Assessment of the ability of the bioelectric effect to eliminate mixed-species biofilms

Biofilm Lifestyle in Recurrent Urinary Tract Infections

Urinary tract infections (UTIs) represent one of the most common infections that are frequently encountered in health care facilities. One of the main mechanisms used by bacteria that allows them to survive hostile environments is biofilm formation. Biofilms are closed bacterial communities that offer protection and safe hiding, allowing bacteria to evade host defenses and hide from the reach of antibiotics. Inside biofilm communities, bacteria show an increased rate of horizontal gene transfer and exchange of resistance and virulence genes. Additionally, bacterial communication within the biofilm allows them to orchestrate the expression of virulence genes, which further cements the infestation and increases the invasiveness of the infection. These facts stress the necessity of continuously updating our information and understanding of the etiology, pathogenesis, and eradication methods of this growing public health concern. This review seeks to understand the role of biofilm formation in recurrent urinary tact infections by outlining the mechanisms underlying biofilm formation in different uropathogens, in addition to shedding light on some biofilm eradication strategies.

Eltarahony M, E. Moustafa M. The impact of titanium oxide nanoparticles and low direct electric current on biofilm dispersal of $Bacillus~cereus$ and $Pseudomonas~aeruginosa$: A comparative study

Bacteria growing in biofilms cause a wide range of environmental, industrial and public health risks. Because biofilm bacteria are very resistant to antibiotics, there is an urgent need in medicine and industry to develop new approaches to eliminating bacterial biofilms. One strategy for controlling these biofilms is to generate an antibiofilm substance locally at the attachment surface. Direct electric current (DC) and nanoparticles (NPs) of metal oxides have outstanding antimicrobial properties. In this study we evaluated the effect of titanium oxide nanoparticle (TiO$_2$-NP) concentrations from 5 to 160 $\mu$g/mL on Bacillus cereus and Pseudomonas aeruginosa biofilms, and compared this with the effect of a 9 V, 6 mA DC electric field for 5, 10 and 15 min. TiO$_2$-NPs were characterized using transmission and scanning electron microscopes, X-ray diffraction and FTIR. They exhibited an average size of 22-34 nm. The TiO$_2$-NP concentrations that attained LD50 were $104 \pm 4$ $\mu$g/mL and $63 \pm 3$ $\mu$g/mL for B. cereus and P. aeruginosa, respectively. The eradication percentages obtained by DC at 5, 10, and 15 min exposure were 21%, 29%, and 33% respectively for B. cereus and 30%, 39%, and 44% respectively for P. aeruginosa. Biofilm disintegration was verified by exopolysaccharide, protein content and cell surface hydrophobicity assessment, as well as scanning electron microscopy. These data were correlated with the reactive oxygen species produced. The results indicated that both DC and TiO$_2$-NPs have a lethal effect on these bacterial biofilms, and that the DC conditions used affect the biofilms in a similar way to TiO$_2$-NPs at concentrations of 20-40 $\mu$g/mL.

Bacterial Biofilm Inhibition: A Focused Review on Recent Therapeutic Strategies for Combating the Biofilm Mediated Infections

Biofilm formation is a major concern in various sectors and cause severe problems to public health, medicine, and industry. Bacterial biofilm formation is a major persistent threat, as it increases morbidity and mortality, thereby imposing heavy economic pressure on the healthcare sector. Bacterial biofilms also strengthen biofouling, affecting shipping functions, and the offshore industries in their natural environment. Besides, they accomplish harsh roles in the corrosion of pipelines in industries. At biofilm state, bacterial pathogens are significantly resistant to external attack like antibiotics, chemicals, disinfectants, etc. Within a cell, they are insensitive to drugs and host immune responses. The development of intact biofilms is very critical for the spreading and persistence of bacterial infections in the host. Further, bacteria form biofilms on every probable substratum, and their infections have been found in plants, livestock, and humans. The advent of novel strategies for treating and preventing biofilm formation has gained a great deal of attention. To prevent the development of resistant mutants, a feasible technique that may target adhesive properties without affecting the bacterial vitality is needed. This stimulated research is a rapidly growing field for applicable control measures to prevent biofilm formation. Therefore, this review discusses the current understanding of antibiotic resistance mechanisms in bacterial biofilm and intensely emphasized the novel therapeutic strategies for combating biofilm mediated infections. The forthcoming experimental studies will focus on these recent therapeutic strategies that may lead to the development of effective biofilm inhibitors than conventional treatments.

Electrochemical methods to enhance osseointegrated prostheses

Osseointegrated (OI) prosthetic limbs have been shown to provide an advantageous treatment option for amputees. In order for the OI prosthesis to be successful, the titanium implant must rapidly achieve and maintain proper integration with the bone tissue and remain free of infection. Electrochemical methods can be utilized to control and/or monitor the interfacial microenvironment where the titanium implant interacts with the biological system (host bone tissue or bacteria). This review will summarize the current understanding of how electrochemical modalities can influence bone tissue and bacteria with specific emphasis on applications where the metallic prosthesis itself can be utilized directly as a stimulating electrode for enhanced osseointegration and infection control. In addition, a summary of electrochemical impedance sensing techniques that could be used to potentially assess osseointegration and infection status of the metallic prosthesis is presented.

Disposable Patterned Electroceutical Dressing (PED-10) Is Safe for Treatment of Open Clinical Chronic Wounds

Objective: To evaluate if patterned electroceutical dressing (PED) is safe for human chronic wounds treatment as reported by wound care providers. Approach: This work reports a pilot feasibility study with the primary objective to determine physically observable effects of PED application on host tissue response from a safety evaluation point of view. For this pilot study, patients receiving a lower extremity amputation with at least one open wound on the part to be amputated were enrolled. Patients were identified through the Ohio State University Wexner Medical Center (OSUWMC) based on inclusion and exclusion criteria through prescreening through the Comprehensive Wound Center's (CWC) Limb Preservation Program and wound physicians and/or providers at OSUWMC. Wounds were treated with the PED before amputation surgery. Results: The intent of the study was to identify if PED was safe for clinical application based on visual observations of adverse or lack of adverse events on skin and wound tissue. The pilot testing performed on a small cohort (N = 8) of patients showed that with engineered voltage regulation of current flow to the open wound, the PED can be used with little to no visually observable adverse effects on chronic human skin wounds. Innovation: The PED was developed as a second-generation tunable electroceutical wound care dressing, which could potentially be used to treat wounds with deeper infections compared with current state of the art that treats wounds with treatment zone limited to the surface near topical application. Conclusion: Technology advances in design and fabrication of electroceutical dressings were leveraged to develop a tunable laboratory prototype that could be used as a disposable low-cost electroceutical wound care dressing on chronic wounds. Design revisions of PED-1 (1 kΩ ballast resistor) circumvented previously observed adverse effects on the skin in the vicinity of an open wound. PED-10 (including a 10 kΩ ballast resistor) was well tolerated in the small cohort of patients (N = 8) on whom it was tested, and the observations reported here warrant a larger study to determine the clinical impact on human wound healing and infection control.

Selective Inactivation of Pseudomonas aeruginosa and Staphylococcus epidermidis with Pulsed Electric Fields and Antibiotics

Objective: Increasing numbers of multidrug-resistant bacteria make many antibiotics ineffective; therefore, new approaches to combat microbial infections are needed. In addition, antibiotics are not selective-they kill pathogenic organisms as well as organisms that could positively contribute to wound healing (bio flora). Approach: Here we report on selective inactivation of Pseudomonas aeruginosa and Staphylococcus epidermidis, potential pathogens involved in wound infections with pulsed electric fields (PEFs) and antibiotics (mix of penicillin, streptomycin, and nystatin). Results: Using a Taguchi experimental design in vitro, we found that, under similar electric field strengths, the pulse duration is the most important parameter for P. aeruginosa inactivation, followed by the number of pulses and pulse frequency. P. aeruginosa, a potential severe pathogen, is more sensitive than the less pathogenic S. epidermidis to PEF (alone or in combination with antibiotics). Applying 200 pulses with a duration of 60 μs at 2.8 Hz, the minimum electric fields of 308.8 ± 28.3 and 378.4 ± 12.9 V/mm were required to inactive P. aeruginosa and S. epidermidis, respectively. Addition of antibiotics reduced the threshold for minimum electric fields required to inactivate the bacteria. Innovation: This study provides essential information, such as critical electric field parameters for bacteria inactivation, required for developing in vivo treatment and clinical protocols for using PEF for wound healing. Conclusion: A combination of PEFs with antibiotics reduces the electric field threshold required for bacteria disinfection. Such an approach simplifies devices required to disinfect large areas of infected wounds.

Low intensity electric field inactivation of Gram-positive and Gram-negative bacteria via metal-free polymeric composite

The adhesion of pathogenic bacteria in medical implants and surfaces is a health-related problem that requires strong inhibition against bacterial growth and attachment. In this work, we have explored the enhancement in the antibacterial activity of metal free-based composites under external electric field. It affects the oxidation degree of polypyrrole-based electrodes and consequently the antibacterial activity of the material. A conductive layer of carbon nanotubes (graphite) was deposited on porous substrate of polyurethane (sandpaper) and covered by polypyrrole, providing highly conductive electrodes characterized by intrinsic antibacterial activity and reinforced by electro-enhanced effect due to the external electric field. The bacterial inhibition of composites was monitored from counting of viable cells at different voltage/time of treatment and determination of biofilm inhibition on electrodes and reactors. The external voltage on electrodes reduces the threshold time for complete bacterial inactivation of PPy-based composites to values in order of 30 min for Staphylococcus aureus and 60 min for Escherichia coli.

Flexible Platform for In Situ Impedimetric Detection and Bioelectric Effect Treatment of Escherichia Coli Biofilms

GOAL

This paper reports a platform for real-time monitoring and treatment of biofilm formation on three-dimensional biomedical device surfaces.

METHODS

We utilize a flexible platform consisting of gold interdigitated electrodes patterned on a polyimide substrate. The device was integrated onto the interior of a urinary catheter and characterization was performed in a custom-developed flow system. Biofilm growth was monitored via impedance change at 100 Hz ac with a 50 mV signal amplitude.

RESULTS

A 30% impedance decrease over 24 h corresponded to Escherichia coli biofilm formation. The platform also enabled removal of the biofilm through the bioelectric effect; a low concentration of antibiotic combined with the applied ac voltage signal led to a synergistic reduction in biofilm resulting in a 12% increase in impedance. Biomass characterization via crystal violet staining confirmed that the impedance detection results correlate with changes in the amount of biofilm biomass on the sensor. We also demonstrated integration with a chip-based impedance converter to enable miniaturization and allow in situ wireless implementation. A 5% impedance decrease measured with the impedance converter corresponded to biofilm growth, replicating the trend measured with the potentiostat.

CONCLUSION

This platform represents a promising solution for biofilm infection management in diverse vulnerable environments.

SIGNIFICANCE

Biofilms are the dominant mode of growth for microorganisms, where bacterial cells colonize hydrated surfaces and lead to recurring infections. Due to the inaccessible nature of the environments where biofilms grow and their increased tolerance of antimicrobials, identification, and removal on medical devices poses a challenge.

Application of bioelectric effect to reduce the antibiotic resistance of subgingival plaque biofilm: An in vitro study

Context:

Biofilms are known for their antimicrobial resistance, and so is the subgingival plaque biofilm, the primary etiologic factor for periodontal infections.

Aims:

The objective of this study is to investigate if the subgingival plaque biofilm resistance can be reduced using doxycycline in the presence of low-intensity electric field (bioelectric effect).

Settings and Design:

The study was an in vitro microbiological study.

Materials and Methods:

Subgingival plaque samples from chronic periodontitis patients were collected to grow subgingival plaque biofilms on hydroxyapatite disks. Hydroxyapatite disks with the plaque biofilms from each patient were divided into four groups: (i) No intervention – control, (ii) current alone – CU; (iii) doxycycline – AB, and (iv) combined treatment – CU + AB. After respective treatments, the disks were anaerobically incubated for 48 h, the biofilm was dispersed and subcultured and colony-forming unit/mL was estimated in all the four groups.

Statistical Analysis:

Statistical analysis was done using Mann–Whitney and Kruskal–Wallis tests for intergroup comparisons. T-test was done to assess the difference in current flow between the groups CU and CU + AB.

Results:

All the three treatment modalities showed antibacterial effect. Application of current alone resulted in reduced bacterial growth than control group. Doxycycline alone resulted in reduction in bacterial counts better than control and current alone groups. The combination treatment showed greatest inhibition of bacterial colonies.

Conclusion:

The ability of doxycycline antibiotic in inhibiting plaque biofilm was significantly enhanced by application of a weak electric field (5 volts for 2 min).

An Integrated Microsystem for Real-Time Detection and Threshold-Activated Treatment of Bacterial Biofilms

Bacterial biofilms are the primary cause of infections in medical implants and catheters. Delayed detection of biofilm infections contributes to the widespread use of high doses of antibiotics, leading to the emergence of antibiotic-resistant bacterial strains. Accordingly, there is an urgent need for systems that can rapidly detect and treat biofilm infections in situ. As a step toward this goal, in this work we have developed for the first time a threshold-activated feedback-based impedance sensor-treatment system for combined real-time detection and treatment of biofilms. Specifically, we demonstrate the use of impedimetric sensing to accurately monitor the growth of Escherichia coli biofilms in microfluidic flow cells by measuring the fractional relative change (FRC) in absolute impedance. Furthermore, we demonstrate the use of growth measurements as a threshold-activated trigger mechanism to initiate successful treatment of biofilms using bioelectric effect (BE), applied through the same sensing electrode array. This was made possible through a custom program that (a) monitored the growth and removal of biofilms within the microfluidic channels in real-time and (b) enabled the threshold-based activation of BE treatment. Such BE treatment resulted in a ∼74.8 % reduction in average biofilm surface coverage as compared to the untreated negative control. We believe that this smart microsystem for integrated biofilm sensing and treatment will enable future development of autonomous biosensors optimized for accurate real-time detection of the onset of biofilms and their in situ treatment, directly on the surfaces of medical implants.

Effect of electrical energy on the efficacy of biofilm treatment using the bioelectric effect

Background/Objectives:

The use of electric fields in combination with small doses of antibiotics for enhanced treatment of biofilms is termed the ‘bioelectric effect’ (BE). Different mechanisms of action for the AC and DC fields have been reported in the literature over the last two decades. In this work, we conduct the first study on the correlation between the electrical energy and the treatment efficacy of the bioelectric effect on Escherichia coli K-12 W3110 biofilms.

Methods:

A thorough study was performed through the application of alternating (AC), direct (DC) and superimposed (SP) potentials of different amplitudes on mature E. coli biofilms. The electric fields were applied in combination with the antibiotic gentamicin (10 μg/ml) over a course of 24 h, after the biofilms had matured for 24 h. The biofilms were analysed using the crystal violet assay, the colony-forming unit method and fluorescence microscopy.

Results:

Results show that there is no statistical difference in treatment efficacy between the DC-, AC- and SP-based BE treatment of equivalent energies (analysis of variance (ANOVA) P>0.05) for voltages <1 V. We also demonstrate that the efficacy of the BE treatment as measured by the crystal violet staining method and colony-forming unit assay is proportional to the electrical energy applied (ANOVA P<0.05). We further verify that the treatment efficacy varies linearly with the energy of the BE treatment (r²=0.984). Our results thus suggest that the energy of the electrical signal is the primary factor in determining the efficacy of the BE treatment, at potentials less than the media electrolysis voltage.

Conclusions:

Our results demonstrate that the energy of the electrical signal, and not the type of electrical signal (AC or DC or SP), is the key to determine the efficacy of the BE treatment. We anticipate that this observation will pave the way for further understanding of the mechanism of action of the BE treatment method and may open new doors to the use of electric fields in the treatment of bacterial biofilms.

Electrochemical biofilm control: a review

One of the methods of controlling biofilms that has widely been discussed in the literature is to apply a potential or electrical current to a metal surface on which the biofilm is growing. Although electrochemical biofilm control has been studied for decades, the literature is often conflicting, as is detailed in this review. The goals of this review are: (1) to present the current status of knowledge regarding electrochemical biofilm control; (2) to establish a basis for a fundamental definition of electrochemical biofilm control and requirements for studying it; (3) to discuss current proposed mechanisms; and (4) to introduce future directions in the field. It is expected that the review will provide researchers with guidelines on comparing datasets across the literature and generating comparable datasets. The authors believe that, with the correct design, electrochemical biofilm control has great potential for industrial use.

Direct electric current treatment under physiologic saline conditions kills Staphylococcus epidermidis biofilms via electrolytic generation of hypochlorous acid

The purpose of this study was to investigate the mechanism by which a direct electrical current reduced the viability of Staphylococcus epidermidis biofilms in conjunction with ciprofloxacin at physiologic saline conditions meant to approximate those in an infected artificial joint. Biofilms grown in CDC biofilm reactors were exposed to current for 24 hours in 1/10^th strength tryptic soy broth containing 9 g/L total NaCl. Dose-dependent log reductions up to 6.7 log₁₀ CFU/cm² were observed with the application of direct current at all four levels (0.7 to 1.8 mA/cm²) both in the presence and absence of ciprofloxacin. There were no significant differences in log reductions for wells with ciprofloxacin compared to those without at the same current levels. When current exposures were repeated without biofilm or organics in the medium, significant generation of free chlorine was measured. Free chlorine doses equivalent to the 24 hour endpoint concentration for each current level were shown to mimic killing achieved by current application. Current exposure (1.8 mA/cm²) in medium lacking chloride and amended with sulfate, nitrate, or phosphate as alternative electrolytes produced diminished kills of 3, 2, and 0 log reduction, respectively. Direct current also killed Pseudomonas aeruginosa biofilms when NaCl was present. Together these results indicate that electrolysis reactions generating hypochlorous acid from chloride are likely a main contributor to the efficacy of direct current application. A physiologically relevant NaCl concentration is thus a critical parameter in experimental design if direct current is to be investigated for in vivo medical applications.

Synergistic bactericidal effects and mechanisms of low intensity ultrasound and antibiotics against bacteria: a review

Low intensity ultrasonic therapy is always an important research area of ultrasonic medicine. This review concentrates on low intensity ultrasound enhancing bactericidal action of antibiotics against bacteria in vitro and in vivo, including planktonic bacteria, bacterial biofilms, Chlamydia, and bacteria in implants. These literatures show that low intensity ultrasound alone is not effective in killing bacteria, while the combination of low intensity ultrasound and antibiotics is promising. Low intensity ultrasound facilitating antibiotic treatment is still in its infancy, and still requires a great deal of research in order to develop the technology on medical treatment scale.

Electrochemical biofilm control: mechanism of action

Although it has been previously demonstrated that an electrical current can be used to control biofilm growth on metal surfaces, the literature results are conflicting and there is no accepted mechanism of action. One of the suggested mechanisms is the production of hydrogen peroxide (H(2)O(2)) on metal surfaces. However, there are literature studies in which H(2)O(2) could not be detected in the bulk solution. This is most likely because H(2)O(2) was produced at a low concentration near the surface and could not be detected in the bulk solution. The goals of this research were (1) to develop a well-controlled system to explain the mechanism of action of the bioelectrochemical effect on 316L stainless steel (SS) surfaces and (2) to test whether the produced H(2)O(2) can reduce cell growth on metal surfaces. It was found that H(2)O(2) was produced near 316L SS surfaces when a negative potential was applied. The H(2)O(2) concentration increased towards the surface, while the dissolved oxygen decreased when the SS surface was polarized to -600 mV(Ag/AgCl). When polarized and non-polarized surfaces with identical Pseudomonas aeruginosa PAO1 biofilms were continuously fed with air-saturated growth medium, the polarized surfaces showed minimal biofilm growth while there was significant biofilm growth on the non-polarized surfaces. Although there was no detectable H(2)O(2) in the bulk solution, it was found that the surface concentration of H(2)O(2) was able to prevent biofilm growth.

Differential Gene Expression to Investigate the Effects of Low-level Electrochemical Currents on Bacillus subtilis

With the emergence and spread of multidrug resistant bacteria, effective methods to eliminate both planktonic bacteria and those embedded in surface-attached biofilms are needed. Electric currents at μA-mA/cm2 range are known to reduce the viability of bacteria. However, the mechanism of such effects is still not well understood. In this study, Bacillus subtilis was used as the model Gram-positive species to systematically investigate the effects of electrochemical currents on bacteria including the morphology, viability, and gene expression of planktonic cells, and viability of biofilm cells. The data suggest that weak electrochemical currents can effectively eliminate B. subtilis both as planktonic cells and in biofilms. DNA microarray results indicate that the genes associated with oxidative stress response, nutrient starvation, and membrane functions were induced by electrochemical currents. These findings suggest that ions and oxidative species generated by electrochemical reactions might be important for the killing effects of these currents.

A biofilm growth protocol and the design of a magnetic field exposure setup to be used in the study of magnetic fields as a means of controlling bacterial biofilms

The use of prosthetic implants is increasing both in the United States and around the world and there is a concomitant rise in cases of biofilm-based, persistent infections that are quite serious and virtually impervious to antibiotic treatment. The development of alternate therapies that do not involve long term use of high levels of antibiotics or surgical intervention is needed. Based on the success of using electric or magnetic fields to alter certain physiological processes, it is hypothesized that relatively low level magnetic fields, in conjunction with the appropriate antibiotic, may be able to help control and eventually clear bacterial biofilms on a prosthetic. In order to test this hypothesis, it is necessary to first develop a means of growing laboratory grade biofilms on specific materials in a way that is repeatable between experiments and that can be reproduced by other laboratories. Secondly, a means of applying controlled magnetic fields to the surfaces supporting the biofilms at a defined temperature must be developed. This article addresses both of these points.

Effect of farnesol on Staphylococcus aureus biofilm formation and antimicrobial susceptibility

Staphylococcus aureus is among the leading pathogens causing bloodstream infections able to form biofilms on host tissue and indwelling medical devices and to persist and cause disease. Infections caused by S. aureus are becoming more difficult to treat because of increasing resistance to antibiotics. In a biofilm environment particularly, microbes exhibit enhanced resistance to antimicrobial agents. Recently, farnesol was described as a quorum-sensing molecule with possible antimicrobial properties. In this study, the effect of farnesol on methicillin-resistant and -susceptible strains of S. aureus was investigated. With viability assays, biofilm formation assessment, and ethidium bromide uptake testing, farnesol was shown to inhibit biofilm formation and compromise cell membrane integrity. The ability of farnesol to sensitize S. aureus to antimicrobials was assessed by agar disk diffusion and broth microdilution methods. For both strains of staphylococci, farnesol was only able to reverse resistance at a high concentration (150 microM). However, it was very successful at enhancing the antimicrobial efficacy of all of the antibiotics to which the strains were somewhat susceptible. Therefore, synergy testing of farnesol and gentamicin was performed with static biofilms exposed to various concentrations of both agents. Plate counts of harvested biofilm cells at 0, 4, and 24 h posttreatment indicated that the combined effect of gentamicin at 2.5 times the MIC and farnesol at 100 microM (22 microg/ml) was able to reduce bacterial populations by more than 2 log units, demonstrating synergy between the two antimicrobial agents. This observed sensitization of resistant strains to antimicrobials and the observed synergistic effect with gentamicin indicate a potential application for farnesol as an adjuvant therapeutic agent for the prevention of biofilm-related infections and promotion of drug resistance reversal.

Effects of localised, low-voltage pulsed electric fields on the development and inhibition of Pseudomonas aeruginosa biofilms

This work describes the use of low-voltage (0.5 - 5 V) pulsed electric fields to prevent Pseudomonas aeruginosa biofilm development. Interdigitated electrodes (IDEs) with 29-mum spacing between 22-mum-wide electrodes, were used as a platform where the effect of localised, high-strength electric fields could be tested. Alternating current, square-wave pulses were applied to the IDEs in 1 sec intervals. A two-level, three-variable factorial design experiment was used to detect the effects of applied voltage, frequency, and pulse duty ratio (i.e. percentage of pulsing time over one cycle) on the inhibition of biofilm formation. The observations indicated that a pulse configuration of 1% duty ratio, 5 V, and 200 Hz frequency reduced the area of the electrodes covered by biofilm by 50%. In general, the application of low-duty ratio pulses had a positive effect on preventing biofouling. Comparatively, frequency and applied voltage were observed to have less influence on biofouling.