Biofilms : how to handle them? Chrisne IMBERT © by author Université de Poiers - UFR Médecine et Pharmacie Laboratoire EBI UMR CNRS 7267– Poiers – France [email protected] Online Lecture Library Bringing PK and PD in fungal infections into the clinic Nijmegen 4-6 July 2014 Background: 2 opposite life-styles: « planktonic » ou « sessile » ? « Planktonic » « sessile » Passively floang Adherent to a substrate © by author ESCMID Online Lecture Library Biofilm 2 Biofilms are on and in us © by author ESCMID Online Lecture Library Candida spp. can form biofilms on ssues and on almost any medical device!3 Biofilms : single-species or mixed ? Single-species biofilms Vascular catheters, Staphylocoques coagulase neg Prosthec cardiac Staphylococcus aureus valve … Pseudomonas aeruginosa Enterobacteries Candida sp Denture, Tissues : skin, Urinary catheter, vaginal mucosa, Contact lenses… © by author lung… • C. albicans + P. aeruginosa ESCMID •Online A. fumigatus Lecture+ P. aeruginosa Library • C. albicans + Streptoccocus Mixed biofilms • C. albicans + Staphylococcus (S. epidermidis, S. aureus) • C. albicans + Gardnerella vaginalis 4 • Fusarium + free living amoebae C Imbert EBI picture A. fumigatus biofilm Ramage et al., 2011 C. albicans biofilm Douglas, 2003 © by author ESCMID Online Lecture Library Bjarnsholt et al, Nature Reviews Drug Discovery 2013 C. neoformans biofilm (polystyrene) 5 Martinez et al, 2010 Main mechanisms explaining anfungal resistance associated to C. albicans biofilms Decreasing Decreasing role role © by author ESCMID Online Lecture Library 6 Ramage et al, 2012, Internaonal Journal of Microbiology Human consequences : high risk of infecon • Biofilms are associated with 90% of catheter–related infecons • Device-associated Candida sp infecons ðmortality rates ≥ 30% Biofilm Biofilm © by author = Infecon Reservoir of infection ESCMID Online Lecture Library Viudes et al., 2002; Finkel & Mitchell, 2011 ; DiDone et al., 2011; Ne et al., 2007 7 So...CombaTng fungal biofilms: strategies and goals? Remove and eradicate the biofilm Inhibit development of biofilm Mechanically disrupt the biofilm Prevenon Systemic therapy Ethanol lock soluons Remove + replace the device Ethanol lock soluons Biofilm © by author Control ESCMIDEradicaon Online Lecture Library lock soluons Other? Other? 8 Anfungal used as Management of a catheter associated candidemia ESCMID guidelines. Cornely et al., CMI 2012 ó Where possible the catheter should be removed Study of Garnacho-Montero et al, JAC 2013 • 188 paents : with posive blood culture for Candida spp. + CVC • Confirmed that : © by author • catheter removal is a protecve factor •ESCMID and adequacy of anfungal therapy in the first 48h seemed to Online Lecture Library reduce the mortality rate 9 CombaTng a biofilm already formed BUT…. removal of the CVC is not always possible Antifungal arsenal SYSTEMIC ANTIFUNGAL OTHER ANTIFUNGAL © by authorLOCK APPROACHES TREATMENT TREATMENT ? ESCMID Online Lecture Library 10 Systemic anfungal therapy ð ATF acve against Candida biofilms: • Lipid formulaons of amphotericin B – L-AmB and ABLC • Echinocandins – caspofungin, micafungin and anidulafungin Flu Cocuaud et al, JAC 2005 ; Cateau et al, ©CMI 2007by ; author Cateau et al, JAC 2008 ; Cateau et al, IJAA 2011 ; Toulet et al, JAC 2012 ; Bachmann et al, AAC 2002 ; Katragkou et al, AAC 2008 ESCMID Online Lecture LibraryCasp, AMB, Abelcet 11 Kuhn et al, 2002 11 However… ð ATF poorly acve on Candida biofilms • Amphotericin B deoxycholate Lewis et al, AAC 2002 ; Ramage et al, AAC 2002 • Azoles Ramage et al, AAC 2001 ; Cateau et al, IJAA 2011 Flu However they may prevent : © by author - dispersion Casp, AMB, Abelcet - propagaon ESCMID Online Lecture Library Kuhn et al, 2002 12 Cornely et al, EFISG, CMI © by author ESCMID Online Lecture Library 13 13 Anfungal combinaons against Candida biofilms? Chatzimoschou et al, AAC 2011 In vitro study ; C. albicans and C. parapsilosis biofilms ð When used serially, triazole-echinocandin combinaons were marginally effecve against biofilms of Candida ð When used simultaneously, triazole-echinocandin demonstrated indifferent interacons against © by author biofilms of Candida ESCMID Online Lecture Library ðInterest not really demonstrated 14 A. fumigatus biofilms Seidler et al, AAC 2008 In vitro results – Mature biofilms © by author HBE : Human Bronchial Epithelial ; CFBE : Cysc Fibrosis Bronchial Epithelial ; PS : Polystyrene ESCMID Online Lecture Library Fiori et al, AAC 2011 : - Amphotericin B, voriconazole, Caspofungin and anidulafungin : poorly active against biofilms - Amphotericin B > voriconazole > echinocandin 15 A. fumigatus biofilms – anfungal combinaon Liu et al, AAC 2012 Synergisc anfungal acvity with a combinaon of : - CAS and AmB - CAS and VORI - no observed antagonism © by author ESCMID Online Lecture Library 16 Prevenon of fungal infecons associated to biofilms Antifungal used as lock solutions ? Antimicrobial coating ? Ethanol, Taurolidine, EDTA, etc used as lock solutions ? Natural© anti-adherentby author components ? ESCMID Online Lecture Library 17 Prevenon of fungal infecons associated to biofilms Antifungal used as lock solutions ? Antimicrobial coating ? Ethanol, Taurolidine, EDTA, etc used as lock solutions ? Natural© anti-adherentby author components ? Guidelines ? ESCMID Online Lecture Library - EFISG guidelines 2012 - ESGB guidelines : soon… BUT recommandations for bacterial biofilms/ infections will be more documented than for fungal ones… 18 Too few available guidelines for prevenon of candidiasis biofilm-related Cornely et al, EFISG C: marginally supports a © by author recommendaon for use ESCMID Online Lecture Library ððThe main issue : deficiency of clinical data 19 Prevenon of fungal infecons associated to biofilms Antifungal used as lock solutions ? Antimicrobial coating ? Ethanol, Taurolidine, EDTA, etc used as lock solutions ? © by author Natural components ? ESCMID Online Lecture Library Other? 20 Anmicrobial coang to prevent biofilm formaon Meta-analysis: Impact of catheter anmicrobial coang on risk of catheter Novikov et al, 2012 colonizaon : anmicrobial- versus standard- CVC ð Increase of Candida sp colonizaon among minocycline-rifampicin CVCs ð Efficiency of silver-sulfadiazine coang (960 adult paents: Walz et al, Crit Care Med, 2010) © by author The use of coating that have limited antifungal activity may serve to increase colonization / infection due to Candida sp ESCMID Online Lecture Library ð The choice of an anmicrobial CVC may be influenced by a previous history of infecon with Candida species 21 Antifungal used as lock solutions ? Antimicrobial coating ? Ethanol, Taurolidine, EDTA, etc used as lock solutions ? © by author Natural anti-adherent components ? ESCMID Online Lecture Library Other? 22 Lock therapy • To prevent or control or eradicate fungal biofilms? • Method: stac insllaon ; 8 – 12h into the catheter lumen • Advantages : • conservave strategy • Cost effecve method • Safe for paents © by author ESCMIDEthanol Lock therapy Online LectureAnfungal Lock therapy Library concentrated soluon (>100 MIC) Role = sll not well defined 23 Ethanol Lock therapy Preven.on / control / eradicaon ? Numerous In vitro models • Rane et al, AAC 2012; Peters et al, AAC 2013, … ð 30% to 35% EtOH for 4h – >99% reducon of mature C. albicans biofilms – and prevented the regrowth of C. albicans on silicone • Oncu, Clin Nutrion 2014 © by author ð 40% EtOH for 30 min is enough to sterilize the catheters ESCMID Online Lecture Library • Wales et al, J Ped Surgery 2011 ; Ghannoum et al, AAC 2011 ð Suggested the interest of EtOH lock combined with EDTA 24 Promising results using Taurolidine lock soluons Preven.on + eradicaon ? Olthof et al, Clinical Nutrion 2014 • In vitro interest of taurolidine containing lock soluons against fungal, Gram- and Gram+ pathogens Diaman4 et al, Clin Nutrion 2014 © by author • 1 paent with repeated and severe C. glabrata central ESCMIDline sepsis was successfully treated with taurolidine Online Lecture Library locks 25 Echinocandins used as lock soluons Control + eradicaon ? Cateau et al, JAC 2008+IJAA 2011 : silicone catheters ; in vitro • CAS, MFG : 5 to 25 mg/L (100-500 x MIC); lock12h, biofilm: 12h/5d ; silicone - C. albicans and C. glabrata biofilms ó acvity ++ - BUT : low persistence of CAS against C. glabrata biofilms Lazzell et al, 2009 ; Shuford et al, 2006 ; Kucharikova et al, 2010: • CAS, MFG = acve using in vivo models © by author ESCMID Online Lecture Library 26 Echinocandins used as lock soluons Control + eradicaon ? Cateau et al, JAC 2008+IJAA 2011 : silicone catheters ; in vitro • CAS, MFG : 5 to 25 mg/L (100-500 x MIC); lock12h, biofilm: 12h/5d ; silicone - C. albicans and C. glabrata biofilms ó acvity ++ - BUT : low persistence of CAS against C. glabrata biofilms Lazzell et al, 2009 ; Shuford et al, 2006 ; Kucharikova et al, 2010: • CAS, MFG = acve using in vivo models © by author Simitsopoulou et al, AAC 2014 ; lock 24h ; polystyrene • Eradicaon + persistence: ESCMID OnlineCAS lock soluons at 512-2048 mg/L Lecture Library • CAS = more acve than ANID and MFG against C. lusitaniae and C. guillermondii biofilms 27 Lipid formulaons of AmB used as lock soluons Control + eradicaon ? Toulet et al., JAC2012: silicone catheters; in vitro • L-AmB (0.2mg/mL or 1mg/mL), 12h-5d old biofilms, single lock : 4 or 12h ðInhibion ≥ 70% of : ð young biofilms ( C. albicans, C. glabrata, C. parapsilosis) ð mature biofilms of C. albicans, C. glabrata ðReduced efficacy on mature C. parapsilosis biofilm: inhibion ≥ 40% Mukherjee et al, IJAA 2009 ; in vivo (rabbit