title: Susceptibility patterns of Staphylococcus aureus biofilms in diabetic foot infections.
abstract: Foot infections are a major cause of morbidity in people with diabetes and the most common cause of diabetes-related hospitalization and lower extremity amputation. Staphylococcus aureus is by far the most frequent species isolated from these infections. In particular, methicillin-resistant S. aureus (MRSA) has emerged as a major clinical and epidemiological problem in hospitals. MRSA strains have the ability to be resistant to most β-lactam antibiotics, but also to a wide range of other antimicrobials, making infections difficult to manage and very costly to treat. To date, there are two fifth-generation cephalosporins generally efficacious against MRSA, ceftaroline and ceftobripole, sharing a similar spectrum. Biofilm formation is one of the most important virulence traits of S. aureus. Biofilm growth plays an important role during infection by providing defence against several antagonistic mechanisms. In this study, we analysed the antimicrobial susceptibility patterns of biofilm-producing S. aureus strains isolated from diabetic foot infections. The antibiotic minimum inhibitory concentration (MIC) was determined for ten antimicrobial compounds, along with the minimum biofilm inhibitory concentration (MBIC) and minimum biofilm eradication concentration (MBEC), followed by PCR identification of genetic determinants of biofilm production and antimicrobial resistance.
  
  
  
  Results demonstrate that very high concentrations of the most used antibiotics in treating diabetic foot infections (DFI) are required to inhibit S. aureus biofilms in vitro, which may explain why monotherapy with these agents frequently fails to eradicate biofilm infections. In fact, biofilms were resistant to antibiotics at concentrations 10-1000 times greater than the ones required to kill free-living or planktonic cells. The only antibiotics able to inhibit biofilm eradication on 50 % of isolates were ceftaroline and gentamicin.
  
  
  
  The results suggest that the antibiotic susceptibility patterns cannot be applied to biofilm established infections. Selection of antimicrobial therapy is a critical step in DFI and should aim at overcoming biofilm disease in order to optimize the outcomes of this complex pathology.
authors.affiliation: Centro de Investigação Interdisciplinar em Sanidade Animal (CIISA), Faculdade de Medicina Veterinária, Universidade de Lisboa, Avenida da Universidade Técnica, 1300-477, Lisbon, Portugal. carlamottola@fmv.ulisboa.pt.
authors.forename: Carla
authors.initials: C
authors.lastname: Mottola
authors.affiliation: Centro de Investigação Interdisciplinar em Sanidade Animal (CIISA), Faculdade de Medicina Veterinária, Universidade de Lisboa, Avenida da Universidade Técnica, 1300-477, Lisbon, Portugal.
authors.forename: Carina S
authors.initials: CS
authors.lastname: Matias
authors.affiliation: Departamento de Medicina Interna, Hospital de Santa Marta/Centro Hospitalar de Lisboa Central, EPE, Lisbon, Portugal.
authors.forename: João J
authors.initials: JJ
authors.lastname: Mendes
authors.affiliation: Faculdade de Medicina, Universidade de Lisboa, Instituto de Microbiologia, Lisbon, Portugal.
authors.forename: José
authors.initials: J
authors.lastname: Melo-Cristino
authors.affiliation: Centro de Investigação Interdisciplinar em Sanidade Animal (CIISA), Faculdade de Medicina Veterinária, Universidade de Lisboa, Avenida da Universidade Técnica, 1300-477, Lisbon, Portugal.
authors.forename: Luís
authors.initials: L
authors.lastname: Tavares
authors.affiliation: TechnoPhage, S.A., Lisbon, Portugal.|Centro de Investigação Interdisciplinar Egas Moniz (CiiEM), Instituto Superior de Ciências da Saúde Egas Moniz, Monte de Caparica, Portugal.
authors.forename: Patrícia
authors.initials: P
authors.lastname: Cavaco-Silva
authors.affiliation: Centro de Investigação Interdisciplinar em Sanidade Animal (CIISA), Faculdade de Medicina Veterinária, Universidade de Lisboa, Avenida da Universidade Técnica, 1300-477, Lisbon, Portugal.
authors.forename: Manuela
authors.initials: M
authors.lastname: Oliveira
mesh_terms: D000900:Anti-Bacterial Agents / Q000494:pharmacology*; D018441:Biofilms / Q000187:drug effects* / Q000254:growth & development; D002511:Cephalosporins / Q000494:pharmacology; D017719:Diabetic Foot / Q000188:drug therapy / Q000382:microbiology*; D005839:Gentamicins / Q000494:pharmacology; D006801:Humans; D055624:Methicillin-Resistant Staphylococcus aureus / Q000187:drug effects* / Q000235:genetics / Q000502:physiology; D008826:Microbial Sensitivity Tests; D016133:Polymerase Chain Reaction / Q000379:methods; D013203:Staphylococcal Infections / Q000188:drug therapy* / Q000382:microbiology; D013211:Staphylococcus aureus / Q000187:drug effects* / Q000235:genetics / Q000302:isolation & purification / Q000502:physiology; D047090:beta-Lactams / Q000494:pharmacology; D000097583:Ceftaroline
chemical_list: D000900:Anti-Bacterial Agents; D002511:Cephalosporins; D005839:Gentamicins; D047090:beta-Lactams; D000097583:Ceftaroline
keywords: Diabetic foot infections; MBEC; MBIC; Resistance genes; Staphylococcus aureus