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      Biofilm is a Major Virulence Determinant in Bacterial Colonization of Chronic Skin Ulcers Independently from the Multidrug Resistant Phenotype

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          Abstract

          Bacterial biofilm is a major factor in delayed wound healing and high levels of biofilm production have been repeatedly described in multidrug resistant organisms (MDROs). Nevertheless, a quantitative correlation between biofilm production and the profile of antimicrobial drug resistance in delayed wound healing remains to be determined. Microbial identification, antibiotic susceptibility and biofilm production were assessed in 135 clinical isolates from 87 patients. Gram-negative bacteria were the most represented microorganisms (60.8%) with MDROs accounting for 31.8% of the total isolates. Assessment of biofilm production revealed that 80% of the strains were able to form biofilm. A comparable level of biofilm production was found with both MDRO and not-MDRO with no significant differences between groups. All the methicillin-resistant Staphylococcus aureus (MRSA) and 80% of Pseudomonas aeruginosa MDR strains were found as moderate/high biofilm producers. Conversely, less than 17% of Klebsiella pneumoniae extended-spectrum beta-lactamase (ESBL), Escherichia coli-ESBL and Acinetobacter baumannii were moderate/high biofilm producers. Notably, those strains classified as non-biofilm producers, were always associated with biofilm producer bacteria in polymicrobial colonization. This study shows that biofilm producers were present in all chronic skin ulcers, suggesting that biofilm represents a key virulence determinant in promoting bacterial persistence and chronicity of ulcerative lesions independently from the MDRO phenotype.

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          Most cited references96

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          Pseudomonas aeruginosa Lifestyle: A Paradigm for Adaptation, Survival, and Persistence

          Pseudomonas aeruginosa is an opportunistic pathogen affecting immunocompromised patients. It is known as the leading cause of morbidity and mortality in cystic fibrosis (CF) patients and as one of the leading causes of nosocomial infections. Due to a range of mechanisms for adaptation, survival and resistance to multiple classes of antibiotics, infections by P. aeruginosa strains can be life-threatening and it is emerging worldwide as public health threat. This review highlights the diversity of mechanisms by which P. aeruginosa promotes its survival and persistence in various environments and particularly at different stages of pathogenesis. We will review the importance and complexity of regulatory networks and genotypic-phenotypic variations known as adaptive radiation by which P. aeruginosa adjusts physiological processes for adaptation and survival in response to environmental cues and stresses. Accordingly, we will review the central regulatory role of quorum sensing and signaling systems by nucleotide-based second messengers resulting in different lifestyles of P. aeruginosa. Furthermore, various regulatory proteins will be discussed which form a plethora of controlling systems acting at transcriptional level for timely expression of genes enabling rapid responses to external stimuli and unfavorable conditions. Antibiotic resistance is a natural trait for P. aeruginosa and multiple mechanisms underlying different forms of antibiotic resistance will be discussed here. The importance of each mechanism in conferring resistance to various antipseudomonal antibiotics and their prevalence in clinical strains will be described. The underlying principles for acquiring resistance leading pan-drug resistant strains will be summarized. A future outlook emphasizes the need for collaborative international multidisciplinary efforts to translate current knowledge into strategies to prevent and treat P. aeruginosa infections while reducing the rate of antibiotic resistance and avoiding the spreading of resistant strains.
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            Biofilms in chronic wounds.

            Chronic wounds including diabetic foot ulcers, pressure ulcers, and venous leg ulcers are a worldwide health problem. It has been speculated that bacteria colonizing chronic wounds exist as highly persistent biofilm communities. This research examined chronic and acute wounds for biofilms and characterized microorganisms inhabiting these wounds. Chronic wound specimens were obtained from 77 subjects and acute wound specimens were obtained from 16 subjects. Culture data were collected using standard clinical techniques. Light and scanning electron microscopy techniques were used to analyze 50 of the chronic wound specimens and the 16 acute wound specimens. Molecular analyses were performed on the remaining 27 chronic wound specimens using denaturing gradient gel electrophoresis and sequence analysis. Of the 50 chronic wound specimens evaluated by microscopy, 30 were characterized as containing biofilm (60%), whereas only one of the 16 acute wound specimens was characterized as containing biofilm (6%). This was a statistically significant difference (p<0.001). Molecular analyses of chronic wound specimens revealed diverse polymicrobial communities and the presence of bacteria, including strictly anaerobic bacteria, not revealed by culture. Bacterial biofilm prevalence in specimens from chronic wounds relative to acute wounds observed in this study provides evidence that biofilms may be abundant in chronic wounds.
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              The relationship between antimicrobial resistance and patient outcomes: mortality, length of hospital stay, and health care costs.

              There is an association between the development of antimicrobial resistance in Staphylococcus aureus, enterococci, and gram-negative bacilli and increases in mortality, morbidity, length of hospitalization, and cost of health care. For many patients, inadequate or delayed therapy and severe underlying disease are primarily responsible for the adverse outcomes of infections caused by antimicrobial-resistant organisms. Patients with infections due to antimicrobial-resistant organisms have higher costs (approximately 6,000-30,000 dollars) than do patients with infections due to antimicrobial-susceptible organisms; the difference in cost is even greater when patients infected with antimicrobial-resistant organisms are compared with patients without infection. Strategies to prevent nosocomial emergence and spread of antimicrobial-resistant organisms are essential.
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                Author and article information

                Contributors
                Role: Academic Editor
                Journal
                Int J Mol Sci
                Int J Mol Sci
                ijms
                International Journal of Molecular Sciences
                MDPI
                1422-0067
                17 May 2017
                May 2017
                : 18
                : 5
                : 1077
                Affiliations
                [1 ]Clinical Pathology and Microbiology, San Gallicano Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00144 Rome, Italy; ilariafarulla@ 123456libero.it (I.F.); grazia.prignano@ 123456ifo.gov.it (G.P.); mariateresa.gallo@ 123456ifo.gov.it (M.T.G.); mvespaziani@ 123456yahoo.it (M.V.); ilaria.cavallo90@ 123456gmail.com (I.C.); martinapontone@ 123456hotmail.it (M.P.); valentina.bordignon@ 123456ifo.gov.it (V.B.); laura81cl@ 123456libero.it (L.C.); alessandra21@ 123456libero.it (A.D.S.); fabiola-91@ 123456hotmail.it (F.D.S.); fulvia.pimpinelli@ 123456ifo.gov.it (F.P.); fabrizio.ensoli@ 123456ifo.gov.it (F.E.)
                [2 ]Biostatistics, San Gallicano Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00144 Rome, Italy; isabella.sperduti@ 123456ifo.gov.it
                [3 ]Department of Dermatology, San Gallicano Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00144 Rome, Italy; ilaria.lesnoni@ 123456ifo.gov.it
                [4 ]Infectious Disease Consultant, Regina Elena National Cancer Institute, Istituto di Ricovero e Cura a Carattere Scientifico (IRCCS), 00144 Rome, Italy; luigi.toma@ 123456ifo.gov.it
                Author notes
                [* ]Correspondence: enea.didomenico@ 123456ifo.gov.it ; Tel.: +39-06-5266-2956; Fax: +39-06-5266-5396
                Article
                ijms-18-01077
                10.3390/ijms18051077
                5454986
                28513576
                b3a12a5d-42c9-495a-bf42-de2068d8a84c
                © 2017 by the authors.

                Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license ( http://creativecommons.org/licenses/by/4.0/).

                History
                : 25 March 2017
                : 11 May 2017
                Categories
                Article

                Molecular biology
                skin ulcer,mdro,biofilm,wound,mrsa,esbl,pseudomonas aeruginosa,klebsiella pneumoniae,escherichia coli,acinetobacter baumannii

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