One-year trial evaluating the durability and antimicrobial efficacy of copper in public transportation systems

Surfaces on transit vehicles are frequently touched and could potentially act as reservoirs for micro-organism transmission. Regular cleaning and disinfection to minimize the spread of micro-organisms is operationally challenging due to the need to keep vehicles in circulation. The application of copper (Cu) alloys to high- touch surfaces could help reduce the risk of cross-contamination, however, little is known about the durability and efficacy of engineered copper surfaces after prolonged use. Three Cu products (decal, thermal fabrication, and alloy covers) were assessed over a 12-month period. These Cu products were randomly installed on 110 stanchions on three buses and four train (SkyTrain) cars in Vancouver and three buses, two subway cars, and two streetcars in Toronto with mirrored control surfaces directly opposite. Bacterial counts (Colony forming units, CFU) and ATP bioluminescence (ATPB) were measured every two months after peak morning routes. Durability of the Cu products were assessed monthly through visual inspection and colorimetry assays or by ex-situ microscopy. Cu products on stanchions reduced the mean colony forming units (CFU) of all vehicles by 42.7% in the mean CFU (0.573 (CI 95% 0.453-0.726), p-value < 0.001) compared to control surfaces. The three Cu products exhibited an overall 87.1% reduction in the mean ATPB readings (0.129 (CI 95% 0.059-0.285, p-value < 0.001) compared to controls. Surface Cu concentration for all three products was consistent throughout the 12-month period. Electron microscopy (SEM) and Energy-dispersive X-ray Spectroscopy (EDS) cross-sectional analysis showed no change in thickness or dealloying of Cu products, however SEM top-down analysis revealed substantial carbon accumulation on all surfaces. Cu products installed on transit vehicles maintained antimicrobial efficacy and durability after 12 months of use.

PVA-Based Films with Strontium Titanate Nanoparticles Dedicated to Wound Dressing Application

Bioactive materials may be applied in tissue regeneration, and an example of such materials are wound dressings, which are used to accelerate skin healing, especially after trauma. Here, we proposed a novel dressing enriched by a bioactive component. The aim of our study was to prepare and characterize poly(vinyl alcohol) films modified with strontium titanate nanoparticles. The physicochemical properties of films were studied, such as surface free energy and surface roughness, as well as the mechanical properties of materials. Moreover, different biological studies were carried out, like in vitro hemo- and cyto-compatibility, biocidal activity, and anti-biofilm formation. Also, the degradation of the materials' utilization possibilities and enzymatic activity in compost were checked. The decrease of surface free energy, increase of roughness, and improvement of mechanical strength were found after the addition of nanoparticles. All developed films were cyto-compatible, and did not induce a hemolytic effect on the human erythrocytes. The PVA films containing the highest concentration of STO (20%) reduced the proliferation of Eschericha coli, Pseudomonas aeruginosa, and Staphylococcus aureus significantly. Also, all films were characterized by surface anti-biofilm activity, as they significantly lowered the bacterial biofilm abundance and its dehydrogenase activity. The films were degraded by the compost microorganism. However, PVA with the addition of 20%STO was more difficult to degrade. Based on our results, for wound dressing application, we suggest using bioactive films based on PVA + 20%STO, as they were characterized by high antibacterial properties, favorable physicochemical characteristics, and good biocompatibility with human cells.

Antibacterial and Antibiofilm Activity of Nanostructured Copper Films Prepared by Ionized Jet Deposition

Metal coatings represent good strategies to functionalize surfaces/devices and limit bacterial contamination/colonization thanks to their pleiotropic activity and their ability to prevent the biofilm formation. Here, we investigated the antibacterial and antibiofilm capacity of copper coatings deposited through the Ionized Jet Deposition (IJD) on the Calgary Biofilm Device (CBD) against the growth of two gram-negative and two gram-positive pathogenic strains. Three areas (i.e., (+)Cu, (++)Cu, and (+++)Cu based on the metal amount) on the CBD were obtained, presenting nanostructured coatings with high surface homogeneity and increasing dimensions of aggregates from the CBD periphery to the centre. The coatings in (++)Cu and (+++)Cu were efficient against the planktonic growth of the four pathogens. This antibacterial effect decreased in (+)Cu but was still significant for most of the pathogens. The antibiofilm efficacy was significant for all the strains and on both coated and uncoated surfaces in (+++)Cu, whereas in (++)Cu the only biofilms forming on the coated surfaces were inhibited, suggesting that the decrease of the metal on the coatings was associated to a reduced metal ion release. In conclusion, this work demonstrates that Cu coatings deposited by IJD have antibacterial and antibiofilm activity against a broad range of pathogens indicating their possible application to functionalize biomedical devices.

Antibacterial Ti-Cu implants: A critical review on mechanisms of action

Titanium (Ti) has been widely used for manufacturing of bone implants because of its mechanical properties, biological compatibility, and favorable corrosion resistance in biological environments. However, Ti implants are prone to infection (peri-implantitis) by bacteria which in extreme cases necessitate painful and costly revision surgeries. An emerging, viable solution for this problem is to use copper (Cu) as an antibacterial agent in the alloying system of Ti. The addition of copper provides excellent antibacterial activities, but the underpinning mechanisms are still obscure. This review sheds light on such mechanisms and reviews how incorporation of Cu can render Ti-Cu implants with antibacterial activity. The review first discusses the fundamentals of interactions between bacteria and implanted surfaces followed by an overview of the most common engineering strategies utilized to endow an implant with antibacterial activity. The underlying mechanisms for antibacterial activity of Ti-Cu implants are then discussed in detail. Special attention is paid to contact killing mechanisms because the misinterpretation of this mechanism is the root of discrepancies in the literature.

Effect of Cu Modified Textile Structures on Antibacterial and Antiviral Protection

Textile structures with various bioactive and functional properties are used in many areas of medicine, special clothing, interior textiles, technical goods, etc. We investigated the effect of two different textile woven structures made of 90% polyester with 10% polyamide (PET) and 100% cotton (CO) modified by magnetron sputtering with copper (Cu) on bioactive properties against Gram-positive and Gram-negative bacteria and four viruses and also on the some comfort parameters. PET/Cu and CO/Cu fabrics have strong antibacterial activity against Staphylococcus aureus and Klebsiella pneumonia. CO/Cu fabric has good antiviral activity in relation to vaccinia virus (VACV), herpes simplex virus type 1 (HSV-1) and influenza A virus H1N1 (IFV), while its antiviral activity against mouse coronavirus (MHV) is weak. PET/Cu fabric showed weak antiviral activity against HSV-1 and MHV. Both modified fabrics showed no significant toxicity in comparison to the control medium and pristine fabrics. After Cu sputtering, fabric surfaces became hydrophobic and the value of the surface free energy was over four times lower than for pristine fabrics. The modification improved thermal conductivity and thermal diffusivity, facilitated water vapour transport, and air permeability did not decrease.

Sustainable Antibacterial and Antiviral High-Performance Copper-Coated Filter Produced via Ion Beam Treatment

With the spread of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), disease prevention has become incredibly important. Consequently, mask and air-purifier use has increased. The filter is the core component of these items. However, most filter materials lack antimicrobial properties. Copper is a sustainable antimicrobial material. When copper is deposited onto the filter’s surface, the microorganisms that come into contact with it can be effectively inactivated. In this study, we used an oxygen ion beam with a controlled process temperature to treat filter surfaces with copper. This enabled a strong adhesion of at least 4 N/cm between the copper and the filter fibers without damaging them. Upon exposing the filter to bacteria (Staphylococcus aureus ATCC 6538, Klebsiella pneumoniae ATCC 4352, Escherichia coli ATCC 25922, and Pseudomonas aeruginosa ATCC 27853) for one hour, a >99.99% removal rate was attained; when the filter was exposed to SARS-CoV-2 virus for one hour, it inactivated more than 99%. These beneficial properties minimize the risk of secondary infections, which are significantly more likely to occur when a conventional filter is replaced or removed.

More Insights about the Efficacy of Copper Ion Treatment on Mycobacterium avium subsp. paratuberculosis (MAP): A Clue for the Observed Tolerance

Background: Scientific evidence is scarce for the antimicrobial effect of copper on bacteria characterized as more resistant. Using Mycobacterium avium subsp. paratuberculosis (MAP), a highly resistant microorganism, as a pathogen model, copper ion treatment has shown a significant bactericidal effect; however, the sustainability of MAP against copper toxicity was also reported in several studies. Accordingly, the present study aimed to evaluate the impacts of copper on MAP. Methodology: This study considered physicochemical properties and copper concentration in a buffer since it could modulate MAP response during the application of copper treatment. Results: Despite the efficacy of copper ions in significantly reducing the MAP load in Phosphate Buffered Saline, some MAP cells were able to survive. The copper concentration generated by the copper ion treatment device increased significantly with increasing exposure times. MAP bacterial load decreased significantly when treated with copper ions as the exposure times increased. An increase in pH decreased oxygen consumption, and an increase in conductivity was reported after treatment application. Conclusions: Even with higher concentrations of copper, the efficacy of MAP control was not complete. The concentration of copper must be a key element in achieving control of highly resistant microorganisms.

Evaluation of copper alloys for reducing infection by methicillin resistant Staphylococcus aureus and vancomycin resistant Enterococcus faecium in intensive care unit and in vitro

BACKGROUND/AIMS

Multi-drug resistant pathogens are increasing among healthcare-associated infections. It is well known that copper and copper alloys have antimicrobial activity. We evaluated the activity of copper against bacteria in a hospital setting in Korea.

METHODS

This study was conducted in a laboratory and medical intensive care unit (ICU). Methicillin resistant Staphylococcus aureus (MRSA) and vancomycin resistant Enterococcus faecium (VRE) were inoculated onto copper, copper alloy and stainless steel plates. After 24 hours of incubation, colony-forming units (CFU) were counted in the laboratory. Two similar rooms were chosen in the ICU; one room had copper-containing surface, and the other room contained items with a stainless steel surfaces. Items were sampled weekly for 8 weeks when the rooms were not crowded and when the rooms were busier with healthcare workers or visitors.

RESULTS

In vitro time-kill curves showed copper or, a copper alloy yielded a significant reduction in MRSA and VRE CFUs over 15 minutes. Upon exposure to stainless steel plates, CFUs were slowly reduced for 24 hours. In vivo, MRSA CFUs were lower in rooms with copper-containing surfaces compared with controls, both after cleaning and after patients had received visitors (p < 0.05). Analysis of VRE revealed similar results, but VRE CFUs from copper-containing surfaces of drug carts in the ICU did not decrease significantly.

CONCLUSION

Copper has antimicrobial activity and appears to reduce the number of multi-drug resistant microorganisms in a hospital environment. This finding suggests the potential of the use of copper fittings, instruments and surfaces in hospital.

Brass Alloys: Copper-Bottomed Solutions against Hospital-Acquired Infections?

Copper has been used for its antimicrobial properties since Antiquity. Nowadays, touch surfaces made of copper-based alloys such as brasses are used in healthcare settings in an attempt to reduce the bioburden and limit environmental transmission of nosocomial pathogens. After a brief history of brass uses, the various mechanisms that are thought to be at the basis of brass antimicrobial action will be described. Evidence shows that direct contact with the surface as well as cupric and cuprous ions arising from brass surfaces are instrumental in the antimicrobial effectiveness. These copper ions can lead to oxidative stress, membrane alterations, protein malfunctions, and/or DNA damages. Laboratory studies back up a broad spectrum of activity of brass surfaces on bacteria with the possible exception of bacteria in their sporulated form. Various parameters influencing the antimicrobial activity such as relative humidity, temperature, wet/dry inoculation or wear have been identified, making it mandatory to standardize antibacterial testing. Field trials using brass and copper surfaces consistently report reductions in the bacterial bioburden but, evidence is still sparse as to a significant impact on hospital acquired infections. Further work is also needed to assess the long-term effects of chemical/physical wear on their antimicrobial effectiveness.

Copper-Polyurethane Composite Materials: Particle Size Effect on the Physical-Chemical and Antibacterial Properties

In this work, thermoplastic polyurethane (TPU) composites incorporated with 1.0 wt% Cu particles were synthesized by the melt blending method. The effect of the incorporated copper particle size on the antibacterial, thermal, rheological, and mechanical properties of TPU was investigated. The obtained results showed that (i) the addition of copper particles increased the thermal and mechanical properties because they acted as co-stabilizers of polyurethane (PU) (ii) copper nanoparticles decreased the viscosity of composite melts, and (iii) microparticles > 0.5 µm had a tendency to easily increase the maximum torque and formation of agglomerates. SEM micrographics showed that a good mixture between TPU and copper particles was obtained by the extrusion process. Additionally, copper-TPU composite materials effectively inhibited the growth of the Gram-negative Escherichia coli and the Gram-positive Staphylococcus aureus. Considering that the natural concentration of copper in the blood is in the range of 0.7-0.12 mg/L and that the total migration value of copper particles from TPU was 1000 times lower, the results suggested that TPU nanocomposites could be adequately employed for biomedical applications without a risk of contamination.

Impact of a dry inoculum deposition on the efficacy of copper-based antimicrobial surfaces

BACKGROUND

The introduction of antimicrobial surfaces into healthcare environments is believed to impact positively on the rate of healthcare-associated infections by significantly decreasing pathogen presence on surfaces.

AIM

To report on a novel efficacy test that uses a dry bacterial inoculum to measure the microbicidal efficacy of antimicrobial surfaces.

METHODS

An aerosolized dry inoculum of Staphylococcus aureus or Acinetobacter baumannii was deposited on copper alloy surfaces or a hospital-grade stainless-steel surface. Surviving bacteria were enumerated following incubation of the inoculated surfaces at an environmentally relevant temperature and relative humidity. Damage caused to bacteria by the aerosolization process and by the different surfaces was investigated.

FINDINGS

Dry inoculum testing showed a <2-log₁₀ reduction in S. aureus or A. baumannii on the copper alloy surfaces tested after 24 h at 20°C and 40% relative humidity. Potential mechanisms of action included membrane damage, DNA damage and arrested cellular respiration. The aerosolization process caused some damage to bacterial cells. Once this effect was taken into account, the antimicrobial activity of copper surfaces was evident.

CONCLUSIONS

Our test provided a realistic deposition of a bacterial inoculum to a surface and, as such, a realistic protocol to assess the efficacy of dry antimicrobial environmental surfaces in vitro.

The Use of Copper as an Antimicrobial Agent in Health Care, Including Obstetrics and Gynecology

Health care-associated infections (HAIs) are a global problem associated with significant morbidity and mortality. Controlling the spread of antimicrobial-resistant bacteria is a major public health challenge, and antimicrobial resistance has become one of the most important global problems in current times. The antimicrobial effect of copper has been known for centuries, and ongoing research is being conducted on the use of copper-coated hard and soft surfaces for reduction of microbial contamination and, subsequently, reduction of HAIs. This review provides an overview of the historical and current evidence of the antimicrobial and wound-healing properties of copper and explores its possible utility in obstetrics and gynecology.

Proteome profiling of Pseudomonas aeruginosa PAO1 identifies novel responders to copper stress

BACKGROUND

The opportunistic pathogen, Pseudomonas aeruginosa is well known for its environmental and metabolic versatility, yet many of the functions of its gene-products remain to be fully elucidated. This study's objective was to illuminate the potential functions of under-described gene-products during the medically relevant copper-stress condition.

RESULTS

We used data-independent acquisition mass spectrometry to quantitate protein expression changes associated with copper stress in P. aeruginosa PAO1. Approximately 2000 non-redundant proteins were quantified, with 78 proteins altering in abundance by +/- 1.5-fold or more when cultured to mid-log growth in the presence of 50 μM copper sulfate. One-third of those differentially expressed proteins have no prior established functional roles.

CONCLUSIONS

This study provides evidence for the functional involvement of some specific proteins in enabling P. aeruginosa to survive under sub-lethal concentrations of copper. This further paves the way for targeted investigations into the specific mechanisms of their activity.

Testing Metal Sensitivity of A. baumannii Strains: Survival in Copper-Supplemented Liquid Media and on Copper-Containing Surfaces

This chapter describes protocols for determining A. baumannii isolates' overall levels of sensitivity to heavy metals; copper is used as a model heavy metal. Measurements of the ability of strains to grow in the presence of various concentrations of copper in liquid media and on copper-containing surfaces are described.

New insights on antimicrobial efficacy of copper surfaces in the healthcare environment: a systematic review

OBJECTIVES

Hospital-acquired infections (HAIs) are a major public health issue. The potential of antimicrobial copper surfaces in reducing HAIs' rates is of interest but remains unclear. We conducted a systematic review of studies assessing the activity of copper surfaces (colony-forming unit (CFU)/surface, both in vitro and in situ) as well as clinical studies. In vitro study protocols were analysed through a tailored checklist developed specifically for this review, in situ studies and non-randomized clinical studies were assessed using the ORION (Outbreak Reports and Intervention studies Of Nosocomial infection) checklist and randomized clinical studies using the CONSORT guidelines.

METHODS

The search was conducted using PubMed database with the keywords 'copper' and 'surfaces' and 'healthcare associated infections' or 'antimicrobial'. References from relevant articles, including reviews, were assessed and added when appropriate. Articles were added until 30 August 2016. Overall, 20 articles were selected for review including 10 in vitro, eight in situ and two clinical studies.

RESULTS

Copper surfaces were found to have variable antimicrobial activity both in vitro and in situ, although the heterogeneity in the designs and the reporting of the results prevented conclusions from being drawn regarding their spectrum and activity/time compared to controls. Copper effect on HAIs incidence remains unclear because of the limited published data and the lack of robust designs. Most studies have potential conflicts of interest with copper industries.

CONCLUSIONS

Copper surfaces have demonstrated an antimicrobial activity but the implications of this activity in healthcare settings are still unclear. No clear effect on healthcare associated infections has been demonstrated yet.

Contact killing and antimicrobial properties of copper

With the emergence of antibiotic resistance, the interest for antimicrobial agents has recently increased again in public health. Copper was recognized in 2008 by the United States Environmental Protection Agency (EPA) as the first metallic antimicrobial agent. This led to many investigations of the various properties of copper as an antibacterial, antifungal and antiviral agent. This review summarizes the latest findings about 'contact killing', the mechanism of action of copper nanoparticles and the different ways micro-organisms develop resistance to copper.

Antimicrobial effect of copper alloys on Acinetobacter species isolated from infections and hospital environment

Background

An increased proportion of Gram-negative bacteria have recently been reported among etiologic agents of infection. In Poland, Acinetobacter baumannii is a big problem for hospitals, especially intensive care units. Touch surfaces made from materials with antimicrobial properties, especially copper alloys, are recommended as a supplementary method of increasing biological safety in the hospital environment.

Aim of the study

The objective of this study is to determine the susceptibility to selected copper alloys of three clinical Acinetobacter baumannii strains, one Acinetobacter lwoffi and an A. pittii strain isolated from the hospital environment.

Material and method

The modification of the Japanese Standard, which the ISO 22196:2011 norm was used for testing antimicrobial properties of CuZn37, CuSn6 and CuNi18Zn20 and Cu-ETP and stainless steel as positive and negative control, respectively.

Results

The highest cidal efficiency, expressed as both time and the degree of reduction of the initial suspension density, against all of the tested Acinetobacter strains was found for ETP copper. But, the results of our study also confirmed effective activity (bacteriocidal or bacteriostatic) of copper alloys selected for the study, contrary to the stainless steel. The reduction in bacterial suspension density is significantly different depending on the strain and copper alloy composition.

Conslusions

The results of our study confirmed the effective antibacterial activity of copper and its selected alloys against clinical Acinetobacter baumannii and Acinetobacter lwoffii strains, and Acinetobacter pittii strain isolated from the hospital environment.

The anti-bacterial activity of titanium-copper sintered alloy against Porphyromonas gingivalis in vitro

This study investigates the anti-bacterial property of Ti-Cu sintered alloys against Porphyromonas gingivalis. The anti-anaerobic property of Ti-Cu sintered alloys against P. gingivalis was investigated by antibacterial activity test, DNA measurement, DAPI staining and morphology observation. The antibacterial rates of the Ti-5Cu against P. gingivalis after 18 and 24 h incubation were 36.04 and 54.39%, and those of Ti-10Cu were 68.69 and 75.39%, which were lower than their anti-aerobic abilities. The concentration of P. gingivalis DNA gradually decreased with the increasing Cu content, which was nearly 50% after 24 h incubation on Ti-10Cu. SEM results showed that the shape of P. gingivalis changed and the bacteria broke apart with the addition of Cu and the extension of the culture time. Ti-Cu sintered alloys could not only kill anaerobic bacteria but also reduce the activity of the survived bacteria. The anti-anaerobic mechanism was thought to be in associated with the Cu ion released from Ti-Cu alloy.

Antibiotic resistance, ability to form biofilm and susceptibility to copper alloys of selected staphylococcal strains isolated from touch surfaces in Polish hospital wards

BACKGROUND

Despite the employment of sanitary regimes, contact transmission of the aetiological agents of hospital infections is still exceedingly common. The issue of microbe transmission becomes particularly important when facing multidrug-resistant microorganisms such as methicillin-resistant staphylococci. In the case of deficiencies in cleaning and disinfection procedures, hospital equipment made of copper alloys can play an important role, complementing traditional hospital hygiene procedures. The objective of this study was to characterize staphylococcal strains isolated from touch surfaces in Polish hospital wards in terms of their drug resistance, ability to form biofilm and susceptibility to antimicrobial activity of copper alloys.

METHODS

The materials for the study were 95 staphylococcal strains isolated from touch surfaces in 13 different hospital wards from Małopolska province (the south of Poland). Phenotypic and genotypic antibiotic resistance were checked for erythromycin, clindamycin, gentamycin, ciprofloxacin, trimethoprim/sulfamethoxazole and mupirocin. Biofilm formation ability for the tested strains was checked with the use of culture on Congo red agar. Susceptibility to copper, tin bronze, brass and new silver was tested using a modification of the Japanese standard.

RESULTS

Over 67% of the analysed staphylococcal strains were methicillin-resistant (MR). Four strains were resistant to all of the tested antibiotics, and 14 were resistant to all except mupirocin. Strains classified as MR had significantly increased resistance to the remaining antibiotic groups. About one-third of the analysed strains revealed biofilm-forming ability. Among the majority of species, biofilm-forming and non-biofilm-forming strains were distributed evenly; in the case of S. haemolyticus only, negative strains accounted for 92.8%. Susceptibility to copper alloys was different between strains and rather lower than in the case of the SA strain selected for comparison.

CONCLUSIONS

Coagulase-negative staphylococci, the most commonly isolated in Polish hospital wards, should not be neglected as an infection risk factor due their high antibiotic resistance. Our experiments confirmed that touch surfaces made of copper alloys may play an important role in eliminating bacteria from the hospital environment.

Antimicrobial Properties of Selected Copper Alloys on Staphylococcus aureus and Escherichia coli in Different Simulations of Environmental Conditions: With vs. without Organic Contamination

Background: Hospital equipment made from copper alloys can play an important role in complementing traditional methods of disinfection. Aims of the study: The aim of this study was to assess the dynamics of the antimicrobial properties of selected copper alloys in different simulations of environmental conditions (with organic contamination vs. without organic contamination), and to test alternatives to the currently used testing methods. Materials and Methods: A modification of Japanese standard JIS Z 2801 as well as Staphylococcus aureus (SA) and Escherichia coli (EC) suspended in NaCl vs. tryptic soy broth (TSB) were used in tests performed on seven commonly used copper alloys, copper, and stainless steel. Results: A much faster reduction of the bacterial suspension was observed for the inoculum prepared in NaCl than in TSB. A faster reduction for EC than for SA was observed in the inoculum prepared in NaCl. The opposite results were found for the inoculum based on TSB. A significant correlation between the copper concentration in the copper alloys and the time and degree of bacterial suspension reduction was only observed in the case of EC. Conclusions: This study confirmed the antimicrobial properties of copper alloys, and additionally showed that Staphylococcus aureus was more resistant than Escherichia coli in the variant of the experiment without organic contamination. However, even for SA, a total reduction of the bacterial inoculum’s density took no longer than 2 h. Under conditions simulating organic contamination, all of the tested alloys were shown to have bactericidal or bacteriostatic properties, which was contrary to the results from stainless steel.

Reduction of Environmental Contamination With Multidrug-Resistant Bacteria by Copper-Alloy Coating of Surfaces in a Highly Endemic Setting

OBJECTIVE To evaluate the efficacy of copper-coating in reducing environmental colonization in an intensive-care unit (ICU) with multidrug-resistant-organism (MDRO) endemicity DESIGN Interventional, comparative crossover trial SETTING The general ICU of Attikon University hospital in Athens, Greece PATIENTS Those admitted to ICU compartments A and B during the study period METHODS Before any intervention (phase 1), the optimum sampling method using 2 nylon swabs was validated. In phase 2, 6 copper-coated beds (ie, with coated upper, lower, and side rails) and accessories (ie, coated side table, intravenous [i.v.] pole stands, side-cart handles, and manual antiseptic dispenser cover) were introduced as follows: During phase 2a (September 2011 to February 2012), coated items were placed next to noncoated ones (controls) in both compartments A and B; during phase 2b (May 2012 to January 2013), all copper-coated items were placed in compartment A, and all noncoated ones (controls) in compartment B. Patients were randomly assigned to available beds. Environmental samples were cultured quantitatively for clinically important bacteria. Clinical and demographic data were collected from medical records. RESULTS Copper coating significantly reduced the percentage of colonized surfaces (55.6% vs 72.5%; P<.0001), the percentage of surfaces colonized by MDR gram-negative bacteria (13.8% vs 22.7%; P=.003) or by enterococci (4% vs 17%; P=.014), the total bioburden (2,858 vs 7,631 cfu/100 cm2; P=.008), and the bioburden of gram-negative isolates, specifically (261 vs 1,266 cfu/100 cm2; P=.049). This effect was more pronounced when the ratio of coated surfaces around the patient was increased (phase 2b). CONCLUSIONS Copper-coated items in an ICU setting with endemic high antimicrobial resistance reduced environmental colonization by MDROs. Infect Control Hosp Epidemiol 2017;38:765-771.

Copper Resistance of the Emerging Pathogen Acinetobacter baumannii

Acinetobacter baumannii is an important emerging pathogen that is capable of causing many types of severe infection, especially in immunocompromised hosts. Since A. baumannii can rapidly acquire antibiotic resistance genes, many infections are on the verge of being untreatable, and novel therapies are desperately needed. To investigate the potential utility of copper-based antibacterial strategies against Acinetobacter infections, we characterized copper resistance in a panel of recent clinical A. baumannii isolates. Exposure to increasing concentrations of copper in liquid culture and on solid surfaces resulted in dose-dependent and strain-dependent effects; levels of copper resistance varied broadly across isolates, possibly resulting from identified genotypic variation among strains. Examination of the growth-phase-dependent effect of copper on A. baumannii revealed that resistance to copper increased dramatically in stationary phase. Moreover, A. baumannii biofilms were more resistant to copper than planktonic cells but were still susceptible to copper toxicity. Exposure of bacteria to subinhibitory concentrations of copper allowed them to better adapt to and grow in high concentrations of copper; this copper tolerance response is likely achieved via increased expression of copper resistance mechanisms. Indeed, genomic analysis revealed numerous putative copper resistance proteins that share amino acid homology to known proteins in Escherichia coli and Pseudomonas aeruginosa Transcriptional analysis revealed significant upregulation of these putative copper resistance genes following brief copper exposure. Future characterization of copper resistance mechanisms may aid in the search for novel antibiotics against Acinetobacter and other highly antibiotic-resistant pathogens.

IMPORTANCE

Acinetobacter baumannii causes many types of severe nosocomial infections; unfortunately, some isolates have acquired resistance to almost every available antibiotic, and treatment options are incredibly limited. Copper is an essential nutrient but becomes toxic at high concentrations. The inherent antimicrobial properties of copper give it potential for use in novel therapeutics against drug-resistant pathogens. We show that A. baumannii clinical isolates are sensitive to copper in vitro, both in liquid and on solid metal surfaces. Since bacterial resistance to copper is mediated though mechanisms of efflux and detoxification, we identified genes encoding putative copper-related proteins in A. baumannii and showed that expression of some of these genes is regulated by the copper concentration. We propose that the antimicrobial effects of copper may be beneficial in the development of future therapeutics that target multidrug-resistant bacteria.

Antimicrobial applications of copper

Copper has long been known to have antimicrobial activity and is used in drinking water treatment and transportation. It has been recognized by the American Environmental Protection Agency as the first metallic antimicrobial agent in 2008. With ongoing waterborne hospital-acquired infections and antibiotic resistance, research on copper as an antimicrobial agent is again very attractive. Many studies have shown that the use of copper surface and copper particles could significantly reduce the environmental bioburden. This review highlights in its first part all the conditions described in the literature to enhance copper antimicrobial activity. Secondly, the different antimicrobial applications of copper in water treatment, hospital care units and public applications are presented. Finally, the future research needs on copper as an antimicrobial agent are discussed.

Als1 and Als3 regulate the intracellular uptake of copper ions when Candida albicans biofilms are exposed to metallic copper surfaces

Copper surfaces possess efficient antimicrobial effect. Here, we reported that copper surfaces could inactivate Candida albicans biofilms within 40 min. The intracellular reactive oxygen species in C. albicans biofilms were immediately stimulated during the contact of copper surfaces, which might be an important factor for killing the mature biofilms. Copper release assay demonstrated that the copper ions automatically released from the surface of 1 mm thick copper coupons with over 99.9% purity are not the key determinant for the copper-mediated killing action. The susceptibility test to copper surfaces by using C. albicans mutant strains, which were involved in efflux pumps, adhesins, biofilms formation or osmotic stress response showed that als1/als1 and als3/als3 displayed higher resistance to the copper surface contact than other mutants did. The intracellular concentration of copper ions was lower in als1/als1 and als3/als3 than that in wild-type strain. Transcriptional analysis revealed that the expression of copper transporter-related gene, CRP1, was significantly increased in als1/als1, als3/als3, suggesting a potential role of ALS1 and ALS3 in absorbing ions by regulating the expression of CRP1 This study provides a potential application in treating pathogenic fungi by using copper surfaces and uncovers the roles of ALS1 and ALS3 in absorbing copper ions for C. albicans.

Carbapenemase-bearing Klebsiella spp. in sink drains: investigation into the potential advantage of copper pipes

Sink drains have long been known to harbour pathogenic bacteria and efforts such as heated sink traps have been made to control them. Sink outlet pipes have been implicated in outbreaks of infection by multi-resistant Klebsiella pneumoniae. To investigate whether a change to copper pipes might prevent cross-infection, sections of standard sink outlet pipe were left in containers of water to which multi-resistant human strains of K. pneumoniae had been added. Bacterial counts from the water of containers to which copper pipe had been added were lower than those from containers to which PVC (polyvinyl chloride) pipe had been added.

Copper-coated textiles: armor against MDR nosocomial pathogens

Soft surfaces in the health-care setting harbor potentially pathogenic bacteria and fungi that can be transferred to patients and personnel. We evaluated the in vitro antimicrobial efficacy of two types of innovative copper-coated textiles against a variety of nosocomial multi-drug resistant (MDR) pathogens. Five isolates each of MDR Staphylococcus aureus, Klebsiella pneumoniae, Pseudomonas aeruginosa, Acinetobacter baumannii and Enterococcus faecium as well as three Candida parapsilosis were tested. The antimicrobial activity of copper-coated para-aramide and copper-coated polyester swatches was compared to that of non-copper coated controls using a quantitative method. Reduction of viable colonies by >3log10 from starting inoculum was characterized as bactericidal activity. No viable colonies of S. aureus, P. aeruginosa, E. faecium and C. parapsilosis were recovered after the first hour of contact while for A. baumannii, no viable colonies were recovered after only 15min of contact with either type of copper-coated textiles. Copper-coated para-aramide exhibited a bactericidal effect at 15min of contact with A. baumannii, at 1h with S. aureus, P. aeruginosa, E. faecium and C. parapsilosis and at 3h with K. pneumoniae. Copper-coated polyester was bactericidal at 15min of contact for A. baumannii and at 1h for the other species tested. Both copper-coated textiles exhibited a rapid and significant antimicrobial effect. Antimicrobial textiles may have a role in the arsenal of strategies aiming to reduce environmental contamination in the health-care setting.

Antimicrobial Activity of Copper Alloys Against Invasive Multidrug-Resistant Nosocomial Pathogens

The emergence and spread of antibiotic resistance demanded novel approaches for the prevention of nosocomial infections, and metallic copper surfaces have been suggested as an alternative for the control of multidrug-resistant (MDR) bacteria in surfaces in the hospital environment. This study aimed to evaluate the antimicrobial activity of copper material for invasive MDR nosocomial pathogens isolated over time, in comparison to stainless steel. Clinical isolates of methicillin-resistant Staphylococcus aureus (MRSA) (n:4), OXA-23 and OXA-58 positive, MDR Acinetobacter baumannii (n:6) and Pseudomonas aeruginosa (n:4) were evaluated. The antimicrobial activity of coupons containing 99 % copper and a brass alloy containing 63 % copper was assessed against stainless steel. All the materials demonstrated statistically significant differences within each other for the logarithmic reduction of microorganisms. Among the three materials, the highest reduction of microorganisms was seen in 99 % copper and the least in stainless steel. The result was statistically significant especially for 0, 2, and 4 h (P = 0.05). 99 % copper showed a bactericidal effect at less than 1 h for MRSA and at 2 h for P. aeruginosa. 63 % copper showed a bactericidal effect at 24 h for P. aeruginosa strains only. Stainless steel surfaces exhibited a bacteriostatic effect after 6 h for P. aeruginosa strains only. 99 % copper reduced the number of bacteria used significantly, produced a bactericidal effect and was more effective than 63 % copper. The use of metallic copper material could aid in reducing the concentration of bacteria, especially for invasive nosocomial pathogens on hard surfaces in the hospital environment.

Emerging issues in gram-negative bacterial resistance: an update for the practicing clinician

The rapid and global spread of antimicrobial-resistant organisms in recent years has been unprecedented. Although resistant gram-positive infections have been concerning to clinicians, the increasing incidence of antibiotic-resistant gram-negative infections has become the most pressing issue in bacterial resistance. Indiscriminate antimicrobial use in humans and animals coupled with increased global connectivity facilitated the transmission of gram-negative infections harboring extended-spectrum β-lactamases in the 1990s. Carbapenemase-producing Enterobacteriaceae, such as those containing Klebsiella pneumoniae carbapenemases and New Delhi metallo-β-lactamases, have been the latest scourge since the late 1990s to 2000s. Besides β-lactam resistance, these gram-negative infections are often resistant to multiple drug classes, including fluoroquinolones, which are commonly used to treat community-onset infections. In certain geographic locales, these pathogens, which have been typically associated with health care-associated infections, are disseminating into the community, posing a significant dilemma for clinicians treating community-onset infections. In this Concise Review, we summarize emerging trends in antimicrobial resistance. We also review the current knowledge on the detection, treatment, and prevention of infection with these organisms, with a focus on the carbapenemase-producing gram-negative bacilli. Finally, we discuss emerging therapies and areas that need further research and effort to stem the spread of antimicrobial resistance.

Role of the Microbial Burden in the Acquisition and Control of Healthcare Associated Infections: The Utility of Solid Copper Surfaces

For more than a century, healthcare has been challenged to keep environmental surfaces clean to control microbes and improve patient outcomes. However despite an annual cost exceeding ten billion dollars cleaning with disinfection has done little to reduce the incidence of healthcare-associated infections (HAI). This chapter will review the scientific evidence delineating the role that the environment and healthcare workers play in the acquisition and movement of the microbes implicated in HAI and how through controlling the microbial burden of the built clinical environment it is possible to mitigate the rate of HAI acquisition. Specifically evidence demonstrating the effectiveness of solid copper surfaces for its ability to continuously limit the concentration of bacteria found on surfaces and objects within the built environment will be reviewed in concert with a discussion of how through the mitigation of the environmental burden copper surfaces are able to concomitantly reduce the incidence of HAI. Insights provided by this chapter are intended to facilitate an understanding and importance of the need to use a comprehensive or systems based approach to fight healthcare associated infections.

Role of copper oxides in contact killing of bacteria

The potential of metallic copper as an intrinsically antibacterial material is gaining increasing attention in the face of growing antibiotics resistance of bacteria. However, the mechanism of the so-called "contact killing" of bacteria by copper surfaces is poorly understood and requires further investigation. In particular, the influences of bacteria-metal interaction, media composition, and copper surface chemistry on contact killing are not fully understood. In this study, copper oxide formation on copper during standard antimicrobial testing was measured in situ by spectroscopic ellipsometry. In parallel, contact killing under these conditions was assessed with bacteria in phosphate buffered saline (PBS) or Tris-Cl. For comparison, defined Cu2O and CuO layers were thermally generated and characterized by grazing incidence X-ray diffraction. The antibacterial properties of these copper oxides were tested under the conditions used above. Finally, copper ion release was recorded for both buffer systems by inductively coupled plasma atomic absorption spectroscopy, and exposed copper samples were analyzed for topographical surface alterations. It was found that there was a fairly even growth of CuO under wet plating conditions, reaching 4-10 nm in 300 min, but no measurable Cu2O was formed during this time. CuO was found to significantly inhibit contact killing, compared to pure copper. In contrast, thermally generated Cu2O was essentially as effective in contact killing as pure copper. Copper ion release from the different surfaces roughly correlated with their antibacterial efficacy and was highest for pure copper, followed by Cu2O and CuO. Tris-Cl induced a 10-50-fold faster copper ion release compared to PBS. Since the Cu2O that primarily forms on copper under ambient conditions is as active in contact killing as pure copper, antimicrobial objects will retain their antimicrobial properties even after oxide formation.