Antimicrobial polymer modifications to reduce microbial bioburden on endotracheal tubes and ventilator associated pneumonia

Electrospun composite-coated endotracheal tubes with controlled siRNA and drug delivery to lubricate and minimize upper airway injury

Endotracheal Tubes (ETTs) maintain and secure a patent airway; however, prolonged intubation often results in unintended injury to the mucosal epithelium and inflammatory sequelae which complicate recovery. ETT design and materials used have yet to adapt to address intubation associated complications. In this study, a composite coating of electrospun polycaprolactone (PCL) fibers embedded in a four-arm polyethylene glycol acrylate matrix (4APEGA) is developed to transform the ETT from a mechanical device to a dual-purpose device capable of delivering multiple therapeutics while preserving coating integrity. Further, the composite coating system (PCL-4APEGA) is capable of sustained delivery of dexamethasone from the PCL phase and small interfering RNA (siRNA) containing polyplexes from the 4APEGA phase. The siRNA is released rapidly and targets smad3 for immediate reduction in pro-fibrotic transforming growth factor-beta 1 (TGFϐ1) signaling in the upper airway mucosa as well as suppressing long-term sequelae in inflammation from prolonged intubation. A bioreactor was used to study mucosal adhesion to the composite PCL-4APEGA coated ETTs and investigate continued mucus secretory function in ex vivo epithelial samples. The addition of the 4APEGA coating and siRNA delivery to the dexamethasone delivery was then evaluated in a swine model of intubation injury and observed to restore mechanical function of the vocal folds and maintain epithelial thickness when observed over 14 days of intubation. This study demonstrated that increase in surface lubrication paired with surface stiffness reduction significantly decreased fibrotic behavior while reducing epithelial adhesion and abrasion.

Antibacterial Iodine-Releasing Coatings of Cross-Linked Poly(N-vinylpyrrolidone) Synthesized by Solvent-Free Initiated Chemical Vapor Deposition

Biomaterial-associated infections caused by bacteria pose a great threat to human health, and therefore, various antibacterial coatings have been developed to control bacterial infections. Povidone iodine (PVP-I) is a broad-spectrum antimicrobial agent without drug resistance to most pathogenic microorganisms and has been widely used in the clinic. However, its applications in the field of coatings are limited due to its strong water solubility. Here, we used initiated Chemical Vapor Deposition (iCVD) technique to synthesize cross-linked poly(N-vinylpyrrolidone-co-ethylene glycol dimethacrylate) (PVE) coatings to firmly immobilize poly(N-vinylpyrrolidone) (PVP) on surfaces. After complexation with iodine, PVE-I coatings exhibited potent bacteria-killing and antifouling activities against Gram-negative Escherichia coli and Gram-positive Staphylococcus aureus in vitro owing to the antibacterial effect of iodine and the hydrophilicity of VP, respectively. The killing and antifouling effects were positively correlated with the VP content. The PVE-I-2 coating displayed excellent anti-infection performance in a rat subcutaneous implantation model in vivo. This study provided a simple method for preparing stable povidone iodine coatings on surfaces via solvent-free iCVD, and combined bacteria-killing and antifouling strategies to fabricate multifunctional antibacterial coatings against bacterial infections on biomaterial surfaces.

Low-cost antiseptic-impregnated tracheostomy tube for the prevention of ventilator-associated pneumonia caused by multidrug-resistant bacteria: In vitro and pilot study in humans

Ventilator-associated pneumonia (VAP) is one of the most common causes of nosocomial infections. The aim of this study was to evaluate the antimicrobial and anti-biofilm activity of an in-house low-cost tracheostomy tube impregnated with chlorhexidine and violet crystal. The impregnated tracheostomy tubes demonstrated antimicrobial activity, including for multidrug-resistant bacteria. Fourteen patients were evaluated. During ventilation, VAP occurred in one patient in the coated group and in three patients in the control group (p=0.28). A reduction of biofilm cells was observed. This study provides preliminary evidence to support that the antiseptic impregnation of a tracheostomy tube provides significant antimicrobial activity.

Two-electron oxidized polyphenol chemistry-inspired superhydrophilic drug-carrying coatings for the construction of multifunctional nasolacrimal duct stents

Nasolacrimal duct obstruction due to infection, inflammation, or excessive fibroblast proliferation may result in persistent tearing, intraocular inflammation, or even blindness. In this study, surface engineering techniques are applied to nasolacrimal duct stents for the first time. Based on the functioning of marine mussels, "one-pot" and "stepwise" methods were employed to construct a novel multifunctional superhydrophilic PDA/RAP coating using dopamine and rapamycin. Micron-sized rapamycin crystals combined with nano-sized polydopamine particles form a micro-nano topographical structure. Therefore, acting synergistically with in situ-generated hydrophilic groups (amino, carboxyl, and phenolic hydroxyl), they impart excellent and long-lasting superhydrophilicity to the nasolacrimal duct stent. The PDA/RAP coating effectively maintained the stability of the initial microenvironment during stent implantation by inhibiting the onset of acute inflammation and infection during the early stages of implantation. Meanwhile, the rapamycin crystals, supported by the superhydrophilic platform, exhibited a sustained-release capability that helped them to better exert their anti-inflammatory, antibacterial, and anti-fibroblast proliferative properties, ensuring conducive conditions for the rapid repair of nasolacrimal duct epithelial cells, verified by a series of experiments. In conclusion, the PDA/RAP hydrophilic coating has anti-inflammatory, antifibrotic, antibacterial, and antithrombotic properties, offering a new strategy to address restenosis following clinical nasolacrimal duct stent implantation.

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

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

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

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

Nanoparticle-Based Inhalation Therapy for Pulmonary Diseases

The lung is exposed to various pollutants and is the primary site for the onset of various diseases, including infections, allergies, and cancers. One possible treatment approach for such pulmonary diseases involves direct administration of therapeutics to the lung so as to maintain the topical concentration of the drug. Particles with nanoscale diameters tend to reach the pulmonary region. Nanoparticles (NPs) have garnered significant interest for applications in biomedical and pharmaceutical industries because of their unique physicochemical properties and biological activities. In this article, we describe the biological and pharmacological activities of NPs as well as summarize their potential in the formulation of drugs employed to treat pulmonary diseases. Recent advances in the use of NPs in inhalation chemotherapy for the treatment of lung diseases have also been highlighted.

Zwitterionic/phosphonate copolymer coatings endow excellent antifouling properties and robust re-mineralization ability of dentine substrates

Inhibition of biofilm formation and induction of the re-mineralization of damaged dental tissues are two major strategies to combat dental hypersensitivity (DH). However, single component synthetic materials normally cannot fulfil these two functions during the repairing of damaged dental tissues. Here, we report zwitterionic phosphorylcholine based polymers to be a new type of dual functional coating for the repairing of DH. Zwitterionic/phosphonate copolymers, p(DEMMP-co-MPC), bearing varied zwitterionic contents (95 and 75 mol%) were prepared through conventional radical copolymerization. ¹H NMR spectroscopy clearly indicated the precise preparation of the copolymers. The copolymers can be easily coated on dentine substrates based on the high affinity between the phosphonate group and the calcium phosphate minerals of the dentine substrates, as evidenced by XPS and water contact angle measurements. Antifouling evaluations indicated that zwitterionic coating can efficiently inhibit protein adsorption (BSA, egg white, and milk, by 85%) and bacterial adhesion (by 97.1%) on dentine substrates. Furthermore, in vitro and in vivo experiments consistently indicated that the zwitterionic coating could not only induce the robust re-mineralization of dentine surfaces, but also template the extensive re-mineralization of dentine tubules to a similar level of pristine dentine. Both the antifouling properties and the re-mineralization potency are positively correlated with the content of zwitterionic pMPC in the coating copolymer. These findings may provide the zwitterionic phosphorylcholine based materials to be a promising candidate to treat dental hypersensitivity and other related dental diseases.

Correlation of ICU Nurses' Cognitive Level with Their Attitude and Behavior toward the Prevention of Ventilator-Associated Pneumonia

Objective

To analyze the correlation of ICU nurses' cognitive level with their attitude and behavior toward the prevention of ventilator-associated pneumonia (VAP).

Methods

A total of 90 ICU nurses working in the adult internal medicine ICU, adult surgery ICU, subacute respiratory care ward, etc. from January 2018 to June 2019 were chosen as the subjects to carry out questionnaire survey with the cognition scale, and the correlation analysis on their cognitive level, attitude, and behavior toward the prevention of VAP was conducted.

Results

The linear fitting analysis finding showed that the cognitive level presented a positive correlation with the attitude score and behavior score (R ² = 0.668, 0.734).

Conclusion

Improving ICU nurses' cognitive level, attitude, and behavior toward preventing VAP is conducive to the upgrade of their quality of nursing services. In addition, the ICU nurses' cognitive level is positively correlated with their attitude and behavior.

A novel antibacterial and antifouling nanocomposite coated endotracheal tube to prevent ventilator-associated pneumonia

Background

The endotracheal tube (ETT) is an essential medical device to secure the airway patency in patients undergoing mechanical ventilation or general anesthesia. However, long-term intubation eventually leads to complete occlusion, ETTs potentiate biofilm-related infections, such as ventilator-associated pneumonia. ETTs are mainly composed of medical polyvinyl chloride (PVC), which adheres to microorganisms to form biofilms. Thus, a simple and efficient method was developed to fabricate CS-AgNPs@PAAm-Gelatin nanocomposite coating to achieve dual antibacterial and antifouling effects.

Results

The PAAm-Gelatin (PAAm = polyacrylamide) molecular chain gel has an interpenetrating network with a good hydrophilicity and formed strong covalent bonds with PVC-ETTs, wherein silver nanoparticles were used as antibacterial agents. The CS-AgNPs@PAAm-Gelatin coating showed great resistance and antibacterial effects against Staphylococcus aureus and Pseudomonas aeruginosa. Its antifouling ability was tested using cell, protein, and platelet adhesion assays. Additionally, both properties were comprehensively evaluated using an artificial broncho-lung model in vitro and a porcine mechanical ventilation model in vivo. These remarkable results were further confirmed that the CS-AgNPs@PAAm-Gelatin coating exhibited an excellent antibacterial capacity, an excellent stain resistance, and a good biocompatibility.

Conclusions

The CS-AgNPs@PAAm-Gelatin nanocomposite coating effectively prevents the occlusion and biofilm-related infection of PVC-ETTs by enhancing the antibacterial and antifouling properties, and so has great potential for future clinical applications.

Graphical Abstract

A universal biocompatible coating for enhanced lubrication and bacterial inhibition

Antibacterial coatings that inhibit bacterial adhesion are essential for many implanted medical devices. A variety of antibacterial strategies, such as repelling or killing bacteria, have been developed, but not yet...

Zwitterionic/active ester block polymers as multifunctional coating for polyurethane-based substrates

Bacterial associated infection, blood coagulation, and tissue adhesion are severe issues associated with biomedical implants & devices in clinic applications. Here, we report a general strategy to simultaneously tackle these...

Recent Progress in Bile Acid-Based Antimicrobials

With the emergence of drug-resistant bacteria and the formation of biofilms by bacteria and fungi, microbial infections gradually threaten global health. Natural antimicrobial peptides (AMPs) have low susceptibility for developing resistance due to the membrane targeted mechanism, but instability and high manufacturing cost limit their applications in clinic. Bile acids, a group of steroids in the human body, with high stability, biocompatibility, and inherent facial amphiphilic structure similar to the characteristics of AMPs, have been applied to the biological field, such as drug delivery systems, self-healing hydrogels, antimicrobials, and so on. In this review, we mainly focus on the different classes of bile acid-based antimicrobials in recent years. Various designs and methods for the preparation of unimolecular antimicrobials with bile acid skeletons are first introduced, including coupling of primary amine, quaternary ammonium, and amino acid units with bile acid skeletons. Some representative oligomeric antimicrobials, including dimers of bile acids, are summarized. Finally, macromolecular antimicrobials bearing some positive charges at the main chain or side chain and interaction mechanisms of these bile acid-based antimicrobials are discussed.

Synergistic Coating Strategy Combining Photodynamic Therapy and Fluoride-Free Superhydrophobicity for Eradicating Bacterial Adhesion and Reinforcing Corrosion Protection

Device-associated infection is one of the significant challenges in the biomedical industry and clinical management. Controlling the initial attachment of microbes upon the solid surface of biomedical devices is a sound strategy to minimize the formation of biofilms and infection. A synergistic coating strategy combining superhydrophobicity and bactericidal photodynamic therapy is proposed herein to tackle infection issues for biomedical materials. A multifunctional coating is produced upon pure Mg substrate through a simple blending procedure without involvement of any fluoride-containing agents, differing from the common superhydrophobic surface preparations. Superhydrophobic features of the coating are confirmed through water contact angle measurements (152.5 ± 1.9°). In vitro experiments reveal that bacterial-adhesion repellency regarding both Gram-negative (Escherichia coli) and Gram-positive (Staphylococcus aureus) strains approaches over 96%, which is evidently ascribed to the proposed synergistic strategy, that is, superhydrophobic nature and microbicidal ability of photodynamic therapy. Electrochemical analysis indicates that the superhydrophobic coating provides pronounced protection against corrosion to underlying Mg with 80% reduction in the corrosion rate in minimum essential medium and retains the original surface features after 168 h exposure to neutral salt spray. The proof-of-concept research holds a great promise for tackling the notorious bacterial infection and poor corrosion resistance of Mg-based biodegradable materials in a simple, efficient, and environmentally benign manner.

Avoiding ventilator-associated pneumonia: Curcumin-functionalized endotracheal tube and photodynamic action

Hospital-acquired infections are a global health problem that threatens patients' treatment in intensive care units, causing thousands of deaths and a considerable increase in hospitalization costs. The endotracheal tube (ETT) is a medical device placed in the patient's trachea to assist breathing and delivering oxygen into the lungs. However, bacterial biofilms forming at the surface of the ETT and the development of multidrug-resistant bacteria are considered the primary causes of ventilator-associated pneumonia (VAP), a severe hospital-acquired infection for significant mortality. Under these circumstances, there has been a need to administrate antibiotics together. Although necessary, it has led to a rapid increase in bacterial resistance to antibiotics. Therefore, it becomes necessary to develop alternatives to prevent and combat these bacterial infections. One possibility is to turn the ETT itself into a bactericide. Some examples reported in the literature present drawbacks. To overcome those issues, we have designed a photosensitizer-containing ETT to be used in photodynamic inactivation (PDI) to avoid bacteria biofilm formation and prevent VAP occurrence during tracheal intubation. This work describes ETT's functionalization with curcumin photosensitizer, as well as its evaluation in PDI against Staphylococcus aureus, Pseudomonas aeruginosa, and Escherichia coli A significant photoinactivation (up to 95%) against Gram-negative and Gram-positive bacteria was observed when curcumin-functionalized endotracheal (ETT-curc) was used. These remarkable results demonstrate this strategy's potential to combat hospital-acquired infections and contribute to fighting antimicrobial resistance.

Evaluation of the Novel Antimicrobial BCP3 in a Coating for Endotracheal Tubes

Ventilator-associated pneumonia (VAP) is a highly common hospital-acquired infection affecting people that require mechanical ventilation. The endotracheal tube (ETT) used during the ventilation process provides a surface that can allow bacterial colonization and biofilm formation, which can lead to VAP. Although various approaches, including ETT design and material selection, as well as antimicrobial coatings have been employed to minimize adverse events, VAP remains a significant unresolved clinical issue. In this study, we have utilized a novel styrylbenzene-based antimicrobial (BCP3) in a simple and robust coating that allows its long-term release at an effective level. BCP3 was applied onto PVC ETT segments blended together with poly(lactic-co-glycolic acid) via a facile dip-coating process with controlled loadings. In vitro studies demonstrated concentration-dependent release of BCP3 from the coatings for at least 31 days. Bacterial assays using major VAP culprits, Staphylococcus aureus and Pseudomonas aeruginosa, demonstrated significant growth inhibition, with a stronger effect on S. aureus. Despite its ability to inhibit bacterial growth, BCP3 showed no cytotoxicity toward mammalian (L929) fibroblasts, which makes it attractive from a clinical perspective. The coating procedure was successfully translated to coat the entire ETTs, making it highly amenable for large-scale manufacturing.

Bacterial membrane permeability of antimicrobial polymethacrylates: Evidence for a complex mechanism from super-resolution fluorescence imaging

Amphiphilic polymers bearing cationic moieties are an emerging alternative to traditional antibiotics given their broad-spectrum activity and low susceptibility to the development of resistance. To date, however, much remains unclear regarding their mechanism of action. Using functional assays (ATP leakage, cell viability, DNA binding) and super-high resolution structured illumination microscopy (OMX-SR) of fluorescently tagged polymers, we present evidence for a complex mechanism, involving membrane permeation as well as cellular uptake, interaction with intracellular targets and possible complexation with bacterial DNA. STATEMENT OF SIGNIFICANCE: This manuscript details the first study to systematically and directly investigate the mechanism of action of antimicrobial polymers, using super-resolution fluorescence imaging as well as functional assays. While many in the field cite membrane permeation as the sole mechanism underlying the activity of such polymers, we present evidence for multimodal actions including high cellular uptake and interaction with intracellular targets. It is also the first report to show competitive binding of antimicrobial polymers with bacterial DNA in a dose-dependent manner.

S-Nitroso-N-acetylpenicillamine impregnated endotracheal tubes for prevention of ventilator-associated pneumonia

The chances of ventilator-associated pneumonia (VAP) increases 6-20 folds when an endotracheal tube (ETT) is placed in a patient. VAP is one of the most common hospital-acquired infections and comprises 86% of the nosocomial pneumonia cases. This study introduces the idea of nitric oxide-releasing ETTs (NORel-ETTs) fabricated by the incorporation of the nitric oxide (NO) donor S-nitroso-N-acetylpenicillamine (SNAP) into commercially available ETTs via solvent swelling. The impregnation of SNAP provides NO release over a 7-day period without altering the mechanical properties of the ETT. The NORel-ETTs successfully reduced the bacterial infection from a commonly found pathogen in VAP, Pseudomonas aeruginosa, by 92.72 ± 0.97% when compared with the control ETTs. Overall, this study presents the incorporation of the active release of a bactericidal agent in ETTs as an efficient strategy to prevent the risk of VAP.

Multifunctional Antibacterial Materials Comprising Water Dispersible Random Copolymers Containing a Fluorinated Block and Their Application in Catheters

Inhibiting the attachment of bacteria and the formation of biofilms on surfaces of materials and devices is the key to ensure public safety and is also the focus of attention and research. Here we report on the synthesis of multifunctional antibacterial materials based on water dispersible random copolymers containing a fluorinated block, poly(acrylic acid-co-1H,1H,2H,2H-perfluorododecyl acrylate) (PAA-co-PFDA), and poly(hexamethylene biguanide) hydrochloride (PHMB). PAA-co-PFDA copolymers were synthesized through a simple free radical polymerization. After lightly cross-linking of PAA-co-PFDA and complexation with PHMB, multifunctional antibacterial PAA-co-PFDA/PHMB complex nanoparticles were generated, which can form transparent coatings on various substrates. The resultant coating has aggregation-induced emission character which can be used to observe the uniformity of the coating on a catheter and has a potential application as a fluorescence probe. It has been demonstrated that the PAA-co-PFDA/PHMB complex nanoparticle coatings can resist bacterial adhesion in physiological environment and exhibit excellent antibacterial activity in infection environment. In vitro and in vivo experiments indicated that the PAA-co-PFDA/PHMB complex nanoparticle coated catheters exhibited excellent antibacterial activity and possessed good biocompatibility. This method is simple and scalable, which is important for future commercialization. The attractive multifunctional properties of the PAA-co-PFDA/PHMB complex nanoparticles, such as antifouling, antimicrobial, emission, and pH-responsive release character, have great potential application in a wide range of biomedical fields.