuevo Leon Mexico
| | | | | | - Cabral-Romero Claudio
- Facultad de Odontologia; Universidad Autonoma de Nuevo Leon, UANL; Monterrey Nuevo Leon Mexico
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Lu Q, Yu J, Bao L, Ran T, Zhong H. Effects of combined treatment with ambroxol and ciprofloxacin on catheter-associated Pseudomonas aeruginosa biofilms in a rat model. Chemotherapy 2013; 59:51-6. [PMID: 23816803 DOI: 10.1159/000351107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2012] [Accepted: 03/26/2013] [Indexed: 11/19/2022]
Abstract
BACKGROUND Pseudomonas aeruginosa is an opportunistic pathogen that causes potentially devastating infections in immunocompromised patients. These infections are particularly difficult to treat if a biofilm forms, which is likely if foreign bodies are present. OBJECTIVE This study aimed to investigate the effect of ambroxol combined with ciprofloxacin on P. aeruginosa biofilm in a rat model. METHODS A rat model of acute lung infection was created by endotracheal (ET) intubation with a tube covered with a P. aeruginosa biofilm. The rats were treated with ciprofloxacin alone, ambroxol alone, or a combination of both for 7 days. The microstructure of the biofilm on the tube was assessed by scanning electron microscopy (SEM). The numbers of bacterial colonies in the lungs and on the ET tube were measured on agar plates. Pathological changes in the lungs were observed with hematoxylin and eosin staining. RESULTS Changes in the microstructure of the biofilm after combined treatment were demonstrated by SEM. Ambroxol combined with ciprofloxacin significantly reduced the number of bacteria in the lungs and ET tube compared to the single treatments (p < 0.05). The pathological changes in the lungs were also mildest after the combined treatment. CONCLUSION The combination treatment of ambroxol with ciprofloxacin has a high ability to eradicate P. aeruginosa biofilms in vivo. These initial results provide the basis of a new strategy for the treatment of P. aeruginosa infections.
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Affiliation(s)
- Qi Lu
- Department of Neonatology, Children's Hospital, Chongqing Medical University, Chongqing, China. qilu_qi @ hotmail.com
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Pulcrano G, Panellis D, De Domenico G, Rossano F, Catania MR. Ambroxol influences voriconazole resistance of Candida parapsilosis biofilm. FEMS Yeast Res 2012; 12:430-8. [PMID: 22315984 DOI: 10.1111/j.1567-1364.2012.00792.x] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2011] [Revised: 01/06/2012] [Accepted: 01/30/2012] [Indexed: 11/29/2022] Open
Abstract
The ability to form biofilm on different surfaces is typical of most Candida species. Microscopic structure and genetic aspects of fungal biofilms have been the object of many studies because of very high resistance to antimycotic agents because of the scarce permeability of the external matrix and to the alterations in cell metabolism. In our study, 31 isolates of Candida parapsilosis, isolated from bloodstream infections, were tested for their ability to produce biofilm and were found to be good producers. The susceptibility to voriconazole, assayed by colorimetrical XTT assay, revealed a very elevated minimum inhibitory concentrations for sessile cells in comparison with planktonic ones. The addition of ambroxol, a mucolytic agent, increased the susceptibility of biofilm forming cells to voriconazole. Expression of the efflux pump genes CDR and MDR was analyzed in biofilms alone or treated with ambroxol, evidencing a role of ambroxol in the expression of genes involved in azole resistance mechanisms of C. parapsilosis biofilms. In conclusion, our data seem to encourage the use of different substances in combination with classical antimycotics, with the aim of finding a solution to the increasing problem of the resistance of biofilms formed on medical devices by nonalbicans Candida species.
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Affiliation(s)
- Giovanna Pulcrano
- Department of Cellular and Molecular Biology and Pathology "Luigi Califano", Medicine School, University of Naples "Federico II", Naples, Italy.
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Paleari D, Rossi GA, Nicolini G, Olivieri D. Ambroxol: a multifaceted molecule with additional therapeutic potentials in respiratory disorders of childhood. Expert Opin Drug Discov 2011; 6:1203-14. [PMID: 22646987 DOI: 10.1517/17460441.2011.629646] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Mucoactive drugs are currently used to cleanse the respiratory tract following disturbance of the normal mucociliary clearance due to mucous hyperproduction and/or modification of its physicochemical characteristics. However, in addition to possessing the ability to perform specific actions on airway secretion, these compounds have the capability to modulate the mechanisms involved in abnormal secretions. Indeed, over the years, in the postmarketing phase, a large number of studies have been published showing interesting pharmacological activities in addition to their secretagogue activity. AREAS COVERED This article collates available data on ambroxol (2-amino-3,5-dibromo-N-[trans-4-hydroxycyclohexyl]benzylamine), a metabolite of bromhexine, used as a secretagogue in the treatment of childhood airway diseases. This article goes beyond the mucoactive aspects of the drug covering its multiple pharmacological properties. EXPERT OPINION The non-mucoactive functions exhibited by the compound may provide beneficial effects on airway structure and function in health and disease. Beyond the mucokinetic and secretagogue effects, ambroxol showed great antioxidant, anti-inflammatory, local anesthetic and surfactant synthesis stimulatory activities. Moreover, some antiviral and antibacterial activities were shown. These findings may better explain the clinical results observed in a variety of airway disorders and suggest additional therapeutic potential. Further studies are needed to better define the clinical relevance of these non-mucolytic activities.
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Affiliation(s)
- Davide Paleari
- Medical Department , Chiesi Farmaceutici , Parma , Italy
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20
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Li F, Wang W, Hu L, Li L, Yu J. Effect of Ambroxol on Pneumonia Caused by Pseudomonas aeruginosa with Biofilm Formation in an Endotracheal Intubation Rat Model. Chemotherapy 2011; 57:173-80. [DOI: 10.1159/000323622] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2010] [Accepted: 08/11/2010] [Indexed: 11/19/2022]
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21
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Lu Q, Yu J, Yang X, Wang J, Wang L, Lin Y, Lin L. Ambroxol interferes with Pseudomonas aeruginosa quorum sensing. Int J Antimicrob Agents 2010; 36:211-5. [DOI: 10.1016/j.ijantimicag.2010.05.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2009] [Revised: 05/02/2010] [Accepted: 05/06/2010] [Indexed: 10/19/2022]
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22
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Liu YCC, Post JC. Biofilms in pediatric respiratory and related infections. Curr Allergy Asthma Rep 2009; 9:449-55. [PMID: 19814917 DOI: 10.1007/s11882-009-0066-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Bacteria can grow as free-floating, planktonic bacteria or complex communities called biofilms. Biofilms promote bacterial growth and diversity and offer bacteria unique environments, including aerobic and anaerobic layers, that facilitate resistance to antimicrobial therapies. Respiratory and related structures provide ideal environments for the development of bacterial biofilms, which predispose patients to recurrent and chronic infections. Biofilms are important for the persistence of chronic rhinosinusitis, pulmonary infections in cystic fibrosis, chronic otitis media, and device-related infections. Antimicrobial therapy that is proven effective against planktonic bacteria is often insufficiently effective against the defenses of biofilms. Furthermore, biofilms modify themselves following exposure to antimicrobial therapy, thus developing increased resistance. Understanding the nature of biofilms in common pediatric infections is essential to comprehending the expected course of bacterial illness and identifying treatments that are most likely to be beneficial against more resistant biofilms.
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Abstract
OBJECTIVE Although most reviews of Pseudomonas aeruginosa therapeutics focus on antibiotics currently in use or in the pipeline, we review evolving translational strategies aimed at using virulence factor antagonists as adjunctive therapies. DATA SOURCE Current literature regarding P. aeruginosa virulence determinants and approaches that target them, with an emphasis on type III secretion, quorum-sensing, biofilms, and flagella. DATA EXTRACTION AND SYNTHESIS P. aeruginosa remains one of the most important pathogens in nosocomial infections, with high associated morbidity and mortality. Its predilection to develop resistance to antibiotics and expression of multiple virulence factors contributes to the frequent ineffectiveness of current therapies. Among the many P. aeruginosa virulence determinants that impact infections, type III secretion, quorum sensing, biofilm formation, and flagella have been the focus on much recent investigation. Here we review how increased understanding of these important bacterial structures and processes has enabled the development of novel approaches to inhibit each. These promising translational strategies may lead to the development of adjunctive therapies capable of improving outcomes. CONCLUSIONS Adjuvant therapies directed against virulence factors have the potential to improve outcomes in P. aeruginosa infections.
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