Antimicrobial activity of photodynamic therapy in combination with colistin against a pan-drug resistant Acinetobacter baumannii isolated from burn patient

Antimicrobial photodynamic effect of the photosensitizer riboflavin, alone and in combination with colistin, against pandrug-resistant Pseudomonas aeruginosa clinical isolates

INTRODUCTION

Development of multi-, extensively-, and pandrug-resistant (MDR, XDR, and PDR) strains of Pseudomonas aeruginosa remains a major problem in medical care. The present study evaluated the effect of antimicrobial photodynamic therapy (aPDT) as a monotherapy and in combination with colistin against P. aeruginosa isolates.

METHODS

Two P. aeruginosa isolates recovered from patients with respiratory tract infections were examined in this study. Minimum inhibitory concentration (MIC) of colistin was determined by the colistin broth disk elution (CBDE) and the reference broth microdilution (rBMD) methods. aPDT was performed using the photosensitizer (Ps) riboflavin at several concentrations and a light-emitting diode (LED) emitting blue light for different irradiation times with or without colistin at 1/2 × MIC concentration.

RESULTS

Both PA1 and PA2 isolates were identified as colistin-resistant P. aeruginosa with a MIC ≥4 μg/mL by the CBDE and MICs of 512 μg/mL and 256 μg/mL, respectively, by the rBMD. In aPDT, neither riboflavin nor LED light alone had antibacterial effects. The values of colony forming units per milliliter (CFU/mL) in both isolates were significantly reduced by LED + Ps treatments in a time-dependent manner (LED irradiation time) and dose-dependent manner (Ps concentration). In comparison with control, treatment with Ps (50 μM) + LED (120 s) and Ps (100 μM) + LED (120 s) resulted in 0.27 log10 CFU/mL and 0.43 log10 CFU/mL reductions in PA1, and 0.28 log10 CFU/mL and 0.34 log10 CFU/mL reductions in PA2, respectively, (P < 0.01). The best results were obtained after the combination of aPDT followed by colistin, which increased bacterial reduction, resulting in a 0.41-0.7 log10 CFU/mL reduction for PA1 and 0.35-0.83 log10 CFU/mL reduction for PA2 (P = 0.001).

CONCLUSIONS

This study suggests the potential implications of aPDT in combination with antibiotics, such as colistin for treatment of difficult-to-treat P. aeruginosa infections.

Decrease of ESKAPE virulence with a cationic heme-mimetic gallium porphyrin photosensitizer: The Trojan horse strategy that could help address antimicrobial resistance

INTRODUCTION

Emerging antibiotic resistance among bacterial pathogens has forced an urgent need for alternative non-antibiotic strategies development that could combat drug resistant-associated infections. Suppression of virulence of ESKAPE pathogens' by targeting multiple virulence traits provides a promising approach.

OBJECTIVES

Here we propose an iron-blocking antibacterial therapy based on a cationic heme-mimetic gallium porphyrin (GaCHP), which antibacterial efficacy could be further enhanced by photodynamic inactivation.

METHODS

We used gallium heme mimetic porphyrin (GaCHP) excited with light to significantly reduce microbial viability and suppress both the expression and biological activity of several virulence traits of both Gram-positive and Gram-negative ESKAPE representatives, i.e., S. aureus and P. aeruginosa. Moreover, further improvement of the proposed strategy by combining it with routinely used antimicrobials to resensitize the microbes to antibiotics and provide enhanced bactericidal efficacy was investigated.

RESULTS

The proposed strategy led to substantial inactivation of critical priority pathogens and has been evidenced to suppress the expression and biological activity of multiple virulence factors in S. aureus and P. aeruginosa. Finally, the combination of GaCHP phototreatment and antibiotics resulted in promising strategy to overcome antibiotic resistance of the studied microbes and to enhance disinfection of drug resistant pathogens.

CONCLUSION

Lastly, considering high safety aspects of the proposed treatment toward host cells, i.e., lack of mutagenicity, no dark toxicity and mild phototoxicity, we describe an efficient alternative that simultaneously suppresses the functionality of multiple virulence factors in ESKAPE pathogens.

Biological Performance of Hexadeca-Substituted Metal Phthalocyanine/Reduced Graphene Oxide Nanobioagents

This study presents a tetra-substituted phthalonitrile derivative, namely, diethyl 2-(3,4-dicyano-2,5-bis(hexyloxy)-6-(4-(trifluoromethoxy)phenoxy)phenyl)malonate (a), cyclotetramerizing in the presence of some metal salts. The resultant hexadeca-substituted metal phthalocyanines [M= Co, Zn, InCl)] (b-d) were used for the modification of reduced graphene oxide for the first time. The effect of the phthalonitrile/metal phthalocyanines on biological features of reduced graphene oxide (rGO) was extensively examined by the investigation of antioxidant, antimicrobial, DNA cleavage, cell viability, and antibiofilm activities of nanobioagents (1-4). The results were compared with those of unmodified rGO (nanobioagent 5), as well. Modification of reduced graphene oxide with the synthesized compounds improved its antioxidant activity. The antioxidant activities of all the tested nanobioagents also enhanced as the concentration increased. The antibacterial activities of all the nanobioagents improved by applying the photodynamic therapeutic (PDT) method. All the phthalonitrile/phthalocyanine-based nanobioagents (especially phthalocyanine-based nanocomposites) exhibited DNA cleavage activities, and complete DNA fragmentation was observed for nanobioagents (1-4) at 200 mg/L. They can be used as potent antimicrobial and antimicrobial photodynamic therapy agents as well as Escherichia coli microbial cell inhibitors. As a result, the prepared nanocomposites can be considered promising candidates for biomedicine.

Polymyxin B-targeted liposomal photosensitizer cures MDR A. baumannii burn infections and accelerates wound healing via M1/M2 macrophage polarization

Multidrug-resistant (MDR) Acinetobacter baumannii infections pose a significant challenge in burn wound management, necessitating the development of innovative therapeutic strategies. In this work, we introduced a novel polymyxin B (PMB)-targeted liposomal photosensitizer, HMME@Lipo-PMB, for precise and potent antimicrobial photodynamic therapy (aPDT) against burn infections induced by MDR A. baumanni. HMME@Lipo-PMB-mediated aPDT exhibited enhanced antibacterial efficacy by specifically targeting and disrupting bacterial cell membranes, and generating increased intracellular ROS. Remarkably, even at low concentrations, this targeted approach significantly reduced bacterial viability in vitro and completely eradicated burn infections induced by MDR A. baumannii in vivo. Additionally, HMME@Lipo-PMB-mediated aPDT facilitated burn infection wound healing by modulating M1/M2 macrophage polarization. It also effectively promoted acute inflammation in the early stage, while attenuated chronic inflammation in the later stage of wound healing. This dynamic modulation promoted the formation of granulation tissue, angiogenesis, and collagen regeneration. These findings demonstrate the tremendous potential of HMME@Lipo-PMB-mediated aPDT as a promising alternative for the treatment of burn infections caused by MDR A. baumannii.

Phage Therapy, a Salvage Treatment for Multidrug-Resistant Bacteria Causing Infective Endocarditis

Infective endocarditis (IE) is defined as an infection of the endocardium, or inner surface of the heart, most frequently affecting the heart valves or implanted cardiac devices. Despite its rarity, it has a high rate of morbidity and mortality. IE generally occurs when bacteria, fungi, or other germs from another part of the body, such as the mouth, spread through the bloodstream and attach to damaged areas in the heart. The epidemiology of IE has changed as a consequence of aging and the usage of implantable cardiac devices and heart valves. The right therapeutic routes must be assessed to lower complication and fatality rates, so this requires early clinical suspicion and a fast diagnosis. It is urgently necessary to create new and efficient medicines to combat multidrug-resistant bacterial (MDR) infections because of the increasing threat of antibiotic resistance on a worldwide scale. MDR bacteria that cause IE can be treated using phages rather than antibiotics to combat MDR bacterial strains. This review will illustrate how phage therapy began and how it is considered a powerful potential candidate for the treatment of MDR bacteria that cause IE. Furthermore, it gives a brief about all reported clinical trials that demonstrated the promising effect of phage therapy in combating resistant bacterial strains that cause IE and how it will become a hope in future medicine.

Effect of photodynamic therapy on multidrug-resistant Acinetobacter baumannii: A scoping review

BACKGROUND

Acinetobacter baumannii is a Gram-negative, non-fermenting coccobacillus of the Moraxellaceae family. It is an opportunistic pathogen responsible for several hospital-acquired infections (HAIs) associated with skin and tissue infections at surgical sites, catheter-associated urinary tract infections, and central line catheters. Multidrug-resistant (MDR) A. baumannii has caused hospital outbreaks that are difficult to eradicate and represent one of the leading producers of HAIs. MDR-A. baumannii presents a broad range of resistance to different antimicrobials, including carbapenems. Due to the low sensitivity to conventional antibiotic therapies, it is necessary to identify other therapeutic options. Antimicrobial photodynamic therapy (aPDT) is a promising alternative and complementary approach to address the shortage of antimicrobials in MDR-A. baumannii. APDT combines a photosensitizer agent, light, and oxygen to achieve a bactericidal/bacteriostatic effect. The effect is given by producing reactive oxygen species (ROS) that produce photooxidative stress over bacterial structures, such as the envelope and the DNA.

METHODS

This study aims to systematically collect bibliographic information from databases such as PubMed, Scopus, and google scholar to analyze the relevant articles critically.

RESULTS

An increasing body of evidence demonstrates the efficacy of photodynamic inactivation in eliminating A. baumannii strains, both in vitro and in vivo.

CONCLUSIONS

The evidence supports that photodynamic inactivation is an alternative capable of eliminating strains of Acinetobacter baumannii and may considerably improve the treatment of MDR strains. Although they do exist, aPDT studies on MDR strains of A. baumannii are scarce and should increase since it is on these strains that photodynamic therapy becomes attractive.

Photodynamic therapy: a new approach to the treatment of Nontuberculous Mycobacterial skin and soft tissue infections

Nontuberculous mycobacterial skin and soft tissue infections are rising and are causing social concern due to the growth of cosmetic dermatology and immune-compromised populations. For the treatment of nontuberculous mycobacteria, several novel strategies have been investigated. One of them, photodynamic therapy, is a recently developed therapeutic strategy that has shown promise in managing nontuberculous mycobacterial skin and soft tissue infections. In this review, we first present an overview of the current status of the therapy and then summarize and analyze the cases of photodynamic therapy used to treat nontuberculous mycobacterial skin and soft tissue infections. We also discussed the feasibility of photodynamic therapy for treating nontuberculous mycobacterial skin soft tissue infections and the related mechanisms, providing a potential new option for clinical treatment.

Photothermally Controlled Drug Release of Poly(d,l-lactide) Nanofibers Loaded with Indocyanine Green and Curcumin for Efficient Antimicrobial Photodynamic Therapy

Chronic wound infections with antibiotic-resistant bacteria have become a significant problem for modern healthcare systems since they are often associated with high costs and require profound topical wound management. Successful wound healing is achieved by reducing the bacterial load of the wound and providing an environment that enhances cell growth. In this context, nanofibers show remarkable success because their structure offers a promising drug delivery platform that can mimic the native extracellular matrix and accelerate cell proliferation. In our study, single-needle electrospinning, a versatile and cost-efficient technique, was used to shape polymers into an applicable and homogeneous fleece capable of a photothermally triggered drug release. It was combined with antimicrobial photodynamic therapy, a promising procedure against resistant bacteria. Therefore, poly(d,l-lactide) nanofibers loaded with curcumin and indocyanine green (ICG) were produced for local antimicrobial treatment. The mesh had a homogeneous structure, and the nanofibers showed a smooth surface. Recordings with a thermal camera showed that near-infrared light irradiation of ICG increased the temperature (>44 °C) in the surrounding medium. Release studies confirmed more than 29% enhanced curcumin release triggered by elevated temperature. The antimicrobial activity was tested against the gram-positive strain Staphylococcus saprophyticus subsp. bovis and the gram-negative strain Escherichia coli DH5 alpha. The nanofibers loaded with both photosensitizers and irradiated with both wavelengths reduced the bacterial viability (~4.4 log₁₀, 99.996%) significantly more than the nanofibers loaded with only one photosensitizer (<1.7 log₁₀, 97.828%) or irradiated with only one wavelength (<2.0 log₁₀, 98.952%). In addition, our formulation efficiently eradicated persistent adhered bacteria by >4.3 log₁₀ (99.995%), which was also confirmed visually. Finally, the produced nanofibers showed good biocompatibility, proven by the cellular viability of mouse fibroblasts (L929). The data demonstrate that we have developed a new economic nanofiber formulation, which offers a triggered drug release, excellent antimicrobial properties, and good biocompatibility.

Combination of photodynamic antimicrobial chemotherapy and ciprofloxacin to combat S. aureus and E. coli resistant biofilms

Photodynamic antimicrobial chemotherapy (PACT) coupled with an antibiotic, ciprofloxacin (CIP), was investigated using two indium metallated cationic photosensitizers, a porphyrin (1) and a phthalocyanine (2). Applying PACT followed by the antibiotic treatment led to a remarkable reduction in the biofilm cell survival of two antibiotic-resistant bacterial strains, S. aureus (Gram-positive) and E. coli (Gram-nenative). Treating both bacteria strains with PACT alone showed no significant activity at 32 µM with 15 min irradiation, while CIP alone exhibited a minimum biofilm inhibition concentration (MBIC) at 4 and 8 µg/mL on S. aureus and E. coli, respectively following 24 h incubation. The combined treatment resulted in the complete eradication of the matured biofilms with high log₁₀ reduction values of 7.05 and 7.20 on S. aureus and E. coli, respectively, at low concentrations. It was found that 15 min PACT irradiation of 8 µM of complexes (1 and 2) combined with 2 µg/mL of CIP have a 100% reduction of the resistant S. aureus biofilms. Whereas the total killing of E. coli was obtained when combining 8 µM of complex 1 and 16 µM of complex 2 both combined with 4 µg/mL of CIP.

Combined Antimicrobial Blue Light and Antibiotics as a Tool for Eradication of Multidrug-Resistant Isolates of Pseudomonas aeruginosa and Staphylococcus aureus: In Vitro and In Vivo Studies

Increased development of resistance to antibiotics among microorganisms promotes the evaluation of alternative approaches. Within this study, we examined the efficacy of antimicrobial blue light (aBL) with routinely used antibiotics against multidrug-resistant isolates of Pseudomonas aeruginosa and Staphylococcus aureus as combined alternative treatment. In vitro results of this study confirm that both S. aureus and P. aeruginosa can be sensitized to antibiotics, such as chloramphenicol, linezolid, fusidic acid or colistin, fosfomycin and ciprofloxacin, respectively. The assessment of increased ROS production upon aBL exposure and the changes in cell envelopes permeability were also goals that were completed within the current study. Moreover, the in vivo experiment revealed that, indeed, the synergy between aBL and antibiotic (chloramphenicol) occurs, and the results in the reduced bioluminescence signal of the S. aureus Xen31 strain used to infect the animal wounds. To conclude, we are the first to present the possible mechanism explaining the observed synergies among photoinactivation with blue light and antibiotics in the term of Gram-positive and Gram-negative representatives.

Thermoresponsive Liposomes for Photo-Triggered Release of Hypericin Cyclodextrin Inclusion Complex for Efficient Antimicrobial Photodynamic Therapy

Antimicrobial strategies with high efficacy against bacterial infections are urgently needed. The development of effective therapies to control bacterial infections is still a challenge. Herein, near-infrared (NIR)-activated thermosensitive liposomes (TSL) were loaded with the NIR-dye 1,1-dioctadecyl-3,3,3,3-tetramethylindotricarbocyanine iodide (DiR) and the water-soluble hypericin (Hyp) β-cyclodextrin inclusion complex (Hyp-βCD). DiR and Hyp-βCD loaded thermosensitive liposomes (DHβCD-TSL) are functionalized for photothermal triggered release and synergistic photodynamic therapy to eliminate the gram-positive Staphylococcus saprophyticus. The dually active liposomes allow the production of heat and singlet oxygen species with the help of DiR and Hyp, respectively. The elevated temperature, generated by the NIR irradiation, irreversibly damages the bacterial membrane, increases the permeation, and melts the liposomes via a phase-transition mechanism, which allows the release of the Hyp-βCD complex. The photodynamic effect of Hyp-βCD eradicates the bacterial cells owing to its toxic oxygen species production. DHβCD-TSL measured the size of 130 nm with an adequate encapsulation efficiency of 81.3% of Hyp-βCD. They exhibited a phase transition temperature of 42.3 °C, while they remained stable at 37 °C, and 44% of Hyp-βCD was released after NIR irradiation (T > 47 °C). The bacterial viability dropped significantly after the synergistic treatment (>4 log₁₀), indicating that the NIR-activated TSL have immense therapeutic potential to enhance the antibacterial efficacy. The liposomes showed good biocompatibility, which was confirmed by the cellular viability of mouse fibroblasts (L929).

Photodynamic therapy for treatment of infected burns

Burns are among the most debilitating and devastating forms of trauma. Such injuries are influenced by infections, causing increased morbidity, mortality, and healthcare costs. Due to the emergence of multidrug-resistant infectious agents, efficient treatment of infections in burns is a challenging issue. Antimicrobial photodynamic therapy (aPDT) is a promising approach to inactivate infectious agents, including multidrug-resistant. In this review, studies on PubMed were gathered, aiming to summarize the achievements regarding the applications of antimicrobial photodynamic therapy for the treatment of infected burns. A literature search was carried out for aPDT published reports assessment on bacterial, fungal, and viral infections in burns. The collected data suggest that aPDT could be a promising new approach against multidrug-resistant infectious agents. However, despite important results being obtained against bacteria, experimental and clinical studies are necessary yet on the effectiveness of aPDT against fungal and viral infections in burns, which could reduce morbidity and mortality of burned patients, mainly those infected by multidrug-resistant strains.

Methylene Blue-Mediated Antimicrobial ​Photodynamic Therapy Against Clinical Isolates of Extensively Drug Resistant ​Gram-Negative Bacteria Causing Nosocomial Infections in Thailand, An In Vitro Study

BACKGROUND/PURPOSE

Some multidrug-resistant gram-negative bacteria as a global threat have been recently prioritized for research and development of new treatments. We studied the efficacy of methylene blue-mediated antimicrobial photodynamic therapy (MB-aPDT) for the reduction of extensively drug-resistant Acinetobacter baumannii (XDR-AB) and Pseudomonas aeruginosa (XDR-PS) and multidrug-resistant Klebsiella pneumoniae (MDR-KP) isolated in a university hospital setting in Thailand.

METHOD

Two isolates of each selected bacterium were collected, XDR-AB1 and AB2, XDR- PS1 and PS2, and MDR-KP1 and KP2. Three triplicate experiments using various MB concentrations alone, various red light fluences alone, as well as the selected non-toxic doses of MB and fluences of red light combined as MB-aPDT were applied on each selected isolate. The colonies were counted [colony forming units (CFU)/ml]. Estimation of the lethal treatment dose defined as reduction of > 2 log₁₀ in CFU/ml compared with untreated bacteria.

RESULT

There were generally negligible changes in the viable counts of the bacterial suspensions treated with all the MB concentrations (p > 0.05). In the second experiment with the only red light treatments, at fluences higher than 2 J/cm, reduction trend in viable counts across all the isolates was observed. Only for MDR-KP1, however, the lethal dose was achieved with the highest fluence of red light (80 J/cm). With the concentration of MB, 50 and 150 mg/L in the third experiment (MB-aPDT), the greater bacterial reduction was observed in all clinical isolates leading to their lethal viable cell reduction when escalating the light fluence to 80 J/cm.

CONCLUSIONS

MB-aPDT evidently killed the selected XDR and MDR-gram negative bacteria. In highly drug-resistant crisis era, MB-aPDT could be a promising option, particularly for local infections and infection complicating chronic wounds.

Effective Strategies to Deal With Infection in Burn Patient

Treatment of bacterial infection is difficult. Treatment protocol of burned patient is hard. Furthermore, treatment in burned patients is accompanied with problems such as complexity in diagnosis of infection's agent, multiple infections, being painful, and involving with different organelles. There are different infections of Gram-positive and Gram-negative bacteria in burned patients. From important bacteria can be noted to Pseudomonas aeruginosa, Acinetobacter baumannii, and Staphylococcus aureus that have high range of morbidity and mortality. Treatment of those bacterial infections is extremely important. Hence, many studies about methods of treatment of bacterial infections have published. Herein, we have suggested practical methods for example ant virulence therapies, nanotechnology, vaccine, and photodynamic therapy in treatment of bacterial infections. Those methods have been done in many researches and had good effect.

Photodynamic and antibiotic therapy in combination against bacterial infections: efficacy, determinants, mechanisms, and future perspectives

Antibiotic treatment, the mainstay for the control of bacterial infections, is greatly hampered by the global prevalence of multidrug-resistant (MDR) bacteria. Photodynamic therapy (PDT) is effective against MDR infections, but PDT-induced bacterial inactivation is often incomplete, causing the relapse of infections. Combination of PDT and antibiotics is a promising strategy to overcome the limitation of both antibiotic treatment and PDT, exerting increased disinfection efficacy on MDR bacterial pathogens versus either of the monotherapies alone. In this review, we present an overview of the therapeutic effects of PDT/antibiotic combinations that have been developed. We further summarize the influencing factors and the governing molecular mechanisms of the therapeutic outcomes of PDT/antibiotic combinations. In the end, we provide concluding remarks on the strengths, limitations, and future research directions of PDT/antibiotic combination therapy to guide its appropriate usage and further development.

Multidrug-resistant Bacterial Profile and Patterns for Wound Infections in Nongovernmental Hospitals of Jordan

Globally, multidrug-resistant bacteria affects wound infections, both hospital-acquired infections and community-acquired infections. The main isolates cultured from 607 subjects with wound infections were methicillin-resistant Staphylococcus aureus (MRSA), Escherichia coli, Pseudomonas aeruginosa, and Acinetobacter spp. [multidrug resistant (MDR)]. Gram-negative bacteria caused most of the infections (67%) compared with gram-positive bacteria. Diabetic patients tend to have wound infections with mixed causative agents compared with non-diabetic patients.

Effects of sub-lethal antimicrobial photodynamic therapy mediated by haematoporphyrin monomethyl ether on polymyxin-resistant Escherichia coli clinical isolate

BACKGROUND AND AIM

It is generally believed that bacteria can not develop resistance to antimicrobial photodynamic therapy (aPDT). This work employed a polymyxin-resistant Escherichia coli clinical isolate (E15017) to study whether it could become resistant to aPDT mediated by haematoporphyrin monomethyl ether (HMME) via consecutive photodynamic treatments at sub-lethal condition.

METHODS

The sub-lethal and lethal photodynamic treatment conditions for E15017 were determined by colony forming units (CFU) assay. Bacterial cells of E15017 were treated with 20 cycles of repeated sub-lethal HMME-mediated aPDT, and subsequently subjected to aPDT at lethal condition. The antibiotic susceptibility, zeta-potential and membrane integrity of sub-lethal aPDT treated E15017 cells were also investigated.

RESULTS

After 20 cycles of repeated HMME-mediated aPDT treatments at sub-lethal condition, E15017 cells didn't become more resistant to aPDT. Sub-lethal HMME-mediated aPDT decreased the MIC values of E15017 to ceftazidime and polymyxin E by 4 and 2-fold, respectively, and increased the electronegativity of bacterial surface and affected the bacterial membrane integrity.

CONCLUSIONS

The results obtained in this study confirmed that antibiotic-resistant bacteria could not develop resistance to aPDT, and HMME-mediated aPDT is an attractive potential treatment for MDR E. coli caused infections.

Antimicrobial photodynamic therapy against Acinetobacter baumannii

Acinetobacter baumannii (A. baumannii) has emerged as a pathogen of global importance able to cause opportunistic infections on the skin, urinary tract, lungs, and bloodstream, being frequently involved in hospital outbreaks. Such bacterium can resist a variety of environmental conditions and develop resistance to different classes of antibiotics. Antimicrobial photodynamic therapy (aPDT) has been considered a promising approach to overcome bacterial resistance once it does not cause selective environmental pressure on bacteria. In this review, studies on aPDT were accessed on PubMed, and their findings were summarized regarding its efficacy against A. baumannii. The data obtained from the literature show that exogenous photosensitizers belonging to different chemical classes are effective against multidrug-resistant A. baumannii strains. However, most of such data is from in vitro studies, and additional studies are necessary to evaluate if the exogenous photosensitizers may induce selective pressure on A. baumannii and the effectiveness of such photosensitizers in clinical practice.

Mapping Global Prevalence of Acinetobacter baumannii and Recent Vaccine Development to Tackle It

Acinetobacter baumannii is a leading cause of nosocomial infections that severely threaten public health. The formidable adaptability and resistance of this opportunistic pathogen have hampered the development of antimicrobial therapies which consequently leads to very limited treatment options. We mapped the global prevalence of multidrug-resistant A. baumannii and showed that carbapenem-resistant A. baumannii is widespread throughout Asia and the Americas. Moreover, when antimicrobial resistance rates of Acinetobacter spp. exceed a threshold level, the proportion of A. baumannii isolates from clinical samples surges. Therefore, vaccines represent a realistic alternative strategy to tackle this pathogen. Research into anti-A. baumannii vaccines have enhanced in the past decade and multiple antigens have been investigated preclinically with varying results. This review summarises the current knowledge of virulence factors relating to A. baumannii–host interactions and its implication in vaccine design, with a view to understanding the current state of A. baumannii vaccine development and the direction of future efforts.

Antimicrobial Photodynamic Therapy Combined With Antibiotic in the Treatment of Rats With Third-Degree Burns

Cationic porphyrin conjugate, protoporphyrin IX-methyl ethylenediamine derivative (PPIX-MED) has a potent photosensitive antibacterial effect on clinically isolated bacteria, including methicillin-resistant Staphylococcus aureus, (MRSA), Escherichia coli, and Pseudomonas aeruginosa. This study investigated (i) the PPIX-MED-mediated antimicrobial photodynamic effect on these three species in vitro and (ii) the effect of antimicrobial photodynamic therapy (aPDT) combined with the use of an antibiotic on the healing in vivo of third-degree burns of rats with the wounds infected by these bacterial species. PPIX-MED exerted a potent inhibitory effect on the growth of the three bacterial species by producing reactive oxygen species when photoactivated. PPIX-MED-mediated antimicrobial photodynamic therapy (PPIX-MED-aPDT) had high bacterial photoinactivation ability in vitro, with a minimum inhibitory concentration of 15.6 μM PPIX-MED against each of the three types of bacteria and minimum bactericidal concentrations of 31.25 μM against MRSA and E. coli and 62.5 μM against P. aeruginosa. In rats with third-degree burns infected by a mixture of these bacteria, the bactericidal efficiency of PPIX-MED–aPDT-combined-with-antibiotic treatment was higher than that of antibiotic or aPDT treatment alone. This was confirmed by analysis of viable bacterial counts in wound tissue and blood. Enzyme-linked immunosorbent assay revealed that aPDT-combined-with-antibiotic treatment resulted in an obvious reduction in tumor necrosis factor-alpha and interleukin-6 levels compared with the no-treatment control group and the other treatment groups. Immunohistochemistry revealed that the expression of basic fibroblast growth factor and CD31 (a marker of neovascularization), expressed in burn wound tissue was higher in the aPDT-combined-with-antibiotic treatment group than in the other groups. PPIX-MED–aPDT has a promising bactericidal effect both in vitro and in vivo, and PPIX-MED–aPDT-combined-with-antibiotic treatment enhanced the healing of infected third-degree burns in rats.

Photodynamic inactivation of bacterial carbapenemases restores bacterial carbapenem susceptibility and enhances carbapenem antibiotic effectiveness

The global emergence of carbapenemases in bacterial pathogens has rendered many life-threatening infections untreatable. Even though using carbapenemase inhibitors are a proven strategy in the battle against bacterial carbapenem resistance, developing inhibitors that could universally inactivate all bacterial carbapenemases is extremely challenging given the large diversity and the continuous evolution of bacterial carbapenemases. Antimicrobial photodynamic therapy (aPDT), an upcoming antimicrobial therapy, is demonstrated here for the first time to be a generalized approach to impair the bacterial carbapenemases without being limited by the molecular identities of the carbapenemases. In addition, aPDT is shown to prevent carbapenem antibiotic degradation, thereby enhancing the efficacy of carbapenem antibiotic against the carbapenemase-producing pathogens. Besides the enzyme activity impairment, aPDT was documented here to be genetically toxic for bacteria, and thus radically damage the carbapenemase genetic determinants in bacteria and prevent the transmission of carbapenemases among pathogens. By leveraging the universal carbapenemase-inactivating property of aPDT, it may be possible to make the incurable infections caused by the bacterial carbapenemases susceptible to carbapenem again.

Comparison of photodynamic therapy with methylene blue associated with ceftriaxone in gram-negative bacteria; an in vitro study

The resistance of microorganisms increases the need for new antimicrobial therapies. The aim of this study was to evaluate the in vitro action of photodynamic therapy and its combination with ceftriaxone in third generation cephalosporin resistant gram-negative bacteria. Clinical strains of Klebsiella pneumoniae, Enterobacter aerogenes and Escherichia coli were obtained, incubated with MB for 15 min combined or not with ceftriaxone and irradiated with fluence of 10 and 25 J/cm². MB internalization was evaluated by confocal microscopy. Cell viability was assessed by counting colony forming units and bacterian metabolism by the resazurin test. MB has been observed within cells, although not in all bacteria. PDT-MB alone and combined with Ceftriaxone reduced bacterial growth by approximately 1 log at 10 J/cm² of fluence and 4 logs by 25 J/cm², with a significant difference from the control group. The reduction in bacterial growth between the treated groups was similar, without significant difference between them. The Resazurin test showed lower bacterial metabolic activity in the treated groups, but it did not allow to observe difference between fluences. It was concluded with this study that the internalization of MB was not observed in all cells of K. pneumoniae, E. aerogenes and E. coli strains. There was less bacterial metabolic activity in the treated groups, with no variation between different fluences. PDT-MB 25 J/cm² alone and combined with Ceftriaxone showed antimicrobial action, but the PDT-MB/Ceftriaxone combination had no potentiating effect.

A Review of the Most Impactful Published Pharmacotherapy-Pertinent Literature of 2017 and 2018 for Clinicians Caring for Patients with Burn or Inhalation Injuries

Staying current and evaluating literature related to pharmacotherapy in burn or inhalation injury can be difficult as burn care teams are multidisciplinary and pertinent content can be spread across a plethora of journals. The goal of this review is to critically evaluate recently published pharmacotherapy-pertinent literature, assist practitioners staying current, and better identify potential future research targets. Twelve board-certified clinical pharmacists with experience caring for patients with burn and inhalation injuries reviewed and graded scientific literature published in 2017 and 2018. An MeSH-based search revealed 1158 articles related to burns, which were published during the 2-year period. One-hundred fifty one were determined to be potentially related to pharmacotherapy. After exclusions, only 82 (7%) remained for scoring, and the top 10 comprehensively presented. More than half of the reviewed manuscripts were assessed as lacking a significant impact on pharmacotherapy. There is a need for higher impact literature to support pharmacotherapy-pertinent treatment of such complex patients.

How Phages Overcome the Challenges of Drug Resistant Bacteria in Clinical Infections

Nowadays the most important problem in the treatment of bacterial infections is the appearance of MDR (multidrug-resistant), XDR (extensively drug-resistant) and PDR (pan drug-resistant) bacteria and the scarce prospects of producing new antibiotics. There is renewed interest in revisiting the use of bacteriophage to treat bacterial infections. The practice of phage therapy, the application of phages to treat bacterial infections, has been around for approximately a century. Phage therapy relies on using lytic bacteriophages and purified phage lytic proteins for treatment and lysis of bacteria at the site of infection. Current research indicates that phage therapy has the potential to be used as an alternative to antibiotic treatments. It is noteworthy that, whether phages are used on their own or combined with antibiotics, phages are still a promising agent to replace antibiotics. So, this review focuses on an understanding of challenges of MDR, XDR, and PDR bacteria and phages mechanism for treating bacterial infections and the most recent studies on potential phages, cocktails of phages, and enzymes of lytic phages in fighting these resistant bacteria.

The effect of antimicrobial photodynamic therapy against virulence genes expression in colistin-resistance Acinetobacter baumannii

Background and Aims

The emergence of drug-resistant infections is a global problem. Acinetobacter baumannii has attracted much attention over the last few years because of resistance to a wide range of antibiotics. Applying new non-antibiotic methods can save lives of many people around the world. Antimicrobial photodynamic therapy (aPDT) technique can be used as a new method for controlling the infections. In this study we investigated the effect of aPDT on the expression of pathogenic genes in colistin-resistance A. baumannii isolated from a burn patient.

Materials and methods

The suspension of colistin-resistance A. baumannii was incubated with 0.01 mg/ml of toluidine blue O (TBO) in the dark; then the light emitting diode device with a wavelength of 630 ± 10 nm and output intensity of 2000-4000 mW /cm² was irradiated to the suspension at room temperature. Subsequently, after the aPDT, genes expression of ompA and pilZ was investigated by using real-time polymerase chain reaction technique.

Result

Among the genes studied, the transcript of the ompA gene after aPDT was increased significantly in comparison with control groups (P < 0.05). Whereas, there was no remarkable different in pilZ gene expression (P > 0.05).

Conclusions

It can be concluded from the results that the ompA as an outer membrane of A. baumannii is degraded after exposing aPDT and it will probably be done the penetration of antibiotics into cells of this bacterium easily.

Antimicrobials Are a Photodynamic Inactivation Adjuvant for the Eradication of Extensively Drug-Resistant Acinetobacter baumannii

The worldwide emergence of extensively drug resistant (XDR) Acinetobacter baumannii has reduced the number of antimicrobials that exert high bactericidal activity against this pathogen. This is the reason why many scientists are focusing on investigations concerning novel non-antibiotic strategies such as antimicrobial photodynamic inactivation (aPDI) or the use of antimicrobial blue light (aBL). Therefore, the aim of the current study was to screen for antimicrobial synergies of routinely used antibiotics and phototherapies, including both aPDI involving exogenously administered photosensitizing molecules, namely, rose bengal, and aBL, involving excitation of endogenously produced photoactive compounds. The synergy testing was performed in accordance with antimicrobial susceptibility testing (AST) standards, including various methodological approaches, i.e., antibiotic diffusion tests, checkerboard assays, CFU counting and the evaluation of postantibiotic effects (PAEs). We report that combining antimicrobials and aPDI/aBL treatment led to a new strategy that overcomes drug resistance in XDR A. baumannii, rendering this pathogen susceptible to various categories of antibiotics. Sublethal aPDI/aBL treatment in the presence of sub-MIC levels of antimicrobials effectively killed A. baumannii expressing drug resistance to studied antibiotics when treated with only antibiotic therapy. The susceptibility of XDR A. baumannii to a range of antibiotics was enhanced following sublethal aPDI/aBL. Furthermore, 3′-(p-aminophenyl) fluorescein (APF) testing indicated that significantly increased reactive oxygen species production upon combined treatment could explain the observed synergistic activity. This result represents a conclusive example of the synergistic activity between photodynamic inactivation and clinically used antimicrobials leading to effective eradication of XDR A. baumannii isolates and indicates a potent novel therapeutic approach.

Modulation of Toxin-Antitoxin System Rnl AB Type II in Phage-Resistant Gammaproteobacteria Surviving Photodynamic Treatment

Type II toxin-antitoxin (TA) systems are the particular type of TA modules which take part in different kinds of cellular actions, such as biofilm formation, persistence, stress endurance, defense of the bacterial cell against multiple phage attacks, plasmid maintenance, and programmed cell death in favor of bacterial population. Although several bioinformatics and Pet lab studies have already been conducted to understand the functionality of already discovered TA systems, still, more work in this area is required. Rnl AB type II TA module, which is composed of RnlA toxin and RnlB antitoxin, is a newly discovered type II TA module which takes part in the defense mechanism against T4 bacteriophage attack in Escherichia coli K-12 strain MH1 that has not been widely studied in other bacteria. Because of the significant role of class Gammaproteobacteriacea in a diverse range of health problems, we chose here to focus on this class to survey the presence of the Rnl AB TA module. For better categorization and description of the distribution of this module in this class of bacteria, the corresponding phylogenetic trees are illustrated here. Neighbor-joining and the maximum parsimony methods were used in this study to take a look at the distribution of domains present in RnlA and RnlB proteins, among members of Gammaproteobacteria. Also, the possible roles of photodynamic therapy (PDT) in providing a substrate for better phage therapy are herein discussed.

Antimicrobial Photodynamic Therapy: An Effective Alternative Approach to Control Bacterial Infections

Introduction: The purpose of this review was to evaluate the available literature for in vitro and in vivo effectiveness of antimicrobial Photodynamic therapy (aPDT) in the field of bacteriology. Methods: A review of the relevant articles carried out in PubMed and Scopus to determine the efficiency of aPDT used in the reduction of microbial infection. Thirty-one relevant documents retrieved from PubMed, Scopus by inserting "antimicrobial photodynamic therapy" and "bacterial infection" and "photodynamic therapy" keywords. Results: According to different results, aPDT can be used as an adjuvant for the treatment of infectious diseases. The use of photosensitizer methylene blue, toluidine blue O (TBO), indocyanine green with light diode laser centered at (630±10 nm) and (650±10 nm) wavelengths have been shown to have significant results for the treatment of infectious diseases and bactericidal properties Conclusion: These findings suggest that, aPDT can be an efficient method in the treatment of localized and superficial infections.

Effects of Blue-Light-Induced Free Radical Formation from Catechin Hydrate on the Inactivation of Acinetobacter baumannii, Including a Carbapenem-Resistant Strain

Catechin is a flavan-3-ol, a derivative of flavans, with four phenolic hydroxyl groups, which exhibits a wide range of physiological properties. Chromatographic analyses were employed to examine the effects of blue light irradiation on the changes of catechin hydrate in an alkaline condition. In particular, the detection of a superoxide anion radical (O₂•⁻), a reactive oxygen species (ROS), and the inactivation of Acinetobacter baumannii (A. baumannii)—including a carbapenem-resistant A. baumannii (CRAB)—was investigated during the photoreaction of catechin hydrate. Following basification with blue light irradiation, the transparent solution of catechin hydrate turned yellowish, and a chromogenic catechin dimer was separated and identified as a proanthocyanidin. Adding ascorbic acid during the photolytic treatment of catechin hydrate decreased the dimer formation, suggesting that ascorbic acid can suppress the photosensitive oxidation of catechin. When catechin hydrate was irradiated by blue light in an alkaline solution, O₂•⁻ was produced via photosensitized oxidation, enhancing the inactivation of A. baumannii and CRAB. The present findings on the photon-induced oxidation of catechin hydrate provides a safe practice for the inactivation of environmental microorganisms.

Combined Antimicrobial Activity of Photodynamic Inactivation and Antimicrobials-State of the Art

Antimicrobial photodynamic inactivation (aPDI) is a promising tool for the eradication of life-threatening pathogens with different profiles of resistance. This study presents the state-of-the-art published studies that have been dedicated to analyzing the bactericidal effects of combining aPDI and routinely applied antibiotics in in vitro (using biofilm and planktonic cultures) and in vivo experiments. Furthermore, the current paper reviews the methodology used to obtain the published data that describes the synergy between these antimicrobial approaches. The authors are convinced that even though the combined efficacy of aPDI and antimicrobials could be investigated with the wide range of methods, the use of a unified experimental methodology that is in agreement with antimicrobial susceptibility testing (AST) is required to investigate possible synergistic cooperation between aPDI and antimicrobials. Conclusions concerning the possible synergistic activity between the two treatments can be drawn only when appropriate assays are employed. It must be noticed that some of the described papers were just aimed at determination if combined treatments exert enhanced antibacterial outcome, without following the standard methodology to evaluate the synergistic effect, but in most of them (18 out of 27) authors indicated the existence of synergy between described antibacterial approaches. In general, the increase in bacterial inactivation was observed when both therapies were used in combination.

Dual antibacterial behavior of a curcumin–upconversion photodynamic nanosystem for efficient eradication of drug-resistant bacteria in a deep joint infection

The curcumin–upconversion photodynamic nanosystem exhibits dual antibacterial behavior for MRSA-induced periprosthetic joint infection under NIR irradiation.

Antibiotic resistance of pathogenic Acinetobacter species and emerging combination therapy

The increasing antibiotic resistance of Acinetobacter species in both natural and hospital environments has become a serious problem worldwide in recent decades. Because of both intrinsic and acquired antimicrobial resistance (AMR) against last-resort antibiotics such as carbapenems, novel therapeutics are urgently required to treat Acinetobacter-associated infectious diseases. Among the many pathogenic Acinetobacter species, A. baumannii has been reported to be resistant to all classes of antibiotics and contains many AMR genes, such as bla _ADC (Acinetobacter-derived cephalosporinase). The AMR of pathogenic Acinetobacter species is the result of several different mechanisms, including active efflux pumps, mutations in antibiotic targets, antibiotic modification, and low antibiotic membrane permeability. To overcome the limitations of existing drugs, combination theraphy that can increase the activity of antibiotics should be considered in the treatment of Acinetobacter infections. Understanding the molecular mechanisms behind Acinetobacter AMR resistance will provide vital information for drug development and therapeutic strategies using combination treatment. Here, we summarize the classic mechanisms of Acinetobacter AMR, along with newly-discovered genetic AMR factors and currently available antimicrobial adjuvants that can enhance drug efficacy in the treatment of A. baumannii infections.