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John G. Thomas, PhD, Sara B. Posey, MPH, and Staff. WVU School of Medicine Department of Pathology Biofilm Research Laboratory for Translational Studies Morgantown, WV 26506-9203
Contents: I. Objectives & Goals II. Introduction/Background: Biofilms.. III. Micro 101 Universal Principles General Principles IV. Biofilms 201: We Live in a Microbial World V. Clinical Consequences. VI. Clinical Cases & Pictures (SEMs). VII. Biofilm Models (in vitro/in vivo) VIII. Rules: Dos and Donts.. IX. Glossary/Terms.. X. Key References/Web sites/ etc... XI. FAQs...
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I. Goals & Objectives: Objectives: To provide an understanding of microbiology, generally, and biofilms, specifically, upon design strategy. In order to do this, we have selected approximately 60 PowerPoint slides from over 1,500 used in 100 presentations by me, internationally, since 2001, which highlight significant principals and features of biofilms. Many of these originated from experimentation utilizing the VEL (Ventilator-Endotrach-Lung) Model (now called Simulator), which helped evaluate the efficacy of silver-coated endotracheal tubes, and subsequent studies of sutures, ETT suction devices and chronic wounds. This educational tool also compliments our Micro Mini Educational Series, and additional support are available on our WVU website: http://www.hsc.wvu.edu/som/pathology/thomas/ Goals: To provide useful understanding of how biofilms are constructed, their architecture and their hydrated polymer-like features. To unmask the consequences and collateral damage associated with biofilms, specifically IMDs (Indwelling Medical Devices) To develop rules (Dos and Donts) for design strategy in the evolving green microbial ecology and probiotics era. The PowerPoints are arranged by five (V) Sections, and key points are highlighted underneath each PowerPoint.
II. Introduction/Background: Biofilms Engineers were first to describe problems associated with microbial communities and filtration devices (water, sand, etc.) in mid-1980s Earliest literature (1980s) appeared in Engineering journals Engineers coined the name biofilm and slime bacteria Now, biofilm evolution, description and importance highlighted in medical/ scientific literature (1995 Present) Biofilms are the preferred means of microbial survival and growth and are a global concerns associated with infinite number of problems: engineering, medical, environmental, and Global Warming (below).
In the beginning, engineers were the first to recognize the importance of biofilms in altering or reducing the effectiveness of selected devices. Although biofilms are the preeminent form of microbes, their impact on medical and dental applications did not occur until approximately the 1980s.
III. Micro 101 UNIVERSAL MICROBIAL PRINCIPLES Principle 1. Being Attached (Biofilm) rather than Suspended (Planktonic) makes a world of difference, and given the opportunity, 99.9% of microorganisms prefer attachment vs. free floating. Principle 2. Sessile and planktonic life forms are not mutually exclusive, existing simultaneously, and demonstrate the same growth cycle: I (Lag), II (Log), III (Stationary), and IV (Death). Principle 3. Shear Forces and Stress Patterns will affect the physical morphology and dynamic behavior of the biofilm more than the seven other influences. Principle 4. Biofilm Structure = Function: multi-species biofilms are formed in cascade fashion, Gram-Positive (Early) to Gram-Negative (Late), bridged by Candida spp. (Universal Engineer or Co-Aggregate), developing a more complex, resilient ecosystem with niches (Evolution/Intellectual Design). Principle 5. A Mixed Species Biofilm is more stable, robust, and cohesive than Monospecies. Principle 6. Infectious Diseases can be quantified where: Infectious Disease = Number(N)1 x Virulence(V)2 Immunity(I)3
Principle 7.
Ecological (Plaque) Hypothesis: Resident flora is distinct in 1) health and 2) disease, where potential pathogens may be present in low numbers; a major ecological shift is necessary for putative pathogens to out compete resident flora, and achieve numerical
dominance needed for disease. Critical Colonization or Synergistic Threshold: Balanced flora between Biofilm and Planktonic phenotypes is critical, recognizing the emerging role of targeted synergistic isolates, particularly Candida albicans, Strep mutans, and P. aeruginosa and the ratio of each towards a critical threshold in oral or chronic wounds, respectively. Principle 8. Biofilms share eight properties of another multi-cellular 3-D community Neoplasia and resemble benign procaryotic, solid tumors, which explain in part their resistance to standard antibiotic interventions and limited success with anti-tumor drugs, particularly those of anti-fungal legacy.
YOUR FRIENDS
The human body is a continuum of microbes, although there are 4 recognized reservoirs that contain the highest concentrations and continually provide resident microbiota. 6
The distinction between dental and medical microbiology is a manman-made fabrication via our simplistic attitude of a very complex total body ecosystem that is just now being uncovered uncovered There is no such thing as dental microbiology
The concept that stratification and separation occurs should be forever lost.
PP
Diseases & Symptoms
RATIO PBF:PP
PBF
Microbes exist in 2 distinct life forms or phenotypes; 1 for survival, biofilms and the alternate life form, planktonic, for transmission.
Cultured (%)
0.001-0.1
Viable, but non-cultivable Freshwater 0.25 Mesotrophic lakes 0.1-1 VBNC Estuarine waters 0.1-3
Activated sludge Sediments Soil 1-15 0.25 0.3
Out of the millions of microbes that inhabit the human body and the earth, most are uncultivable and represent viable but nonculturable classifications (VBNC).
Medical = 0
In infectious diseases, the principle of infections can be simplified into a formula. Infections = numbers x virulence over the immunity.
Microorganism:
An Organism that Cannot be Seen Without the Use of a Microscope
Antonie van Leeuwenhoek (16321723) was the first to see microorganisms from plaque samples animalcules
Microbes were first identified by Antoin Van Leevenhook in 1632 when he scraped plaque from a tooth surface and called the moving organisms animacules. He was an early optometrist.
Types of Microorganisms
1. Viruses: Viruses smallest (0.02-0.3 m diameter); simplest: nucleic acid & protein coat (& lipoprotein envelope) 2. Bacteria: Bacteria 0.5-2.0 m diameter; prokaryotes; cellular; simple internal organization; binary fission. 3. Fungi: Fungi Yeasts and molds, non-photosynthetic, immotile; rigid cell wall 4. Protozoa: Protozoa most >2 m- 2 mm; eukaryotic; unicellular; non-photosynthetic; flexible cell membrane; no cell wall; wide range of sizes and shapes; hardy cysts (flagellates, amoebae, ciliates, sporozoans, microsporidia) 5. Algae: Algae Photosynthetic, Rigid cell wall, Wide range of sizes and shapes 2 micrometers and larger
The classifications and types of organisms observable under a microscope are usually listed as 5: Viruses, bacteria, fungi, protozoa and algae. 9
PROTOZOAN PARASITE
BACTERIUM VIRUS 0.1 um 1 X 2 UM
Relative comparison of viruses, bacteria and parasites: The largest of the microorganisms is a mold estimated at over 30 miles long in upper Michigan.
Bacteria versus human cells or prokaryotic versus eukaryotic cells. They share many features but bacteria have a cell wall. Note: Although fungi and yeast are described as microorganisms, they are a eukaryote possessing no cell wall. 10
The bacterial cell wall can be complex or simple, and the constituents help describe 2 primary shapes within the microbial world; gram-positive cocci and gram-negative rods. Positive and negative refers to the retention of dyes used to stain the organisms to make them visual. Gram-positive blue, gramnegative red.
The diversity of microbes in the oral cavity with 1 additional class of isolates called mycoplasma, often referred to as CWD or cell wall deficient bacteria. 11
Normal Microflora
The "normal microflora flora" colonize the oral cavity, skin, gastrointestinal tract, upper respiratory tract and parts of the genitourinary tract (urethra and vagina) Colonization by normal flora can be neutral or beneficial. Harmful outcomes are also possible; can lead to disease and invasion of other parts of the body (opportunistic pathogens)
Normal flora is a misused word and today better described as beneficial flora.
12
Terminology
Commensal microorganisms: frequently isolated from the human body, not associated with disease Pathogen: frequently cause human infection when present in the body Opportunistic pathogen: commensal that cause infection under certain conditions
The terms Commensal, Pathogen and Opportunistic need to be clearly highlighted.
There is a dynamic interface between the host human cells and those of microbes, and we now understand that quorum sensing is a vehicle of signaling shared between eukaryotic and prokaryotic cells. 13
Acquisition of oral flora depends upon exposure at the time of birth, cesarean or vaginal. Shortly thereafter, caregivers provide the next insult of microorganisms.
VBNC (viable but not culturable) describes the fact that most scientists believe less than 0.5 of the microbial world has been cultured or is culturable. Part of this may be due to biofilm.
Candida spp.
Genus comprised of 150 species with ~8 recognized as opportunistic pathogens of humans
C. albicans C. krusei C.guilliermondii C. kefyr C. lisitaniae C.tropicalis C.parapsilosis C.glabrata C.dubliniensis
Arteriosclerosis $5 Billion/yr
ORAL BIOFILMS
REFERNCES: Low Birth VAP 1. NIH: Disease-specific estimates of direct and indirect costs of illness and NIH support. Weight http://ospp.od.nih.gov/ecostudies/COIreportweb.htm. $26 Billion/year 2. Shahbabies NP, et al. Direct medical costs associated with using vancomycin in methicillin-resistant staph. aurues $150,000/patient infections: an economic model. Thrushassociated pneumonia: results from a large US $2 Billion/yr 3. Kollef MH, et al. Epidemiology and outcomes of health-care database of culture-positive pneumonia. Chesi 2005. Throat Strep.
$600 million
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Biofilm Principle Being Attached Rather than Suspended, Makes a World of Difference
Given a choice, 99.9% of bacteria will form a BIOFILM
INTELLECTUAL DESIGN
West Virginia University Biofilm Research Laboratory
The fundamental of biofilms is that being attached rather than being suspended is a mechanism of survival. The unique 3-dimensional organization has recently been referred to as intellectual design.
3 COMPONENTS OF BIOFILMS
COMPONENTS & 3-D ARCHITECTURE PHYSIOLOGY GRADIENTS METABOLISM
+ 420
+
SURFACE O2 O2 Gradient
14 14
420
Eh Scale
pH Scale
BIOFILM
410
410
H2
There are 3 components of biofilms; its architecture, its physiologic gradients and its physical properties. 18
Genotypic Factors
The Physico-Chemical Environment THE BIOFILM COMMUNITY STRUCTURE AND EVOLUTION Mechanical Factors and Shear Forces
Cyclic Stage
There are 8 features that define the architecture and physical features; 3 are critical - surface, organism and stress.
CROSS-TALK/CO-ADHESION Growth Stimulation
C. albicans and Pseudomonas C. albicans and CoNS
Synergy
Antagonism
West Virginia University Biofilm Research Laboratory
Organisms that compose the biofilm in mixed species may be synergistic, antagonistic or simply cooperative.
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Definition: Biofilm
A primitive type of developmental biology in which spatial organization of the cells within the matrix optimizes the utilization of the nutritional resources available An immobilized enzyme system in which the milieu and the enzyme activities are constantly changing and evolving to appropriate steady state. The steady state can be radically altered by applying physical factors such as high sheer.
West Virginia University Biofilm Research Laboratory
The biofilm is a developmental biology, primitive although focused on enzymes and resistance to steady states.
Component of Biofilms
Component
Water Microbial Cells Polysaccharide Proteins DNA & RNA Ions HOST
% of Matrix
- Up to 97% - 2-5% (many species) - 1-2% (neutral & Polyanionic) - <1-2% - <1-2% -? Fibrin, RBCs, WBCs
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SURFACE O2
+ + 420
O2 Gradient
14 14
420
Eh Scale
pH Scale
H2
410
410
A biofilms 3-dimensional architecture allows for gradients, often pH dependent, allowing pH regions to exist from pH 11 to pH 3.
21
CONSEQUENCES
The most unrecognized property is that the consequence of microbes existing as a biofilm is that they respond as hydrated polymers, taking on physical parameters of those materials.
MICROBIAL COMMUNITIES: Properties of which are greater than the sum of component species
3 2
Organization of microbes is intellectually established and represents multilayers effectively diluting out the activity of many antimicrobials. 22
The complex interaction of Early and Late shifting from a gram-positive cocci to a gram-negative rod is extremely well choreographed.
Biofilm Mixture: Matrix: Glycocalyx from microbes Plasticizer: water Fillers: planktonic microbes, microbial colonies, hyphae
23
The effect of force on the hydrated polymer can be significant in transmitting aggregates of the organism pool.
The Society of Rheology : Panta Rei Everything Flows Greek Philosopher Heraclitus (540-480BC) of Ephesus: Everything flows and nothing abides; everything gives way and nothing stays fixed.
Biofilms do flow.
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STOP HERE
PROMOTE HERE
Complex Community
Intra Oral Sessile (PBF) and planktonic (PP) life forms are not mutually exclusive, but biofilms are the preferred growth vehicle West Virginia University Biofilm Research Laboratory
The life cycle of a free-floating planktonic or biofilm phenotype is characterized by Lag, Log, Stationary and Death. It is cyclical and repetitive, as rapid as 18 minutes and as slow as 48 hours.
A BIOTIC SUBSTRATUM Strep. mutans @ 24hrs in poloxamer Stage II: Early & Immature
Thickness 25 m
Golfball shape
Microcolonies
Loose association
Limited co-aggregation
Early biofilm configuration (or pioneers) is often spherical where the building block is microcolonies, usually Gram-Positive Organisms. 25
A BIOTIC SUBSTRATUM P. gingivalis @ 24hrs in poloxamer Stage II: Synergy & Cooperation
Gram-Negative Organisms (or Late Stage Colonizers) often form a spiral, rising from the base to the environment.
A BIOTIC SUBSTRATUM P. gingivalis & S. mutans @ 72hrs in poloxamer Stage III: Complex and Diverse
Thickness 55 m
Domain 1
Domain 2
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A BIOTIC SUBSTRATUM In vitro analyses of gram positive organism B using poloxamer Stage I (microcolonies); Early & Immature
Quantification
1
Open & Loosly spaced
Biofilm Thickness
Biovolume
3 4 Unstable
Substratum Coverage
Thickness 250 m
A BIOTIC SUBSTRATUM In vitro analyses of gram positive organism A using poloxamer Stage I-II: Moderate
Microcolony Organization pattern
Quantification
2
Biofilm Thickness
Biovolume
1 pH 5
3 pH 11
Substratum Coverage
Thickness 250 m
Robust Association
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A BIOTIC SUBSTRATUM In vitro analyses of gram positive organism A + B using poloxamer Stage III
Quantification
1 Crosstalk
Stable Integration of Function Microcolony & Increased BioBio-Diversity with Focused Marker Organisms Organization
pattern Spatial Arrangement Complexity Heterogen Biomass
Biofilm Thickness
2 Crosstalk
Biovolume
Substratum Coverage
Thickness 250 m
3
Images provided by Convatec
A BIOTIC SUBSTRATUM In vitro analyses of gram positive organism B using poloxamer under increased stress, Stage III-IV: Late/ Apoptosis or Necrosis Apoptosis Top Microcolony Organization pattern Spatial Arrangement Domain I
Biovolume
Quantification
Biofilm Thickness
Substratum Coverage
Thickness 250 m
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BIOTIC SUBSTRATUM 3D anaglyph Attachment Microcolony Organization pattern Vertical Orientation of Hyphae Spatial Arrangement Complexity Heterogen Biomass
Substratum Coverage
Quantification
Biofilm Thickness
Biovolume
Hyphae
Thickness 250 m
Malic et al (2006)
C. albicans (Yeast)
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V. Clinical Consequences
The environment faced by microbes on the outside of the endotrach versus the inside is one reason the biofilm survived so readily in the lumen.
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2.
1. 2.
Airway Resistance
Increased airway resistance known to delay vent weaning and increase length of intubation
Hypothesis: biofilm prevention reduces attachment of secretions and thus prevents airway resistance buildup Metric: Metric pressure drop measurements i.e. smaller effective diameters produce higher pressures
Mucus Attached
Biofilm
In the lumen of the endotrach, the hypothesis for increased airway resistance is the adhesion of cellular components in pertinacious materials to the biofilm which acts as a bridge to the surface of the endotrach.
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Patient A: Close-up
PHASE I
Extubated endotrach in accumulated accretion in spite of suctioning and nurse intervention at the time of extubation.
Data from the pressure-drop study showing reproducibility of the clean endotrach versus unrecognized consequences of biofilm and accretion buildup. 32
ORAL FLORA
GI FLORA
LUNG FLORA
Hypothetical drawing established by WVU Engineering in airflow dynamics in carrying metastasizing fragments to the lung from the endotrach.
Stage IV. Degradation is probably the most important stage in pathogenesis of VAP
In stage IV analysis of metastasizing fragments and recognition that 1-5 micron-size aggregates could integrate into the alveolar spaces of the lung.
33
Overview of methods for biofilms to compete with single cells in survival and dispersal.
Pathologic consequences in VAP, recognizing aggregates of 1-5 microns in the alveolar space.
34
PP
PB
ACUTE
CHRONIC
Shift in ratio from planktonic to biofilm phenotype is associated with more organisms of resistant biofilm.
Collateral Damage: Two Pathways to Patient Disease
30 Million Surgery
Device
KEY: Device
Infection (VAP) MICRO
MICRO
colonies
Endotrach Tube
M FI L Dispersal of Stage IV BIO INK Biofilm aggregates L / VIA NCE E N R HE TIO LAVA AD FEC CHS PRINCIPLES OF O N I LIKE K ATES RHEOLOGY TIAN STUL PO
3-6% INFECTION
(VAP)
1. 2.
Collateral damage, the significance of biofilm in 3 features: VAP, airway resistance and loss of function.
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Paradigm Shift:
MEDICAL
DENTAL
Medical diseases with planktonic isolates need zero organism population in marked contrast to biofilm diseases where normal flora may be of benefit.
Anxiety Threshold
MRSA -lactamase in Hemophilus PCN S. aureus Aminoglycoside Augmented PCN PCN Sulpha Aminoglycoside
Doxycycline (Stable)
1940
1950
1960
1970
1980
1990
2000
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MIC
West Virginia University
MBEC
Ratio May be Important Chemically: MIC MBEC
Biofilm Research Laboratory
Resistance associated with biofilms called colonization resistance where minimal inhibitory concentration planktonic is less than minimal biofilm elimination concentration (biofilm).
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1.
2.
3.
1.
Plaque is the prominent biofilm example, linked to over $92 million in diseases per year. 38
Advanced Periodontitis
Not that uncommon a presentation in dental clinics in Appalachia and the reason for the Surgeon Generals 2000 Report on Oral Care Accessibility and Inequality.
Oral Flora reservoir now include the sinus tracts which ping-pongs with oral microbes. 39
2.
IMDs are more and more difficult to treat once in place and require very expensive removal once infected by a biofilm.
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Culture Negative Biofilm Phenotype: Examples Viable, But NonNon-Cultable Cultable (VBNC)
Staph. aureus
Two cases, associated with biofilms, resulting in death at WVUH. Both were VBNC.
The prefect We live in a Microbial World, and care givers providing a mixture of organisms. 41
A lumenal brushing of a line associated with Line Sepsis, organisms going from attached to free floating, and then attachedmetastasis.
42
A Superficial Wound
Wounds are a growing problem with an aging population, but the importance of biofilms and pathogenicity are controversial.
Chronic wounds are NOT only seen in adults; this lad died at age 16 with sepsis related to skin biofilm.
43
Wound biofilms reflect with organism community and the stress/nutrient (pH) availability, which determine the 3-D structure. 44
3.
www.mbec.ca
West Virginia University Biofilm Research Laboratory
The environment and abiotic surfaces are the perfect conditions for biofilms, constructed from the 99.9% of microbes we have never recovered or identified.
Agricultural Biofilms
Ref: www.mbec.ca
West Virginia University Biofilm Research Laboratory
TRANSPORT DEVICES
Blood Culture Bottles
STORAGE
Room Temperature
REJECTION CRITERIA
Over or underinoculated No skin prep performed Line draws** Single draws
Unrefrigerated >2 hrs Received >24 hours after collection Fecal contamination No work up on cultures with >2 isolates
Sterile container (except B. pertussis) B. pertussisRegan Lowe transport or Coughplate using Regan Lowe agar
Gram stain showing contamination with saliva (>10 squamous pithelials/10X) Quality scores provide consistency of reporting
GI Infections
Salmonella spp. Shigella spp. Campylobacter spp. Escherichia coli (STEC) Clostridium difficile toxin Staphylococcus aureus Yersinia enterocolytica Center for Biofilm Research Vibrio spp.
Sterile Container Enteric Pathogen Vial Rectal swab (not for C. difficile)
Models used for studying biofilms are few and not very representative of environment.
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Dental Cocktail
VAP Cocktail
VEL model simulator, created as a result of a 50 patient ICU study, was based on replicating the stress of a mechanically ventilated patient.
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SHEAR FORCES
Microscopy
ZONE Y
Culture/ Non-culture
Sheer forces were the most important and demanded analysis of the endotrach in 3 zones; A, B and C.
VENT PROFILES
ZONE X
A (NORMAL) REQUIRED PARAMETERS RANGE VALUE TIDAL VOLUME (ml) >750 800 RESPIRATORY RATE (breaths/min 10-15 12 FIO2 SET (%) 35-45 40 PEEP (cm of H2O) PIP (cm of H2O) FLOWRATE (litres per min or LPM)
West Virginia University
5 20 50
10 30 60
15 40 80
Calculations by the School of Engineering in concert with respiratory therapy for establishing 3 ventilator profiles.
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VII. Rules: Dos and Donts Dont select for overgrowth. Dont select for antibiotic resistance. Dont destroy normal flora. Be green. Be reusable. Be nontoxic. Save mixed flora.
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IX. Glossary/Terms Commensal microorganisms: frequently isolated from the human body, not associated with disease Pathogen: frequently cause human infection when present in the body Opportunistic pathogen: commensal microorganisms that cause infection under certain conditions Normal microflora flora (beneficial flora): colonize the oral cavity, skin, gastrointestinal tract, upper respiratory tract and parts of the genitourinary tract (urethra and vagina) Colonization: by normal flora can be neutral or beneficial. Harmful outcomes are also possible; can lead to disease and invasion of other parts of the body (opportunistic pathogens) VBNC (Viable But Not Culturable): the 99.9% of bacteria in the environment and >40% in oral cavity which cannot be cultured by traditional methods; may be partially due to biofilm. Reynolds units: a unit of Dynamic Viscosity used to measure stress, in this case, in a biofilm. Greater than 5,000 is considered significant in biofilm structure.
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Data from 9 years of Collaborative Research, including: 1) Quantitative Imaging 2) Microbial Cultures 3) Anti-infectives 4) Others -UNDER CONSTRUCTION-
Micro Mini Educational Series: http://www.hsc.wvu.edu/som/pathology/thomas/micromini.asp Coming Soon! The 19th and 20th Annual John G. Thomas Microbiology Symposium Lecture Series. Available at: SOLE.wvu.edu. For information about access: 304-239-1584. Center for Biofilm Engineering: http://www.erc.montana.edu/
Thomas JG, Posey SP. Emergence of Oral/Dental Microbiology. ADVANCE for Administrators of the Laboratory. June 2009;18(6):35-38. Thomas JG, Posey SP, Namsupak A. Probiotics: The Link Between Beneficial Oral Bacteria and Total Health. Sherman Oaks, CA. Health Pointe Press; 2009. Thomas JG, Nakaishi L, Corum L. Ch 14. Consequences of Biofilms on Indwelling Medical Devices: Cost and Prevention. In: Manivannan G, ed. Disinfection and Decontamination: Principles, Applications, and Related Issues. Boca Raton, FL: CRC Press; 2008:289-338. Thomas JG, Litton I, Rinde H. Ch 2. Economic Impact of Biofilms on Treatment Costs. In: Pace JL, Rupp ME, Finch RG, eds. Biofilms, Infections, and Antimicrobial Therapy. Boca Raton, FL: CRC Press; 2006: 21-38.
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Thomas JG, Posey SP. Biofilms. In: APIC Text of Infection Control and Epidemiology - 3rd Edition. Washington, DC: APIC; 2009. Wilson A, Gray D, Thomas JG. Increases in Endotracheal Tube Resistance are Independent of Duration of Intubation. CHEST. 2009. Accepted for Publication. Costerton JW. Biofilm Theory Can Guide the Treatment of Device-Related Orthopaedic Infections. Clin Ortho and Related Res. Aug 2005;437:7-11. Costerton JW, Stewart PS, Greenberg EP. Bacterial biofilms: a common cause of persistent infections. Science. 1999;284:131822. Hall-Stoodley L, Stoodley P. Biofilm formation and dispersal and the transmission of human pathogens. Trends in Micro. Jan 2005;13(1):7-10. Kite P, Wilcox MH, Dobbins BM. Evaluation of a Novel Endoluminal Brush for the in situ Diagnosis of Catheter Related Sepsis. J Clin Path. 1997;50:2782. Kollef MH, Afessa B, Anzueto, et al. Silver-Coated Endotracheal Tubes and Incidence of Ventilator-Associated Pneumonia; The NASCENT Randomized Trial. JAMA. August 2008;300(7):805-13. Ramage G, Martinez JP, Lopez-Ribot JL. Candida biofilms on implanted biomaterials: a clinically significant problems. FEMS Yeast Res. June 2006;6(7):979-86. Walcott RD, Ehrlich GD. Biofilms and Chronic Infections. JAMA. June 2008; 299(22):2682-84.
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XI. FAQs 1. Which came first, the planktonic free floating microorganism or attached biofilms? Biofilms appeared on the Earth 4.5 billion years ago, or 2 billion years before planktonic isolates, primarily for transmission. 2. Are biofilms easy to culture and recover? NO. Detection is best recognized by non-culture techniques and recovery using standard laboratory methods is very poor, probably less than 10%. 3. What is the most effective means of treatment? Prevention. Biofilms to not like smooth, dry surfaces with zero stress a static environment. 4. What is the most overlooked feature of a biofilm? pH. Biofilms are gradients of pH niches or communities, with lower pH providing an unrecognized means of protection.
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