In Vivo Potentiation of Antimicrobial Photodynamic Therapy in a Mouse Model of Fungal Infection by Addition of Potassium Iodide

Antimicrobial photodynamic inactivation (aPDI) involves the use of a nontoxic dye or photosensitizer excited with visible light to produce reactive oxygen species that can kill all classes of microorganisms. Antimicrobial photodynamic therapy (aPDT) can be used in vivo as an alternative therapeutic strategy to treat localized infections due to its ability to selectively kill microbes while preserving host mammalian cells. aPDI can be potentiated by the addition of the nontoxic inorganic salt potassium iodide (KI). KI is an approved drug for antifungal therapy. The mechanism of potentiation with iodide is likely to be singlet oxygen addition to iodide to form iodine radicals, hydrogen peroxide, and molecular iodine. A previous chapter in this volume described potentiation of aPDI in vitro by addition of KI, while in this chapter we address the ability of KI to potentiate aPDT in vivo using an animal model of localized fungal infection. We employed oral candidiasis in immunosuppressed mice caused by a bioluminescent strain of Candida albicans and monitored by bioluminescence imaging.

In Vitro Potentiation of Antimicrobial Photodynamic Inactivation by Addition of Potassium Iodide

The current increase in antibiotic resistance worldwide and the emergence of microbial strains that are resistant to all known antibiotics have stimulated research into novel strategies such as aPDI that are thought to be unlikely to lead to the development of resistance. Although many studies have reported in vitro aPDI killing of microorganisms by a range of different photosensitizers, there are still limitations to the effectiveness of aPDI, and recurrence of bacterial growth may occur in animal studies after completion of the illumination. In this chapter we cover a novel and relatively simple method to improve the efficacy of aPDI against Gram-positive Staphylococcus aureus, Gram-negative Escherichia coli, and fungal yeast Candida albicans by the addition of potassium iodide, a nontoxic inorganic salt. Under some circumstances up to six-logs additional killing can be obtained.

Eradication of Acinetobacter baumannii Planktonic and Biofilm Cells Through Erythrosine-Mediated Photodynamic Inactivation Augmented by Acetic Acid and Chitosan

Photodynamic inactivation (PDI) is an attractive treatment modality for multidrug-resistant bacterial infections. The effectiveness of photosensitization by anionic photosensitizers such as erythrosine B can be further enhanced by the addition of biological or chemical molecules. This study aimed to investigate of the enhancement effect of acetic acid and chitosan on erythrosine-mediated PDI of Acinetobacter baumannii in planktonic and biofilm forms. The planktonic cell growth of three A. baumannii strains was subjected to PDI by using erythrosine B (50 µM) in 0.01% acetic acid and green laser light (530 nm) at fluence of 40 J/cm². The phototoxic effect of erythrosine B (100 µM) in combination with chitosan (12.5 mg/ml) (in a solution of acetic acid) at fluence of 80 J/cm2 on biofilms was also evaluated. Finally, the cytotoxicity and phototoxicity of the mentioned mixture were assessed on human fibroblasts. Planktonic cells of all three studied A. baumannii strains were almost eradicated by erythrosine B-mediated PDI in the presence of acetic acid. Also, PDI combined with chitosan resulted in a marked decrease in the number of viable biofilm cells (> 3 log₁₀ CFU). At the same experimental conditions, only 15% of the fibroblasts were photoinactivated. The results showed that PDI by using erythrosine B in acetic acid is very effective against A. baumannii planktonic cells and could eliminate them significantly. Also, chitosan enhanced the anti-biofilm efficacy of erythrosine B-mediated PDI against A. baumannii, suggesting that combination therapy may be useful in targeting biofilms.

Quorum sensing-regulated functions of Serratia marcescens are reduced by eugenol

Background and Objectives

Serratia marcescens has emerged as a nosocomial pathogen responsible for human infections, where antibiotic resistance further complicates the treatments. In S. marcescens, biofilm formation and virulence factor production are controlled via quorum sensing (QS) system. QS is a signaling system that enables gene regulation to control diverse physiological functions in bacteria. Essential oils have shown to be potential in diminishing the pathogenicity and virulence of drug-resistant bacteria. This study was performed to determine whether eugenol would affect QS system, biofilm formation and virulence factor production of S. marcescens.

Materials and Methods

Biofilm formation, extracellular virulence factor production (hemolysin and protease), swarming motility and pigment formation of S. marcescens ATCC 13880 and S. marcescens Sm2 were assessed after eugenol exposure at 1.25 and 2.5 µg/ml concentrations. The expression of genes involved in motility (flhD), attachment (fimC), biofilm formation (bsmB, bsmA), and QS regulatory (swrR) were also evaluated.

Results

Eugenol treatment at 1.25 and 2.5 µg/ml concentrations caused a significant reduction in biofilm formation. The pigment, hemolysin and protease production of two studied S. marcescens strains, also reduced significantly by eugenol treatments (p<0.05). The bsmA, bsmB, flhD and fimC genes were down-regulated after eugenol treatment. The swrR gene expression was also reduced significantly by eugenol in both S. marcescens strains (p<0.05).

Conclusion

Eugenol inhibited quorum sensing-regulated functions of two studied S. marcescens strains.

Sub-lethal antimicrobial photodynamic inactivation affects Pseudomonas aeruginosa PAO1 quorum sensing and cyclic di-GMP regulatory systems

BACKGROUND

Antimicrobial photodynamic inactivation (APDI) is a new therapeutic modality which needs more precision during application due to the possibility of exposure of bacteria to sub-lethal doses (sAPDI). In this study, we aimed to evaluate the effect of sAPDI on Pseudomonas aeruginosa quorum sensing (QS) and c-di-GMP signaling which are important virulence factor regulatory systems.

METHODS

Biofilm formation, pyoverdine, pyocyanin and protease production of P. aeruginosa was evaluated before and after a single sAPDI treatment with 0.8 mM methylene blue (MB) plus 1, 2, and 5-min irradiation with red laser light. Fluorescent lasB, rhlA, pqsA, and cdrA reporters of P. aeruginosa PAO1 and P. aeruginosa ΔmexAB-oprM were treated individually with sAPDI and the regulatory signals were detected. The gene expressions were also assessed after sAPDI using quantitative real-time PCR analysis.

RESULTS

Morphological observations and molecular assessments indicated that sAPDI with 0.8 mM MB along with 2- and 5-min irradiation led to an increase in the expression of the Las QS system and c-di-GMP signaling, while 1 min irradiation revealed dissimilar results (increase in lasB expression and decrease in c-di-GMP levels). Expression of rhlA and pqsA did not change in response to sAPDI. Further, a severe lethal effect of sAPDI was observed in P. aeruginosa ΔmexAB-oprM as compared with the wild type strain, whilst there was no difference in QS and c-di-GMP levels as detected by reporters between treated and untreated samples.

CONCLUSION

The results suggest that sAPDI affects QS and c-di-GMP signaling inP. aeruginosa in a time-dependent manner.

Quorum-sensing-regulated virulence factors in Pseudomonas aeruginosa are affected by sub-lethal photodynamic inactivation

BACKGROUND

Photodynamic inactivation (PDI) is recognized as a new antimicrobial approach. It is likely that in human hosts receiving this therapy, pathogens may encounter sub-lethal doses of PDI (sPDI), which may affect microbial virulence. This study was aimed to evaluate the effect of sPDI using methylene blue (MB) on the expression of genes belonging to two quorum sensing (QS) operons (rhl and las systems) and two genes necessary for pyocyanin and rhamnolipid production (phzM and rhlA) under QS control in Pseudomonas aeruginosa.

METHODS

Ability of pyocyanin and rhamnolipid production of P. aeruginosa ATCC 27853 and clinical isolates exposed to sPDI (MB at 0.012 mM and light dose of 23 J/cm² was evaluated. The effect of sPDI on expression of rhlI, rhlR, lasI, lasR, phzM and rhlA were also evaluated by quantitative real time polymerase chain reaction.

RESULTS

sPDI led to the down-regulation of the expression of all four QS genes (lasI, lasR, rhlI and rhlR) and rhamnolipid gene (rhlA). However, up-regulation of pyocyanin gene (phzM) was observed after sPDI. These results were consistent with phenotypic changes.

CONCLUSION

This study suggests that oxidative stress induced by sPDI can affect QS-regulated virulence factors of P. aeruginosa such as pyocyanin and rhamnolipids in different ways.

Advances in antimicrobial photodynamic inactivation at the nanoscale

The alarming worldwide increase in antibiotic resistance amongst microbial pathogens necessitates a search for new antimicrobial techniques, which will not be affected by, or indeed cause resistance themselves. Light-mediated photoinactivation is one such technique that takes advantage of the whole spectrum of light to destroy a broad spectrum of pathogens. Many of these photoinactivation techniques rely on the participation of a diverse range of nanoparticles and nanostructures that have dimensions very similar to the wavelength of light. Photodynamic inactivation relies on the photochemical production of singlet oxygen from photosensitizing dyes (type II pathway) that can benefit remarkably from formulation in nanoparticle-based drug delivery vehicles. Fullerenes are a closed-cage carbon allotrope nanoparticle with a high absorption coefficient and triplet yield. Their photochemistry is highly dependent on microenvironment, and can be type II in organic solvents and type I (hydroxyl radicals) in a biological milieu. Titanium dioxide nanoparticles act as a large band-gap semiconductor that can carry out photo-induced electron transfer under ultraviolet A light and can also produce reactive oxygen species that kill microbial cells. We discuss some recent studies in which quite remarkable potentiation of microbial killing (up to six logs) can be obtained by the addition of simple inorganic salts such as the non-toxic sodium/potassium iodide, bromide, nitrite, and even the toxic sodium azide. Interesting mechanistic insights were obtained to explain this increased killing.

Can microbial cells develop resistance to oxidative stress in antimicrobial photodynamic inactivation?

Infections have been a major cause of disease throughout the history of humans on earth. With the introduction of antibiotics, it was thought that infections had been conquered. However, bacteria have been able to develop resistance to antibiotics at an exponentially increasing rate. The growing threat from multi-drug resistant organisms calls for intensive action to prevent the emergence of totally resistant and untreatable infections. Novel, non-invasive, non-antibiotic strategies are needed that act more efficiently and faster than current antibiotics. One promising alternative is antimicrobial photodynamic inactivation (APDI), an approach that produces reactive oxygen species when dyes and light are combined. So far, it has been questionable if bacteria can develop resistance against APDI. This review paper gives an overview of recent studies concerning the susceptibility of bacteria towards oxidative stress, and suggests possible mechanisms of the development of APDI-resistance that should at least be addressed. Some ways to potentiate APDI and also to overcome future resistance are suggested.

In vitro Activity of Linezolid in Combination with Photodynamic Inactivation Against Staphylococcus aureus Biofilms

BACKGROUND

Biofilm infections are a major challenge in medical practice. Bacteria that live in a biofilm phenotype are more resistant to both antimicrobial therapy and host immune responses compared to their planktonic counterparts. So, there is need for new therapeutic strategies to combat these infections. A promising approach [known as Photodynamic Inactivation (PDI)] to kill bacteria growing as biofilms uses light in combination with a photosensitizer to induce a phototoxic reaction which produces reactive oxygen species that can destroy lipids and proteins causing cell death. PDI does not always guarantee full success, so, combination of PDI with antibiotics may give increased efficiency. This study aimed to determine if PDI was effective in the eradication of Staphylococcus aureus (S. aureus) biofilms in combination with linezolid.

METHODS

The susceptibility of biofilm cultures of three S. aureus strains to Methylene Blue (MB) and Toluidine Blue O (TBO)-mediated PDI was determined alone and in combination with linezolid.

RESULTS

Bactericidal activity (≥3 log₁₀ reduction in viable cell count) was not achieved with MB/TBO-PDI or antibiotic treatment alone. When antibiotic treatment was combined with TBO-PDI, a greater reduction in viable count than antibiotic alone was observed for two strains.

CONCLUSION

This study showed that although TBO-PDI did not have good bactericidal activity against S. aureus biofilms; it increased the antimicrobial activity of linezolid against these bacteria.

Chitosan nanoparticles enhance the efficiency of methylene blue-mediated antimicrobial photodynamic inactivation of bacterial biofilms: An in vitro study

BACKGROUND

Biodegradable chitosan nanoparticles (CSNPs) with an intrinsic antimicrobial activity may be a good choice to improve the effectiveness of antimicrobial photodynamic inactivation (APDI). The aim of this study was to investigate the effect of CSNPs on the efficiency of methylene blue (MB)-mediated APDI of Staphylococcus aureus and Pseudomonas aeruginosa biofilms. We also assessed the phototoxicity of MB+CSNPs towards human fibroblasts.

METHODS

CSNPs were prepared using ionic gelation method and characterized by dynamic light scattering (DLS) and field-emission scanning electron microscope (FESEM). Biofilms were developed in a 96-well polystyrene plate for 24h. In vitro phototoxic effect of MB+CSNPs (at final concentrations of 50μM MB) at fluence of 22.93J/cm(2)) on biofilms were studied. Appropriate controls were included. Also, in vitro cytotoxicity and phototoxicity of the above mixture was assessed on human dermal fibroblasts.

RESULTS

DLS and FESEM measurements confirmed the nanometric size of the prepared CSNPs. APDI mediated by the mixture of MB and CSNPs showed significant anti-biofilm photoinactivation (P<0.001, >3 and >2 log10 CFU reduction in S. aureus and P. aeruginosa biofilms, respectively) while MB-induced APDI led to approximately <1 log10 CFU reduction. At the same experimental conditions, only 25.1% of the fibroblasts were photoinactivated by MB+CSNPs.

CONCLUSION

Our findings showed that CSNPs enhanced the efficacy of MB-APDI; it may be due to the disruption of biofilm structure by polycationic CSNPs and subsequently deeper and higher penetration of MB into the biofilms.

Application of fnbA gene as new target for the species-specific and quantitative detection of Staphylococcus aureus directly from lower respiratory tract specimens by real time PCR

Staphylococcus aureus is a significant cause of hospital-acquired pneumonia (HAP), particularly in mechanically ventilated patients. We used the fibronectin-binding protein A gene (fnbA) for the species-specific and quantitative detection of S. aureus directly from lower respiratory tract (LRT) specimens by a Taq Man real time PCR. For this reason, a total of 269 lower respiratory tract (LRT) specimens collected from patients with hospital-acquired pneumonia were assayed. Amplification of fnbA in serial dilutions ranged from 10(9) CFU/ ml to 10(2) CFU/ml. Standard curve of triplicate every dilution had slope 3.34±0.1 and R2>0.99 with SD 0.1. Based on these data, the sensitivity and specificity of the newly developed real time PCR targeting the fnbA gene were both 100%. The Cohen's Kappa test showed the Kappa value of 1.0. The fnbA gene is a potential marker for the species-specific detection of S. aureus and can be used to detect this bacterium in any clinical specimens by real time PCR. Moreover, this method reduces the time needed for quantitative detection of Staphylococcus aureus from LRT specimens to nearly 2 hours compared to 1 to 4 days for culture and provided sensitivity equal to or greater than culture.

Photodynamic effect of hypericin on the microorganisms and primary human fibroblasts

BACKGROUND

Hypericin (HYP) is a natural photosensitizer considered for the new generation of photodynamic therapy (PDT) drugs. The aim of this study was to evaluate the in vitro bactericidal effect of HYP-PDT on four bacterial species, assessing its photocytotoxicity to primary human fibroblasts to determine possible side effects.

METHODS

Effect of photosensitizer concentration (0.1, 0.3, 0.6, and 1 μg/ml) and light irradiation time (3, 5, 10 min) on photodynamic inactivation of microorganisms and primary human fibroblasts was investigated.

RESULTS

A 6.3 log killing was obtained for Staphylococcus aureus (ATCC 25923) treated with 1 μg/ml at 48 J/cm². For this set of PDT parameters, Enterococcus faecalis (ATCC 11700) showed 6.5 log killing, Escherichia coli (ATCC 25922) 6.2 log killing, and Pseudomonas aeruginosa (ATCC 27853) 0.7 log killing. Fibroblasts can be preserved by keeping the HYP concentration below 0.6 μg/ml and the light dose below 48 J/cm².

CONCLUSION

S. aureus, E. faecalis, and E. coli appear to be suitable for treatment with HYP-PDT without significant damage to fibroblasts.

Photodynamic inactivation of drug-resistant bacteria isolated from diabetic foot ulcers

BACKGROUND AND OBJECTIVES

Due to the extensive use of antibiotics, the spread of drug-resistant bacteria is one of the most worrisome threats to public health. One strategy that can be used to overcome potential shortcomings might be the inactivation of these organisms by photodynamic therapy. In this study, we have investigated whether drug-resistant wound-associated organisms (Staphylococcus aureus, Staphylococcus epidermidis and Escherichia coli) are sensitive to lethal photosensitization using the dye methylene blue coupled with laser light of 660 nm.

MATERIALS AND METHODS

Effect of photosensitizer concentration (25, 50, 100 µg/ml) and laser light dose (27.3, 54.6 and 109.2 J/cm(2)) on lethal photosensitization was investigated.

RESULTS

All species were susceptible to killing by photodynamic inactivation. The bactericidal effect was not dependent on the concentration of methylene blue but it was dependent on the light dose. Methylene blue photosensitization using red laser light (109.2 J/cm(2)) was able to achieve reductions of 99.03% and 98.95% in the viable counts of S. aureus and S. epidermidis (using starting concentrations of 10(4)-10(5) CFU/ml). Eradication of 92.23% were obtained for E. coli (initial concentration 10(4)-10(5) CFU/ml) photosensitized by the red light (109.2 J/cm(2)).

CONCLUSION

These findings imply that MB in combination with red light may be an effective means of eradicating drug- resistant bacteria from wounds.

A randomized clinical trial on the effect of low-level laser therapy on chronic diabetic foot wound healing: a preliminary report

BACKGROUND AND OBJECTIVES

Low-level laser therapy (LLLT) has been shown to promote chronic wound healing in conditions of reduced microcirculation. In this preliminary study, we report the results of using LLLT to heal foot ulcers in patients with diabetes mellitus.

MATERIALS AND METHODS

Twenty-three patients with a diabetic foot wound for at least 3 months were included in this double-blind randomized clinical trial. Patients were randomized to receive placebo treatment (n = 10) or LLLT (n = 13) (685 nm, energy density 10 J/cm(2)) in addition to conventional therapy. Patients were followed for 20 weeks. Ulcer size reduction and the number of patients with complete healing were compared between the LLLT and placebo groups.

RESULTS

There were no significant differences in baseline characteristics of patients and foot ulcers receiving LLLT and placebo treatment. At week 4, the size of ulcers decreased significantly in the LLLT group (p = 0.04). After 20 weeks, in the LLLT group, eight patients had complete healing and in the placebo group only three patients experienced complete wound healing. The mean time of complete healing in LLLT patients (11 weeks) was less than that in placebo patients (14 weeks) though the difference was not statistically significant.

CONCLUSIONS

The study provides evidence that LLLT can accelerate the healing process of chronic diabetic foot ulcers, and it can be presumed that LLLT may shorten the time period needed to achieve complete healing.

Breastfeeding and helicobacter pylori infection in children with digestive symptoms

OBJECTIVE

This study aims to evaluate the role of breastfeeding in the acquisition of Helicobacter pylori (H. pylori) infection in Iran and to compare the histopathologic changes occurring in children feeding on breast milk with those in infants feeding on formula.

METHODS

In a case-control study parents of children with and without H. pylori infection who had undergone endoscopic survey and gastric biopsy in the Children's Medical Center, Tehran, were asked about their feeding practices during the first 6 months after birth, the duration of breastfeeding period, the symptoms, and the duration of symptoms and concomitant diseases.

FINDINGS

A total of 154 children were included in this study. From this sample, 77 children formed the case group and 77 children formed the control group. A significant difference was found between H. pylori infection and feeding with formula (P=0.045). In case group, a significant difference was found between breastfeeding and age of the infected child (P=0.034), shorter duration of symptoms (P=0.016), and finally degree of H. pylori colonization (P=0.021).

CONCLUSION

It appears that breastfeeding in the first 6 months after birth can decrease the degree of H. pylori colonization, postpone infection until older age, shorten the duration of symptoms, and be concomitant with milder gastritis.

Antimicrobial susceptibility patterns of community-acquired uropathogens in Tehran, Iran

BACKGROUND

Antibiotic resistance of urinary tract pathogens has increased worldwide. Knowledge of the antibiotic resistance patterns of uropathogens in specific geographical locations is an important factor for choosing an appropriate empirical antimicrobial treatment. The aim of this study was to provide information regarding local resistance patterns of urinary pathogens to the commonly used antibiotics in Tehran, Iran.

METHODOLOGY

Urine samples collected and submitted to two pathobiology laboratories in Tehran were identified by conventional methods over a period of three years (December 2006 to May 2009). Antimicrobial resistance testing was performed by the standard disk diffusion technique in accordance with the recommendations of the Clinical and Laboratory Standards Institute.

RESULTS

Of the total 13,333 mid-stream urine samples collected from suspected cases of urinary tract infection, 840 (6.3%) were positive for pathogenic bacteria. Escherichia coli (E. coli) was the most common isolate (68.8%) followed by Proteus spp. (12.4%), and Klebsiella spp. (9.6%). E. coli isolates were mostly susceptible to nitrofurantoin (71.3%), followed by ciprofloxacin (68.1%); however, only 38.2% of E. coli isolates were susceptible to trimethoprim-sulfamethoxazole.

CONCLUSION

Nitrofurantoin may be considered as a first-line empiric antibacterial agent for urinary tract infections in outpatients in Tehran, Iran.

Mast cell density in gastric biopsies of pediatric age group and its relation to inflammation and presence of Helicobacter pylori

Background

The aim of this study was to investigate the relationship between mast cell density, histological severity of gastritis, and presence of Helicobacter pylori (H. pylori) in the antral mucosa of pediatric patients.

Methods

The study included 352 (192 male and 160 female, < 14 years old) patients. All cases underwent endoscopy, and biopsies were obtained for histopathological examination and evaluation of Helicobacter pylori. All biopsies were evaluated according to the Sydney system and mast cell density in the antral mucosa was analyzed by Giemsa stain. Spearman's correlation test was used to determine the relationship between mast cell density and other histopathological parameters. The comparison of mast cell density between H. pylori positive and negative groups was analyzed by Mann Whitney U test.

Results

Mast cell density was 12.6 ± 0.87 in 0.25 mm² (0–81). Means of severity of gastric inflammation in H. pylori-positive and negative patients were 1.7 ± 0.6 and 0.6 ± 0.7, respectively, which was statistically significant (p = 0.0001). Mast cell density was not correlated with presence and degree of inflammation, activity, presence and score of H. pylori in the antrum (p > 0.05). There was no significant correlation between mast cell density and allergy.

Discussion

We concluded that there may be some other ways for contribution of mast cells in pathologic processes involving gastrointestinal tract in children.

Synthesis and characterization of Pseudomonas aeruginosa alginate–tetanus toxoid conjugate

Chronic infection withPseudomonas aeruginosais the main proven perpetrator of lung function decline and ultimate mortality in cystic fibrosis (CF) patients. Mucoid strains of this bacterium elaborate mucoid exopolysaccharide, also referred to as alginate. Alginate-based immunization of naïve animals elicits opsonic antibodies and leads to clearance of mucoidP. aeruginosafrom the lungs. Alginate was isolated from mucoidP. aeruginosastrain 8821M by repeated ethanol precipitation, dialysis, proteinase and nuclease digestion, and chromatography. To improve immunogenicity, the purified antigen was coupled to tetanus toxoid (TT) with adipic acid dihydrazide (ADH) as a spacer and 1-ethyl-3-(3-dimethylaminopropyl)-carbodiimide (EDAC) as a linker. The reaction mixture was passed through a Sepharose CL-4B column. The resulting conjugate was composed of TT and large-size alginate polymer at a ratio of about 3 : 1; it was non-toxic and non-pyrogenic, and elicited high titres of alginate-specific IgG. Antisera raised against the conjugate had high opsonic activity against the vaccine strain. The alginate conjugate was also able to protect mice against a lethal dose of mucoidP. aeruginosa. These data indicate that an alginate-based vaccine has significant potential to protect against chronic infection with mucoidP. aeruginosain the CF host.