Bacterial sensitivity to chlorhexidine and povidone-iodine antiseptics over time: a systematic review and meta-analysis of human-derived data

Surgical site infection (SSI) is the most common complication of surgery, increasing healthcare costs and hospital stay. Chlorhexidine (CHX) and povidone-iodine (PVI) are used for skin antisepsis, minimising SSIs. There is concern that  resistance to topical biocides may be emergeing, although the potential clinical implications remain unclear. The objective of this systematic review was to determine whether the minimum bactericidal concentration (MBC) of topical preparations of CHX or PVI have changed over time, in microbes relevant to SSI. We included studies reporting the MBC of laboratory and clinical isolates of common microbes to CHX and PVI. We excluded studies using non-human samples and antimicrobial solvents or mixtures with other active substances. MBC was pooled in random effects meta-analyses and the change in MBC over time was explored using meta-regression. Seventy-nine studies were included, analysing 6218 microbes over 45 years. Most studies investigated CHX (93%), with insufficient data for meta-analysis of PVI. There was no change in the MBC of CHX to Staphylococci or Streptococci over time. Overall, we find no evidence of reduced susceptibility of common SSI-causing microbes to CHX over time. This provides reassurance and confidence in the worldwide guidance that CHX should remain the first-choice agent for surgical skin antisepsis.

Investigation of drug resistance of caries-related streptococci to antimicrobial peptide GH12

Dental caries is associated with caries-related streptococci and antimicrobial agents have been widely used for caries control, but troubled by antibiotic resistance. This study aimed to investigate the intrinsic and acquired resistance of caries-related streptococci to antimicrobial peptide GH12, which was proven promising for caries control, and preliminarily explore the phenotypic changes and whole genome of stable acquired resistant strains. In this study, susceptibility assays and resistance assays were performed, followed by stability assays of resistance, to evaluate the intrinsic resistance and the potential resistance of caries-related streptococci. Then, the phenotypic changes of the stable acquired resistant strain were explored. The whole genome of the resistant strain was sequenced and analyzed by second-generation and third-generation high-throughput sequencing technologies. Streptococcus gordonii and Streptococcus sanguinis were intrinsically resistant to GH12 compared to cariogenic Streptococcus mutans. Acquired GH12 resistance in one S. sanguinis and four S. mutans clinical strains was transient but stable in one S. mutans strain (COCC33-14). However, acquired resistance to daptomycin (DAP) and chlorhexidine in all strains was stable. Furthermore, the COCC33-14 showed cross-resistance to DAP and delayed growth rates and a lower population. However, no drug-resistant gene mutation was detected in this strain, but 6 new and 5 missing genes were found. Among them, annotation of one new gene (gene 1782|COCC33-14R) is related to the integral component of the membrane, and one missing gene rpsN is associated with the metabolism and growth of bacteria. The results indicate that stable resistant mutants of caries-related streptococci could hardly be selected by exposure to consecutive sublethal GH12, but the risk still existed. Resistance in COCC33-14R is mainly related to changes in the cell envelope.

Ecological Effects of Daily Antiseptic Treatment on Microbial Composition of Saliva-Grown Microcosm Biofilms and Selection of Resistant Phenotypes

Antiseptics are widely used in dental practice and included in numerous over-the-counter oral care products. However, the effects of routine antiseptic use on microbial composition of oral biofilms and on the emergence of resistant phenotypes remain unclear. Microcosm biofilms were inoculated from saliva samples of four donors and cultured in the Amsterdam Active Attachment biofilm model for 3 days. Then, they were treated two times daily with chlorhexidine digluconate (CHX) or cetylpyridinium chloride (CPC) for a period of 7 days. Ecological changes upon these multiple antiseptic treatments were evaluated by semiconductor-based sequencing of bacterial 16S rRNA genes and identification of amplicon sequence variants (ASVs). Furthermore, culture-based approaches were used for colony-forming units (CFU) assay, identification of antiseptic-resistant phenotypes using an agar dilution method, and evaluation of their antibiotic susceptibilities. Both CHX and CPC showed only slight effects on CFU and could not inhibit biofilm growth despite the two times daily treatment for 7 days. Both antiseptics showed significant ecological effects on the microbial compositions of the surviving microbiota, whereby CHX led to enrichment of rather caries-associated saccharolytic taxa and CPC led to enrichment of rather gingivitis-associated proteolytic taxa. Antiseptic-resistant phenotypes were isolated on antiseptic-containing agar plates, which also exhibited phenotypic resistance to various antibiotics. Our results highlight the need for further research into potential detrimental effects of antiseptics on the microbial composition of oral biofilms and on the spread of antimicrobial resistance in the context of their frequent use in oral healthcare.

Phenotypic Adaptation to Antiseptics and Effects on Biofilm Formation Capacity and Antibiotic Resistance in Clinical Isolates of Early Colonizers in Dental Plaque

Despite the wide-spread use of antiseptics in dental practice and oral care products, there is little public awareness of potential risks associated with antiseptic resistance and potentially concomitant cross-resistance. Therefore, the aim of this study was to investigate potential phenotypic adaptation in 177 clinical isolates of early colonizers of dental plaque (Streptococcus, Actinomyces, Rothia and Veillonella spp.) upon repeated exposure to subinhibitory concentrations of chlorhexidine digluconate (CHX) or cetylpyridinium chloride (CPC) over 10 passages using a modified microdilution method. Stability of phenotypic adaptation was re-evaluated after culture in antiseptic-free nutrient broth for 24 or 72 h. Strains showing 8-fold minimal inhibitory concentration (MIC)-increase were further examined regarding their biofilm formation capacity, phenotypic antibiotic resistance and presence of antibiotic resistance genes (ARGs). Eight-fold MIC-increases to CHX were detected in four Streptococcus isolates. These strains mostly exhibited significantly increased biofilm formation capacity compared to their respective wild-type strains. Phenotypic antibiotic resistance was detected to tetracycline and erythromycin, consistent with the detected ARGs. In conclusion, this study shows that clinical isolates of early colonizers of dental plaque can phenotypically adapt toward antiseptics such as CHX upon repeated exposure. The underlying mechanisms at genomic and transcriptomic levels need to be investigated in future studies.

Comparison of the Antibacterial Activity and Effect on Membrane Permeability of Hibiscus Acid and a Commercial Chlorhexidine Mouthrinse Against Pathogenic Oral Bacteria and Determination of Hibiscus Acid Toxicity

The main aim of this study was to determine and compare the antimicrobial effect of hibiscus acid and a commercial 0.12% (w/v) chlorhexidine mouthrinse against Streptococcus mutans, Streptococcus sanguinis, Capnocytophaga gingivalis, and Staphylococcus aureus, and to determine the effect on bacterial cell membrane permeability and the toxicity of hibiscus acid in a mouse model. Hibiscus acid was obtained from acetone extract of Hibiscus sabdariffa calyces. Chlorhexidine (0.12% w/v) mouthrinse was purchased from a local pharmacy. The antimicrobial activity of hibiscus acid and mouthrinse were determined using the gel diffusion technique. The minimum inhibitory concentration (MIC) and minimum bactericidal concentration (MBC) of the solutions were determined using the broth dilution method. The effect on bacterial cell membrane permeability of hibiscus acid and mouthrinse was determined by crystal violet assay. The toxicity of hibiscus acid was investigated in a mouse model (registration number: UAEH2019-A1-S-8288). Hibiscus acid and mouthrinse showed antibacterial activity against all oral pathogenic bacteria. However, hibiscus acid showed a lower antibacterial effect compared with chlorhexidine mouthrinse. The MIC and MBC for hibiscus acid were 3 and 5 mg/mL, respectively, and was between 30 and 50 μg/mL for mouthrinse. The crystal violet test results indicate that hibiscus acid and mouthrinse alter the permeability of the bacterial membrane. Finally, hibiscus acid did not show toxicity in mouse studies.

Minimum inhibitory concentrations of chlorhexidine- and lactic acid-based teat disinfectants: An intervention trial assessing bacterial selection and susceptibility

Teat disinfection is a recommended preventive tool to improve udder health and to prevent new intramammary infections. However, side effects are discussed, such as bacterial selection of less-susceptible bacteria with the application of certain teat disinfectants. The objective of this study was to assess the species composition and bacterial in vitro susceptibility by means of an interventive trial. For this purpose, 3 different postmilking teat treatments (disinfection with 0.215% chlorhexidine or 3.5% lactic acid, or control group with no dipping) were applied to 28 cows in a 6-d intervention approach using a split-udder design. Milk samples were taken before and after intervention. Bacteria were cultured and differentiated to species or genus level by MALDI-TOF mass spectrometry. Minimum inhibitory concentrations (MIC) were determined, and MIC changes over time were recorded. Susceptibilities to chlorhexidine and lactic acid were compared between species of the genera Staphylococcus, Streptococcus, Corynebacterium, and others. Species composition changed during the intervention. Under the treatment of chlorhexidine and lactic acid, the proportion of coagulase-negative staphylococci (CNS) decreased. An increased proportion of species belonging to the genus Corynebacterium was observed especially under the application of lactic acid. Although both teat disinfectants were basically effective, isolates differed in their susceptibility to both teat disinfectants. Populations of CNS, Staphylococcus aureus, and Corynebacterium spp. showed significantly lower absolute MIC values for chlorhexidine. Compared with other species, Corynebacterium spp. showed the lowest susceptibility for chlorhexidine as well as for lactic acid. A significant increase in MIC values after 6 d of intervention was observed with the lactic acid treatment in all isolates, as well as in CNS. This increase can be interpreted as either adaptation of isolates or displacement of more-susceptible species by less-susceptible species. Further studies using long-term intervention might reveal more pronounced effects on MIC values and species composition.

DexA70, the Truncated Form of a Self-Produced Dextranase, Effectively Disrupts Streptococcus mutans Biofilm

Billions of people suffer from dental caries every year in spite of the effort to reduce the prevalence over the past few decades. Streptococcus mutans is the leading member of a specific group of cariogenic bacteria that cause dental caries. S. mutans forms biofilm, which is highly resistant to harsh environment, host immunity, and antimicrobial treatments. In this study, we found that S. mutans biofilm is highly resistant to both antimicrobial agents and lysozyme. DexA70, the truncated form of DexA (amino acids 100–732), a dextranase in S. mutans, prevents S. mutans biofilm formation and disassembles existing biofilms within minutes at nanomolar concentrations when supplied exogenously. DexA70 treatment markedly enhances biofilm sensitivity to antimicrobial agents and lysozyme, indicating its great potential in combating biofilm-related dental caries.

Controlled release, antimicrobial activity, and oral mucosa irritation of cetylpyridinium chloride-montmorillonite incorporated in a tissue conditioner

This study examined the controlled release of cetylpyridinium chloride (CPC) from a tissue conditioner (TC) containing CPC-montmorillonite (CPC-Mont), the associated antimicrobial activity, and oral mucosa irritation. The CPC release test was performed daily for 28 days in three test solutions: distilled water, 0.2 M NaCl, and 0.2 M HCl. The antimicrobial activities for 7, 14, 21, and 28 days against Candida albicans, Staphylococcus aureus, and Streptococcus mutans were assessed according to the JIS Z 2801/ISO 22196 standard. An oral mucosa irritation test was conducted using cheek pouches in five male hamsters according to the ISO 10993-10:2010 standard. The amount of CPC released each day and the cumulative amount released over 28 days (6.12 mg) were less than the daily safe maximum of sore throat medicines (8 mg). Additionally, TC with CPC-Mont could sustain antimicrobial activity against adherent bacteria for 14 days and has no oral mucosa irritation potential.

Phage Targeting Streptococcus mutans In Vitro and In Vivo as a Caries-Preventive Modality

Dental caries is a common infectious disease worldwide. Current conventional therapies lack specific antimicrobial effects against Streptococcus mutans, a key bacterium that induces caries. A promising alternative approach is bacteriophage (phage) therapy. Recently, SMHBZ8 phage targeting S. mutans was isolated and characterized. The aim of this study was to evaluate the caries-prevention efficacy of SMHBZ8 using in vitro and in vivo caries models. Hemi-mandibles dissected from euthanized healthy mice were subjected to caries-promoting conditions in vitro. Jaws treated with phage therapy in suspension and in formulation with a sustained-release delivery system showed no carious lesions, similar to control and chlorhexidine-treated jaws. Subsequently, SMHBZ8 phage suspension also prevented carious lesion development in a murine caries model in vivo. In both models, caries lesions were analyzed clinically and radiographically by µCT scans. This study shows how SMHBZ8 phage therapy targeting S. mutans can serve as an efficient caries-prevention modality, in suspension or with a sustained-release delivery system, by in vitro and in vivo mouse models.

Synthesis and characterization of an experimental primer containing chitosan nanoparticles - Effect on the inactivation of metalloproteinases, antimicrobial activity and adhesive strength

OBJECTIVE

The aim of this study was to synthesize and characterize an experimental primer containing cationic lipid nanoparticles (NPL-chitosan) and to evaluate its properties.

DESIGN

The NPL-chitosan were synthesized by emulsion and sonication method. The experimental primers were applied in dentin surface of fifty human molars. The experimental groups were: 1) application of commercial primer; 2) Primer containing 2% of Chlorhexidine (CHX) 3); Primer with 2% NPL-chitosan 4); Primer with 0.6 % of NPL-chitosan 5); Primer with 0.4 % of NPL-chitosan. A composite resin plateau was used for the analysis, where sections were made for making the dentin beams. The effect of experimental primer with cationic nanoparticles in the inhibition of matrix metalloproteinase (MMP) activity was carrying out by in situ zymography. For the Resin-Dentin Adhesive Strength and in situ Zymography analysis, was used the One-way analysis of variance (ANOVA) with significance level of 95 %.

RESULTS

Spherical NPL-chitosan presented size below 220 nm, polydispersity index of 0.179 and zeta potential positive and was stable over 75 days. These nanoparticles showed antibacterial activity agsainst S. mutans with MIC of the 0.4 % and MBC of 0.67 %. In the Microtensile Strength, no statistical difference was observed between the experimental groups (p = 0.9054). The in situ zymography assay showed that the group with 2% of NPL-chitosan presented higher inactivation activity of MMPs compared to the other groups (p < 0.05).

CONCLUSION

The experimental primer containing NPL-chitosan has antimicrobial activity, does not alter the adhesive resistance and inactivates MMPs present in dentin.

Development of a herbal mouthwash containing a mixture of essential oils and plant extracts and in vitro testing of its antimicrobial efficiency against the planktonic and biofilm-enclosed cariogenic bacterium Streptococcus mutans

A herbal mouthwash containing essential oils of holy basil and mountain tea, extracts of St John's wort and European goldenrod (Bucovia™) and cetylpyridinium chloride, was developed and in vitro tested for its efficiency against biofilm formation by Streptococcus mutans, together with its eradicating activity against already preformed (48 h with saccharose) streptococcal biofilm. The minimum inhibitory (MIC) and bactericidal concentrations (MBC) of the final formulation, as well as of its individual components, were initially determined. The results revealed that the mouthwash needed to be applied at two-times its MIC (0.63% v.v^-1) to completely inhibit biofilm formation by S. mutans, which was otherwise capable of developing a robust biofilm on the tested surface. Once fully developed, the matrix of the biofilm was found to contain a significant amount of exopolysaccharides protecting the cells, being impossible to eradicate even when exposed to pure mouthwash for 15 min, highlighting the great recalcitrance of biofilm-embedded S. mutans.

Root Caries Preventive Effect of Varnishes Containing Fluoride or Fluoride + Chlorhexidine/Cetylpyridinium Chloride In Vitro

Caries preventive varnishes containing only fluoride might differ from those containing a combination of fluoride and antimicrobial components in terms of mineralization properties and their impact on the cariogenic biofilm. We compared a fluoride and a fluoride + chlorhexidine (CHX)/cetylpyridinium chloride (CPC) varnish on root caries formation in vitro. One hundred bovine root dentin samples were allocated to five groups (n = 20/group): (1) 7700 ppm fluoride varnish (Fluorprotector S (F)), (2) experimental placebo varnish for F (F-P), (3) 1400 ppm fluoride + 0.3% CHX/0.5% CPC varnish (Cervitec F (CF)), (4) experimental placebo varnish for CF (CF-P), (5) untreated control. Cariogenic challenge was provided using a multi-station, continuous-culture 3-species (Streptococcus mutans (SM), Lactobacillus rhamnosus (LR), Actinomyces naeslundii (AN)) biofilm model for 10 days. Mineral loss (ΔZ) was evaluated using transversal microradiography and bacterial counts in the biofilm assessed as colony-forming units. Fluorescence in situ hybridization (FISH) and confocal microscopy were performed to assess the three-dimensional biofilm architecture. Mean ± SD (vol% × μm) ΔZ was significantly lower for F (9133 ± 758) and CF (9835 ± 1677) compared to control (11362 ± 919) (p < 0.05), without significant differences between F and CF. SM counts were significantly lower and LR counts significantly higher in F- and CF-biofilms compared to control. AN counts were significantly higher in the F-biofilms than in all other groups. According to FISH, SM and LR invaded dentinal tubules only in the control-group. In the CF-group, the basal biofilm layer did not contain SM and AN. Both F and CF varnishes had similar caries-preventive effects and a considerable impact on biofilm structure and composition.

Cetylpyridinium Chloride: Mechanism of Action, Antimicrobial Efficacy in Biofilms, and Potential Risks of Resistance

Antimicrobial resistance is a serious issue for public health care all over the world. While resistance toward antibiotics has attracted strong interest among researchers and the general public over the last 2 decades, the directly related problem of resistance toward antiseptics and biocides has been somewhat left untended. In the field of dentistry, antiseptics are routinely used in professional care, but they are also included in lots of oral care products such as mouthwashes or dentifrices, which are easily available for consumers over-the-counter. Despite this fact, there is little awareness among the dental community about potential risks of the widespread, unreflected, and potentially even needless use of antiseptics in oral care. Cetylpyridinium chloride (CPC), a quaternary ammonium compound, which was first described in 1939, is one of the most commonly used antiseptics in oral care products and included in a wide range of over-the-counter products such as mouthwashes and dentifrices. The aim of the present review is to summarize the current literature on CPC, particularly focusing on its mechanism of action, its antimicrobial efficacy toward biofilms, and on potential risks of resistance toward this antiseptic as well as underlying mechanisms. Furthermore, this work aims to raise awareness among the dental community about the risk of resistance toward antiseptics in general.