1. Introduction
The ESKAPEs are a group of pathogens that pose a global health threat due to their ability to escape the biocidal action of antimicrobials and the immune system response. This group of pathogens is composed of both Gram-positive and Gram-negative bacterial species, namely:
Enterococcus faecium,
Staphylococcus aureus,
Klebsiella pneumoniae,
Acinetobacter baumannii,
Pseudomonas aeruginosa, and
Enterobacter species [
1].
ESKAPE pathogens are mainly responsible for nosocomial infections, causing infections that are defined as hospital-acquired infections (HAIs) that affect patients within 48 h of hospital admission, 3 days after discharge, or 30 days after a surgical intervention [
2]. Furthermore, ESKAPE pathogens are responsible for more than 40% of infections in intensive care units (ICUs) and require unaffordable economic expenses, especially in developing countries [
3]. Over the years, an increasing number of pathogens have been reported as becoming multi-drug resistant (MDR) as a result of the misuse and the abuse of antibiotics [
4,
5]. A new report from the European Centre for Disease Prevention and Control (ECDC) ascribes over 35,000 deaths a year, and 874,000 disability-adjusted life years, for complications caused by hospital-acquired (HA) and community-acquired (CA) antimicrobial resistance (AMR), accounting for EUR 1.4 billion in direct and indirect costs.
ESKAPE pathogens have developed resistance mechanisms against the major classes of antibiotics such as oxazolidinones, aminoglycosides, macrolides, fluoroquinolones, tetracyclines, and beta-lactam, also in combination with inhibitors, through genetic mutations and the acquisition of mobile genetic elements [
6]. Furthermore, they also became resistant to the last line of defense, represented by carbapenems and glycopeptides [
7]. These pathogens display drug resistance via numerous and different phenotypic and/or genotypic mechanisms, such as drug inactivation by irreversible enzyme cleavage, drug-binding site alteration, diminution in permeability of drug or drug efflux increment to reduce its accumulation, or by the production of biofilm [
8,
9]. Overall, the constitutive and/or inducible expression of these drug-resistance mechanisms led to the increased representation of these species in HA infections [
10]. Moreover, the heterogenicity of the antimicrobial-resistance profile within the same bacterial species remarkably complicates the development of new effective therapies [
5]. Subsequently, it is important to find alternative targets to inhibit the growth and spread of pathogens, taking into account that the emergence of MDR bacteria has been paralleled by a declining antibiotic development pipeline [
11].
The scientific community has shown significant interest in using novel strategies to counteract the virulence of MDR pathogens, including ESKAPEs. In this context, the anti-virulence strategy can be used to combat the emergence of antibiotic-resistant pathogens. Anti-virulence drugs do not necessarily kill bacterial cells but prevent bacterial pathogenesis by targeting their virulence traits [
12]. In this approach, the anti-ESKAPE drugs would interfere with bacterial virulence factors to treat disease, thus leading to the development of new strategies for the prevention and control of infections [
12].
In the search for new anti-virulence drugs, the development of anti-biofilm strategies is therefore of major interest, and currently represents an important field of investigation in which nonbiocidal molecules are highly valuable to avoid the rapid appearance of MDR species [
13].
The aim of this paper was to search for new anti-biofilm activities against ESKAPE pathogens. We focused our attention on anti-biofilm molecules since these compounds do not induce the appearance of escape mutants and can be used in combination with conventional antibiotics to increase their activity.
In the research of new anti-biofilm agents, microorganisms able to thrive in harsh conditions, like in Antarctica, represent an unexploited reservoir of biodiversity [
14]. Indeed, Antarctic marine bacteria established different survival strategies to live in extreme environmental conditions [
15] that decrease the presence of competitive microorganisms. Such behavior is mandatory when nutrients are limited or difficult to uptake. Biofilm formation allows cells to grow even in oligotrophic environments [
16,
17], and the production of anti-biofilm molecules can reduce the biofilm formation of competitors and their ability to survive. Therefore, it is not surprising that some recent papers report that marine Antarctic bacteria produce and secrete anti-biofilm molecules [
13,
18,
19,
20,
21,
22,
23]. Furthermore, cell-free supernatants and organic extracts obtained from different bacterial cultures of Polar marine bacteria showed interesting anti-biofilm activities on
P. aeruginosa and
S. aureus [
13,
19,
22].
In this work, we analyzed the effect of supernatants derived from four selected Antarctic marine bacteria, belonging to Pseudoalteromonas, Psychrobacter, and Pseudomonas genera, against ESKAPE pathogens.
The anti-biofilm effects of Antarctic bacterial-cell-free culture supernatants (SNs) were examined on 60 clinical ESKAPE pathogens either during biofilm development, by adding them to the medium at the beginning of the growth, or after biofilm formation. Firstly, their antimicrobial activity was evaluated to exclude any effect of SNs on bacterial viability; the results did not highlight any antimicrobial activity on all ESKAPE pathogens. On the contrary, SNs were able to prevent biofilm formation and promote the disaggregation of mature biofilm.
The obtained results have shown the great potential of Antarctic bacteria as producers of molecules that counteract the biofilm of bacterial species of significant clinical interest.
3. Discussion
Due to the resistance of ESKAPE bacteria to a broad range of antibiotics, infections sustained by these species are very difficult to eradicate, especially when they form a biofilm [
29]. It is well known that biofilm-forming bacteria are about 1000 times more resistant to antimicrobials compared to planktonic cells [
30]. For this reason, biofilm-associated bacteria, in particular the ESKAPE pathogens, represent a serious medical challenge worldwide. Consequently, there is an urgent need to develop new weapons to fight these pathogens, with particular emphasis on the eradication of their biofilms [
31]. Several strategies are currently being explored in order to treat ESKAPE-related biofilms [
2,
32]. Despite this, there are no available molecules that are actually able to interfere with biofilm formation or promote biofilm disaggregation. In fact, research is mainly focused on the discovery of novel antibiotics and/or on studies of synergy with existing antibiotics so as to counter life-threatening infections.
In the search for new effective activities against pathogens, natural compounds represent more efficient products than chemically synthesized ones, with less resistance and lower side effects [
31,
33].
We focused our attention on cold-adapted marine bacteria deriving from Antarctica for the discovery of new anti-biofilm compounds [
19]. This exotic and unusual ecological niche holds great potential as a possible source of novel drugs. Moreover, microorganisms that inhabit this environment possess a wide range of metabolic capabilities due to the physical and chemical conditions that rapidly change in this ecosystem, forcing them to abruptly adapt. For example, some molecules obtained from these bacteria display antifouling, antimicrobial, and other activities interesting for possible pharmaceutical applications [
13,
34,
35].
The main routes for ESKAPE infections are undoubtedly medical devices such as central venous catheters, endotracheal tubes, vesical catheters, tracheostomy tubes, and percutaneous endoscopic gastrostomy, which are easily colonized by these bacteria which are ubiquitous and are members of human physiological microbiota. The prospect to chemically modify the surfaces of these devices with molecules able to impair bacterial adhesion could be a promising prevention strategy. Consequently, we are searching for molecules able to inhibit biofilm development, to prevent nosocomial infections. Furthermore, it is well-known that once a biofilm has been established, it is very difficult to eradicate. In fact, in the literature, few molecules are reported as capable of acting in the disintegration of a preformed biofilm [
23,
36]. For this reason, we also searched for molecules able to destabilize mature biofilms.
Biofilm quantification was assessed by using crystal violet-based assay. In the literature, various methods have been reported that quantify total biofilm or different components of biofilm [
37,
38].
Different methods allow the quantification of total biomass, total amount of bacterial cells, viable cell number, and amount of extracellular polymeric substances. However, these methods are often confusedly used, leading to discrepancies and misleading results.
Crystal violet staining is a reliable method for total biomass quantification. Although crystal violet binds mainly to the biofilm matrix and does not allow distinguishing between viable or dead cells, it exhibited high reproducibility and repeatability and allowed us to rapidly analyze multiple samples simultaneously [
39].
In light of these reports, we think that the screening of antibiofilm activity against a large number of bacterial strains can be performed with crystal violet.
The obtained results clearly showed that any of the tested supernatants are active against all tested bacterial species. Furthermore, as expected, the activity profiles of biofilm inhibition and disaggregation are profoundly different. This result certainly confirms the heterogeneity of clinical strains, even those belonging to the same genera and species, but also suggests the different composition of supernatants deriving from the four Antarctic bacteria. The obtained results underline the deep differences between reference strains and clinical ones. This makes the need for experimental approaches such as those proposed in this work more evident, and also underlines the biofilm development complexity. Different microorganisms, although belonging to the same species, respond completely differently to treatment with the same sample. Additionally, the understanding of the mechanisms responsible for the increase in biofilm observed in such cases is certainly useful and requires a dedicated study.
Some supernatants contain molecules active both on biofilm formation and on mature biofilm disaggregation. Undoubtedly, in many cases, different molecules act on the two stages of biofilm formation; for example, supernatants deriving from TAC125 have no activity on biofilm formation by
Enterococcus EF3 but contain at least one molecule able to disaggregate its biofilm. Similarly, the supernatant from TAE6080 is effective in preventing the biofilm formation of EF1, but it is ineffective on mature biofilm (
Figure 1).
Although it could be interesting to purify the active molecules in order to gain a complete understanding of the reported results, a general overview of the reported results indicates that the anti-biofilm activity is more pronounced on Gram-negative bacterial species (
Figure 8), and that for each of the 60 tested clinical ESKAPE strains, at least one supernatant effective on biofilm inhibition and/or on mature biofilm was identified, except for the mature biofilm produced by PA27 or EC8739. This very promising result confirms Antarctic marine bacteria as a valuable source of anti-biofilm molecules.
It must also be considered that infections associated with ESKAPE bacteria are often due to multispecies biofilm where different bacteria aggregate and proliferate simultaneously. For example,
K. pneumoniae,
A. baumannii,
P. aeruginosa,
S. aureus, and
Enterobacter species are all associated with respiratory infections and pneumonia, while
K. pneumoniae,
A. baumannii,
P. aeruginosa, and
Enterobacter species are involved in urinary infections [
29].
For this reason, we evaluated the activity of each supernatant on each bacterial species in order to identify samples that can simultaneously act on multiple targets in multi-species infection (
Figure 9). For example, the SNs deriving from TAD2020 and TAC125 were able to disaggregate biofilms produced by
K. pneumoniae,
A. baumannii, and
Enterobacter species, all involved in urinary infections.
Therefore, the possibility of using molecules capable of contrasting multi-species biofilms due to their simultaneous action on different bacterial species is certainly of interest.
5. Conclusions
In conclusion, this study was focused on exploring the potential of Antarctic marine bacteria as a source of anti-biofilm molecules to fight ESKAPE pathogen infection. Four Antarctic bacterial strains were chosen, and their cell-free supernatants were tested against 60 clinical ESKAPE isolates. The supernatants did not exhibit antimicrobial activity but effectively prevented biofilm formation and dispersed mature biofilms. In detail, the obtained data showed that any of the tested supernatants is active against all ESKAPE species and that, as expected, the activity profiles of biofilm inhibition and disaggregation are profoundly different and specifically strain- and species-dependent. This result certainly confirms the heterogeneity of clinical strains but also suggests the different composition of supernatants deriving from the four Antarctic bacteria. Moreover, the evaluation of the activity of each supernatant on each pathogenic species allowed the identification of Antarctic samples that can simultaneously act on multiple targets in multi-species infections.
In light of the data shown, the message of this study is to pursue the search for anti-virulence molecules, even from unexpected sources, in order to identify new weapons against infections sustained by ESKAPE bacteria. These new activities could represent the starting point for the identification of promising new drugs that can be used in synergy with conventional antibiotics for the eradication of ESKAPE-associated infections. Given the challenges, any potential solution must be explored.