Observations on the adherence of Proteus mirabilis onto polymer surfaces

N-acetylcysteine prevents catheter occlusion and inflammation in catheter associated-urinary tract infections by suppressing urease activity

Introduction

Proteus mirabilis is a key pathobiont in catheter-associated urinary tract infections (CA-UTIs), which is well known to form crystalline biofilms that occlude catheters. Urease activity alkylates urine through the release of ammonia, consequentially resulting in higher levels of Mg2+ and Ca2+ and formation of crystals. In this study, we showed that N-acetyl cysteine (NAC), a thiol antioxidant, is a potent urease inhibitor that prevents crystalline biofilm formation.

Methods

To quantify urease activity, Berthelot's method was done on bacterial extracts treated with NAC. We also used an in vitro catheterised glass bladder model to study the effect of NAC treatment on catheter occlusion and biofilm encrustation in P. mirabilis infections. Inductively-coupled plasma mass spectrometry (ICP-MS) was performed on catheter samples to decipher elemental profiles.

Results

NAC inhibits urease activity of clinical P. mirabilis isolates at concentrations as low as 1 mM, independent of bacterial killing. The study also showed that NAC is bacteriostatic on P. mirabilis, and inhibited biofilm formation and catheter occlusion in an in vitro. A significant 4-8log10 reduction in viable bacteria was observed in catheters infected in this model. Additionally, biofilms in NAC treated catheters displayed a depletion of calcium, magnesium, or phosphates (>10 fold reduction), thus confirming the absence of any urease activity in the presence of NAC. Interestingly, we also showed that not only is NAC anti-inflammatory in bladder epithelial cells (BECs), but that it mutes its inflammatory response to urease and P. mirabilis infection by reducing the production of IL-6, IL-8 and IL-1b.

Discussion

Using biochemical, microbiological and immunological techniques, this study displays the functionality of NAC in preventing catheter occlusion by inhibiting urease activity. The study also highlights NAC as a strong anti-inflammatory antibiofilm agent that can target both bacterial and host factors in the treatment of CA-UTIs.

Extraction, Modification and Biomedical Application of Agarose Hydrogels: A Review

Numerous compounds present in the ocean are contributing to the development of the biomedical field. Agarose, a polysaccharide derived from marine red algae, plays a vital role in biomedical applications because of its reversible temperature-sensitive gelling behavior, excellent mechanical properties, and high biological activity. Natural agarose hydrogel has a single structural composition that prevents it from adapting to complex biological environments. Therefore, agarose can be developed into different forms through physical, biological, and chemical modifications, enabling it to perform optimally in different environments. Agarose biomaterials are being increasingly used for isolation, purification, drug delivery, and tissue engineering, but most are still far from clinical approval. This review classifies and discusses the preparation, modification, and biomedical applications of agarose, focusing on its applications in isolation and purification, wound dressings, drug delivery, tissue engineering, and 3D printing. In addition, it attempts to address the opportunities and challenges associated with the future development of agarose-based biomaterials in the biomedical field. It should help to rationalize the selection of the most suitable functionalized agarose hydrogels for specific applications in the biomedical industry.

Estimation of the post-mortem interval by modelling the changes in oral bacterial diversity during decomposition

AIMS

Decomposition, a complicated process, depends on several factors, including carrion insects, bacteria and the environment. However, the composition of and variation in oral bacteria over long periods of decomposition remain unclear. The current study aims to illustrate the composition of oral bacteria and construct an informative model for estimating the post-mortem interval (PMI) during decomposition.

METHODS AND RESULTS

Samples were collected from rats' oral cavities for 59 days, and 12 time points in the PMI were selected to detect bacterial community structure by sequencing the V3-V4 region of the bacterial 16S ribosomal RNA (16S rRNA) gene on the Ion S5 XL platform. The results indicated that microorganisms in the oral cavity underwent great changes during decomposition, with a tendency for variation to first decrease and then increase at day 24. Additionally, to predict the PMI, an informative model was established using the random forest algorithm. Three genera of bacteria (Atopostipes, Facklamia and Cerasibacillus) were linearly correlated at all 12 time points in the 59-day period. Planococcaceae was selected as the best feature for the last 6 time points. The R² of the model reached 93.94%, which suggested high predictive accuracy. Furthermore, to predict the functions of the oral microbiota, PICRUSt results showed that energy metabolism was increased on day 3 post-mortem and carbohydrate metabolism surged significantly on days 3 and 24 post-mortem.

CONCLUSIONS

Overall, our results suggested that post-mortem oral microbial community data can serve as a forensic resource to estimate the PMI over long time periods.

SIGNIFICANCE AND IMPACT OF THE STUDY

The results of the present study are beneficial for estimating the PMI. Identifying changes in the bacterial community is of great significance for further understanding the applicability of oral flora in forensic medicine.

Novel Phage-Derived Depolymerase with Activity against Proteus mirabilis Biofilms

The adherence of Proteus mirabilis to the surface of urinary catheters leads to colonization and eventual blockage of the catheter lumen by unique crystalline biofilms produced by these opportunistic pathogens, making P. mirabilis one of the leading causes of catheter-associated urinary tract infections. The Proteus biofilms reduce efficiency of antibiotic-based treatment, which in turn increases the risk of antibiotic resistance development. Bacteriophages and their enzymes have recently become investigated as alternative treatment options. In this study, a novel Proteus bacteriophage (vB_PmiS_PM-CJR) was isolated from an environmental sample and fully characterized. The phage displayed depolymerase activity and the subsequent genome analysis revealed the presence of a pectate lyase domain in its tail spike protein. The protein was heterologously expressed and purified; the ability of the purified tail spike to degrade Proteus biofilms was tested. We showed that the application of the tail spike protein was able to reduce the adherence of bacterial biofilm to plastic pegs in a MBEC (minimum biofilm eradication concentration) assay and improve the survival of Galleria mellonella larvae infected with Proteus mirabilis. Our study is the first to successfully isolate and characterize a biofilm depolymerase from a Proteus phage, demonstrating the potential of this group of enzymes in treatment of Proteus infections.

Potential Probiotics Bacillus subtilis KATMIRA1933 and Bacillus amyloliquefaciens B-1895 Co-Aggregate with Clinical Isolates of Proteus mirabilis and Prevent Biofilm Formation

A urinary tract infection (UTI) is a multi-factorial disease including cystitis, pyelonephritis, and pyelitis. After Escherichia coli, Proteus mirabilis is the most common UTI-associated opportunistic pathogen. Antibiotic resistance of bacteria and infection recurrence can be connected to biofilm formation by P. mirabilis. In this study, human and sheep isolates of P. mirabilis were investigated for antibiotic sensitivity using an antibiotic disk test. Co-aggregation of the tested potential probiotic bacilli, Bacillus amyloliquefaciens B-1895 and Bacillus subtilis KATMIRA1933, with the isolated pathogen was also evaluated. Then, the anti-biofilm activity of naturally derived metabolites, such as subtilin and subtilosin, in the bacilli-free supernatants was assessed against biofilms of P. mirabilis isolates. The isolated pathogens were sensitive to 30 μg of amikacin and 5 μg of ciprofloxacin but resistant to other tested antibiotics. After 24 h, auto-aggregation of B. amyloliquefaciens B-1895 was at 89.5% and higher than auto-aggregation of B. subtilis KATMIRA1933 (59.5%). B. amyloliquefaciens B-1895 strongly co-aggregated with P. mirabilis isolates from human UTIs. Cell-free supernatants of B. amyloliquefaciens B-1895 and B. subtilis KATMIRA1933 showed higher antimicrobial activity against biofilms of P. mirabilis isolated from humans as compared with biofilms of sheep isolates. According to our knowledge, this is the first report evaluating the anti-biofilm activity of probiotic spore-forming bacilli against clinical and animal UTI isolates of P. mirabilis. Further studies are recommended to investigate the anti-biofilm activity and the mode of action for the antimicrobial substances produced by these bacilli, subtilosin and subtilin.

Reduced Crystalline Biofilm Formation on Superhydrophobic Silicone Urinary Catheter Materials

Crystalline biofilm formation in indwelling urinary catheters is a serious health problem as it creates a barrier for antibacterial coatings. This emphasizes the failure of antibacterial coatings that do not have a mechanism to reduce crystal deposition on catheter surfaces. In this study, trifluoropropyl spray-coated polydimethylsiloxane (TFP-PDMS) has been employed as an antibiofilm forming surface without any antibacterial agent. Here, TFP was coated on half-cured PDMS using the spray coating technique to obtain a durable superhydrophobic coating for a minimum five cycles of different sterilization methods. The crystalline biofilm-forming ability of Proteus mirabilis in artificial urine, under static and flow conditions, was assessed on a TFP-PDMS surface. In comparison to the commercially available silver-coated latex and silicone catheter surfaces, TFP-PDMS displayed reduced bacterial attachment over 14 days. Moreover, the elemental analysis determined by atomic absorption spectroscopy and energy-dispersive X-ray analysis revealed that the enhanced antibiofilm forming ability of TFP-PDMS was due to the self-cleaning activity of the surface. We believe that this modified surface will significantly reduce biofilm formation in indwelling urinary catheters and further warrant future clinical studies.

Infection-Triggered, Self-Cleaning Surfaces with On-Demand Cleavage of Surface-Localized Surfactant Moieties

Biofouling of surfaces is a major cause of infection and leads to significant patient morbidity and mortality within healthcare settings. With ever-increasing concerns over antibiotic resistance and associated challenges in eradicating surface-attached biofilm communities, efficacious antifouling materials are urgently required. We herein describe the development of an inherently antiadherent polymer system with the capacity for on-demand cleavage of surface-localized surfactant moieties. The nonionic surfactant, Triton X-100, was linked to hydrogel monomers via hydrolytically labile ester bonds. Synthesized copolymers exhibited pH-dependent switching of surfactant release, with elution triggered under the alkaline conditions characteristic of catheter-associated urinary tract infections and subsequently slowed down as the pH decreased, representing eradication of infection. In addition, the materials demonstrated complete resistance to adherence of Staphylococcus aureus following 24 h incubation in infected artificial urine, with reductions in adherence of Proteus mirabilis of up to 89% also observed. This dual-pronged approach with active, infection-responsive cleavage of surfactant to enhance the antiadherent properties of the surfactant-modified surfaces represents a promising self-cleaning strategy without associated concerns over bacterial resistance.

A scope at antifouling strategies to prevent catheter-associated infections

The use of invasive medical devices is becoming more common nowadays, with catheters representing one of the most used medical devices. However, there is a risk of infection associated with the use of these devices, since they are made of materials that are prone to bacterial adhesion with biofilm formation, often requiring catheter removal as the only therapeutic option. Catheter-related urinary tract infections (CAUTIs) and central line-associated bloodstream infections (CLABSIs) are among the most common causes of healthcare-associated infections (HAIs) worldwide while endotracheal intubation is responsible for ventilator-associated pneumonia (VAP). Therefore, to avoid the use of biocides due to the potential risk of bacterial resistance development, antifouling strategies aiming at the prevention of bacterial adherence and colonization of catheter surfaces represent important alternative measures. This review is focused on the main strategies that are able to modify the physical or chemical properties of biomaterials, leading to the creation of antiadhesive surfaces. The most promising approaches include coating the surfaces with hydrophilic polymers, such as poly(ethylene glycol) (PEG), poly(acrylamide) and poly(acrylates), betaine-based zwitterionic polymers and amphiphilic polymers or the use of bulk-modified poly(urethanes). Natural polysaccharides and its modifications with heparin, have also been used to improve hemocompatibility. Recently developed bioinspired techniques yielding very promising results in the prevention of bacterial adhesion and colonization of surfaces include slippery liquid-infused porous surfaces (SLIPS) based on the superhydrophilic rim of the pitcher plant and the Sharklet topography inspired by the shark skin, which are potential candidates as surface-modifying approaches for biomedical devices. Concerning the potential application of most of these strategies in catheters, more in vivo studies and clinical trials are needed to assure their efficacy and safety for possible future use.

A Rare Opportunist, Morganella morganii, Decreases Severity of Polymicrobial Catheter-Associated Urinary Tract Infection

Catheter-associated urinary tract infections (CAUTIs) are common hospital-acquired infections and frequently polymicrobial, which complicates effective treatment. However, few studies experimentally address the consequences of polymicrobial interactions within the urinary tract, and the clinical significance of polymicrobial bacteriuria is not fully understood. Proteus mirabilis is one of the most common causes of monomicrobial and polymicrobial CAUTI and frequently cocolonizes with Enterococcus faecalis, Escherichia coli, Providencia stuartii, and Morganella morganiiP. mirabilis infections are particularly challenging due to its potent urease enzyme, which facilitates formation of struvite crystals, catheter encrustation, blockage, and formation of urinary stones. We previously determined that interactions between P. mirabilis and other uropathogens can enhance P. mirabilis urease activity, resulting in greater disease severity during experimental polymicrobial infection. Our present work reveals that M. morganii acts on P. mirabilis in a contact-independent manner to decrease urease activity. Furthermore, M. morganii actively prevents urease enhancement by E. faecalis, P. stuartii, and E. coli Importantly, these interactions translate to modulation of disease severity during experimental CAUTI, predominantly through a urease-dependent mechanism. Thus, products secreted by multiple bacterial species in the milieu of the catheterized urinary tract can directly impact prognosis.

Association between urine pH and common uropathogens in children with urinary tract infections

BACKGROUND/PURPOSE

Urinary tract infections (UTIs) are one of the most common pediatric infections. Our objective in this study is to investigate the association between urine pH and uropathogens in pediatric patients.

METHODS

The source population comprised 26 066 paired urinalysis (UA) and urine culture (UC) samples obtained from pediatric patients. We classified the paired UA-UC samples into UTI positive (N = 6348) and UTI negative (N = 19 718) according to the colony forming units corresponding to the sampling source. We included UTI positive patients with infection caused by a single species of pathogen (N = 5201) and frequency matched them with UTI negative patients (N = 4729) by age, sex, sampling source, and visit type.

RESULTS

This study included 5201 pediatric patients with UTIs and found that urine with Proteus mirabilis or Pseudomonas aeruginosa demonstrated the least acidic pH (mean pH = 6.72 and 6.62, respectively), whereas urine with Escherichia coli or Klebsiella pneumoniae exhibited the most acidic pH (pH = 6.21 and 6.18). After stratifying the UTI samples by their pH range (<6, 6-6.9, 7-7.9, and ≥8). The prevalence of P. mirabilis increased significantly across increasing pH categories.

CONCLUSION

This research is the first epidemiological study that linked urine pH to specific uropathogens in a pediatric population. Both urine pH and age are associated with certain causative uropathogens. Urine that grew P. mirabilis or P. aeruginosa had the least acidic pH. Additional studies should validate the role of urine pH in predicting uropathogens and UTI.

Pathogenesis of Proteus mirabilis Infection

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

Biodegradable ciprofloxacin-incorporated waterborne polyurethane polymers prevent bacterial biofilm formation in vitro

The aim of the present study was to explore whether ciprofloxacin-incorporated waterborne polyurethane (WBPU) polymers have the capacity to inhibit bacterial biofilm formation in vitro. WBPU polymers were incorporated with ciprofloxacin and were cultured with Escherichia coli (E. coli) or Staphylococcus aureus (S. aureus) in media for 2, 4 or 7 days. In another experiment, the WBPU membranes were cultured with Proteus mirabilis (P. mirabilis) in artificial urine for 2, 4 or 7 days. Colony counting, scanning electron microscopy and fluorescence confocal microscopy were utilized to examine bacterial biofilms on the surfaces of membranes. The membranes were further co-cultured with P. mirabilis in a simple model of an artificial catheterized bladder in order to evaluate their ability to control encrustation. The WBPU films with ciprofloxacin effectively inhibited bacterial biofilm formation in the culture medium and in artificial urine. In addition, in artificial urine, the films with ciprofloxacin reduced catheter obstruction. In conclusion, ciprofloxacin-incorporated WBPU polymers are able to effectively inhibit bacterial biofilm formation in vitro.

Emerging medical and engineering strategies for the prevention of long-term indwelling catheter blockage

Urinary catheters have been used on an intermittent or indwelling basis for centuries, in order to relieve urinary retention and incontinence. Nevertheless, the use of urinary catheters in the clinical setting is fraught with complication, the most common of which is the development of nosocomial urinary tract infections, known as catheter-associated urinary tract infections. Infections of this nature are not only significant owing to their high incidence rate and subsequent economic burden but also to the severe medical consecutions that result. A range of techniques have been employed in recent years, utilising various technologies in attempts to counteract the perilous medical cascade following catheter blockage. This review will focus on the current advancement (within the last 10 years) in prevention of encrustation and blockage of long-term indwelling catheters both from engineering and medical perspectives, with particular emphasis on the importance of stimuli-responsive systems.

Mussel-inspired nano-multilayered coating on magnesium alloys for enhanced corrosion resistance and antibacterial property

Magnesium alloys are promising candidates for load-bearing orthopedic implants due to their biodegradability and mechanical resemblance to natural bone tissue. However, the high degradation rate and the risk of implant-associated infections pose grand challenges for their clinical applications. Herein, we developed a nano-multilayered coating strategy through polydopamine and chitosan assisted layer-by-layer assembly of osteoinductive carbonated apatite and antibacterial sliver nanoparticles on the surface of AZ31 magnesium alloys. The fabricated nano-multilayered coating can not only obviously enhance the corrosion resistance but also significantly increase the antibacterial activity and demonstrate better biocompatility of magnesium alloys.

From Catheter to Kidney Stone: The Uropathogenic Lifestyle of Proteus mirabilis

Proteus mirabilis is a model organism for urease-producing uropathogens. These diverse bacteria cause infection stones in the urinary tract and form crystalline biofilms on indwelling urinary catheters, frequently leading to polymicrobial infection. Recent work has elucidated how P. mirabilis causes all of these disease states. Particularly exciting is the discovery that this bacterium forms large clusters in the bladder lumen that are sites for stone formation. These clusters, and other steps of infection, require two virulence factors in particular: urease and MR/P fimbriae. Highlighting the importance of MR/P fimbriae is the cotranscribed regulator, MrpJ, which globally controls virulence. Overall, P. mirabilis exhibits an extraordinary lifestyle, and further probing will answer exciting basic microbiological and clinically relevant questions.

Co-immobilization of Palm and DNase I for the development of an effective anti-infective coating for catheter surfaces

Biomaterial-associated infections, in particular, catheter-associated infections (CAI) are a major problem in clinical practice due to their ability to resist antimicrobial treatment and the host immune system. This study aimed to co-immobilize the antimicrobial lipopeptide Palm and the enzyme DNase I to introduce both antimicrobial and anti-adhesive functionalities to polydimethylsiloxane (PDMS) material, using dopamine chemistry. Surface characterization confirmed the immobilization of both compounds and no leaching of Palm from the surfaces for up to 5days. Co-immobilization of both agents resulted in a bifunctional coating with excellent surface antimicrobial and anti-biofilm properties against both Staphylococcus aureus and Pseudomonas aeruginosa. The modified surfaces demonstrated superior biocompatibility. To better discriminate co-adhesion of both species on modified surfaces, PNA FISH (Fluorescence in situ hybridization using peptide nucleic acid probes) was employed, and results showed that P. aeruginosa was the dominant organism, with S. aureus adhering afterwards on P. aeruginosa agglomerates. Furthermore, Palm immobilization exhibited no propensity to develop bacterial resistance, as opposite to the immobilization of an antibiotic. The overall results highlighted that co-immobilization of Palm and DNase I holds great potential to be applied in the development of catheters.

STATEMENT OF SIGNIFICANCE

Catheter-associated infections (CAI) are the most common hospital-acquired infections worldwide. Several coating strategies have been proposed to fight these infections but most of them present some important limitations, including the emergence of resistant bacteria and toxicity concerns. The present work describes a two-step polydopamine-based surface modification strategy to successfully co-immobilize an antimicrobial peptide (Palm) and an enzyme targeting an important component of biofilm matrix (DNase I). This immobilization approach imparted polydimethylsiloxane surfaces with both anti-adhesive and antimicrobial properties against the adhesion of relevant bacteria as single and dual-species, with excellent stability and biocompatible and anti-biofilm properties, holding, therefore, great potential in the development of catheters able to prevent CAI.

Development of a Phage Cocktail to Control Proteus mirabilis Catheter-associated Urinary Tract Infections

Proteus mirabilis is an enterobacterium that causes catheter-associated urinary tract infections (CAUTIs) due to its ability to colonize and form crystalline biofilms on the catheters surface. CAUTIs are very difficult to treat, since biofilm structures are highly tolerant to antibiotics. Phages have been used widely to control a diversity of bacterial species, however, a limited number of phages for P. mirabilis have been isolated and studied. Here we report the isolation of two novel virulent phages, the podovirus vB_PmiP_5460 and the myovirus vB_PmiM_5461, which are able to target, respectively, 16 of the 26 and all the Proteus strains tested in this study. Both phages have been characterized thoroughly and sequencing data revealed no traces of genes associated with lysogeny. To further evaluate the phages’ ability to prevent catheter’s colonization by Proteus, the phages adherence to silicone surfaces was assessed. Further tests in phage-coated catheters using a dynamic biofilm model simulating CAUTIs, have shown a significant reduction of P. mirabilis biofilm formation up to 168 h of catheterization. These results highlight the potential usefulness of the two isolated phages for the prevention of surface colonization by this bacterium.

Bio-Inspired Coating Strategies for the Immobilization of Polymyxins to Generate Contact-Killing Surfaces

Microbial colonization of indwelling devices remains a major concern in modern healthcare. Developing approaches to prevent biomaterial-associated infections (BAI) is, therefore, in great demand. This study aimed to immobilize two antimicrobial peptides (polymyxins B and E) onto polydimethylsiloxane (PDMS) using two polydopamine (pDA)-based approaches: the conventional two-step method involving the deposition of a pDA layer to which biomolecules are immobilized, and a one-step method where peptides are dissolved together with dopamine before its polymerization. Surface characterization confirms the immobilization of polymyxins onto PDMS at a non-toxic concentration. Immobilization of polymyxins using a one-step pDA-based approach is able to prevent Pseudomonas aeruginosa adhesion and kill a significant fraction of the adherent ones. Living cells adhered to these modified surfaces exhibit the same susceptibility pattern as cells adhered to unmodified surfaces, highlighting no resistance development. Results suggest that polymyxins immobilization holds a great potential as an additional antimicrobial functionality in the design of biomaterials.

IPN hydrogel nanocomposites based on agarose and ZnO with antifouling and bactericidal properties

Nanocomposite hydrogels with interpenetrating polymer network (IPN) structure based on poly(ethylene glycol) methyl ether methacrylate modified ZnO (ZnO-PEGMA) and 4-azidobenzoic agarose (AG-N3) were prepared by a one-pot strategy under UV irradiation. The hydrogels exhibited a highly macroporous spongelike structure, and the pore size decreased with the increase of the ZnO-PEGMA content. Due to the entanglement and favorable interactions between the two crosslinked networks, the IPN hydrogels exhibited excellent mechanical strength and light transmittance. The maximum compressive and tensile strengths of the IPN hydrogels reached 24.8 and 1.98 MPa respectively. The transparent IPN hydrogels transmitted more than 85% of visible light at all wavelengths (400-800 nm). The IPN hydrogels exhibited anti-adhesive property towards Gram-negative Escherichia coli (E. coli) and Gram-positive Staphylococcus aureus (S. aureus), and the bactericidal activity increased with the ZnO-PEGMA content. The incorporation of ZnO-PEGMA did not reduce the biocompatibility of the IPN hydrogels and all the IPN nanocomposites showed negligible cytotoxicity. The present study not only provided a facile method for preparing hydrogel nanocomposites with IPN structure but also developed a new hydrogel material which might be an excellent candidate for wound dressings.

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

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

Antibiotic-decorated titanium with enhanced antibacterial activity through adhesive polydopamine for dental/bone implant

Implant-associated infections, which are normally induced by microbial adhesion and subsequent biofilm formation, are a major cause of morbidity and mortality. Therefore, practical approaches to prevent implant-associated infections are in great demand. Inspired by adhesive proteins in mussels, here we have developed a novel antibiotic-decorated titanium (Ti) material with enhanced antibacterial activity. In this study, Ti substrate was coated by one-step pH-induced polymerization of dopamine followed by immobilization of the antibiotic cefotaxime sodium (CS) onto the polydopamine-coated Ti through catechol chemistry. Contact angle measurement and X-ray photoelectron spectroscopy confirmed the presence of CS grafted on the Ti surface. Our results demonstrated that the antibiotic-grafted Ti substrate showed good biocompatibility and well-behaved haemocompatibility. In addition, the antibiotic-grafted Ti could effectively prevent adhesion and proliferation of Escherichia coli (Gram-negative) and Streptococcus mutans (Gram-positive). Moreover, the inhibition of biofilm formation on the antibiotic-decorated Ti indicated that the grafted CS could maintain its long-term antibacterial activity. This modified Ti substrate with enhanced antibacterial activity holds great potential as implant material for applications in dental and bone graft substitutes.

Elucidating the genetic basis of crystalline biofilm formation in Proteus mirabilis

Proteus mirabilis forms extensive crystalline biofilms on urethral catheters that occlude urine flow and frequently complicate the management of long-term-catheterized patients. Here, using random transposon mutagenesis in conjunction with in vitro models of the catheterized urinary tract, we elucidate the mechanisms underpinning the formation of crystalline biofilms by P. mirabilis. Mutants identified as defective in blockage of urethral catheters had disruptions in genes involved in nitrogen metabolism and efflux systems but were unaffected in general growth, survival in bladder model systems, or the ability to elevate urinary pH. Imaging of biofilms directly on catheter surfaces, along with quantification of levels of encrustation and biomass, confirmed that the mutants were attenuated specifically in the ability to form crystalline biofilms compared with that of the wild type. However, the biofilm-deficient phenotype of these mutants was not due to deficiencies in attachment to catheter biomaterials, and defects in later stages of biofilm development were indicated. For one blocking-deficient mutant, the disrupted gene (encoding a putative multidrug efflux pump) was also found to be associated with susceptibility to fosfomycin, and loss of this system or general inhibition of efflux pumps increased sensitivity to this antibiotic. Furthermore, homologues of this system were found to be widely distributed among other common pathogens of the catheterized urinary tract. Overall, our findings provide fundamental new insight into crystalline biofilm formation by P. mirabilis, including the link between biofilm formation and antibiotic resistance in this organism, and indicate a potential role for efflux pump inhibitors in the treatment or prevention of P. mirabilis crystalline biofilms.

Flagellum density regulates Proteus mirabilis swarmer cell motility in viscous environments

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

Merging mythology and morphology: the multifaceted lifestyle of Proteus mirabilis

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

An indwelling urinary catheter for the 21st century

What's known on the subject? and What does the study add? A vast literature has been published on the prevalence, morbidity and microbiology of catheter-associated urinary tract infections. Research and development in recent years has focused on producing antibacterial coatings for the indwelling Foley catheter with insufficient attention to its design. This article provides a critical examination of the design of the indwelling Foley catheter. Design specifications are outlined for a urine collection device that should reduce the vulnerability of catheterised urinary tract to infection. The indwelling urinary catheter is the most common cause of infections in hospitals and other healthcare facilities [1]. As long ago as 1958, Paul Beeson [2] warned '… the decision to use this instrument should be made with the knowledge that it involves the risk of producing a serious disease which is often difficult to treat'. Since then, scientific studies have progressed revealing a greater understanding of the bladder's defence mechanisms against infection and how they are undermined by the Foley catheter [3-5]. In addition, the complications caused by the development of bacterial biofilms on catheters have been recognised and the ways in which these bacterial communities develop on catheters have become clear [5,6]. It is now obvious that fundamental problems with the basic design of the catheter, which has changed little since it was introduced into urological practice by Dr Fredricc Foley in 1937 [7], induce susceptibility to infection. These issues need to be addressed urgently if we are to produce a device suitable for use in the 21st century.

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

OBJECTIVES

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

METHODS

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

RESULTS

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

CONCLUSION

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

A flow chamber assay for quantitative evaluation of bacterial surface colonization used to investigate the influence of temperature and surface hydrophilicity on the biofilm forming capacity of uropathogenic Escherichia coli

We have established a simple flow chamber-based procedure which provides an accurate and reproducible way to measure the amount of biofilm formed on an implantable biomaterial surface. The method enables the side-by-side evaluation of different materials under hydrodynamic flow conditions similar to those found on an implanted device. We have used the method to evaluate the biofilm forming capacity of clinically isolated Escherichia coli on silicone rubber and on silicone rubber containing a hydrophilic coating. It was found that the surface chemistry influenced the colonization of the isolates very differently. In addition, the temperature was found to have a considerable influence upon the adhesion and biofilm forming capacity of some of the isolates, and that the influence of surface chemistry depended on temperature. Our results suggest that the step from using E. coli laboratory strains to clinical isolates entails a significant rise in complexity and yields results that cannot be generalized. The results should be valuable information for researchers working with pre-clinical evaluation of device-associated E. coli infections.

Frictional properties of light-activated antimicrobial polymers in blood vessels

The adhesion of microbes to catheter surfaces is a serious problem and the resulting infections frequently lead to longer hospitalisation and higher risk for the patient. Several approaches have been developed to produce materials that are less susceptible to microbial colonisation. One such approach is the incorporation of photoactivated compounds, such as Toluidine Blue O (TBO), in the polymeric matrix resulting in 'light-activated antimicrobial materials'. The insertion and removal of catheters can cause tissue damage and patient discomfort through frictional forces; hence the lubricity of a catheter material is also very important. In this work the tribological performance of silicone and polyurethane containing TBO and gold nanoparticles were evaluated using two different surfaces, the inner part of the aorta and the superior vena cava of sheep. Static and kinetic friction coefficients of these materials were measured using a tribometric device developed for in vitro applications using dry materials and those lubricated with blood. It was found that neither the preparation process nor the presence of TBO or gold nanoparticles, had an effect on the friction factors in comparison to those of untreated materials. In all cases, static and kinetic friction coefficients on aorta tissue were higher than those on vena cava due to higher surface roughness of the aorta. The presence of blood as a lubricant resulted in lower friction coefficients.

Ureteral stent symptoms and associated infections: a biomaterials perspective

Ureteral stents are commonly used in the field of urology, and, given their indwelling nature, are often a nidus for infection and a cause of discomfort. To minimize symptoms, the urologic surgeon should first consider whether a stent needs to be placed at all. Softer stents do not seem to improve patient comfort. Stents that are too long, specifically those that cross the midline of the bladder, significantly increase the frequency of stent-related symptoms. Administering alpha blockers while the stent is indwelling can reduce these symptoms. Antibiotic prophylaxis or concomitant antibiotic administration does not seem to reduce the incidence of stent-related urinary tract infection. At present, drug-eluting stents have shown the most promise for inhibiting bacterial adhesion and biofilm formation. Future stent designs that maintain drainage of the kidney and ureter while minimizing inflammation and contact with the urothelium will improve patient outcomes. By better understanding the basic pathways of bacterial adhesion to biomaterials, new stents and medications that target these mechanisms can be developed to eliminate bacterial adhesion and infection in patients with ureteral stents.

The effect of EDTA instillations on the rate of development of encrustation and biofilms in Foley catheters

The aim of this research was to examine whether a daily instillation of tetra sodium ethylenediaminetetraacetic acid (EDTA) solution could reduce the rate at which encrustation by crystalline Proteus mirabilis biofilms blocks urinary catheters. Sets of three bladder models were fitted with size 14 all-silicone catheters. Tetra sodium EDTA solution was instilled into the catheter following biofilm development. Catheters were examined by digital photography and scanning electron microscopy for evidence of encrustation. The results showed that the mean time to blockage of the control catheters was 45 h for saline, 57 h for water and 67 h for those exposed to daily instillations of the EDTA solution. Statistical analysis confirmed that the mean encrustation rate on the EDTA-treated catheters was significantly lower than on the control-treated devices (P = 0.047). This in vitro study indicates that EDTA may have beneficial effects in reducing the complication of catheter encrustation and blockage by crystalline biofilms.

Bacterial biofilms in patients with indwelling urinary catheters

Bacteria have a basic survival strategy: to colonize surfaces and grow as biofilm communities embedded in a gel-like polysaccharide matrix. The catheterized urinary tract provides ideal conditions for the development of enormous biofilm populations. Many bacterial species colonize indwelling catheters as biofilms, inducing complications in patients' care. The most troublesome complications are the crystalline biofilms that can occlude the catheter lumen and trigger episodes of pyelonephritis and septicemia. The crystalline biofilms result from infection by urease-producing bacteria, particularly Proteus mirabilis. Urease raises the urinary pH and drives the formation of calcium phosphate and magnesium phosphate crystals in the biofilm. All types of catheter are vulnerable to encrustation by these biofilms, and clinical prevention strategies are clearly needed, as bacteria growing in the biofilm mode are resistant to antibiotics. Evidence indicates that treatment of symptomatic, catheter-associated urinary tract infection is more effective if biofilm-laden catheters are changed before antibiotic treatment is initiated. Infection with P. mirabilis exposes the many faults of currently available catheters, and plenty of scope exists for improvement in both their design and production; manufacturers should take up the challenge to improve patient outcomes.

Competition of Lactobacillus paracasei with Salmonella enterica for adhesion to Caco-2 cells

Competition of commensal and probiotic bacteria with pathogens for adhesion and colonization is one of the important protective mechanisms of gastrointestinal tract. In this study, we examined the ability of Lactobacillus paracasei to inhibit the adhesion of pathogenic Salmonella enterica to human colon adenocarcinoma Caco-2 cells. Caco-2 cells were grown for 6 or 21 days to obtain nondifferentiated or well-differentiated cells, respectively. In adhesion experiments, bacteria were added to the cells for 2 or 4 hours. The number of attached bacteria was expressed as colony-forming units (CFUs), Caco-2 cells were counted in hematocytometer. Both bacterial strains used adhered better to well-differentiated than to nondifferentiated Caco-2 cells, however, the amount of Salmonella adhered to Caco-2 after 2 hours of contact was 12-fold higher in comparison to L. paracasei and almost 27-fold higher after 4 hours of contact. Two types of experiments were done: coincubation (both bacteria were added to Caco-2 cells simultaneously), and preincubation (L. paracasei was incubated with Caco-2 cells first, and then S. enterica was added). In coincubation experiment, the presence of L. paracasei decreased S. enterica adhesion by 4-fold and in preincubation experiment even 7-fold. Generally, Lactobacillus spent culture supernatants (SCSs) acted weaker as inhibitors of Salmonella adhesion in comparison to the whole L. paracasei culture in coincubation experiment. In conclusion, the displacement of pathogens by lactic acid bacteria and its secretions showed here depends on the time of bacteria-epithelial cell contact, and also on the stage of Caco-2 differentiation.

Use of an electronic nose for detection of biofilms

BACKGROUND

Prior work has indicated that electronic nose (enose) technology can distinguish among bacteria samples and identify patients with ventilator-associated pneumonia and rhinosinusitis. This study was performed to test the hypothesis that an enose can distinguish between biofilm-producing and non-biofilm-producing bacteria of the same species.

METHODS

Biofilm-producing and non-biofilm-producing mutant strains of Pseudomonas (PA01 and Sad36) and Staphylococcus (Staph WT and Staph SrtA-B-) were incubated and then sampled by the enose. Data were evaluated by logistic regression to perform binary classification of the bacteria. Training sets and testing sets were developed in two ways: by cross-validation with a leave-1-day-out method, and then by testing the last 4 days versus the first 18 days.

RESULTS

By the leave-1-day-out method, logistic regression analysis of 198 samples of each bacterium determined that the training accuracy of the enose for both Pseudomonas species was 100% and the testing accuracy was 91.4% for PA01 and 88.4% for Sad36. The training accuracy of the enose for Staphylococcus species was 87.1% for Staph SrtA-B- and 88.2% for Staph WT and the testing accuracy was, respectively, 75.3 and 76.8%. By separating the first 18 days from the last 4 days, logistic regression analysis determined that the training accuracy of the enose for both Pseudomonas species was 100% and the testing accuracy was 100% for PA01 and 80.6% for Sad36. The training accuracy of the enose for Staphylococcus species was 87.7% for Staph SrtA-B- and 86.4% for Staph WT and the testing accuracy was respectively, 72.2 and 91.7%.

CONCLUSION

The enose was able to identify correctly biofilm- versus non-biofilm-producing Pseudomonas and Staphylococcus species with accuracy ranging from 72.2 to 100%, depending on the particular organism and the data analysis methodology. These results suggest that biofilms may be an in vivo marker, which the enose can use to identify patients with particularly virulent and medically recalcitrant forms of chronic rhinosinusitis.

Complicated catheter-associated urinary tract infections due to Escherichia coli and Proteus mirabilis

Catheter-associated urinary tract infections (CAUTIs) represent the most common type of nosocomial infection and are a major health concern due to the complications and frequent recurrence. These infections are often caused by Escherichia coli and Proteus mirabilis. Gram-negative bacterial species that cause CAUTIs express a number of virulence factors associated with adhesion, motility, biofilm formation, immunoavoidance, and nutrient acquisition as well as factors that cause damage to the host. These infections can be reduced by limiting catheter usage and ensuring that health care professionals correctly use closed-system Foley catheters. A number of novel approaches such as condom and suprapubic catheters, intermittent catheterization, new surfaces, catheters with antimicrobial agents, and probiotics have thus far met with limited success. While the diagnosis of symptomatic versus asymptomatic CAUTIs may be a contentious issue, it is generally agreed that once a catheterized patient is believed to have a symptomatic urinary tract infection, the catheter is removed if possible due to the high rate of relapse. Research focusing on the pathogenesis of CAUTIs will lead to a better understanding of the disease process and will subsequently lead to the development of new diagnosis, prevention, and treatment options.

Some Observations on the Diffusion of Antimicrobial Agents Through the Retention Balloons of Foley Catheters

PURPOSE

We examined the ability of antimicrobial agents to diffuse through the retention balloons of urinary catheters and inhibit their encrustation by Proteus mirabilis.

MATERIALS AND METHODS

An agar diffusion screening test was developed to detect agents capable of diffusing through catheter balloons and inhibiting the growth of P. mirabilis. The effect of inflating the balloons with antibacterials on the ability of P. mirabilis to encrust catheters was tested in laboratory models of the catheterized bladder.

RESULTS

Of 18 antimicrobial agents active on P. mirabilis only mandelic acid, phenoxyethanol, nalidixic acid and triclosan diffused through all-silicone catheter balloons to produce zones of inhibition against P. mirabilis. Polyurethane balloons were permeable to gentamicin and fluoroquinolones. Experiments with silicone catheters showed that inflating balloons with mandelic acid (100 gm/l) or ciprofloxacin (10 gm/l) failed to extended the time at which catheters became blocked in models inoculated with P. mirabilis. However, nalidixic acid (50 gm/l) significantly extended the lifespan of catheters (p <0.05). Triclosan (10 gm/l) prevented the increase in urinary pH that induces crystal formation and inhibited the formation of crystalline biofilm, enabling the catheters to drain freely for the full 7-day experimental period.

CONCLUSIONS

Inflation of silicone catheter retention balloons with solutions of nalidixic acid or triclosan rather than water should be considered as strategies to control catheter encrustation. Polyurethane balloons are more permeable than silicone balloons to gentamicin and the fluoroquinolones, and they should be investigated as an alternative to silicone or latex in catheter manufacture.

Structure of Proteus mirabilis biofilms grown in artificial urine and standard laboratory media

Proteus mirabilis is a urinary pathogen that can differentiate from a swimmer cell into a swarmer cell morphotype and can form biofilms on the surfaces of urinary catheters. These biofilms block these catheters due to crystals trapped within these structures. The effect of encrustation on biofilm formation and structure has not been studied using confocal scanning laser microscopy (CSLM). Therefore, a comparison of biofilm structure in artificial urine (AU) and laboratory media was undertaken. We compared the structure of P. mirabilis biofilms in AU and Luria-Bertani broth using CSLM and 3D imaging. Biofilms grown in Luria-Bertani broth formed mushroom structures at 24 h and contained nutrient channels. AU biofilms were observed to form a different structure at 24 h. AU biofilm structure was observed to be a flat layer, almost devoid of nutrient channels. Swarmer cells were observed protruding out of the biofilm into the bulk fluid. This could be due to nutrient depravation within the biofilm or a means of further colonizing the surface. This study has demonstrated that two markedly different biofilm structures are formed, depending on the growth media utilized.