Evasion of cellular ocular defenses by contact lens isolates of Serratia marcescens

Chloramphenicol Resurrected: A Journey from Antibiotic Resistance in Eye Infections to Biofilm and Ocular Microbiota

The advent of multidrug resistance among pathogenic bacteria is devastating the worth of antibiotics and changing the way of their administration, as well as the approach to use new or old drugs. The crisis of antimicrobial resistance is also due to the unavailability of newer drugs, attributable to exigent regulatory requirements and reduced financial inducements. The emerging resistance to antibiotics worldwide has led to renewed interest in old drugs that have fallen into disuse because of toxic side effects. Thus, comprehensive efforts are needed to minimize the pace of resistance by studying emergent microorganisms and optimize the use of old antimicrobial agents able to maintain their profile of susceptibility. Chloramphenicol is experiencing its renaissance because it is widely used in the treatment and prevention of superficial eye infections due to its broad spectrum of activity and other useful antimicrobial peculiarities, such as the antibiofilm properties. Concerns have been raised in the past for the risk of aplastic anemia when chloramphenicol is given intravenously. Chloramphenicol seems suitable to be used as topical eye formulation for the limited rate of resistance compared to fluoroquinolones, for its scarce induction of bacterial resistance and antibiofilm activity, and for the hypothetical low impact on ocular microbiota disturbance. Further in-vitro and in vivo studies on pharmacodynamics properties of ocular formulation of chloramphenicol, as well as its real impact against biofilm and the ocular microbiota, need to be better addressed in the near future.

Disturbing the balance: effect of contact lens use on the ocular proteome and microbiome

Contact lens wear is a popular, convenient and effective method for vision correction. In recent years, contact lens practice has expanded to include new paradigms, including orthokeratology; however, their use is not entirely without risk, as the incidence of infection has consistently been reported to be higher in contact lens wearers. The explanations for this increased susceptibility have largely focused on physical damage, especially to the cornea, due to a combination of hypoxia, mechanical trauma, deposits and solution cytotoxicity, as well as poor compliance with care routines leading to introduction of pathogens into the ocular environment. However, in recent years, with the increasing availability and reduced cost of molecular techniques, the ocular environment has received greater attention with in-depth studies of proteins and other components. Numerous proteins were found to be present in the tears and their functions and interactions indicate that the tears are far more complex than formerly presumed. In addition, the concept of a sterile or limited microbial population on the ocular surface has been challenged by analysis of the microbiome. Ocular microbiome was not considered as one of the key sites for the Human Microbiome Project, as it was thought to be limited compared to other body sites. This was proven to be fallacious, as a wide variety of micro-organisms were identified in the analyses of human tears. Thus, the ocular environment is now recognised to be more complicated and interference with this ecological balance may lead to adverse effects. The use of contact lenses clearly changes the situation at the ocular surface, which may result in consequences which disturb the balance in the healthy eye.

The Effect of Closed-Eye Tear Film Conditions on Blood-Isolated Neutrophils, In Vitro

PURPOSE

Eyelid closure results in influx of neutrophils onto the ocular surface, which are non-responsive to inflammatory stimuli. This investigation examined whether incubation of blood-isolated neutrophils in closed-eye conditions induce a tear-film neutrophil phenotype.

METHODS

Blood-isolated neutrophils were incubated combining various conditions: hypoxia, corneal epithelial cells (HCEC), artificial tear solution (ATS).

RESULTS

A hypoxic environment induced no differential effect on membrane receptor expression. Incubation in the presence of HCEC resulted in membrane receptor upregulation and increase in caspase activation.

CONCLUSIONS

Hypoxia, corneal epithelial cell exposure, or artificial tear fluid are insufficient to replicate a tear-film neutrophil phenotype using blood-isolated neutrophils.

Antimicrobial compounds in tears

The tear film coats the cornea and conjunctiva and serves several important functions. It provides lubrication, prevents drying of the ocular surface epithelia, helps provide a smooth surface for refracting light, supplies oxygen and is an important component of the innate defense system of the eye providing protection against a range of potential pathogens. This review describes both classic antimicrobial compounds found in tears such as lysozyme and some more recently identified such as members of the cationic antimicrobial peptide family and surfactant protein-D as well as potential new candidate molecules that may contribute to antimicrobial protection. As is readily evident from the literature review herein, tears, like all mucosal fluids, contain a plethora of molecules with known antimicrobial effects. That all of these are active in vivo is debatable as many are present in low concentrations, may be influenced by other tear components such as the ionic environment, and antimicrobial action may be only one of several activities ascribed to the molecule. However, there are many studies showing synergistic/additive interactions between several of the tear antimicrobials and it is highly likely that cooperativity between molecules is the primary way tears are able to afford significant antimicrobial protection to the ocular surface in vivo. In addition to effects on pathogen growth and survival some tear components prevent epithelial cell invasion and promote the epithelial expression of innate defense molecules. Given the protective role of tears a number of scenarios can be envisaged that may affect the amount and/or activity of tear antimicrobials and hence compromise tear immunity. Two such situations, dry eye disease and contact lens wear, are discussed here.

Microbial adhesion to silicone hydrogel lenses: a review

PURPOSE

Microbial adhesion to contact lenses is believed to be one of the initiating events in the formation of many corneal infiltrative events, including microbial keratitis, that occur during contact lens wear. The advent of silicone hydrogel lenses has not reduced the incidence of these events. This may partly be related to the ability of microbes to adhere to these lenses. The aim of this study was to review the published literature on microbial adhesion to contact lenses, focusing on adhesion to silicone hydrogel lenses.

METHODS

The literature on microbial adhesion to contact lenses was searched, along with associated literature on adverse events that occur during contact lens wear. Particular reference was paid to the years 1995 through 2012 because this encompasses the time when the first clinical trials of silicone hydrogel lenses were reported, and their commercial availability and the publication of epidemiology studies on adverse events were studied.

RESULTS

In vitro studies of bacterial adhesion to unworn silicone hydrogel lens have shown that generally, bacteria adhere to these lenses in greater numbers than to the hydroxyethyl methacrylate-based soft lenses. Lens wear has different effects on microbial adhesion, and this is dependent on the type of lens and microbial species/genera that is studied. Biofilms that can be formed on any lens type tend to protect the bacteria and fungi from the effects on disinfectants. Fungal hyphae can penetrate the surface of most types of lenses. Acanthamoeba adhere in greater numbers to first-generation silicone hydrogel lenses compared with the second-generation or hydroxyethyl methacrylate-based soft lenses.

CONCLUSION

Microbial adhesion to silicone hydrogel lenses occurs and is associated with the production of corneal infiltrative events during lens wear.

Detection of virulence factors in Serratia strains isolated from contact lens-associated corneal ulcers

PURPOSE

This paper reports on the microbiological findings pertaining to three Serratia isolates from soft contact lens-related corneal ulcers, which represent a complication of contact lens wear reported with increasing frequency.

METHODS

Bacterial identification and antibiotic susceptibility testing were performed using the Vitek system. Serratia's ability to form biofilm, produce gelatinase, elastase and alkaline protease, and invade human corneal epithelial (HCE) cells was investigated. The isolates' susceptibility to the following disinfectants was tested: (a) ReNu MultiPlus(®) , containing polyaminopropyl biguanide 0.0001%; (b) Opti-Free Express(®) , containing polyquaternium-1 0.001% and myristamidopropyldimethylamine 0.0005%; (c) Opti-Free Replenish(®) , containing polyquaternium-1 0.001% and myristamidopropyldimethylamine 0.0005%, and (d) Oxysept Comfort(®) , a one-step 3% hydrogen peroxide-catalase system.

RESULTS

Two Serratia marcescens and one Serratia liquefaciens were identified. All the strains were susceptible to aminoglycosides and fluoroquinolones. No isolate formed biofilm or significantly invaded HCE cells; all produced alkaline protease and gelatinase, but not elastase. Opti-Free Express(®) and Opti-Free Replenish(®) were active against S. liquefaciens, but failed to kill the S. marcescens isolates within the minimum recommended time (6 hours). ReNu MultiPlus(®) needed 6 hours to kill one strain of S. marcescens, which is 2 hours more than recommended. Conversely, Oxysept Comfort(®) was always effective within the minimum recommended time (6 hours).

CONCLUSIONS

The ability to produce alkaline protease and gelatinase may play a major role in the pathogenesis of contact lens-related Serratia keratitis. Several types of contact lens solutions may be ineffective in eradicating Serratia from contaminated contact lens cases within the minimum recommended time. Only exposure to Oxysept Comfort(®) was always effective against Serratia in this study.

The impact of inoculation parameters on the pathogenesis of contact lens-related infectious keratitis

PURPOSE

Contact lens wear predisposes to Pseudomonas aeruginosa keratitis, but the mechanisms involved remain unclear. An in vivo model was used to study lens inoculation conditions enabling disease.

METHODS

Custom-made hydrogel contact lenses were fitted to rats after incubation in P. aeruginosa approximately 10(11) cfu/mL (3 hours) or approximately 10(3) cfu/mL (24 hours). Another group was inadvertently inoculated with a suction pen previously used with high inocula, but rinsed in ethanol and stored dry (6 months). Some corneas were tissue paper-blotted to cause fluorescein staining before lens fitting. Contralateral eyes were untreated. Twenty-four hours after disease detection, lenses were transferred to naive rats or examined by confocal microscopy before homogenization to quantify viable bacteria. After lens removal, corneas were washed to collect nonadherent bacteria and were analyzed by immunohistochemistry.

RESULTS

All eyes challenged with unworn contaminated lenses developed keratitis after approximately 7 to 10 days. Disease delay and severity were unaffected by inoculum parameters or tissue blotting but occurred sooner with lenses transferred from infected eyes ( approximately 2 days). Worn lenses and corneal washes contained infecting bacteria. Posterior, not anterior, lens surfaces harbored P. aeruginosa biofilms that penetrated the lens matrix. Diseased corneas showed an infiltration of phagocytes and T-lymphocytes.

CONCLUSIONS

P. aeruginosa induces keratitis in this lens-wearing model after a single inoculation. Delayed disease onset was interesting considering the greater keratitis risk during extended wear. Infection did not require the disruption of corneal barrier function before lens wear and occurred without exposure to lens care solutions. The data suggest that keratitis involves biofilm formation or other bacterial adaptations in vivo.

Increased resistance of contact lens-related bacterial biofilms to antimicrobial activity of soft contact lens care solutions

PURPOSE

To determine if clinical and reference strains of Pseudomonas aeruginosa, Serratia marcescens, and Staphylococcus aureus form biofilms on silicone hydrogel contact lenses and ascertain antimicrobial activities of contact lens care solutions.

METHODS

Clinical and American Type Culture Collection reference strains of P. aeruginosa, S. marcescens, and S. aureus were incubated with lotrafilcon A lenses under conditions that facilitate biofilm formation. Biofilms were quantified by quantitative culturing (colony-forming units, CFUs), and gross morphology and architecture were evaluated using scanning electron microscopy and confocal microscopy. Susceptibilities of the planktonic and biofilm growth phases of the bacteria to 5 common multipurpose contact lens care solutions and 1 hydrogen peroxide care solution were assessed.

RESULTS

Pseudomonas aeruginosa, S. marcescens, and S. aureus reference and clinical strains formed biofilms on lotrafilcon A silicone hydrogel contact lenses, as dense networks of cells arranged in multiple layers with visible extracellular matrix. The biofilms were resistant to commonly used biguanide-preserved multipurpose care solutions. Pseudomonas aeruginosa and S. aureus biofilms were susceptible to a hydrogen peroxide and a polyquaternium-preserved care solution, whereas S. marcescens biofilm was resistant to a polyquaternium-preserved care solution but susceptible to hydrogen peroxide disinfection. In contrast, the planktonic forms were always susceptible.

CONCLUSION

Pseudomonas aeruginosa, S. marcescens, and S. aureus form biofilms on lotrafilcon A contact lenses, which in contrast to planktonic cells are resistant to the antimicrobial activity of several soft contact lens care products.

The cyclic AMP-dependent catabolite repression system of Serratia marcescens mediates biofilm formation through regulation of type 1 fimbriae

The mechanisms by which environmental carbon sources regulate biofilm formation are poorly understood. This study investigates the roles of glucose and the catabolite repression system in Serratia marcescens biofilm formation. The abilities of this opportunistic pathogen to proliferate in a wide range of environments, to cause disease, and to resist antimicrobials are linked to its ability to form biofilms. We observed that growth of S. marcescens in glucose-rich medium strongly stimulated biofilm formation, which contrasts with previous studies showing that biofilm formation is inhibited by glucose in Escherichia coli and other enteric bacteria. Glucose uptake is known to inversely mediate intracellular cyclic AMP (cAMP) synthesis through regulation of adenylate cyclase (cyaA) activity, which in turn controls fundamental processes such as motility, carbon utilization and storage, pathogenesis, and cell division in many bacteria. Here, we demonstrate that mutation of catabolite repression genes that regulate cAMP levels (crr and cyaA) or the ability to respond to cAMP (crp) confers a large increase in biofilm formation. Suppressor analysis revealed that phenotypes of a cAMP receptor protein (crp) mutant require the fimABCD operon, which is responsible for type 1 fimbria production. Consistently, fimA transcription and fimbria production were determined to be upregulated in a cyaA mutant background by using quantitative real-time reverse transcription-PCR and transmission electron microscopy analysis. The regulatory pathway by which environmental carbon sources influence cAMP concentrations to alter production of type 1 fimbrial adhesins establishes a novel mechanism by which bacteria control biofilm development.

Serratia Corneal Ulcers

PURPOSE

To study the clinical and microbiological profile of Serratia corneal ulcers at the Cornea Service of the Wills Eye Hospital.

METHODS

This was a retrospective, observational case series. The clinical records of patients with Serratia marcescens corneal ulcers seen at the Cornea Service of the Wills Eye Hospital between January 1, 1998 and December 31, 2002 were reviewed.

RESULTS

Twenty-four cases of Serratia keratitis were identified in 21 patients. Two patients (9.5%) had recurrent keratitis, 1 of which recurred twice. Both had corneal graft edema and were on topical steroids and antiglaucoma drops. The Serratia infection in 15 patients (71%) was associated with an abnormal corneal surface. Twelve of these patients (57%) had the ulcer in a corneal graft, 4 (19%) of which were associated with suture infiltrates. Fifteen patients (71%) were on topical medications-15 used corticosteroids and 13 used antiglaucoma drops. Six patients (29%) were contact lens wearers-1 had a concomitant suture infiltrate associated with a corneal graft, and 5 had otherwise healthy corneas. One isolate lacked in vitro susceptibility to ciprofloxacin and ofloxacin but was susceptible to gentamicin and tobramycin. Nineteen patients had a favorable response to medical therapy. Two patients with poor outcome had large corneal ulcers with severe necrosis and thinning associated with delay in treatment.

CONCLUSIONS

Serratia marcescens keratitis is associated with the presence of an abnormal corneal surface, use of topical medications, and contact lens wear. Prompt medical therapy results in a good clinical response in the majority of cases.

Bacterial Biofilms and Ocular Infections

Serious bacterial infections of the eye are often associated with abiotic prosthetic materials, such as contact lenses, intraocular lenses, and scleral buckles. In recent years, microbiologists have recognized substantial differences between bacteria growing in a sessile community attached to a surface and free-living or planktonic bacteria. These sessile surface-attached communities are known as biofilms, whose properties have important consequences for clinical medicine. As a population, bacteria in biofilms are more resistant to antimicrobial agents and the immune system, and they are more persistent than planktonic bacteria in hostile environments. These characteristics are likely the result of both biofilm-specific phenotypes and increased phenotypic diversity within biofilms as compared with planktonic communities of bacteria. Bacterial biofilm formation has been observed on human tissues, as well as on abiotic prosthetic devices. A better understanding of biofilm formation may lead to the development of novel antimicrobial agents as well as prosthetic devices that are resistant to bacterial colonization.

The periplasmic serine protease inhibitor ecotin protects bacteria against neutrophil elastase

Ecotin is a dimeric periplasmic protein from Escherichia coli that has been shown to inhibit potently many trypsin-fold serine proteases of widely varying substrate specificity. To help elucidate the physiological function of ecotin, we examined the family of ecotin orthologues, which are present in a subset of Gram-negative bacteria. Phylogenetic analysis suggested that ecotin has an exogenous target, possibly neutrophil elastase. Recombinant protein was expressed and purified from E. coli, Yersinia pestis and Pseudomonas aeruginosa, all species that encounter the mammalian immune system, and also from the plant pathogen Pantoea citrea. Notably, the Pa. citrea variant inhibits neutrophil elastase 1000-fold less potently than the other orthologues. All four orthologues are dimeric proteins that potently inhibit (<10 pM) the pancreatic digestive proteases trypsin and chymotrypsin, while showing more variable inhibition (5 pM to 24 microM) of the blood proteases Factor Xa, thrombin and urokinase-type plasminogen activator. To test whether ecotin does, in fact, protect bacteria from neutrophil elastase, an ecotin-deficient strain was generated in E. coli. This strain is significantly more sensitive in cell-killing assays to human neutrophil elastase, which causes increased permeability of the outer membrane that persists even during renewed bacterial growth. Ecotin affects primarily the ability of E. coli to recover and grow following treatment with neutrophil elastase, rather than the actual rate of killing. This suggests that an important part of the antimicrobial mechanism of neutrophil elastase may be a periplasmic bacteriostatic effect of protease that has translocated across the damaged outer membrane.