Though biofilms were first described by Antonie van Leeuwenhoek, the theory describing the biofilm process was not developed until 1978. We now understand that biofilms are universal, occurring in aquatic and industrial water systems as well as a large number of environments and medical devices relevant for public health. Using tools such as the scanning electron microscope and, more recently, the confocal laser scanning microscope, biofilm researchers now understand that biofilms are not unstructured, homogeneous deposits of cells and accumulated slime, but complex communities of surface-associated cells enclosed in a polymer matrix containing open water channels. Further studies have shown that the biofilm phenotype can be described in terms of the genes expressed by biofilm-associated cells. Microorganisms growing in a biofilm are highly resistant to antimicrobial agents by one or more mechanisms. Biofilm-associated microorganisms have been shown to be associated with several human diseases, such as native valve endocarditis and cystic fibrosis, and to colonize a wide variety of medical devices. Though epidemiologic evidence points to biofilms as a source of several infectious diseases, the exact mechanisms by which biofilm-associated microorganisms elicit disease are poorly understood. Detachment of cells or cell aggregates, production of endotoxin, increased resistance to the host immune system, and provision of a niche for the generation of resistant organisms are all biofilm processes which could initiate the disease process. Effective strategies to prevent or control biofilms on medical devices must take into consideration the unique and tenacious nature of biofilms. Current intervention strategies are designed to prevent initial device colonization, minimize microbial cell attachment to the device, penetrate the biofilm matrix and kill the associated cells, or remove the device from the patient. In the future, treatments may be based on inhibition of genes involved in cell attachment and biofilm formation.

Biofilms: Survival Mechanisms of Clinically Relevant Microorganisms

In this review, initial microbial adhesive interactions are divided into adhesion to substratum surfaces, coaggregation between microbial pairs and co-adhesion between sessile and planktonic microorganisms of different strains or species. The physico-chemical mechanisms underlying the adhesive interactions are described and a critical review is given of currently employed methods to study microbial adhesive interactions, with an emphasis on the use of the parallel plate flow chamber. Subsequently, for each of the three microbial adhesive interactions distinguished, the role of Lifshitz-van der Waals, acid-base and electrostatic interactions is described based on existing literature.

Physico-chemistry of initial microbial adhesive interactions – its mechanisms and methods for study

Acute infections caused by pathogenic bacteria have been studied extensively for well over 100 years. These infections killed millions of people in previous centuries, but they have been combated effectively by the development of modern vaccines, antibiotics and infection control measures. Most research into bacterial pathogenesis has focused on acute infections, but these diseases have now been supplemented by a new category of chronic infections caused by bacteria growing in slime-enclosed aggregates known as biofilms. Biofilm infections, such as pneumonia in cystic fibrosis patients, chronic wounds, chronic otitis media and implant- and catheter-associated infections, affect millions of people in the developed world each year and many deaths occur as a consequence. In general, bacteria have two life forms during growth and proliferation. In one form, the bacteria exist as single, independent cells (planktonic) whereas in the other form, bacteria are organized into sessile aggregates. The latter form is commonly referred to as the biofilm growth phenotype. Acute infections are assumed to involve planktonic bacteria, which are generally treatable with antibiotics, although successful treatment depends on accurate and fast diagnosis. However, in cases where the bacteria succeed in forming a biofilm within the human host, the infection often turns out to be untreatable and will develop into a chronic state. The important hallmarks of chronic biofilm-based infections are extreme resistance to antibiotics and many other conventional antimicrobial agents, and an extreme capacity for evading the host defences. In this thesis, I will assemble the current knowledge on biofilms with an emphasis on chronic infections, guidelines for diagnosis and treatment of these infections, before relating this to my previous research into the area of biofilms. I will present evidence to support a view that the biofilm lifestyle dominates chronic bacterial infections, where bacterial aggregation is the default mode, and that subsequent biofilm development progresses by adaptation to nutritional and environmental conditions. I will make a series of correlations to highlight the most important aspects of biofilms from my perspective, and to determine what can be deduced from the past decades of biofilm research. I will try to bridge in vitro and in vivo research and propose methods for studying biofilms based on this knowledge. I will compare how bacterial biofilms exist in stable ecological habitats and opportunistically in unstable ecological habitats, such as infections. Bacteria have a similar lifestyle (the biofilm) in both habitats, but the fight for survival and supremacy is different. On the basis of this comparison, I will hypothesize how chronic biofilm infections are initiated and how bacteria live together in these infections. Finally, I will discuss different aspects of biofilm infection diagnosis. Hopefully, this survey of current knowledge and my proposed guidelines will provide the basis and inspiration for more research, improved diagnostics, and treatments for well-known biofilm infections and any that may be identified in the future.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/apm.12099

The role of bacterial biofilms in chronic infections

Pleiotropic Roles of Bile Acids in Metabolism

Unequivocal direct observations have established that the bacteria that cause device-related and other chronic infections grow in matrix-enclosed biofilms. The diagnostic and therapeutic strategies that have served us so well in the partial eradication of acute epidemic bacterial diseases have not yielded accurate data or favorable outcomes when applied to these biofilm diseases. We discuss the potential benefits of the application of the new methods and concepts developed by biofilm science and engineering to the clinical management of infectious diseases.

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The application of biofilm science to the study and control of chronic bacterial infections

Bacteria can invade the biliary tract by ascending from the duodenum and via the hematogenous route from the hepatic portal venous blood. The sphincter of Oddi, situated at the junction of the biliary tract and the upper gastrointestinal tract, forms an effective mechanical barrier to duodenal reflux and ascending bacterial infection. Conversely, Kupffer cells and the tight junctions between hepatocytes help prevent bacteria and toxic metabolites from entering the hepatobiliary system from the portal circulation. The continuous flushing action of bile and the bacteriostatic effects of bile salts keeps the biliary tract sterile under normal conditions. Secretory immunoglobulin A (sIgA), the predominant immunoglobulin in the bile, and mucus excreted by the biliary epithelium probably function as antiadherence factors, preventing microbial colonization. When barrier mechanisms break down, as in surgical or endoscopic sphincterotomy and with insertion of biliary stents, pathogenic bacteria enter the biliary system at high concentrations and take up residence on any foreign bodies. Intrabiliary pressure is a key factor in the development of cholangitis. Chronic biliary obstruction raises the intrabiliary pressure. This adversely influences the defensive mechanisms such as the tight junctions, Kupffer cell functions, bile flow, and sIgA production in the system, resulting in a higher incidence of septicemia and endotoxemia in these patients. Knowledge of biliary defense against infection is still quite primitive. Unclear are the roles of sIgA in the bile, mechanism of bacterial adhesion to the biliary epithelium, Kupffer cell function in biliary obstruction, and the antimicrobial activity of bile salts.

Defense system in the biliary tract against bacterial infection.

This study examines the morphology, ultrastructure, and microbiology of the intact biofilm developing on an implant surface. Silastic subdermal implant material was colonized with P. aeruginosa and surgically inserted into the peritoneal cavity of adult rabbits. After 4, 8, 28, and 42 days implants were recovered and the intact biofilms examined. P. aeruginosa colonized the implant throughout the entire experimental time. Microcolonies of glycocalyx-coated bacteria were observed within the biofilm. However, the bulk of the biofilm was host-generated and typically contained phagocytes trapped within a thick mesh of fibrin. Polymorphonuclear neutrophils were the predominant cell type. Isolated erythrocytes, macrophages, and fibroblasts were also observed. By day 28, the biofilm was enclosed in a fibrous capsule of vascularized connective tissue. The low numbers of neutrophils seen in biofilms from sterile Silastic sheets implanted into control animals suggested that neutrophilia may represent a specific cellular response to the bacterial colonization. The results indicate that the cell-mediated immune response provides for most of the biofilm mass on colonized implant surfaces. Inactivated phagocytes trapped in fibrin may “wall-off” the embedded bacterial micro-colonies and thus shield them from live phagocytic leucocytes. Such a mechanism may play an important role in the pathogenesis of prosthetic device infections.

An in vivo model to study the pathobiology of infectious biofilms on biomaterial surfaces.

It has been widely accepted that there is an ascending route of bacterial infection of the biliary tract but there is a lack of direct evidence. This hypothesis was tested in an animal experiment using the cat as an animal model. The implantation of biliary stents and surgical sphincterotomy were performed in these animals, with sham controls. Stents bypassing the sphincter of Oddi with the tip in the duodenal micro-organisms and the biliary tract was heavily contaminated. Blockage of these stents resulted in biliary obstruction. Stents implanted within the common bile duct, proximal to the sphincter were largely unaffected by biofilm formation. After surgical sphincterotomy the biliary tract was also contaminated but, in the absence of obstruction, the animals did not develop any symptoms. It was concluded that ascending infection by duodenal biliary reflux, via the sphincter of Oddi, is an important route of infection in the biliary system.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting

In vitro studies have demonstrated that bile salts have cytotoxic and bacteriostatic properties. The cytotoxic effect of bile salts is reduced when lecithin is added. The effect of lecithin on the bacteriostatic property of bile salts is not known. In this report, we test the hypotheses that (1) the bacteriostatic activity of bile salts is a function of the hydrophobicity of the molecules, and (2) lecithin, by engaging the hydrophobic component of bile salts, attenuates the bacteriostatic property of these molecules. Two common biliary pathogens, Escherichia coli and Enterococcus fecalis, were tested in this experiment. The results demonstrate that hydrophobic bile salts (sodium taurodeoxycholate, sodium deoxycholate) have more significant inhibition on the growth of bacteria when compared with the hydrophilic bile salts (sodium taurocholate, sodium chenodeoxycholate, and sodium tauroursodeoxycholate). When lecithin is added, creating a mixed micellar solution and mimicking the in vivo conditions, the antibacterial activities of even the more potent bacteriostatic bile salts are significantly reduced. The finding that lecithin significantly attenuates the bacteriostatic property of even the hydrophobic bile salts raises questions about the clinical significance of such bacteriostatic effect in vivo; as bile salts in the bile exist in mixed micellar solution.

Antibacterial activity of bile salts against common biliary pathogens. Effects of hydrophobicity of the molecule and in the presence of phospholipids.

Bacterial pathogens gain access into the biliary system by descending via the portal venous circulation or ascending through the sphincter of Oddi in duodenal-biliary reflux. Bacteria thrive as glycocalyx-enclosed microcolonies, coalescing to form an adherent biofilm. The establishment of biofilm is a key event in the formation of biliary sludge and pigment gallstones, and the blockage of biliary stents. The biofilm mode of growth is very effective because it provides bacteria with a measure of protection from antibacterial agents and phagocytic leucocytes. Calcification of the matrix confers further protection for the micro-organisms living inside the biofilm. To date, attempts to prevent blockage of biliary stent have employed physical methods by using large self-expandable stents and stents without side hole. Incorporation of antibiotics within stents has not been successful presumably because bacteria once living in their biofilm are quite resistant to antimicrobial agents. Even the most toxic bile salts have no effect on the biofilm bacteria. Yet, hydrophobic bile salts reduce bacterial adhesion on biomaterial, suggesting that incorporation of such bile salts might prevent the formation of bacterial biofilm.

J. W. Costerton

Papers

Defense system in the biliary tract against bacterial infection.

An in vivo model to study the pathobiology of infectious biofilms on biomaterial surfaces.

Ascending infection of the biliary tract after surgical sphincterotomy and biliary stenting

Antibacterial activity of bile salts against common biliary pathogens. Effects of hydrophobicity of the molecule and in the presence of phospholipids.

Bacterial biofilm, brown pigment stone and blockage of biliary stents