Ability of Proteus mirabilis to swarm over urethral catheters

Overview of Proteus mirabilis pathogenicity and virulence. Insights into the role of metals

Proteus mirabilis is a Gram-negative bacterium with exclusive molecular and biological features. It is a versatile pathogen acclaimed for its distinct urease production, swarming behavior, and rapid multicellular activity. Clinically, P. mirabilis is a frequent pathogen of the human urinary system where it causes urinary tract infections (UTIs) and catheter-associated urinary tract infections (CAUTIs). This review explores the epidemiology, risk factors, clinical manifestations, and treatment of P. mirabilis infections, emphasizing its association with UTIs. The bacterium's genome analysis revealed the presence of resistance genes against commonly used antibiotics, an antibiotic-resistant phenotype that poses a serious clinical challenge. Particularly, the emergence of extended-spectrum β-lactamases (ESBLs) and carbapenemases resistant P. mirabilis strains. On a molecular level, P. mirabilis possesses a wide array of virulence factors including the production of fimbriae, urease, hemolysins, metallophores, and biofilm formation. This review thoroughly tackles a substantial gap in understanding the role of metallophores in shaping the virulence factors of P. mirabilis virulence. Siderophores, iron metal chelating and transporting metallophores, particularly contribute to the complex pathogenic strategies, displaying a potential target for therapeutic intervention.

Tackling catheter-associated urinary tract infections with next-generation antimicrobial technologies

Urinary catheters and other medical devices associated with the urinary tract such as stents are major contributors to nosocomial urinary tract infections (UTIs) as they provide an access path for pathogens to enter the bladder. Considering that catheter-associated urinary tract infections (CAUTIs) account for approximately 75% of UTIs and that UTIs represent the most common type of healthcare-associated infections, novel anti-infective device technologies are urgently required. The rapid rise of antimicrobial resistance in the context of CAUTIs further highlights the importance of such preventative strategies. In this review, the risk factors for pathogen colonization in the urinary tract are dissected, taking into account the nature and mechanistics of this unique environment. Moreover, the most promising next-generation preventative strategies are critically assessed, focusing in particular on anti-infective surface coatings. Finally, emerging approaches in this field and their likely clinical impact are examined.

Adjustment in the Composition and Organization of Proteus mirabilis Lipids during the Swarming Process

Proteus mirabilis, an opportunistic pathogen of the urinary tract, is known for its dimorphism and mobility. A connection of lipid alterations, induced by the rods elongation process, with enhanced pathogenicity of long-form morphotype for the development of urinary tract infections, seems highly probable. Therefore, research on the adjustment in the composition and organization of P. mirabilis lipids forming elongated rods was undertaken. The analyses performed using the ultra-high performance liquid chromatography with tandem mass spectrometry showed that drastic modifications in the morphology of P. mirabilis rods that occur during the swarming process are directly related to deprivation of the long-form cells of PE 33:1 and PG 31:2 and their enrichment with PE 32:1, PE 34:1, PE 34:2, PG 30:2, PG 32:1, and PG 34:1. The analyses conducted by the gas chromatography-mass spectrometry showed negligible effects of the swarming process on fatty acids synthesis. However, the constant proportions between unsaturated and saturated fatty acids confirmed that phenotypic modifications in the P. mirabilis rods induced by motility were independent of the saturation of the phospholipid tails. The method of the Förster resonance energy transfer revealed the influence of the swarming process on the melting of ordered lipid rafts present in the short-form rods, corresponding to the homogeneity of lipid bilayers in the long-form rods of P. mirabilis. Confocal microscope photographs visualized strong Rhod-PE fluorescence of the whole area of swarmer cells, in contrast to weak membrane fluorescence of non-swarmer cells. It suggested an increased permeability of the P. mirabilis bilayers in long-form rods morphologically adapted to the swarming process. These studies clearly demonstrate that swarming motility regulates the lipid composition and organization in P. mirabilis rods.

Role of Proteus mirabilis flagella in biofilm formation

Proteus mirabilis(P. mirabilis) is a common etiological agent of urinary tract infections, particularly those associated with catheterization. P. mirabilis efficiently forms biofilms on different surfaces and shows a multicellular behavior called 'swarming', mediated by flagella. To date, the role of flagella in P. mirabilis biofilm formation has been under debate. In this study, we assessed the role of P. mirabilis flagella in biofilm formation using an isogenic allelic replacement mutant unable to express flagellin. Different approaches were used, such as the evaluation of cell surface hydrophobicity, bacterial motility and migration across catheter sections, measurements of biofilm biomass and biofilm dynamics by immunofluorescence and confocal microscopy in static and flow models. Our findings indicate that P. mirabilis flagella play a role in biofilm formation, although their lack does not completely avoid biofilm generation. Our data suggest that impairment of flagellar function can contribute to biofilm prevention in the context of strategies focused on particular bacterial targets.

Structure and Assembly of the Proteus mirabilis Flagellar Motor by Cryo-Electron Tomography

Proteus mirabilis is a Gram-negative Gammaproteobacterium and a major causative agent of urinary tract infections in humans. It is characterized by its ability to switch between swimming motility in liquid media and swarming on solid surfaces. Here, we used cryo-electron tomography and subtomogram averaging to reveal the structure of the flagellar motor of P. mirabilis at nanometer resolution in intact cells. We found that P. mirabilis has a motor that is structurally similar to those of Escherichia coli and Salmonella enterica, lacking the periplasmic elaborations that characterize other more specialized gammaproteobacterial motors. In addition, no density corresponding to stators was present in the subtomogram average suggesting that the stators are dynamic. Finally, several assembly intermediates of the motor were seen that support the inside-out assembly pathway.

In Vivo Role of Two-Component Regulatory Systems in Models of Urinary Tract Infections

Two-component signaling systems (TCSs) are finely regulated mechanisms by which bacteria adapt to environmental conditions by modifying the expression of target genes. In bacterial pathogenesis, TCSs play important roles in modulating adhesion to mucosal surfaces, resistance to antibiotics, and metabolic adaptation. In the context of urinary tract infections (UTI), one of the most common types infections causing significant health problems worldwide, uropathogens use TCSs for adaptation, survival, and establishment of pathogenicity. For example, uropathogens can exploit TCSs to survive inside bladder epithelial cells, sense osmolar variations in urine, promote their ascension along the urinary tract or even produce lytic enzymes resulting in exfoliation of the urothelium. Despite the usefulness of studying the function of TCSs in in vitro experimental models, it is of primary necessity to study bacterial gene regulation also in the context of host niches, each displaying its own biological, chemical, and physical features. In light of this, the aim of this review is to provide a concise description of several bacterial TCSs, whose activity has been described in mouse models of UTI.

Spreading rates of bacterial colonies depend on substrate stiffness and permeability

The ability of bacteria to colonize and grow on different surfaces is an essential process for biofilm development. Here, we report the use of synthetic hydrogels with tunable stiffness and porosity to assess physical effects of the substrate on biofilm development. Using time-lapse microscopy to track the growth of expanding Serratia marcescens colonies, we find that biofilm colony growth can increase with increasing substrate stiffness, unlike what is found on traditional agar substrates. Using traction force microscopy-based techniques, we find that biofilms exert transient stresses correlated over length scales much larger than a single bacterium, and that the magnitude of these forces also increases with increasing substrate stiffness. Our results are consistent with a model of biofilm development in which the interplay between osmotic pressure arising from the biofilm and the poroelastic response of the underlying substrate controls biofilm growth and morphology.

Relevance of iron metabolic genes in biofilm and infection in uropathogenic Proteus mirabilis

The microorganisms are found in the environment, forming sessile communities embedded in an extracellular matrix of their own production, called biofilm. These communities have a great relevance in the clinical context, since they are associated with infections caused by biofilm in medical implants, such as urinary catheters. The development of biofilms is a complex process where a great diversity of genes participate. The present work is based on the study of genes related to iron metabolism and its implication in the development of P. mirabilis biofilms and pathogenicity. For this study, two mutant strains defective in biofilm formation were selected, generated by the interruption of genes that encoded non-heme ferritin and TonB-dependent receptor. The mutations influence on the development of the biofilm was evaluated by different approaches. The complexity of the biofilm was analyzed using Confocal Laser Microscopy and image analysis. The mutants infectivity potential was assessed in two experimental mice models of urinary tract infection. The results obtained in the present work show us the role of the ferritin and a TonB-associated porin protein over the initial and later stages of biofilm development. Moreover, in the ascending UTI mouse model, both mutants failed to colonize the urinary tract. In CAUTI models, ferritin mutant damaged the bladder similarly to wild type but the Ton-B mutant was unable to generate infection in the urinary tract. The results obtained in the present work confirm the relevant role that iron metabolism genes have in P. mirabilis biofilm development and for infection in the urinary tract.

UV-Assisted Deposition of Antibacterial Ag-Tannic Acid Nanocomposite Coating

The marked increase in bacterial colonization of medical devices and multiple drug resistance to traditional antibiotics underline the pressing need for developing novel antibacterial surface coatings. In the present investigation, natural polyphenol tannic acid (TA)-capped silver nanoparticles (TA-Ag NPs) were synthesized via an environmentally friendly and sustainable one-step redox reaction under UV irradiation with a simultaneous and uniform deposition on polydimethylsiloxane (PDMS) and other substrate surfaces. In the synthesis process, the dihydroxyphenyl and trihydroxyphenyl groups of TA actively participate in Ag⁺ reduction, forming co-ordination linkages with Ag NPs and bestowing the deposition on the PDMS surface. The physico-chemical features of TA-Ag NPs were characterized in detail. Microscopic examination, surface elemental analysis, and wettability measurements clearly reveal the decoration of TA-Ag NPs on the substrate surfaces. The modified PDMS surfaces can kill the adhered bacteria or resist the bacterial adhesion, and no live bacteria can be found on their surfaces. Most importantly, the modified PDMS surfaces exhibit predominant antibacterial effects both in vitro in the catheter bridge model and in vivo in a rat subcutaneous infection model. On the other hand, the functionalized surfaces exhibit only a negligible level of cytotoxicity against L929 mouse fibroblasts with no side effects on the major organs of Sprague-Dawley rats after implantation, indicating their biocompatibility for potential biomedical applications.

Pathogenesis of Proteus mirabilis in Catheter-Associated Urinary Tract Infections

Proteus mirabilis (PM) is a Gram-negative rod-shaped bacterium and widely exists in the natural environment, and it is most noted for its swarming motility and urease activity. PM is the main pathogen causing complicated urinary tract infections (UTIs), especially catheter-associated urinary tract infections. Clinically, PM can form a crystalline biofilm on the outer surface and inner cavity of the urethral indwelling catheter owing to its ureolytic biomineralization. This leads to catheter encrustation and blockage and, in most cases, is accompanied by urine retention and ascending UTI, causing cystitis, pyelonephritis, and the development of bladder or kidney stones, or even fatal complications such as septicemia and endotoxic shock. In this review, we discuss how PM is mediated by a catheter into the urethra, bladder, and then rose to the kidney causing UTI and the main virulence factors associated with different stages of infection, including flagella, pili or adhesins, urease, hemolysin, metal intake, and immune escape, encompassing both historical perspectives and current advances.

Proteus mirabilis Biofilm: Development and Therapeutic Strategies

Proteus mirabilis is a Gram negative bacterium that is a frequent cause of catheter-associated urinary tract infections (CAUTIs). Its ability to cause such infections is mostly related to the formation of biofilms on catheter surfaces. In order to form biofilms, P. mirabilis expresses a number of virulence factors. Such factors may include adhesion proteins, quorum sensing molecules, lipopolysaccharides, efflux pumps, and urease enzyme. A unique feature of P. mirabilis biofilms that build up on catheter surfaces is their crystalline nature owing to their ureolytic biomineralization. This leads to catheter encrustation and blockage and, in most cases, is accompanied by urine retention and ascending UTIs. Bacteria embedded in crystalline biofilms become highly resistant to conventional antimicrobials as well as the immune system. Being refractory to antimicrobial treatment, alternative approaches for eradicating P. mirabilis biofilms have been sought by many studies. The current review focuses on the mechanism by which P. mirabilis biofilms are formed, and a state of the art update on preventing biofilm formation and reduction of mature biofilms. These treatment approaches include natural, and synthetic compounds targeting virulence factors and quorum sensing, beside other strategies that include carrier-mediated diffusion of antimicrobials into biofilm matrix. Bacteriophage therapy has also shown successful results in vitro for combating P. mirabilis biofilms either merely through their lytic effect or by acting as facilitators for antimicrobials diffusion.

Chemotactic behaviour of Escherichia coli at high cell density

At high cell density, swimming bacteria exhibit collective motility patterns, self-organized through physical interactions of a however still debated nature. Although high-density behaviours are frequent in natural situations, it remained unknown how collective motion affects chemotaxis, the main physiological function of motility, which enables bacteria to follow environmental gradients in their habitats. Here, we systematically investigate this question in the model organism Escherichia coli, varying cell density, cell length, and suspension confinement. The characteristics of the collective motion indicate that hydrodynamic interactions between swimmers made the primary contribution to its emergence. We observe that the chemotactic drift is moderately enhanced at intermediate cell densities, peaks, and is then strongly suppressed at higher densities. Numerical simulations reveal that this suppression occurs because the collective motion disturbs the choreography necessary for chemotactic sensing. We suggest that this physical hindrance imposes a fundamental constraint on high-density behaviours of motile bacteria, including swarming and the formation of multicellular aggregates and biofilms.

Cell Shape and Population Migration Are Distinct Steps of Proteus mirabilis Swarming That Are Decoupled on High-Percentage Agar

Swarming on rigid surfaces requires movement of cells as individuals and as a group of cells. For the bacterium Proteus mirabilis, an individual cell can respond to a rigid surface by elongating and migrating over micrometer-scale distances. Cells can form groups of transiently aligned cells, and the collective population is capable of migrating over centimeter-scale distances. To address how P. mirabilis populations swarm on rigid surfaces, we asked whether cell elongation and single-cell motility are coupled to population migration. We first measured the relationship between agar concentration (a proxy for surface rigidity), single-cell phenotypes, and swarm colony phenotypes. We find that cell elongation and single-cell motility are coupled with population migration on low-percentage hard agar (1% to 2.5%) and become decoupled on high-percentage hard agar (>2.5%). Next, we evaluate how disruptions in lipopolysaccharide (LPS), specifically the O-antigen components, affect responses to hard agar. We find that LPS is not essential for elongation and motility of individual cells, as predicted, and instead functions to broaden the range of agar concentrations on which cell elongation and motility are coupled with population migration. These findings demonstrate that cell elongation and motility are coupled with population migration under a permissive range of surface conditions; increasing agar concentration is sufficient to decouple these behaviors. Since swarm colonies cover greater distances when these steps are coupled than when they are not, these findings suggest that collective interactions among P. mirabilis cells might be emerging as a colony expands outwards on rigid surfaces.IMPORTANCE How surfaces influence cell size, cell-cell interactions, and population migration for robust swarmers like P. mirabilis is not fully understood. Here, we have elucidated how cells change length along a spectrum of sizes that positively correlates with increases in agar concentration, regardless of population migration. Single-cell phenotypes can be decoupled from collective population migration simply by increasing agar concentration. A cell's lipopolysaccharides function to broaden the range of agar conditions under which cell elongation and single-cell motility remain coupled with population migration. In eukaryotes, the physical environment, such as a surface matrix, can impact cell development, shape, and migration. These findings support the idea that rigid surfaces similarly act on swarming bacteria to impact cell shape, single-cell motility, and collective population migration.

Titanium Kirschner Wires Resist Biofilms Better Than Stainless Steel and Hydroxyapatite-coated Wires: An In Vitro Study

Aim

External fixation surgery is frequently complicated by percutaneous pin site infection focused on the surface of the fixator pin. The primary aim of this study was to compare biofilm growth of clinically isolated pin site bacteria on Kirschner wires of different materials.

Materials and methods

Two commonly infecting species, Staphylococcus epidermidis and Proteus mirabilis, were isolated from patients’ pin sites. A stirred batch bioreactor was used to grow these bacteria as single culture and co-cultured biofilms on Kirschner wires made of three different materials: stainless steel, hydroxyapatite-coated steel and titanium alloy.

Results

We found that the surface density of viable cells within these biofilms was 3x higher on stainless steel and 4.5x higher on hydroxyapatite-coated wires than on the titanium wires.

Conclusion

Our results suggest that the lower rates of clinical pin site infection seen with titanium Kirschner wires are due to, at least in part, titanium’s better bacterial biofilm resistance.

Clinical significance

Our results are consistent with clinical studies which have found that pin site infection rates are reduced by the use of titanium relative to stainless steel or hydroxyapatite-coated pins.

How to cite this article

McEvoy JP, Martin P, Khaleel A, et al. Titanium Kirschner Wires Resist Biofilms Better Than Stainless Steel and Hydroxyapatite-coated Wires: An In Vitro Study. Strategies Trauma Limb Reconstr 2019;14(2):57–64.

Bacterial biofilm formation on indwelling urethral catheters

Urethral catheters are the most commonly deployed medical devices and used to manage a wide range of conditions in both hospital and community care settings. The use of long-term catheterization, where the catheter remains in place for a period >28 days remains common, and the care of these patients is often undermined by the acquisition of infections and formation of biofilms on catheter surfaces. Particular problems arise from colonization with urease-producing species such as Proteus mirabilis, which form unusual crystalline biofilms that encrust catheter surfaces and block urine flow. Encrustation and blockage often lead to a range of serious clinical complications and emergency hospital referrals in long-term catheterized patients. Here we review current understanding of bacterial biofilm formation on urethral catheters, with a focus on crystalline biofilm formation by P. mirabilis, as well as approaches that may be used to control biofilm formation on these devices. SIGNIFICANCE AND IMPACT OF THE STUDY: Urinary catheters are the most commonly used medical devices in many healthcare systems, but their use predisposes to infection and provide ideal conditions for bacterial biofilm formation. Patients managed by long-term urethral catheterization are particularly vulnerable to biofilm-related infections, with crystalline biofilm formation by urease producing species frequently leading to catheter blockage and other serious clinical complications. This review considers current knowledge regarding biofilm formation on urethral catheters, and possible strategies for their control.

Pathogenesis of Proteus mirabilis Infection

Proteus mirabilis, a Gram-negative rod-shaped bacterium most noted for its swarming motility and urease activity, frequently causes catheter-associated urinary tract infections (CAUTIs) that are often polymicrobial. These infections may be accompanied by urolithiasis, the development of bladder or kidney stones due to alkalinization of urine from urease-catalyzed urea hydrolysis. Adherence of the bacterium to epithelial and catheter surfaces is mediated by 17 different fimbriae, most notably MR/P fimbriae. Repressors of motility are often encoded by these fimbrial operons. Motility is mediated by flagella encoded on a single contiguous 54-kb chromosomal sequence. On agar plates, P. mirabilis undergoes a morphological conversion to a filamentous swarmer cell expressing hundreds of flagella. When swarms from different strains meet, a line of demarcation, a "Dienes line," develops due to the killing action of each strain's type VI secretion system. During infection, histological damage is caused by cytotoxins including hemolysin and a variety of proteases, some autotransported. The pathogenesis of infection, including assessment of individual genes or global screens for virulence or fitness factors has been assessed in murine models of ascending urinary tract infections or CAUTIs using both single-species and polymicrobial models. Global gene expression studies performed in culture and in the murine model have revealed the unique metabolism of this bacterium. Vaccines, using MR/P fimbria and its adhesin, MrpH, have been shown to be efficacious in the murine model. A comprehensive review of factors associated with urinary tract infection is presented, encompassing both historical perspectives and current advances.

Analysis of Proteus mirabilis Social Behaviors on Surfaces

The opportunistic pathogen Proteus mirabilis engages in visually dramatic and dynamic social behaviors. Populations of P. mirabilis can rapidly occupy surfaces, such as high-percentage agar and latex, through a collective surface-based motility termed swarming. When in these surface-occupying swarm colonies, P. mirabilis can distinguish between clonal siblings (self) and foreign P. mirabilis strains (nonself). This ability can be assessed by at least two standard methods: boundary formation, aka a Dienes line, and territorial exclusion. Here we describe methods for quantitative analysis of swarm colony expansion, of boundary formation, and of territorial exclusion. These assays can be employed to assess several aspects of P. mirabilis sociality including collective swarm motility, competition, and self versus nonself recognition.

Lipopolysaccharide-affinity copolymer senses the rapid motility of swarmer bacteria to trigger antimicrobial drug release

An intelligent drug release system that is triggered into action upon sensing the motion of swarmer P. mirabilis is introduced. The rational design of the drug release system focuses on a pNIPAAm-co-pAEMA copolymer that prevents drug leakage in a tobramycin-loaded mesoporous silica particle by covering its surface via electrostatic attraction. The copolymer chains are also conjugated to peptide ligands YVLWKRKRKFCFI-NH2 that display affinity to Gram-negative bacteria. When swarmer P. mirabilis cells approach and come in contact with the particle, the copolymer-YVLWKRKRKFCFI-NH2 binds to the lipopolysaccharides on the outer membrane of motile P. mirabilis and are stripped off the particle surface when the cells move away; hence releasing tobramycin into the swarmer colony and inhibiting its expansion. The release mechanism is termed Motion-Induced Mechanical Stripping (MIMS). For swarmer B. subtilis, the removal of copolymers from particle surfaces via MIMS is not apparent due to poor adherence between bacteria and copolymer-YVLWKRKRKFCFI-NH2 system.

Fluoxetine and thioridazine inhibit efflux and attenuate crystalline biofilm formation by Proteus mirabilis

Proteus mirabilis forms extensive crystalline biofilms on indwelling urethral catheters that block urine flow and lead to serious clinical complications. The Bcr/CflA efflux system has previously been identified as important for development of P. mirabilis crystalline biofilms, highlighting the potential for efflux pump inhibitors (EPIs) to control catheter blockage. Here we evaluate the potential for drugs already used in human medicine (fluoxetine and thioridazine) to act as EPIs in P. mirabilis, and control crystalline biofilm formation. Both fluoxetine and thioridazine inhibited efflux in P. mirabilis, and molecular modelling predicted both drugs interact strongly with the biofilm-associated Bcr/CflA efflux system. Both EPIs were also found to significantly reduce the rate of P. mirabilis crystalline biofilm formation on catheters, and increase the time taken for catheters to block. Swimming and swarming motilies in P. mirabilis were also significantly reduced by both EPIs. The impact of these drugs on catheter biofilm formation by other uropathogens (Escherichia coli, Pseudomonas aeruginosa) was also explored, and thioridazine was shown to also inhibit biofilm formation in these species. Therefore, repurposing of existing drugs with EPI activity could be a promising approach to control catheter blockage, or biofilm formation on other medical devices.

Inhibition of Urease Enzyme Production and some Other Virulence Factors Expression in Proteus mirabilis by N-Acetyl Cysteine and Dipropyl Disulphide

Proteus mirabilis is one of the important pathogens that colonize the urinary tract and catheters resulting in various complications, such as blockage of the catheters and the formation of infective stones.

PURPOSE

In this study we evaluated the effect of N-acetyl cysteine (NAC) and dipropyl disulphide on some virulence factors expressed by a Proteus mirabilis strain isolated from a catheterized patient.

METHODS

Antibacterial activity of both compounds was determined by broth microdilution method. Their effect on different types of motility was determined by LB medium with variable agar content and sub-MIC of each drug. Their effect on adherence and mature biofilms was tested by tissue culture plate assay. Inhibitory effect on urease production was determined and supported by molecular docking studies.

RESULTS

The minimum inhibitory concentration (MIC) of NAC and dipropyl disulphide was 25 mM and 100 mM, respectively. Both compounds decreased the swarming ability and biofilm formation of the tested isolate in a dose-dependent manner. NAC had higher urease inhibitory activity (IC50 249 ±0.05 mM) than that shown by dipropyl disulphide (IC₅₀ 10±0.2 mM). Results were supported by molecular docking studies which showed that NAC and dipropyl disulphide interacted with urease enzyme with binding free energy of -4.8 and -8.528 kcal/mol, respectively. Docking studies showed that both compounds interacted with Ni ion and several amino acids (His-138, Gly-279, Cysteine-321, Met-366 and His-322) which are essential for the enzyme activity.

CONCLUSION

NAC and dipropyl disulphide could be used in the control of P. mirabilis urinary tract infections.

Cranberry derivatives enhance biofilm formation and transiently impair swarming motility of the uropathogen Proteus mirabilis HI4320

Proteus mirabilis is a major cause of catheter-associated urinary tract infection (CAUTI), emphasizing that novel strategies for targeting this bacterium are needed. Potential targets are P. mirabilis surface-associated swarming motility and the propensity of these bacteria to form biofilms that may lead to catheter blockage. We previously showed that the addition of cranberry powder (CP) to lysogeny broth (LB) medium resulted in impaired P. mirabilis swarming motility over short time periods (up to 16 h). Herein, we significantly expanded on those findings by exploring (i) the effects of cranberry derivatives on biofilm formation of P. mirabilis, (ii) whether swarming inhibition occurred transiently or over longer periods more relevant to real infections (∼3 days), (iii) whether swarming was also blocked by commercially available cranberry juices, (iv) whether CP or cranberry juices exhibited effects under natural urine conditions, and (v) the effects of cranberry on medium pH, which is an indirect indicator of urease activity. At short time scales (24 h), CP and commercially available pure cranberry juice impaired swarming motility and repelled actively swarming bacteria in LB medium. Over longer time periods more representative of infections (∼3 days), the capacity of the cranberry material to impair swarming diminished and bacteria would start to migrate across the surface, albeit by exhibiting a different motility phenotype to the regular "bull's-eye" swarming phenotype of P. mirabilis. This bacterium did not swarm on urine agar or LB agar supplemented with urea, suggesting that any potential application of anti-swarming compounds may be better suited to settings external to the urine environment. Anti-swarming effects were confounded by the ability of cranberry products to enhance biofilm formation in both LB and urine conditions. These findings provide key insights into the long-term strategy of targeting P. mirabilis CAUTIs.

Fimbriae have distinguishable roles in Proteus mirabilis biofilm formation

Proteus mirabilis is one of the most common etiological agents of complicated urinary tract infections, especially those associated with catheterization. This is related to the ability of P. mirabilis to form biofilms on different surfaces. This pathogen encodes 17 putative fimbrial operons, the highest number found in any sequenced bacterial species so far. The present study analyzed the role of four P. mirabilis fimbriae (MR/P, UCA, ATF and PMF) in biofilm formation using isogenic mutants. Experimental approaches included migration over catheter, swimming and swarming motility, the semiquantitative assay based on adhesion and crystal violet staining, and biofilm development by immunofluorescence and confocal microscopy. Different assays were performed using LB or artificial urine. Results indicated that the different fimbriae contribute to the formation of a stable and functional biofilm. Fimbriae revealed particular associated roles. First, all the mutants showed a significantly reduced ability to migrate across urinary catheter sections but neither swimming nor swarming motility were affected. However, some mutants formed smaller biofilms compared with the wild type (MRP and ATF) while others formed significantly larger biofilms (UCA and PMF) showing different bioarchitecture features. It can be concluded that P. mirabilis fimbriae have distinguishable roles in the generation of biofilms, particularly in association with catheters.

Environmental scanning electron microscopy analysis of Proteus mirabilis biofilms grown on chitin and stainless steel

Proteus mirabilis is a human pathogen able to form biofilms on the surface of urinary catheters. Little is known about P. mirabilis biofilms on natural or industrial surfaces and the potential consequences for these settings. The main aim of this work was to assess and compare the adhesion and biofilm formation of P. mirabilis strains from different origins on chitin and stainless steel surfaces within 4 to 96 h. Using environmental scanning electron microscopy, the biofilms of a clinical strain grown on chitin at 4 h showed greater adhesion, aggregation, thickness, and extracellular matrix production than those grown on stainless steel, whereas biofilms of an environmental strain had less aggregation on both surfaces. Biofilms of both P. mirabilis strains developed different structures on chitin, such as pillars, mushrooms, channels, and crystalline-like precipitates between 24 and 96 h, in contrast with flat-layer biofilms produced on stainless steel. Significant differences (p < 0.05) were found in the frequency of pillars and channels. Images of transmission electron microscopy demonstrated abundant fimbriae in 100 % of cells from both strains, which could be related to surface adherence and biofilm formation. This represents the first study of P. mirabilis showing adhesion, biofilm formation, and development of different structures on surfaces found outside the human host.

Arginine promotes Proteus mirabilis motility and fitness by contributing to conservation of the proton gradient and proton motive force

Swarming contributes to Proteus mirabilis pathogenicity by facilitating access to the catheterized urinary tract. We previously demonstrated that 0.1–20 mmol/L arginine promotes swarming on normally nonpermissive media and that putrescine biosynthesis is required for arginine-induced swarming. We also previously determined that arginine-induced swarming is pH dependent, indicating that the external proton concentration is critical for arginine-dependent effects on swarming. In this study, we utilized survival at pH 5 and motility as surrogates for measuring changes in the proton gradient (ΔpH) and proton motive force (μH⁺) in response to arginine. We determined that arginine primarily contributes to ΔpH (and therefore μH⁺) through the action of arginine decarboxylase (speA), independent of the role of this enzyme in putrescine biosynthesis. In addition to being required for motility, speA also contributed to fitness during infection. In conclusion, consumption of intracellular protons via arginine decarboxylase is one mechanism used by P. mirabilis to conserve ΔpH and μH⁺ for motility.

Clinical complications of urinary catheters caused by crystalline biofilms: something needs to be done

This review is largely based on a previous paper published in the journal Spinal Cord. The care of many patients undergoing long-term bladder catheterization is complicated by encrustation and blockage of their Foley catheters. This problem stems from infection by urease-producing bacteria, particularly Proteus mirabilis. These organisms colonize the catheter forming an extensive biofilm; they also generate ammonia from urea, thus elevating the pH of urine. As the pH rises, crystals of calcium and magnesium phosphates precipitate in the urine and in the catheter biofilm. The continued development of this crystalline biofilm blocks the flow of urine through the catheter. Urine then either leaks along the outside of the catheter and the patient becomes incontinent or is retained causing painful distension of the bladder and reflux of urine to the kidneys. The process of crystal deposition can also initiate stone formation. Most patients suffering from recurrent catheter encrustation develop bladder stones. P. mirabilis establishes stable residence in these stones and is extremely difficult to eliminate from the catheterized urinary tract by antibiotic therapy. If blocked catheters are not identified and changed, serious symptomatic episodes of pyelonephritis, septicaemia and endotoxic shock can result. All types of Foley catheters including silver- or nitrofurazone-coated devices are vulnerable to this problem. In this review, the ways in which biofilm formation on Foley catheters is initiated by P. mirabilis will be described. The implications of understanding these mechanisms for the development of an encrustation-resistant catheter will be discussed. Finally, the way forward for the prevention and control of this problem will be considered.

Observation of multicellular spinning behavior of Proteus mirabilis by atomic force microscopy and multifunctional microscopy

This study aimed to observe the multicellular spinning behavior of Proteus mirabilis by atomic force microscopy (AFM) and multifunctional microscopy in order to understand the mechanism underlying this spinning movement and its biological significance. Multifunctional microscopy with charge-coupled device (CCD) and real-time AFM showed changes in cell structure and shape of P. mirabilis during multicellular spinning movement. Specifically, the morphological characteristics of P. mirabilis, multicellular spinning dynamics, and unique movement were observed. Our findings indicate that the multicellular spinning behavior of P. mirabilis may be used to collect nutrients, perform colonization, and squeeze out competitors. The movement characteristics of P. mirabilis are vital to the organism's biological adaptability to the surrounding environment.

Inhibition of bacterial motility and spreading via release of cranberry derived materials from silicone substrates

The motility of bacteria plays a key role in their colonization of surfaces during infection. Derivatives of cranberry fruit have been shown to interfere with bacterial motility. Herein, we report on the incorporation of cranberry derived materials (CDMs) into silicone substrates with the aim of impairing bacterial pathogen motility and spreading on the substrate surface. The release of CDMs from the silicone substrates when soaking in an aqueous medium was quantified for a period of 24h. Next, we showed that CDMs released from two silicone substrates remain bioactive as they downregulate the expression of the flagellin gene of two key uropathogens - Escherichia coli CFT073 and Proteus mirabilis HI4320. Furthermore, we demonstrate that CDM-modified silicone inhibits the swarming motility of P. mirabilis, an aggressive swarmer. The bioactive, CDM-modified substrates can find broad applications in the medical device and food industries where the impairment of bacterial colonization of surfaces is of paramount importance.

Flagellum density regulates Proteus mirabilis swarmer cell motility in viscous environments

Proteus mirabilis is an opportunistic pathogen that is frequently associated with urinary tract infections. In the lab, P. mirabilis cells become long and multinucleate and increase their number of flagella as they colonize agar surfaces during swarming. Swarming has been implicated in pathogenesis; however, it is unclear how energetically costly changes in P. mirabilis cell morphology translate into an advantage for adapting to environmental changes. We investigated two morphological changes that occur during swarming--increases in cell length and flagellum density--and discovered that an increase in the surface density of flagella enabled cells to translate rapidly through fluids of increasing viscosity; in contrast, cell length had a small effect on motility. We found that swarm cells had a surface density of flagella that was ∼5 times larger than that of vegetative cells and were motile in fluids with a viscosity that inhibits vegetative cell motility. To test the relationship between flagellum density and velocity, we overexpressed FlhD(4)C(2), the master regulator of the flagellar operon, in vegetative cells of P. mirabilis and found that increased flagellum density produced an increase in cell velocity. Our results establish a relationship between P. mirabilis flagellum density and cell motility in viscous environments that may be relevant to its adaptation during the infection of mammalian urinary tracts and movement in contact with indwelling catheters.

Merging mythology and morphology: the multifaceted lifestyle of Proteus mirabilis

Proteus mirabilis, named for the Greek god who changed shape to avoid capture, has fascinated microbiologists for more than a century with its unique swarming differentiation, Dienes line formation and potent urease activity. Transcriptome profiling during both host infection and swarming motility, coupled with the availability of the complete genome sequence for P. mirabilis, has revealed the occurrence of interbacterial competition and killing through a type VI secretion system, and the reciprocal regulation of adhesion and motility, as well as the intimate connections between metabolism, swarming and virulence. This Review addresses some of the unique and recently described aspects of P. mirabilis biology and pathogenesis, and emphasizes the potential role of this bacterium in single-species and polymicrobial urinary tract infections.

Zinc uptake contributes to motility and provides a competitive advantage to Proteus mirabilis during experimental urinary tract infection

Proteus mirabilis, a Gram-negative bacterium, represents a common cause of complicated urinary tract infections in catheterized patients or those with functional or anatomical abnormalities of the urinary tract. ZnuB, the membrane component of the high-affinity zinc (Zn(2+)) transport system ZnuACB, was previously shown to be recognized by sera from infected mice. Since this system has been shown to contribute to virulence in other pathogens, its role in Proteus mirabilis was investigated by constructing a strain with an insertionally interrupted copy of znuC. The znuC::Kan mutant was more sensitive to zinc limitation than the wild type, was outcompeted by the wild type in minimal medium, displayed reduced swimming and swarming motility, and produced less flaA transcript and flagellin protein. The production of flagellin and swarming motility were restored by complementation with znuCB in trans. Swarming motility was also restored by the addition of Zn(2+) to the agar prior to inoculation; the addition of Fe(2+) to the agar also partially restored the swarming motility of the znuC::Kan strain, but the addition of Co(2+), Cu(2+), or Ni(2+) did not. ZnuC contributes to but is not required for virulence in the urinary tract; the znuC::Kan strain was outcompeted by the wild type during a cochallenge experiment but was able to colonize mice to levels similar to the wild-type level during independent challenge. Since we demonstrated a role for ZnuC in zinc transport, we hypothesize that there is limited zinc present in the urinary tract and P. mirabilis must scavenge this ion to colonize and persist in the host.

The encrustation and blockage of long-term indwelling bladder catheters: a way forward in prevention and control

OBJECTIVES

To review the literature showing that understanding how Foley catheters become encrusted and blocked by crystalline bacterial biofilms has led to strategies for the control of this complication in the care of patients undergoing long-term indwelling bladder catheterization.

METHODS

A comprehensive PubMed search of the literature published between 1980 and December 2009 was made for relevant articles using the Medical Subject Heading terms 'biofilms', 'urinary catheterization', 'catheter-associated urinary tract infection' and 'urolithiasis'. Papers on catheter-associated urinary tract infections and bacterial biofilms collected during 40 years of working in the field were also reviewed.

RESULTS

There is strong experimental and epidemiological evidence that infection by Proteus mirabilis is the main cause of the crystalline biofilms that encrust and block Foley catheters. The ability of P. mirabilis to generate alkaline urine and to colonize all available types of indwelling catheters allows it to take up stable residence in the catheterized tract in bladder stones and cause recurrent catheter blockage.

CONCLUSION

The elimination of P. mirabilis by antibiotic therapy as soon as it appears in the catheterized urinary tract could improve the quality of life for many patients and reduce the current expenditure of resources when managing the complications of catheter encrustation and blockage. For patients who are already chronic blockers and stone formers, antibiotic treatment is unlikely to be effective owing to the resistance of cells in the crystalline biofilms. Strategies such as increasing fluid intake with citrated drinks could control the problem until bladder stone removal can be organized.

Studying the dynamics of flagella in multicellular communities of Escherichia coli by using biarsenical dyes

This paper describes a new approach for labeling intact flagella using the biarsenical dyes FlAsH and ReAsH and imaging their spatial and temporal dynamics on live Escherichia coli cells in swarming communities of bacteria by using epifluorescence microscopy. Using this approach, we observed that (i) bundles of flagella on swarmer cells remain cohesive during frequent collisions with neighboring cells, (ii) flagella on nonmotile swarmer cells at the leading edge of the colony protrude in the direction of the uncolonized agar surface and are actively rotated in a thin layer of fluid that extends outward from the colony, and (iii) flagella form transient interactions with the flagella of other swarmer cells that are in close proximity. This approach opens a window for observing the dynamics of cells in communities that are relevant to ecology, industry, and biomedicine.

Bacterial Swarming: A Model System for Studying Dynamic Self-assembly

Bacterial swarming is an example of dynamic self-assembly in microbiology in which the collective interaction of a population of bacterial cells leads to emergent behavior. Swarming occurs when cells interact with surfaces, reprogram their physiology and behavior, and adapt to changes in their environment by coordinating their growth and motility with other cells in the colony. This review summarizes the salient biological and biophysical features of this system and describes our current understanding of swarming motility. We have organized this review into four sections: 1) The biophysics and mechanisms of bacterial motility in fluids and its relevance to swarming. 2) The role of cell/molecule, cell/surface, and cell/cell interactions during swarming. 3) The changes in physiology and behavior that accompany swarming motility. 4) A concluding discussion of several interesting, unanswered questions that is particularly relevant to soft matter scientists.

Role of bacterial biofilms in urinary tract infections

Bacterial urinary tract infections represent the most common type of nosocomial infection. In many cases, the ability of bacteria to both establish and maintain these infections is directly related to biofilm formation on indwelling devices or within the urinary tract itself. This chapter will focus on the role of biofilm formation in urinary tract infections with an emphasis on Gram-negative bacteria. The clinical implications of biofilm formation will be presented along with potential strategies for prevention. In addition, the role of specific pathogen-encoded functions in biofilm development will be discussed.

Urinary catheter use in older people

Long-term indwelling urinary catheters can be an effective means of managing bladder dysfunction for some older people, where alternative strategies are unsuitable or unsatisfactory, and where careful assessment of the patient and their particular problem has been undertaken. However, catheter-associated risks are well known and, consequently, catheters should be avoided wherever possible. Although prevalence of catheterization varies widely in different settings and different cultures of care, there is evidence that many older people are catheterized inappropriately and also remain catheterized unnecessarily. This paper discusses issues to be considered in decision-making processes regarding long-term catheterization. It examines catheter-associated problems, their management and factors influencing the quality of evidence to guide clinical practice.

Characterisation of the internal and external surfaces of four types of Foley catheter using SEM and profilometry

Unfortunately the use of Foley catheters for long-term catheterisation is frequently associated with complications such as infection and encrustation. This study investigated whether a link could exist between the surface properties of the catheters and the problems that can develop. The internal and external surfaces of four different types of urinary catheter were examined. Three latex devices coated with either PTFE or hydrogel or surface treated with silicone were investigated. In addition, an all-silicone device was examined. The surfaces of the all-silicone catheters were relatively smooth and featureless. In contrast, the external surfaces of each of the latex devices were 'paved' in nature. The internal surfaces of latex based devices produced by different manufacturers showed distinct differences with evidence of inorganic inclusions on the internal surfaces of two of the catheter types. These findings may be significant in the context of catheter infection and encrustation.

Role of swarming in the formation of crystalline Proteus mirabilis biofilms on urinary catheters

The care of many patients undergoing long-term bladder catheterization is frequently complicated by infection with Proteus mirabilis. These organisms colonize the catheter, forming surface biofilm communities, and their urease activity generates alkaline conditions under which crystals of magnesium ammonium phosphate and calcium phosphate are formed and become trapped in the biofilm. As the biofilm develops it obstructs the flow of urine through the catheter, causing either incontinence due to leakage of urine around the catheter or retention of urine in the bladder. The aim of this study was to investigate the role of the surface-associated swarming motility of P. mirabilis in the initiation and development of these crystalline catheter biofilms. A set of stable transposon mutants with a range of swimming and swarming abilities were tested for their ability to colonize silicone surfaces in a parallel-plate flow cell. A laboratory model of the catheterized bladder was then used to examine their ability to form crystalline, catheter-blocking biofilms. The results showed that neither swarming nor swimming motility was required for the attachment of P. mirabilis to silicone. Mutants deficient in swarming and swimming were also capable of forming crystalline biofilms and blocking catheters more rapidly than the wild-type strain.

Materials for urinary catheters: a review of their history and development in the UK

The Foley catheter, introduced in the mid-1930s and originally manufactured from latex, is still the most commonly used device for the management of urinary incontinence (UI). Despite the passage of time, there are still problems associated with the use of these devices. It is currently estimated that the management and treatment of UI costs the UK National Health Service (NHS) in the order of 500 million pound per annum. Faced with the known demographic changes in the adult population these costs will continue to rise for the foreseeable future. This review examines the range of materials currently used to manufacture Foley catheters from both latex and silicone. It outlines the common problems associated with their clinical use-infection, encrustation and blockage. The main changes that have been made to the materials employed in response to these problems are analysed. In the first instance the use of controlled release glass and slow release polymers to introduce disinfectants and antibacterial agents is considered. Attempts to alter surface properties by using coatings based on silver, polytetrafluoroethylene (PTFE), hydrogels and silicone are then described. It can be seen that despite these approaches, problems remain with the design and materials currently used to manufacture catheters. The review concludes that changes to the materials currently used for the manufacture of commercially available catheters could potentially alleviate many of the existing problems. However, standards need to be developed in order to enable direct comparison of the mechanical and physical properties of existing and potential catheter designs to ensure their effective function in-service.

Ultrastructure of Proteus mirabilis swarmer cell rafts and role of swarming in catheter-associated urinary tract infection

Proteus mirabilis is a common cause of catheter-associated urinary tract infection (C-UTI). It blocks indwelling urethral catheters through the formation of extensive crystalline biofilms. The obstruction of urine flow can induce episodes of pyelonephritis, septicemia, and shock. P. mirabilis exhibits a type of motility referred to as swarming, in which multicellular rafts of elongated, hyperflagellated swarmer cells form and move rapidly in concert over solid surfaces. It has been suggested that swarming is important in the pathogenesis of C-UTI. In this study we generated a set of stable transposon mutants deficient in swarming and used them to assess the role of swarming in the migration of P. mirabilis over urinary catheters. Swarming was found to be essential for migration over all-silicone catheters. Swarming-deficient mutants were attenuated in migration over hydrogel-coated latex catheters, but those capable of swimming motility were able to move over and infect these surfaces. A novel vapor fixation technique for the preparation of specimens and scanning electron microscopy were used to resolve the ultrastructure of P. mirabilis multicellular rafts. The flagellar filaments of P. mirabilis were found to be highly organized during raft migration and were interwoven in phase to form helical connections between adjacent swarmer cells. Mutants lacking these novel organized structures failed to swarm successfully. We suggest that these structures are important for migration and formation of multicellular rafts. In addition, the highly organized structure of multicellular rafts enables P. mirabilis to initiate C-UTI by migration over catheter surfaces from the urethral meatus into the bladder.

URINARY TRACT BIOMATERIALS

PURPOSE

As a result of endourological advances, biomaterials have become increasingly used within the urinary tract. This review article provides an update on the current status of urinary tract biomaterials, discussing issues of biocompatibility, biomaterials available for use, clinical applications and biomaterial related complications. Perspectives on future materials for use in the urinary tract are also provided.

MATERIALS AND METHODS

We performed a comprehensive search of the peer reviewed literature on all aspects of biomaterials in the urinary tract using PubMed and MEDLINE. All pertinent articles were reviewed in detail.

RESULTS

Any potential biomaterial must undergo rigorous physical and biocompatibility testing prior to its commercialization and use in humans. There are currently many different bulk materials and coatings available for the manufacturing of biomaterials, although the ideal material has yet to be discovered. For use in the urinary tract, biomaterials may be formed into devices, including ureteral and urethral stents, urethral catheters and percutaneous nephrostomy tubes. Despite significant advances in basic science research involving biocompatibility issues and biofilm formation, infection and encrustation remain associated with the use of biomaterials in the urinary tract and, therefore, limit their long-term indwelling time.

CONCLUSIONS

Prosthetic devices formed from biomaterials will continue to be an essential tool in the practicing urologist's armamentarium. Ongoing research is essential to optimize biocompatibility and decrease biomaterial related complications such as infection and encrustation within the urinary tract. Future advances include biodegradables, novel coatings and tissue engineering.

Incidence of catheter-associated urinary tract infection among dogs in a small animal intensive care unit

OBJECTIVE

To determine incidence of and possible risk factors for catheter-associated urinary tract infection (UTI) among dogs hospitalized in an intensive care unit and compare results of bacterial culture of urine samples with results of bacterial culture of catheter tips.

DESIGN

Prospective study.

ANIMALS

39 dogs.

PROCEDURE

A standard protocol for aseptic catheter placement and maintenance was used. Urine samples were obtained daily and submitted for bacterial culture. When possible, the urinary catheter tip was collected aseptically at the time of catheter removal and submitted for bacterial culture. Bacteria that were obtained were identified and tested for antimicrobial susceptibility.

RESULTS

4 of the 39 (10.3%) dogs developed a UTI. The probability of remaining free from UTI after 1 day in the intensive care unit was 94.9%, and the probability of remaining free from UTI after 4 days was 63.3%. Bacteria isolates were generally common urinary tract pathogens and were susceptible to most antimicrobials. Specific risk factors for catheter-associated UTI, beyond a lack of antimicrobial administration, were not identified. Positive predictive value of bacterial culture of urinary catheter tips was only 25%.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that placement of an indwelling urinary catheter in dogs is associated with a low risk of catheter-associated UTI during the first 3 days after catheter placement, provided that adequate precautions are taken for aseptic catheter placement and maintenance. Results of bacterial culture of urinary catheter tips should not be used to predict whether dogs developed catheter-associated UTI.

Urinary catheter care in the intensive care unit

Urinary catheters are associated with a number of complications, and nurses are ideally suited to minimize the associated risks by utilizing the available research in their practice. Urine tract infections caused by urine catheters are associated with increased mortality; however, urine catheter care is a nursing procedure, the importance of which is sometimes overlooked. This study reviews recommended guidelines on urine catheter care and current published literature on the subject. The aim of the study was to identify recommended practice and compare it with the current research and literature to conclude best practice. Conclusions made from this study are that existing guidelines correspond to the recommendations and findings in recent research and literature. However, more detailed guidelines and further research on how to prevent catheter-associated urine tract infections and other complications may be of benefit.

Swarming ofProteus mirabilisover Ureteral Stents: A Comparative Assessment

BACKGROUND AND PURPOSE

Encrustation on indwelling ureteral stents is commonly related to the presence of urease-producing bacteria that elevate the pH of the urine through the hydrolysis of urea, resulting in the precipitation of calcium and magnesium salts. Using a model previously shown to measure accurately the ability of Proteus mirabilis to swarm over catheter surfaces (Eur J Clin Microbiol Infect Dis 1999;18:206), we investigated the ability of this organism to swarm over three ureteral stents with potential encrustation-resistance properties.

MATERIALS AND METHODS

Three commercially available ureteral stents were selected for evaluation: a low surface-energy stent, a hydrogel-coated stent, and a silicone stent. Ten-microliter aliquots of a 4-hour culture of P. mirabilis 296 in Trypticase soya (TSA) broth was inoculated 5 mm from a 1-cm channel cut out from TSA plates. Ten-millimeter stent sections were placed as bridges across the central channel adjacent to the inocula. Time to pathogen crossing was measured.

RESULTS

The mean time (+/- SD) to pathogen migration across the three test materials was 15.9 +/- 6.1, 19.8 +/- 9.5, and 29.7 +/- 14.3 hours for the low surface-energy, hydrogel-coated, and silicone stents, respectively. Statistical analysis revealed significant differences between the crossing times of the low surface-energy (P = 0.001) and hydrogel-coated (P = 0.034) stents compared with silicone but not between the low surface-energy and hydrogel-coated stents (P = 0.387).

CONCLUSION

Migration of P. mirabilis 296 across silicone stents was significantly reduced compared with low surface-energy and hydrogel-coated stents. These findings suggest that P. mirabilis may have a lower affinity for silicone stents, which may translate into a reduced risk of infection with P. mirabilis and associated stent encrustation.

Managing recurrent urinary catheter encrustation

Recurrent blockage of the urinary catheter is a common problem in around 40-50% of long-term catheterized patients, leading to problems which are distressing to patients and costly to health services in both time and resources. Blockage is frequently caused by the build-up of mineral deposits on the catheter surface following precipitation from the urine under alkaline conditions. The presence of urea-splitting bacteria in the urine promotes a strongly alkaline urine and their adhesion to the catheter as a biofilm makes them extremely difficult to remove. This article addresses strategies for early identification of potential 'blockers'; proactive approaches to care; and the evidence for use of catheter maintenance solutions.