**About the Editor**

**Ana Mar´ıa D´ıez-Pascual** graduated with a degree in Chemistry in 2001 (awarded the Extraordinary Prize) from Complutense University (Madrid, Spain), where she also carried out her Ph.D. studies (2002–2005) on the dynamic and equilibrium properties of fluid interfaces under the supervision of Prof. Rubio. In 2005, Dr. Diez-Pascual worked at the Max Planck Institute of Colloids and Interfaces (Germany) with Prof. Miller on the rheological characterization of water-soluble polymers. From 2006 to 2008, she was a Postdoctoral Researcher at the Physical Chemistry Institute of the RWTH Aachen University (Germany), where she worked on the layer-by-layer assembly of polyelectrolyte multilayers onto thermoresponsive microgels. Dr. Diez-Pascual then moved to the Institute of Polymer Science and Technology (Madrid, Spain) and participated in a Canada–Spain joint project to develop carbon nanotube (CNT)-reinforced epoxy and polyetheretherketone composites for transport applications. Currently, Dr. Diez-Pascual is a Permanent Professor at Alcala University (Madrid, Spain), where she focuses on the development of polymer/nanofiller systems for biomedical applications. She has participated in 25 research projects (15 international and 10 national, of which 3 have been with private companies, and she was the principal investigator in 6 of the projects). She has published 112 SCI articles (97% in Q1 journals) and has an h-index of 41 and more than 3500 total citations. More than 50% of her articles are in journals with an impact factor of ≥4.8, such as *J. Mater. Chem, Carbon*, and *J. Phys. Chem. C.* She is the first and corresponding author of two invited reviews in Prog. Mater. Sci. and a frequent reviewer for journals published by ACS, MDPI, and Elsevier. Dr. Diez-Pascual has published 22 book chapters and 2 monographs and edited 5 books; she is the first author of an international patent. She has contributed to 65 international conferences (49 oral communications, including 6 by invitation) and has been a member of the organizing committee in 3 workshops and 1 national meeting. She has been invited to present seminars at prestigious international research centers, such as Max Planck in Germany, NRC in Canada, and the School of Materials in Manchester, UK. She was awarded the TR35 2012 Prize by the Massachusetts Institute of Technology (MIT) for her innovative work in the field of nanotechnology.

### *Editorial* **Recent Progress in Antimicrobial Nanomaterials**

#### **Ana Maria Díez-Pascual**

Department of Analytical Chemistry, Physical Chemistry and Chemical Engineering, Faculty of Sciences, Institute of Chemistry Research "Andrés M. del Río" (IQAR), University of Alcalá, Ctra. Madrid-Barcelona, Km. 33.6, 28871 Alcalá de Henares, Madrid, Spain; am.diez@uah.es; Tel.: +34-918-856-430

Received: 23 October 2020; Accepted: 13 November 2020; Published: 23 November 2020

Bacterial infections are a well-known and serious problem in numerous areas of everyday life, causing death, pain, and huge added costs to healthcare worldwide. They also cause major issues in many other industries, such as textiles, water treatment, marine transport, medicine, and food packaging. Despite strong efforts by academic researchers and industries, a universal solution for controlling bacterial adhesion and proliferation has not yet been found. Over the last years, many novel antibacterial nanomaterials have been developed, and some of them are already applied in hospitals and public buildings. This Special Issue, with a collection of nine original contributions and two reviews, provides selected examples of the latest advances in the field of antibacterial nanomaterials and their applications in various fields.

Recent advances in nanoscience and nanotechnology have led to the development of advanced functional nanomaterials with unique chemical and physical properties. The large surface-area-to-volume ratio of nanoparticles (NPs) opens many possibilities for developing bactericidal agents to treat deadly microbial infections. In particular, metal and metal-oxide NPs have attracted great attention as promising candidates for antibacterial agents [1,2]. The key mechanisms for the antibacterial activities of these NPs include: (a) oxidative stress due to reactive oxygen species (ROS) generation [3], in which the oxidation in bacteria cells induces peroxidation of the lipid membrane, thus destructing proteins and DNA.;(b) the release of metal ions release from metal or metal-oxide NPs penetrating over bacteria cell walls that directly interact with amino and carboxylic acid groups of proteins and nucleic acids, resulting in cell death [4]; (c) membrane disruption due to accumulation of the NPs at the bacterial membrane followed by NP internalization.

Silver nanoparticles (AgNPs) have been applied as antibacterial agents for textile fabrics, healthcare products, cosmetics, coatings, and wound dressings, owing to their effective bactericidal action. Furthermore, they are employed in clinical practice for an extensive range of treatments, such as burns, chronic ulcers, and diabetic wounds that have developed antibiotic resistance. In addition to anti-inflammatory effects, AgNPs-treated wounds have revealed abundant collagen deposition able to accelerate wound healing [5]. However, AgNPs are toxic for several human cell lines and induce dose-, size-, and time-dependent cytotoxicity, especially those with sizes of ≤10 nm [6]. To overcome these disadvantages, their immobilization onto various supporting materials, such as metal oxides, activated carbon, graphene oxide, polymers, etc., have been investigated [7]. The modification of AgNPs with titanate nanotubes (TNT) leads to changes in their physicochemical characteristics, such as size, shape, stability, and oxidation state, leading to improved antibacterial, photocatalytic, and catalytic activities. Immobilization onto polysaccharides such as carboxymethyl-cellulose (CMC) with different degrees of substitution and molecular weight has also been reported [8], and it was found that the particle size distribution and morphology of AgNPs are conditioned by the number of functional groups available for their immobilization. Accordingly, smaller particle sizes were obtained for CMC with a higher degree of substitution, resulting in increased antibacterial activity and cytotoxicity of the samples.

Compared to other types of nanoparticles, titanium dioxide (TiO2) is particularly attractive for photocatalytic bactericidal activity, owing to its somewhat low cost, natural abundance, and improved chemical stability [9]. It is an n-type semiconductor due to the presence of oxygen vacancies that favor the formation of Ti3<sup>+</sup> centers, acting as electron donors [10]. Furthermore, these vacancies can influence charge transport and electron–hole recombination processes by trapping charge carriers in the defect sites. To achieve antibacterial inactivation under visible light, TiO2 NPs can be doped with metal and nonmetal elements, modified with carbonaceous nanomaterials, coupled with other metal-oxide semiconductors, or deposited onto fibrous materials [11,12]. The modification of TiO2 NPs with carbon-based nanomaterials, such as nanotubes or graphene, also results in efficient ROS formation under visible-light irradiation [13]. By incorporating TiO2 NPs into polymers such as chitosan or epoxidized vegetable oils [14], the resulting polymer nanocomposites exhibit excellent antimicrobial properties that can have applications in fruit/food wrapping films, self-cleaning fabrics, medical scaffolds, antimicrobial coatings, and wound dressings.

Copper-containing compounds, such as CuSO4 and Cu(OH)2, are used as conventional antibacterial agents. In addition, aqueous copper solutions, complex copper species, or copper-containing polymers are used as antifungal compounds. On the other hand, liposomes are nanovesicles made with phospholipids traditionally used as delivery vehicles because phospholipids facilitate cellular uptake. Their carrier capacity and hydrophilic/hydrophobic balance are beneficial for developing hybrid nanostructures based on metallic NPs. Thus, with the aim to improve the effectiveness of traditional bactericide agents, nanovesicular systems have been loaded with Cu NPs electrosynthesized in organic media [15]. The nanovesicles have been synthesized by the thin-film hydration technique in aqueous media, using phosphatidylcholine and cholesterol as membrane stabilizers. Several quaternary ammonium salts were tested as stabilizing surfactants for the synthesis and insertion of CuNPs. These are attached mainly to the membrane, probably due to the attraction of their hydrophobic shell to the phospholipid bilayers. It was found that the stability of the liposomes increased upon increasing NP loading, signifying a charge-stabilization effect in a novel material that can fight against antibiotic-resistant biofilms. The use of nanovesicles is of great interest since their size is in the order of 100 to 1000 nm, whereas safety regulations apply for ultrafine NPs [16].

Zinc oxide (ZnO) nanostructures are widely used materials capable of antimicrobial action [17]. With a wide bandgap of 3.4 eV and large exciton-binding energy of 60 meV at room temperature, they are widely used for optical devices [18]. These environmentally friendly materials possess a large volume-to-area ratio, crystalline structure, radiation hardness, good mechanical properties, and high thermal conductivity and are highly suitable as catalysts, gas sensors, or reinforcing fillers in polymers [19]. They can be obtained by several methods, including physical and chemical approaches. Bearing in mind the recent growth in environmentally friendly and low-cost synthetic routes for nanomaterial synthesis, electrochemical techniques represent a valid alternative to biogenic synthesis. In this regard, the aqueous electrosynthesis of ZnO nanomaterials (both rod-like and flower-like structures) with different aspect ratios based on the use of alternative stabilizers such as benzyl-hexadecyl-dimethylammonium chloride (BAC) and poly-diallyl-(dimethylammonium) chloride (PDDA) has been reported [20]. The combination of UV–vis, FTIR, and XPS spectroscopies demonstrated the whole conversion of the raw colloidal materials into stoichiometric ZnO species with moderate morphological modification. Both BAC- and PDDA-modified nanomaterials showed a strong antimicrobial efficacy against *B. subtilis*, as demonstrated by agar diffusion tests. This approach is an efficient alternative to current methodologies to produce elongated ZnO nanomaterials in an aqueous solution with cationic capping agents, leading to higher yields and milder preparation conditions. Application of these ZnO nanostructures in transistor devices (PDDA-capped) and for cultural heritage preservation (BAC-capped) is foreseen.

Layer-by-layer (LbL) assemblies, based on the alternated adsorption of oppositely charged compounds, is a versatile approach that allows control at the nanoscale [21]. A wide range of LbL antimicrobial coatings comprising polymers, nanoparticles, enzymes, peptides, biological molecules, and antibiotics as building units have been reported [22]. Their antimicrobial action is based on bioadhesion resistance, contact-killing, release-killing, or a combination of such mechanisms [23].

LbL assemblies comprising poly(allylamine hydrochloride) and poly(sodium 4-styrene sulfonate) showed significant antimicrobial activity via contact killing, and poly (L-lysine)/poly (L-glutamic acid) multilayers with the top bilayers bearing the pegylated polyanion drastically suppressed the adsorption of *E. coli* [24]. LbL assemblies comprising two naturally occurring antimicrobials, lysozyme, and chitosan, together with Nafion, a synthetic ionomer-bearing hydrophilic sulfonic acid group, has recently been reported [25]. Owing to its chemical composition, Nafion forms proton-exchange membranes with utmost structural and chemical stability highly suitable for fuel cell applications. Although the surface charges of Nafion were neutralized and even overcompensated by the adsorption of positively charged molecules, the coatings displayed noticeable antimicrobial activity against *E. coli* and *S. aureus*. It is envisaged that the synergistic effect of Nafion and conventional antimicrobial agents can generate highly effective platform coatings with enhanced bactericidal action.

Polyhydroxyalkanoates (PHAs) are a class of biocompatible and biodegradable polymers belonging to the family of natural polyesters synthesized by bacterial fermentation from renewable resources such as cane sugar [26], widely used in a variety of applications ranging from nanotechnology, medical, tissue engineering, and packing industries [27]. However, PHAs possess limited applications in the biomedical field due to their brittleness and poor mechanical properties. To improve the mechanical and thermal properties of PHAs, they can be copolymerized with different monomers such as 3-hydroxyhexanoate (HHx), providing better flexibility and biodegradability compared to raw PHAs [28]. Furthermore, blending with other biopolymers such as chitosan (Ch) can lead to improved physicochemical properties [29].

Other natural compounds that have a low environmental impact are also receiving widespread attention. In particular, plant-derived bioactive substances have been applied as natural preservatives (e.g., essential oils) in the food industry due to their antifungal properties [14]. Eugenol (1,2-methoxy-4-(2-propenyl)-phenol), a main component of the herbal oil from basil, has been categorized as GRAS (generally recognized as safe) food additive since it is beneficial for the food field due to its antimicrobial properties against a comprehensive range of microorganisms [30]. However, eugenol is highly volatile and has poor water solubility, which limits its applications. Caseins, the main component of milk proteins in bovine milk, is a cheap and commercially available food-grade additive. The amphiphilic nature of caseins makes them suitable for encapsulating compounds of poor water solubility. In this regard, eugenol-entrapped casein nanoparticles have been prepared via a low-energy and simple self-emulsifying technique [31]. A mass ratio of 5:1 of caseins/eugenol yielded the best encapsulation efficiency and stability. This encapsulation with casein noticeably enhances the antifungal efficacy against anthracnose. These results indicate that EC-NPs nanoparticles could be used as an economical and simple-manufactured preservative for postharvest fruits against microbial spoilage.

On the other hand, hexagonal boron nitride (hBN) nanostructures exhibit comparable or even better properties than their carbon counterparts and are stable under oxidative conditions up to 1000 ◦C. They display a very high Young's modulus (up to 1.3 TPa), piezoelectricity, hydrogen storage capacity, superhydrophobicity, lubricant behavior, and good biocompatibility, which makes them suitable for biomedical applications including drug delivery, biosensors, biomaterials, and neutron capture therapy [32]. The potential antibacterial effect and cell viability efficacy of PHA/Ch-hBN nanocomposites loaded with three different concentrations of hBN nanoparticles have been recently investigated [33]. Nanocomposites were prepared through a simple solvent casting technique. The fabricated PHA/Ch-hBN nanocomposites demonstrated effective antimicrobial against *S. Aureus* and *E. Coli*, and good biocompatibility properties that would be suitable for biomedical applications.

Synthetic bactericidal patterned surfaces that are capable of killing the bacteria via mechanical mechanisms have recently been developed via nano-/microfabrication techniques [34]. Different design parameters are known to affect the bactericidal activity of nanopatterns. Evaluating the effects of each parameter, isolated from the others, requires systematic studies. A recent article has evaluated the influence of the interspacing and disordered arrangement of nanopillars on the bactericide properties of nanopatterned surfaces [35]. Electron beam induced deposition (EBID) was used to manufacture the nanopatterns with accurately controlled dimensions as well as disordered versions of them. The killing efficiency of the nanopatterns against *S. Aureus* increased by decreasing the interspace, achieving the highest efficiency on the nanopatterns with 100 nm interspacing. In contrast, the disordered nanopatterns did not influence the killing efficiency significantly, as compared to their ordered correspondents. Thus, optimizing the design of nanopatterns should focus on the interspacing as an important parameter affecting the bactericidal properties.

#### **References**


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## *Review* **Nanoparticle-Based Therapeutic Approach for Diabetic Wound Healing**

**Hariharan Ezhilarasu 1, Dinesh Vishalli 2, S. Thameem Dheen 1, Boon-Huat Bay <sup>1</sup> and Dinesh Kumar Srinivasan 1,\***


Received: 2 June 2020; Accepted: 22 June 2020; Published: 25 June 2020

**Abstract:** Diabetes mellitus (DM) is a common endocrine disease characterized by a state of hyperglycemia (higher level of glucose in the blood than usual). DM and its complications can lead to diabetic foot ulcer (DFU). DFU is associated with impaired wound healing, due to inappropriate cellular and cytokines response, infection, poor vascularization, and neuropathy. Effective therapeutic strategies for the management of impaired wound could be attained through a better insight of molecular mechanism and pathophysiology of diabetic wound healing. Nanotherapeutics-based agents engineered within 1–100 nm levels, which include nanoparticles and nanoscaffolds, are recent promising treatment strategies for accelerating diabetic wound healing. Nanoparticles are smaller in size and have high surface area to volume ratio that increases the likelihood of biological interaction and penetration at wound site. They are ideal for topical delivery of drugs in a sustained manner, eliciting cell-to-cell interactions, cell proliferation, vascularization, cell signaling, and elaboration of biomolecules necessary for effective wound healing. Furthermore, nanoparticles have the ability to deliver one or more therapeutic drug molecules, such as growth factors, nucleic acids, antibiotics, and antioxidants, which can be released in a sustained manner within the target tissue. This review focuses on recent approaches in the development of nanoparticle-based therapeutics for enhancing diabetic wound healing.

**Keywords:** nanoparticle; drug delivery system; diabetes mellitus; wound healing; diabetic foot ulcer; pathophysiology

#### **1. Introduction**

Diabetes mellitus (DM) is a chronic health problem that is prevalent among the human population. DM is an endocrine disorder which is distinguished by the state of hyperglycemia (higher level of glucose in the blood), and is classified into Type 1 DM and Type 2 DM. Factors associated with a steady increase in DM are aging populations, dietetic revolutions and sedentary lifestyles [1,2]. On the basis of 2019 prevalence data from the International Diabetes Federation (IDF), the estimated number of adults (20–79) with DM worldwide is 463 million, which is expected to increase to 578.4 million by 2030 and 700.2 million by 2045 [3]. It is anticipated that DM may increase in developing countries as compared to developed countries (Figure 1). In 2019, IDF revealed that the number of deaths resulting from DM and its complications was 4.2 million worldwide [3]. It is projected that the annual global health expenditure on DM in 2019 is USD 760 billion, which will reach USD 825 billion by 2030 and USD 845 billion by 2045 [3]. Therefore, DM has emerged as one of the serious health threats with a huge socioeconomic burden.

**Figure 1.** Prevalence of DM (millions) by IDF regions in adults (>65 years) in 2019, 2030 and 2045 [3]. IDF: International Diabetes Federation; NAC: North America and Caribbean; EUR: Europe; MENA: Middle East and North Africa; SEA: South-East Asia; SACA: South and Central America; AFR: Africa; WP: Western Pacific.

DM increases the risk of infection and delays wound healing due to impairment of metabolic activity. As DM advances, a complication that may occur is diabetic foot ulcers (DFUs), a chronic wound that affects the lifestyle of patients and consequently, heightening the risk of mortality [1]. Worldwide, 9.1 to 26.1 million people with DM develop DFU annually. Individuals with DM stand a 25% chance of risk for DFU, and sadly, many cases must ultimately opt for amputation as the treatment modality. Fifty percent DFU amputees have an average 3-year survival rate as a result of infection and unsolved arterial injury, while for post-treatment patients with healed DFU, 50% to 70% may have recurrence within 5 years [1,4,5]. Though DFU is preventable, it puts a massive burden on patients and health care services. A cautious lifestyle as a preventive front, timely assessment and high-level treatments by a multi-disciplinary group of specialists are effective approaches for DFU management [6].

#### *1.1. Pathophysiology of Diabetic Foot Ulcer (DFU)*

Peripheral arterial disease (PAD), neuropathy, ischemia, and infection are the key factors influencing the development of DFU. Figure 2 shows a flow diagram depicting the factors that contribute to the pathophysiology of DFU [7].

#### *1.2. Neuropathy*

DFU may develop as a result of neuropathy caused by hyperglycemia [8]. The hyperglycemic condition increases stimulation of the enzymes, aldose reductase and sorbitol dehydrogenase, which lead to conversion of intracellular glucose to sorbitol and fructose. The accumulation of converted glucose products results in a decrease in the synthesis of nerve cell myoinositol [9]. In addition, the chemical change associated with glucose induces depletion of nicotinamide adenine dinucleotide phosphate (NADP), which is essential for the detoxification of reactive oxygen species (ROS) and for the synthesis of the vasodilator, nitric oxide (NO). There is a subsequent upsurge in oxidative stress on the nerve cells and an increase in vasoconstriction leading to ischemia, which will cause nerve cell damage and cell death [10,11]. Neuropathy affects all the components of the nervous

system, viz., sensory, motor and autonomic. In autonomic neuropathy, the foot becomes dry as it loses the ability to moisturize its surface due to decreased secretory functions of the sebaceous and sweat glands, thereby encouraging infections to spread [5,8].

**Figure 2.** Pathophysiology of DFU. Reproduced from [7], with permission from Elsevier, 2006.

#### *1.3. Peripheral Arterial Disease (PAD)*

DFUs are also known to be caused by the complications of PAD. Multiple factors other than DM are associated with greater risk of PAD including age, smoking, hypertension, hyperlipidemia, inflammatory markers, and renal dysfunction [12]. Diabetic vascular complications are divided into microvascular and macrovascular disease. In the diabetic state, due to the upsurge in glucose, endothelial cellular dysfunction and smooth muscle abnormalities develop as a consequence of a reduction in endothelium-derived vasodilators, leading to constriction of blood arteries in the foot [13]. Furthermore, atherosclerosis with thickening of blood capillaries and hardening of arteriolar walls, cause blockage in major arteries such as femoro-popliteal and aortoiliac vessels, resulting in ischemia [2].

#### **2. Normal and Diabetic Wound Healing**

Wound healing is a complex process with dynamic interactions of different cell types, extracellular matrix (ECM), cytokines and growth factors. The fundamental steps of wound healing include hemostasis, inflammation, cell movement, and proliferation, followed by wound compression and further remodeling [14]. Any bleeding associated with penetration of skin to the dermis layer by trauma is considered as a wound [15]. The first step in initiating the wound healing process is hemostasis, a clotting process involving the coagulation cascade that leads to cessation of bleeding. The first subset of cells that enter the injury site are platelets, which release several growth factors such as platelet derived growth factor (PDGF), transforming growth factor beta (TGF-β), endothelial growth factor (EGF), and fibroblast growth factor (FGF), which support the inflammation process [16,17]. The inflammatory phase occurs immediately after hemostasis and is characterized by vascular delivery of inflammatory agents and migration of cells into the injury site. Release of inflammatory mediators,

such as prostaglandins, histamine and leukotrienes by mast cells, which stimulates angiogenesis and permeability to allow cells and molecules from the blood stream to enter the wound site [18,19]. Neutrophils, monocytes and lymphocytes are white blood cells that invade the injury site. Neutrophils combat microbial infections and macrophages, stimulate angiogenesis by secretion of TGF-β, vascular endothelial growth factor (VEGF) and FGF, and produce tumor necrosis factor alpha (TNF-α), which breakdown necrotic tissue, facilitating the proliferation of fibroblasts that deposit collagen for tissue granulation [20,21]. Wound contraction begins 2 weeks after a dermal wound. During tissue granulation, fibroblasts differentiates to myofibroblasts phenotype, with enhanced alpha smooth muscle actin (α-SMA) cytoskeleton, which plays a vital role in wound closure. Re-epithelialization of tissue occurs when the wound bed is covered by new tissue and keratinocytes migrate, differentiate and proliferate to generate a stratified epidermis along the superficial area of injury, providing cover for newly formed tissue [22,23]. The last phase in the wound healing process (which lasts 6 to 24 months) is wound remodeling. In this phase, granulation tissue forms accompanied by replacement of the ECM with type I collagen (substituting collagen III) mediated via PDGF and TGF-β [24,25] (Figure 3).

**Figure 3.** Factors affecting normal and diabetic wound healing. Reproduced from [1], with permission from Royal Society of Chemistry, 2017.

In diabetic wounds, a larger number of inflammatory macrophages continue to stay at the site of injury for a longer period, compared to normal wound healing. These macrophages produce an increased ratio of pro-inflammatory cytokines, such as TNF-α and interleukin 6 (IL-6) and elaborate ROS causing persistent inflammation, which lead to stimulation of proliferative factors for successful wound healing. However, the common cytokine cascade is perturbed due to inefficient efferocytosis (phagocytosis of apoptotic cells) by macrophages, related to the higher burden of apoptotic cells. Increased ratio of pro-inflammatory cytokines (IL-1β and TNF-α) and matrix metalloproteinase-9 (MMP-9) with decreased anti-inflammatory signals (CD206, IGF-1, TGF-β and IL-10) will lead to abnormal apoptosis of fibroblasts and keratinocytes, together with decreased angiogenesis [26–28]. In diabetic wound healing, fibroblasts do not properly differentiate into myofibroblasts, leading to reduced mechanical tension of ECM, and subsequently poor wound closure due to lack ofα-SMA [28–30]. In impaired wound healing, a non-equilibrium balance between MMPs that degrade the disorganized collagen in normal wound healing and tissue inhibitor of metalloproteinases (TIMPs), lead to abnormal ECM degradation and deposition. Lower expression of TIMPs and higher expression of MMPs are due to the persistently high levels of pro-inflammatory cytokines and pro-fibrotic cytokines. In a chronic wound, levels of MMPs are raised 60 times more than that for acute wound healing [30]. Increase in protease activity in tissue reconstruction enhances degradation of ECM, growth factors and collagen deposition, which are crucial for effective wound healing [31,32]. All these factors, together with a dysregulated molecular and cellular wound microenvironment that is not conducive to normal healing responses, culminate in impaired healing of diabetic ulcer [1] (as illustrated in Figure 3).

#### **3. Therapeutic Modalities for Diabetic Foot Ulcers**

Chronic wounds remain a significant public health problem. Alterations in normal physiological healing processes caused by aging or diabetes, lead to impaired tissue repair and the development of chronic and non-healing wounds. Understanding the unique features of the wound environment will be required to develop new therapeutics that impact these disabling conditions. Although there are numerous strategies for the treatment of DFU, it remains a major challenge to optimize the therapeutic approach in the clinical healthcare setting [33]. Systemic delivery, the most common approach for administering drugs to patients, relies on adequate perfusion of the target tissue and blood supply, that many chronic wounds lack. Moreover, there may be significant potential harmful side-effects to non-target tissues. On the other hand, topical delivery is primarily intended for a local effect which can potentially eliminate the need for systemic administration of drug therapies, minimize the total dose required to reach the target site, and reduce off-target adverse effects [34,35]. Wound care has traditionally relied on dressings, including both natural and synthetic materials and drugs, to sustain a warm and moist surrounding for conducive wound healing, while diminishing bacterial infection [35]. Topical delivery of free siRNA, proteins, antibiotics, and nucleic acids, may lead to degradation of these encapsulated compounds by endogenous enzymes produced in chronic wounds, increased drug clearance due to rapid half-life, toxicity to tissues or organs, and uncontrolled delivery of drugs, leading to under dosage or over dosage and inappropriate immune responses [36,37]. Moreover, topical application of therapeutic drugs offers a poor solution with regard to diabetic wound healing due to the development of bacterial resistance against antibiotics [38].

Other diabetic wound healing therapies, such as bioengineered grafts, face the problems of decreased angiogenesis and physiological rejection. Growth factor therapy may encounter problems associated with breakdown of growth factor at wound site, synthetic hydrophobic polymer dressings with ineffective release of bioactive components, silver dressings with cellular toxicity at specific concentrations, and natural polymer dressings may give rise to allergic reactions [39]. Commercially available hydrofiber and hydropolymer dressings, as well as alginates, are not suitable for dry wounds. On the other hand, hydrocolloidal dressings require a secondary dressing to prevent contamination and also not an option for substantial draining wounds. Foam dressings may cause dehydration of wounds, which arrest epithelialization of the ulcer. Currently, there is no experimental verification of a single type of wound dressing that is effective in eliminating every limitation posed by DFU [40].

#### **4. Nanotechnology Based Drug Delivery System**

New drug-delivery systems (DDSs) may enhance the current and future therapies for this challenging clinical problems [35]. Recently, nanotechnology has become one of the most focused research areas for the treatment of DM patients and its associated complications. The advantage of nanomaterials (with a range of 1–100 nm) are versatility in use, controlled size, and tunability of physiochemical properties. Nanomaterials with a larger surface area to volume ratio allow for cell adhesion, and possibly can encapsulate a greater number of surface functionalized active components to accelerate specific regenerative functions [41]. The nanotechnology-based wound healing methods confer advantages such as topical drug delivery, cell specificity, and sustainable and controlled release of encapsulated drugs for a required period until the wound heals [34,42]. In the case of wound healing, nanoparticles are ideal for topical delivery, supporting better interactions with the biological target and increased penetration at the wound sites. Besides, encapsulated drugs could be delivered in a sustained manner and delivery rate could be suitably altered by changing the nanoparticle distribution. Thus, wound healing treatments incorporating the nanotherapeutics approach for delivery of therapeutic biomolecules, paves the way for an excellent opportunity to tackle the complexity of diabetic wound healing by [43,44].

Conceptually, topical delivery of nanotherapeutics has major advantages for chronic wounds such as diabetic wound, by promoting effective wound healing and skin regeneration due to: (a) multifactorial factors and cell-type specificity and (b) use of therapeutic agent for a limited time or until the wound has healed. Nanotechnology-based materials act as smart nanomaterials in the form of nanofibers and hydrogel, foams loaded with nanoparticles which can encapsulate antibiotics, growth factors, peptides, nucleic acids and extracellular substrates, with the possibility of combined delivery of two different therapeutic agent with dissimilar characteristics to enhance the healing process, that include liposomes, polymeric nanoparticles, inorganic nanoparticles, lipid nanoparticles, nanofibrous structures, and nanohydrogel [34,39,45–47] (as shown in Figure 4).

**Figure 4.** Nano-DDSs in skin regeneration and wound treatment. Adapted from [46], with permission from Springer Nature, 2019.

Drugs are absorbed, dispersed or dissolved around the nanoparticle, and confined in an aqueous core with shell like surroundings, or alternatively the drug can be covalently bound to the surface matrix of nanoparticles [48]. In the biological system, the drugs loaded in the nanoparticles will be released by diffusion, dissolution, reduction and distension. Furthermore, nanoparticles can be encapsulated in nanofiber, hydrogel, foam, films and nanocrystals as a nanocomposite system along with other drugs (Figure 5), which allows for synergistic effect between nanoparticles and the drug of interest, creating a new concept of wound dressing that promotes enhanced wound healing [49]. Such dressings have increased porosity surface-to-volume ratio, and their structure simulates the topographic appearance of endogenous ECM, allowing attachment and spreading of both fibroblasts and keratinocytes, thereby facilitating collagen synthesis and re-epithelialization of wounds [41].

**Figure 5.** Schematic of nanomaterial, from nanoparticle to nanoparticulate system for wound regeneration. NFs—Nanofibers, NPs—Nanoparticles, HGs—Hydrogel, FMs—Films and membrane, MCs—Multicomposites. Reproduced from [49], with permission from Elsevier, 2017.

#### **5. Nanoparticle Delivery of Therapeutic Drugs for Diabetic Wound Healing**

It is well established that delivering of therapeutic active components such as growth factors, nitric oxide, nucleic acid, antioxidants, and antibiotics to damaged tissue, can stimulate cell proliferation, migration, angiogenesis, and collagen secretion, and inhibit microbes, thereby influencing healing of chronic wounds [50]. Nanofibers have received much attention because of their structural similarity, which closely mimics the native ECM environment [51,52]. Nanofibers promote wound healing by providing characteristics of high surface area to volume ratio, tunable mechanical properties, increased porosity, and ability to encapsulate nanoparticles and bioactive compounds for controlled release, which can support the cells to actively interact with the matrix during functionalization and remodeling [53,54]. Hydrogels are hydrophilic 3D polymer networks with established applications in tissue engineering and drug delivery. Hydrogels with high water content, tunable viscoelasticity and biocompatibility have been intensively explored to enable topical delivery of bioactive molecules [55,56]. More importantly, nanoparticle and biomolecules can be incorporated in hydrogels and thus, opens the door to more advanced topical drug delivery with unique benefits such as improved tissue localization, minimized burst release and controlled sequential drug release, by preserving its structural integrity of nanoparticle [57]. Non-polymeric nanoparticles such as silver nanoparticles (AgNPs) and gold nanoparticles (AuNPs) are widely used as therapeutic agents, primarily for their anti-infective and anti-inflammatory effects [58]. There is an unmet need for a novel antibiofilm approach and effective antimicrobial compounds, and silver nanotechnology-based therapeutics has captured the attention of health care providers for enhancing health care [59]. AgNPs are used in clinical practice for a wide range of treatments such as burns, chronic ulcers and diabetic wounds that have developed antibiotic resistance and hospital acquired bacterial infection. In addition to anti-inflammatory effects, AgNPs treated wounds have shown abundant collagen deposition that could accelerate wound healing [60,61]. Biocompatible AuNPs are extensively used in tissue regeneration, targeted drug delivery and wound healing. Unlike Ag nanomaterials, Au nanomaterials as a single material alone does not have any antimicrobial activity. Thus, AuNPs must be incorporated with other biomolecules to be used for effective biological functions [62,63]. Zinc (Zn) can be used for treating type 1 and type 2 DM, owing to its role in the function of >300 enzymes that are necessary to maintain metabolic homeostasis in the body. Zn reduces blood sugar levels by inhibiting glucose absorption and raising glucose absorption

by skeletal muscles and adipose tissues [64]. Zinc oxide (ZnO) nanoparticles have been explored as drug delivery carriers and therapeutic approaches for human biomedical applications because of the fact of their biocompatibility [65]. ZnO nanoparticles have exhibited therapeutic activities against melanoma, diabetes, bacterial infection, and inflammation, and have shown potential for wound healing applications [66]. Ceramic nanoparticles containing inorganic components have fundamental therapeutic ability and can transport drugs to injury sites [67]. Lipid-based nanoparticles, in addition to being safe, are extensively used to deliver both hydrophilic and hydrophobic drugs. Liposomes sustain long term release of drugs by reducing the toxicity exerted by huge release of drugs via conventional administration [68]. In the case of polymeric nanoparticles, chitosan is a natural polymer to use, due to its biocompatibility and antimicrobial activity. It is possible to encapsulate a wide range of natural components such as aloe vera, vitamin E and curcumin, which have potential beneficial effects on skin wound healing [69,70]. PLGA or poly (lactic-*co*-glycolic acid), poly (ε-caprolactone) (PCL), poly (lactic acid) (PLA), and poly (ethylene glycol) (PEG) are synthetic polymers approved by Food and Drug Administration (FDA). Among these polymers, PLGA is considered the best biodegradable polymer due to its ability to release lactate, a degradation byproduct. PLGA nanoparticles have been reported to stimulate cell proliferation and shorten the duration of wound healing in diabetic rats and despite moderate drug loading may be a promising delivery system for growth factors [71,72].

The type of therapeutics that can be delivered by nanoparticles are given below.

#### *5.1. Growth Factors*

Growth factors are physiologically active proteins involved in cell proliferation, migration, differentiation, and metabolism. Physiologically, every healing process is regulated by growth factors and cytokines. Growth factors bind to a specific receptor and stimulate a series of molecular mechanisms that are essential for cell function [73]. In the wound healing process, growth factors play an important role by stimulating inflammatory response, angiogenesis, granulation of tissue, and modelling. It is well established that in a diabetic wound, the availability of growth factors will decrease due to the pathophysiology [74,75]. External administration of growth factors can be given, but proteases present in the wound bed can easily degrade these growth factors physiologically. Furthermore, the short half-life of growth factors and their reasonably large size, together with toxicity at an elevated systemic dosage, shows that conventional delivery techniques of growth factor in a free form are not appropriate to transport growth factors effectively in the wound bed. In addition, as various biomolecules are engaged in wound healing progression, sometimes it may be inadequate to utilize a single growth factor to accelerate wound closure in diabetic ulcers [76,77]. With these problems, encapsulation of growth factors in nanoparticles have been widely used to overcome the limitation of protein administration by improving the half-life, encapsulation of more than one biomolecule, and protection against degradation by proteases in the wound bed through protective characteristics of nanoparticles [78]. Nanoparticle-loaded recombinant human EGF (rhEGF) has been shown to provide faster healing of wound compared to free rhEGF administration in rats, due to the sustained release of rhEGF [79]. Nanoparticle-loaded VEGF have been observed to induce faster acceleration of wound closure in both diabetic and non-diabetic mice, as compared to PLGA nanoparticle and VEGF alone [80]. Gainza et al. fabricated rhEGF loaded solid lipid nanoparticles (SLN) and nanostructure lipid carrier (NLC) using the emulsion ultrasonication method. The same investigators showed that SLN-rhEGF and NLC-rhEGF significantly increased wound closure in diabetic mice compared to free rhEGF and alginate microspheres with rhEGF, suggesting that there is controlled release of rhEGF from lipid nanoparticle without loss of rhEGF bioactivity after encapsulation [81]. In another study, Losi et al. reported that poly(ether)urethane-polydimethylsiloxane/fibrin-based scaffold containing PLGA nanoparticles loaded with VEGF and basic fibroblast growth factor (bFGF) (scaffold/growth factor-loaded NPs) stimulated significant granulation tissue formation, collagen secretion and re-epithelialization, thereby promoting considerable increase in wound closure rate in diabetic mice, as compared to scaffold with PLGA nanoparticles without growth factors and controls. The same authors further suggested that

the observed results may be due to: (i) controlled delivery of growth factor from the encapsulated nanoparticles, (ii) simultaneous delivery of more than one growth factor, and (iii) administration of growth factor protecting from enzymatic hydrolysis by encapsulating in nanoparticles [82]. In another study, chitosan-based hydrogel carrying human epidermal growth factor was conjugated with sodium carboxymethyl chitosan nanoparticles (NaCMCh-rhEGF) for controlled release of growth factor in an excision wound model on diabetic rats. The in vitro results demonstrated that the NaCMCh-rhEGF stimulated higher cell viability, thereby reducing the wound area significantly on day 15 in comparison to free rhEGF and controls [83]. Lai et al. fabricated a collagen (Col)- hyaluronic acid (HA) electrospun nanofibrous scaffold encapsulated with gelatin nanoparticles that can release multiple angiogenic growth factors such as VEGF, PDGF, bFGF, and EGF at the excision wound site. Topical application of Col-HA membrane with four kinds of growth factors (Col-Ha w/4GF) on the diabetic wound bed accelerated complete healing of excision wound in rats along with elevated collagen synthesis, re-epithelialization and vascularization compared to control animals [84]. Furthermore, Li et al. conjugated keratinocyte growth factor (KGF) with AuNPs to determine the stability and binding affinity of KGF for diabetic wound healing. The result showed that by KGF-AuNPs conjugation, KGF retained its bioactive affect at the wound site at greater stability and resistance against proteolytic degradation to promote keratinocytes proliferation and migration and generated greater binding effect to its physiological receptor than unmodified KGF. Moreover, KGF-AuNPs at wound site supported re-epithelialization and wound contraction along with elevated expression of Col-I, α-SMA and TGF-β1. These observed conditions lead to accelerated wound healing by fabricated KGF-AuNPs when compared to controls [85]. Recently, the safety and efficiency of topically administered exogenous growth factors (VEGF or bFGF) in the healing of chronic diabetic wounds were examined in clinical trials, where local administration of growth factors was proven to be well tolerated. However, the free form of exogenous growth factor administration has encountered problems such as rapid leakage from the wound bed, short biological half-life and the rapid enzymatic degradation, which makes it difficult to achieve effective concentration to treat diabetic ulcer, leading to inefficacy of the treatment [86,87]. The afore-mentioned growth factor delivery by nanoparticles (as summarized in Table 1) has also addressed the common clinical barriers, which include achieving a sustained and controlled release of biomolecule proteins, distributing concurrently more than one growth factor, and protecting the growth factors against enzymatic hydrolysis when administrated at the wound site, suggesting promising future clinical application of growth factor-loaded nanoparticles for diabetic wound healing.

#### *5.2. Nucleic Acid*

Nucleic acid encapsulated particulate combines gene therapy and nanotechnology to knockdown or express a specific gene for successful healing of a chronic wound [88]. Gene delivery to injury site supports expressing specific proteins which can accelerate healing of chronic wounds. For instance, VEGF for induction of angiogenesis in chronic wound has been transfected by viral vectors in diabetic patients and the effect in wound healing observed [89]. However, the use of non-viral vectors such as nanoparticles to deliver nucleic acid is a better choice as viral vectors can cause immune response and should always be treated with caution [90,91]. siRNA permits knockdown of gene expression by selectively targeting genes such as *MMP, ganglioside-monosialic acid 3 synthase (GM3S)* and *TNF-*α, which are overexpressed in chronic wounds. In vivo delivery of siRNA requires a carrier for transport into cells to protect against physiological nucleases. Nanoparticle-based technology has enabled targeted transport of siRNA and prevention from degradation [92,93]. Clinical studies delivering siRNA to cure several diseases have been promising, yet primary clinical trials were unsuccessful due to inadequate efficacy or significant off-target effects. RNAi technology demands additional refinement prior to widespread clinical use. Barriers for successful siRNA delivery for efficient therapy are degradation of siRNAs by enzymes in the wound environment and siRNAs not readily taken up by the cells due to electrostatic constraints, as the negatively charged cell wall will not easily allow penetration of negatively charged siRNAs into the cells. To address these problems, a wide variety of delivery systems have been pre-clinically tested using nanoparticles. Delivery vehicles for siRNAs such as those mentioned below have attained varying degrees of efficacy, with topical dosing and intravenous formulations, and are currently at the forefront of testing for clinical use [94,95].



**1.**Nanoparticles-basedtherapeuticincorporatedwithgrowthfactorsfordiabeticwoundhealing.

#### *5.3. Antibiotics*

The most common characteristic of prolonged chronic wound healing is infection. In diabetic wounds, surface infections lead to the development of biofilms superficially within the wound, disrupting normal physiological wound healing [117]. Contamination by pathogens in a wound can evolve into colonization of bacteria, leading to localized infection and even systemic infection, sepsis and multi-organ dysfunction [118]. The presence of a biofilm leads to prolonged inflammation by stimulation of NO, cytokines and free radicals [119]. Hence, an effective treatment is required to deliver antimicrobial drugs to infected wounds for normal wound healing. In this regard, nanoparticles can be utilized to specifically target and eliminate pathogens. The antimicrobial effect of nanoparticles comprises destruction of cell membranes, impediment of enzyme pathways, modifications of microbial cell wall and nucleic materials pathway, and as a delivery system.

AgNPs have demonstrated a huge potential for different biomedical applications, such as in detection and diagnosis, drug delivery, coating of biomaterials, devices for novel antimicrobial agents and in regeneration materials [59]. For instance, AgNPs are known to have antimicrobial activity, which when incorporated with EGF, promotes re-epithelization, resulting in wound healing in diabetic mice [120]. AgNPs embedded in cellulose nanocrystals (CNCs) isolated from *syzygium cumini* leaves (which help to preserve the moist environment in the wound) has accelerated wound healing in diabetic mice [121].

Nanoparticle encapsulation with antimicrobial drug has developed as a novel and capable alternative to address diabetic wound infection with minimal undesirable side effects [122]. A major challenge faced in antibiotic therapy is antibiotic resistance. According to the World Health Organization (WHO), Methicillin-resistant *Staphylococcus aureus* (MRSA) infections have caused a higher mortality in patients by 64% compared to the non-resistant form [123]. To overcome the challenges of multi-drug resistant bacteria and to restore the efficacy of antibiotics, Kalita et al. designed lysozyme capped gold nanoclusters (AUNC-L) functionalized with a widely used β-lactam antibiotic, ampicillin, as a model drug to combat MRSA resistance against ampicillin and to accelerate diabetic wound with MRSA persistent infection [117]. Free ampicillin has failed to reduce MRSA infection on diabetic wounds while AUNC-L-Amp has accelerated wound healing by eliminating the MRSA persisted infection within the wound [117]. This same study showed that metallic nanoclusters in combination with antibiotics, augment their antibacterial properties and thereby mitigate the cytotoxicity of both the agents by reducing the necessity for high drug dosages. For the development of nano-antibiotics against microbial pathogens, toxicity of non-natural materials is a limiting step for utilization in clinical application.

The emergence of bacterial resistance to conventional antibiotics represents a general challenge in clinical trials. Dai et al. developed an AgNPs-coated <sup>ε</sup>-Polylysine (EPL-g-butyl@AgNPs) bacterial binding nanocomposite, in which ε-Polylysine was used to coat AgNPs so as to act as bacterial affinity ligand to combat multiple-drug resistance bacteria. The nanocomposites and levofloxacin were introduced in the culture of Gram-negative (*P. aeruginosa*) and Gram-positive (*S. aureus*) bacteria, respectively. After 30 passages, MIC remained the same for EPL-g-butyl@AgNPs, while the MIC value of levofloxacin increased from 0.64 to 78 μg mL−<sup>1</sup> against *S. aureus* and from 3.2 to 156 μg mL−<sup>1</sup> against *P. aeruginosa*. Compared with the antibiotic, no antimicrobial resistance was detected against the EPL-g-butyl@AgNPs nanocomposite, providing a promising solution to control and prevent drug resistance. Furthermore, the same investigators proved that EPL-g-butyl@AgNPs offer effective antibacterial effect and wound-healing acceleration in diabetic rats by the synergetic effect of ε-Polylysine and AgNPs [124] (Figure 6).



**Figure 6.** Nanocomposite (EPL-g-butyl@AgNPs) shows effective antibacterial activity against both Gram-negative (*P. aeruginosa*) and Gram-positive (*S. aureus*) bacteria without the emergence of bacterial resistance, which effectively promoted infected wound healing in diabetic rats. Reproduced from [124], with permission from American Chemical Society, 2016.

According to the American Diabetes Association, 25% of hyperglycaemic patients experience delayed wound healing. Chronic wound infections are frequently polymicrobial, whereby several microorganisms share a common niche [125]. Polymicrobial wound infections usually necessitate increased doses of antibiotics and fungicides. Yet, continued antimicrobial treatments are related with possible systemic side effects and possible risk of developing drug-resistant microorganisms. Hence, Thattaruparambil-Raveendran et al. has developed chitosan (CH) bandages using fibrin nanoparticles (FNPs) encapsulated with antimicrobial agents, such as ciprofloxacin and fluconazole (cFNPs+fFNPs−CH) and demonstrated significant reduction in microbial contamination with accelerated wound healing, as compared to control animals with topical application of cFNPs+fFNPs−CH in vivo. Also, this same study analyzed the antimicrobial ability of the bandages containing nanoparticles-loaded antibiotics against a co-culture of *S. aureus, E. coli,* and *C. albicans*, to mimic the clinical scenario of polymicrobial infection in chronic wounds. The findings verified that the chitosan bandages had significant antimicrobial property towards co-cultures of bacteria and fungi, indicating that this bandage is a potential candidate for clinical applications for diabetic wound healing [126]. Liang et al. established a glycidyl methacrylate functionalized quaternized chitosan (QCSG) and gelatin methacrylate (GM) hydrogel, encapsulated with graphene oxide (GO), for drug-resistant bacterial infective wound healing. Development of injectable conductive nanocomposite hydrogel dressings based on GO and cationic polymer for wound healing is highly promising as the QCSG/GM/GO hydrogels demonstrated 95% killing ratio against *S. aureus* and *E. coli*, and for clinical drug-resistant bacterium MRSA, the bacterial killing ratio is also higher than 90%. Based on the known photothermal effectiveness of these hydrogels, near-infrared light-assisted photothermal antimicrobial activity was analyzed. Infrared irradiation of QCSG/GM/GO hydrogel for more than 10 min had killing ratios of almost 100% for all three bacteria, affirming the effective near-infrared-assisted photothermal antibacterial properties of QCSG/GM/GO hydrogels. In order to evaluate the continuous

drug release ability of hydrogels, an inhibition zone assay was conducted to assess the antimicrobial activity of the doxycycline that was released from hydrogels. Inhibition for *S. aureus* and MRSA lasted for 9 days, which further confirmed sustained drug release of the hydrogels. Cell compatibility data demonstrated higher L929 cell viability with increase in incubation time for the hydrogel groups. It was noted that IL-6 expression (a biological cytokine plays a significant role in inflammatory response and secreted by several types of cells) in the wounds of the hydrogel-treated group was lower than that of the Tegaderm group on the third day, while inflammation was significantly reduced on the 7th day. Moreover, injectable QCSG/GM/GO hydrogels with antibiotics accelerated infectious skin defect wounds compared to commercially available Tegaderm with an increase in collagen deposition and re-epithelialization [127].

Bacterial infection and prolonged inflammation is a very important factor in preventing successful clinical intervention for diabetic wound healing. The above discussed research studies evaluated the antibacterial property of nanoparticles loaded with antibiotics (summarized in Table 3). The findings that showed the effective antibacterial property of nanoparticulate systems against major drug-resistant bacteria may give rise to novel clinical applications in the near future.

#### *5.4. Antioxidants*

In the inflammatory phase of wound healing, neutrophils, leucocytes, and monocytes will be attracted to the wound sites by biologically active mediators and then attack the microorganisms and foreign debris via phagocytosis, which will lead to the production of ROS [128]. The antioxidant system in the cell evolves to play central roles in scavenging these free radicals to maintain redox homeostasis or the equilibrium between free radicals and antioxidants [129]. ROS including superoxide (O2-), hydrogen peroxide (H2O2), hydroxyl radical, and other reactive oxygen derivatives, are very lethal and cause extensive damage to protein, DNA and lipids, thereby affecting normal cellular functioning [130]. ROS is produced in the cell as an unavoidable by-product of oxidative phosphorylation [131]. ROS is constantly being generated at basal levels. However, they are unable to cause damage, as they are being scavenged by different antioxidant mechanisms [132]. As high levels of ROS can damage cells by oxidizing lipids and proteins, the levels are tightly controlled by the presence of ROS scavenging enzymes and small molecule antioxidants [133]. Altered redox signaling (non-equilibrium between free radicals and antioxidants) that leads to oxidative stress is widely accepted as a contributor to the development of diabetic complications, including cardiovascular disease, nephropathy and retinopathy [134,135]. Accumulation of ROS leads to significant destruction of endogenous stem cells, growth factors, and nucleic acids in the wounded tissue, thus greatly affecting their regenerative potential, causing delayed wound healing [136].


*Nanomaterials* **2020**, *10*, 1234

Nanoparticles-based treatment has shown promising results in promoting antioxidant activities in diabetic rodents for effective wound healing. Bairagi et al. has developed PLGA nanoparticles encapsulated with ferulic acid (FA; 4-hydroxy-3-methoxycinnamic acid) to study its effect in diabetic wound healing. FA is a phenolic compound and a natural antioxidant with a potential synergistic therapeutic effect in diabetic wound healing due to its hypoglycemic, free radical scavenging, angiogenic, antibacterial, and neurogenic effects. In this same study, the investigators demonstrated that FA-loaded polymeric nanoparticles dispersion (oral administration) and FA-loaded polymeric nanoparticles-based hydrogel (topical administration) treated wounds had faster epithelization of the wound, leading to effective wound closure on day 14 as compared with the diabetic wound group [137]. The formation of advanced glycation end products (AGEs) has been recognized as an important pathophysiological mechanism in the development of diabetic ulcers; the binding of circulatory AGE to RAGE (receptor for AGEs) on different cell types leads to impaired function of growth factors. Glycation is an important pathway in the pathogenesis of microvascular and macrovascular complications of DFUs. AGE and RAGE result in oxidative stress and cause abnormal angiogenesis in wound healing [138]. In type 2 diabetic skin tissues, the expression of both AGE and RAGE were increased when compared with normal skin tissues. Moreover, a study on human dermal fibroblasts demonstrated that cell arrest and apoptosis was increased [139]. The levels of nitric oxide were increased in glycated soluble protein (AGE-BSA) treated kidney cell lines, suggesting oxidative stress [140]. The blockage of RAGE by intraperitoneal soluble RAGE, significantly suppressed the TNF-α and IL-6 while enhancing cutaneous wound closure in db/db mice [141]. A previous study reported that an antioxidant, epigallocatechin gallate (EGCG) decreased RAGE mRNA and protein expression in AGE-treated human mesangial cells [142]. EGCG also attenuated AGE-induced RAGE in neuronal cells [143,144], and alpha-lipoic acid (ALA) is a scavenger of many ROS [144]. Chen et al. demonstrated that the combination of antioxidants EGCG, ALA and AuNPs in specific concentrations significantly decreased expression of the RAGE protein within cultured fibroblasts (Hs68) and diabetic wound healing in a mouse model. In this study, the authors showed that a mixture of AuNP, EGCG and ALA (AuEA) significantly decreased AGE-induced RAGE protein expression in fibroblasts (Hs68). Furthermore, topical AuEA application decreased RAGE expression in diabetic mouse skin, which suggests that a combination of EGCG, ALA and AuNPs considerably accelerated diabetic wound healing through anti-inflammatory and angiogenesis via modulation of antioxidants [145]. Similarly, topical gas-injection of a EGCG and AuNP liquid mixture (AuE) using the GNT GoldMed™ liquid DDS showed a significantly higher rate of wound closure on wild-type and streptozotocin-induced diabetic mouse skin, associated with increased epidermal growth factor receptors and VEGF, which stimulate wound recovery and the new tissue formation. Besides, collagen I, III and hyaluronic acid protein expressions increased in the wound area. These are essential factors of physiological matrix and wound healing [146]. In another study, Ponnanikajamideen et al., using the leaf extract powder of a plant, *Chamaecostus Cuspidatus*, and fabricated green synthesized AuNPs, showed 50% inhibition of free radicals by green synthesized AuNPs without inducing any lethal effects in a mouse model, with restoration of blood glucose, glycogen and insulin levels in the diabetic mice after 21 days of treatment [147]. He et al. fabricated PCL and quaternized chitosan-g-polyaniline (QCSP) nanofibers to promote wound healing [128]. The nanofibrous wound dressings displayed comparable mechanical characteristics to soft tissue, free radical scavenging capability, antimicrobial property and biocompatibility. Their data suggested that the antioxidant capability of PCL/QCSP15 nanofibers heightened with increasing concentration of QCSP and almost 70% of free radicals can be cleared by 6 mg mL−<sup>1</sup> of PCL/QCSP15 dispersion liquid, and the scavenging efficacy for DPPH has shown more than 80% when the content of PCL/QCSP15 dispersion liquid reached 8 mg mL<sup>−</sup>1. Furthermore, wounds that received treatment by PCL/QCSP15 nanofiber dressing showed elevated collagen secretion, granulation tissue thickness and enhanced angiogenesis, leading to accelerated wound closure compared to commercially available Tegaderm [128]. As DFU remain a complex problem in clinical settings, the above discussed studies (highlighted in Table 4) strongly support the beneficial effects of anti-oxidants and nanoparticles on diabetic patients with cutaneous wounds and clearly provide a basis for the potential therapeutic application of AuEA, PLGA nanoparticles in chronic wound therapy.


*Nanomaterials* **2020**, *10*, 1234

#### **6. Regulatory Pathway for Nanomaterial**

Nanotechnology is an emerging technology that can be used in a broad array of FDA-regulated products. There are two main points for consideration when providing an initial screening tool that can be applied to FDA-regulated nanotechnology products. 1. Whether an engineered material is in nanoscale range of 1 to 100 nm with at least one external dimension. 2. Whether an engineered material demonstrates properties involving physical characteristics or biological effects that are attributable to its dimensions, even if these dimensions fall outside the nanoscale range, up to 1 μm (1000 nm). FDA regulatory framework and review process adequately identify and manage potential risk associated with the use of nanomaterials in products [148,149]. The safety assessment and the toxicity and biocompatibility of nanomedicines go through the same FDA regulatory process as drugs that do not contain nanotechnology products. Primary development of a nanotech product is at the nexus of basic and preclinical research, where further development often includes collaborations among academic supervisor and industrial researchers. Primary studies may be initial tests for its translational potential and will offer a base for further preclinical development, which involves tests that meet the regulatory requirements for investigational new drug (IND) applications, new drug applications (NDAs), and abbreviated new drug applications (ANDAs) by the United States FDA [150]. After gaining the status of a new research drug, to administer an investigation drug or biologic to humans from IND, nanomedicines or nano DDSs, investigations are initiated to evaluate their safety and efficacy in humans by clinical trials. These clinical trials are divided into three phases: phase 1 (mainly assesses safety), phase 2 (mainly determines efficacy) and phase 3 (safety, efficacy and dosage are evaluated). After obtaining approval in these three phases, the IND can be filed by the FDA to request endorsement of the new nanomedicine or nano DDSs [151,152]. FDA regulations, as well, specifically address nanomaterials safety, for which it is essential to explore the properties to understand the mechanisms by which nanomaterials communicate with biological systems to identify exposure, hazards and their possible risks [153]. Biocompatibility is an essential property in the design of nanomaterial-based DDSs. Biocompatibility is defined as material that has the potential to perform the desired function in a specific application and its surface would not elicit any undesired response from the organisms [154]. Pre-clinical evaluation of nanomaterials goes through a complete biocompatibility testing that includes in vivo studies followed by essential in vitro assays to prove its biocompatibility, so as to avoid toxicology concerns [155]. The pharmacokinetics and distribution of nanoparticles in the body depends on their surface physicochemical characteristics, shape and size. For example, nanoparticles that are 10 nm in size, are observed in blood, liver, spleen, kidney, testis, thymus, heart, lung, and brain, whilst larger particles are found only in the spleen, liver, and blood [156]. The surface properties of nanoparticles also affect their distribution in these organs, since combination with serum proteins available in the systemic circulation may influence cellular uptake. It should be reiterated that a biocompatible material does not elicit any physiological immune response. One of the reasons that an immune response is triggered is due to possible adsorption by body proteins, therefore, evaluation of an in vivo protein profile is essential to address the biological interactions and to establish its biocompatibility [157]. Lastly, clearance of nanoparticles is also dependent on size and surface of nanoparticles. Nanoparticles that are below 10 nm size are promptly cleared by renal excretion, whereas nanoparticles larger than 200 nm are efficiently taken up by mononuclear phagocytic system located in the liver, spleen, and bone marrow [158]. Studies are therefore required to address how nanomaterials penetrate cells and tissues, and the respective biodistribution, degradation, and excretion before translation into clinical applications.

#### **7. Clinical Status of Nanomedicine**

Several agents for promoting tissue healing, such as growth factors, small molecules, and siRNA-based therapeutics, have shown promising results in improving wound healing in preclinical trials. Despite recent advances, challenges in retention and duration of the therapeutic effect in the harsh wound environment, has limited the pace for clinical implementation. Nanoparticle formulations, nanofibrous scaffold and hydrogel-related treatments are being devised to overcome this limitation. Ultimately, these technologies will require additional validation by testing in larger animal models, particularly the porcine model, before the consideration of a clinical setting [35,159]. AgNPs have been used for numerous clinical trials in the therapy of wounds, especially burns and chronic wounds (diabetic wounds). Currently, there are some commercially available dressings containing AgNPs [160]. Among the different polymers developed to fabricate polymeric nanoparticles, PLGA is one of the most successfully used synthetic polymers, with FDA approval for clinical use in humans as a DDS, due to the following desirable properties: (1) well-described formulations and methods of production adapted to various types of drugs, ranging from small molecules to macromolecules; and (2) ability to protect drugs from degradation and the possibility of sustained release [161]. Recombinant human-PDGF (rhPDGF), the only FDA-approved growth factor available for clinical use, has been shown in clinical trials to increase the incidence of complete wound closure and decrease the time to achieve complete wound healing [162]. The only siRNA delivery depot in clinical pipeline is the siG12D LODER therapeutic to combat non-resectable pancreatic dual adenocarcinoma [163]. In the market, modern wound bandage materials that are effective for skin regeneration have arrived. Despite the demand for the use of improved dressing materials for wound healing, many of the wound healing material that are applied clinically rely on safety data and experience rather than the efficacy rate. Inorganic-based Au, copper, ZnO, cerium oxide, and silica nanoparticles are still under clinical investigation [164].

#### **8. Future Perspective**

The usage of nanoparticle-based treatments by incorporation of therapeutic drugs and siRNAs, is an exciting and novel field for wound treatment, with unlimited prospects and opportunities. Nanoparticle-based remedies involve delivery of therapeutic drugs that promote wound healing, due to the integral properties of the nanoparticles as efficient delivery systems. There are promises of achieving greater efficacy and specificity, with a smaller amount of systemic side effects. In addition, compared to conventional antibiotics, nanoparticle-based antimicrobial treatment is more likely to eradicate bacteria developing resistance. However, the adverse biological effects elicited by nanoparticles should be further investigated and the development of nanoparticle-based therapies should be undertaken with a reasonable amount of caution, bearing in mind nanosafety concerns. Working towards improving the efficacy of nanoparticle wound treatments should go hand in hand with investigating the long and short-term effects of nanoparticle-based treatments, as well as the mechanisms underpinning them. The current approach of exploiting nanotechnology for the treatment of diabetic wound healing is occurring at an exponential rate. Further research and development efforts in this emerging field will have a positive impact on the treatment of wound regeneration, especially chronic wounds, which pose a significant burden on the quality of life and healthcare. Therefore, it is likely that nanotechnology-based remedies will possibly be the next frontier poised for breakthroughs in meeting the clinical needs of chronic wound healing.

#### **9. Conclusions**

Wound healing is an intricate three-staged process involving inflammation, proliferation and remodeling. The physiology of the healing process is perturbed in the case of DFU by both internal and external factors, such as altered cellular and cytokines response, poor vascularization, and infection by microorganisms. This overview focusing on nanoparticle-based therapeutics that deliver peptides; nucleic acids; antibiotics; and antioxidants incorporated in polymeric and natural nanostructures, hydrogels and nanofibers, have revealed promising results on re-epithelialization, deposition of collagen fibers, tissue regeneration, and ultimately a faster rate of wound closure in chronic diabetic wounds. Moreover, studies have clearly shown the effective antibacterial property of nanoparticulate systems against major drug-resistant bacteria. The combination of nanoparticles and biopolymers as a nanocomposite have a greater effect in speeding up tissue repair and wound healing. The use of nanomaterials for wound healing has been widely explored, although it is still

far from commercialization and routine clinical practice. However, the studies collated in this review may provide more insight for pre-clinical testing of nanoparticle-based therapeutics for DFU, before instituting the relevant clinical trials and further commercialization. The overall outlook of nanoparticle DDSs is promising, as they are being developed not only for treatment of diabetic wounds, but many other diseases including cancer.

**Author Contributions:** Conceptualization, H.E., D.K.S.; writing—original draft preparation, H.E.; design figures (1 & 4) and tables, H.E., D.V.; writing—review and editing, D.K.S., B.-H.B., S.T.D.; supervision, project administration, funding acquisition, D.K.S. All authors have read and agreed to the published version of the manuscript.

**Funding:** This work was funded (DKS) by Singapore Ministry of Education Academic Research Fund Tier 1 Grant (R-181-000-184-114).

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **Abbreviations**

AGEs: Advanced glycation end products; AgNPs, Silver nanoparticles; ALA, Alpha lipoic acid; α-SMA, Alpha smooth muscle actin; ANDAs, Abbreviated new drug applications; ARE, Antioxidant response element; AuE, Gold nanoparticle liquid mixture; AuEA, Gold nanoparticle + EGCG and ALA; AUNC-L, Lysozyme capped gold nanoclusters; AuNPs, Gold nanoparticles; bFGF, Basic fibroblast growth factor; *C. albicans, Candida albicans*; CNCs, Cellulose nanocrystals; CNP, Cerium oxide nanoparticles; CH, Chitosan; cFNPs+fFNPs−CH, CH bandage using fibrin nanoparticles encapsulated with ciprofloxacin and fluconazole; Col, Collagen; DDSs, Drug-delivery systems, DFU, Diabetic foot ulcer; DM, Diabetes mellitus; EGF, Endothelial growth factor; EGCG, Epigallocatechin gallate; EPL-g-butyl@AgNPs, Silver nanoparticle coated <sup>ε</sup>-Polylysine; ECM, Extracellular matrix; *E. coli, Escherichia coli*; FA (4-hydroxy-3-methoxycinnamic acid), Ferulic acid; FNPs, Fibrin nanoparticles; FGF, Fibroblast growth factor; FDA, Food and Drug Administration; GM, Gelatin methacrylate; GM3S, Ganglioside-monosialic acid 3 synthase; GF, Growth factor; GO, Graphene oxide; HA, Hyaluronic acid; HUVEC, Human umbilical vein endothelial cells; H2O2, Hydrogen peroxide; IDF, International Diabetes Federation; IL-6, Interleukin 6; IND, Investigational new drug; IRAK1, Interlukin-1 receptor associated kinase 1; Keap1, Kelch-like erythroid cell-derived protein with CNC homology-associated protein 1; KGF, Keratinocyte growth factor; miR, Micro RNA; MMP, Matrix metalloproteinase; MRSA, Methicillin-resistant *Staphylococcus aureus*; NaCMCh, Sodium carboxymethyl chitosan; NADP, Nicotinamide adenine dinucleotide phosphate; NDAs, New drug applications; NLC, Nanostructure lipid carrier; NO, Nitric oxide; Nrf2, Nuclear factor erythroid 2–related factor 2; O2-, Superoxide; PAD, Peripheral arterial disease; *P. aeruginosa, Pseudomonas aeruginosa*; PDGF, Platelet derived growth factor; PCL, Poly (ε-caprolactone); PEG, Poly (ethylene glycol); PLA, Poly (lactic acid); PLGA, Poly (lactic-co-glycolic acid); QCSG, Glycidyl methacrylate functionalized quaternized chitosan, QCSP, Quaternized chitosan-g-polyaniline; RAGE, receptor for AGEs; rhEGF, Recombinant human EGF; rhPDGF, Recombinant human-PDGF; ROS, Reactive oxygen species; *S. aureus, Staphylococcus aureus*, SLN, Solid lipid nanoparticles; SNAs, SiRNA-based spherical nucleic acids; TGF-β, Transforming growth factor beta; TIMPs, Tissue inhibitor of metalloproteinases; TNF-α, Tumor necrosis factor alpha; TRAF6, Tumor necrosis factor receptor associated kinase 6; VEGF, Vascular endothelial growth factor; WHO, World Health Organization; Zn, Zinc; ZnO, Zinc oxide.

#### **References**


© 2020 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/).

## *Review* **Visible-Light Active Titanium Dioxide Nanomaterials with Bactericidal Properties**

**Chengzhu Liao 1,\*, Yuchao Li <sup>2</sup> and Sie Chin Tjong 3,\***


Received: 6 December 2019; Accepted: 6 January 2020; Published: 9 January 2020

**Abstract:** This article provides an overview of current research into the development, synthesis, photocatalytic bacterial activity, biocompatibility and cytotoxic properties of various visible-light active titanium dioxide (TiO2) nanoparticles (NPs) and their nanocomposites. To achieve antibacterial inactivation under visible light, TiO2 NPs are doped with metal and non-metal elements, modified with carbonaceous nanomaterials, and coupled with other metal oxide semiconductors. Transition metals introduce a localized d-electron state just below the conduction band of TiO2 NPs, thereby narrowing the bandgap and causing a red shift of the optical absorption edge into the visible region. Silver nanoparticles of doped TiO2 NPs experience surface plasmon resonance under visible light excitation, leading to the injection of hot electrons into the conduction band of TiO2 NPs to generate reactive oxygen species (ROS) for bacterial killing. The modification of TiO2 NPs with carbon nanotubes and graphene sheets also achieve the efficient creation of ROS under visible light irradiation. Furthermore, titanium-based alloy implants in orthopedics with enhanced antibacterial activity and biocompatibility can be achieved by forming a surface layer of Ag-doped titania nanotubes. By incorporating TiO2 NPs and Cu-doped TiO2 NPs into chitosan or the textile matrix, the resulting polymer nanocomposites exhibit excellent antimicrobial properties that can have applications as fruit/food wrapping films, self-cleaning fabrics, medical scaffolds and wound dressings. Considering the possible use of visible-light active TiO2 nanomaterials for various applications, their toxicity impact on the environment and public health is also addressed.

**Keywords:** antibacterial activity; photocatalyst; titania; nanomaterial; doping; *Staphylococcus aureus*; *Escherichia coli*; reactive oxygen species; silver nanoparticle; visible light

#### **1. Introduction**

The overuse of antimicrobials in humans, animal husbandry and aquafarming gives rise to the development of dangerous, antibiotic-resistant bacteria [1,2]. Infections caused by antibiotic-resistant bacteria are now emerging as worldwide public health challenges. Medicines find it harder to treat infections, increasing the risk of mortality and morbidity. For instance, Staphylococci such as *Staphylococcus aureus* (*S. aureus*) and *Staphylococcus epidermidis* (*S. epidermidis*), that cause orthopedic infections (e.g., osteomyelitis), have developed into methicillin-resistant *S. aureus* (MRSA) and methicillin-resistant *S. epidermidis* (MRSE). MRSA is capable of forming biofilms on medical devices, giving rise to antibiotic resistance [3,4]. Osteomyelitis is a bone infection induced by *Staphylococci,* leading to progressive bone loss and tissue damage. Moreover, multidrug-resistant (MDR) bacteria spread not only between hospital inpatients, but also through food chains and potable water [5]. Accordingly, researchers have concentrated on developing antimicrobial nanomaterials as alternatives to conventional antibiotics [6–9].

Current developments in nanoscience and nanotechnology have led to the creation of advanced functional nanomaterials with unique chemical, physical, and biological properties [9–17]. Nanomaterials with large, specific surface area-to-volume ratios enhance surface chemical reactivity due to the size reduction at the nanoscale. Thus, nanomaterials have opened up new opportunities for developing bactericidal agents to treat deadly microbial infections [18]. In particular, metal and metal oxide nanoparticles (NPs) have attracted great attention as promising candidates for antibacterial agents [19,20]. The main mechanisms of the antibacterial activities of those nanoparticles proposed in the literature include: (a) oxidative stress induction associated with the generation of reactive oxygen species (ROS) [21], where the oxidation process in bacterial cells causes peroxidation of the lipid membrane, thereby damaging proteins and DNA; (b) released metal ions from metal or metal oxide NPs penetrating through bacterial cell walls, directly interacting with the –SH, –NH and –COOH groups of nucleic acid and protein and eventually causing cell death [15,22]. For example, silver nanoparticles (AgNPs) have been employed as antibacterial agents for textile fabrics, healthcare products, cosmetics, coatings and wound dressings, because they exhibit relatively high bactericidal activity [15,23–27]. However, AgNPs are toxic for several human cell lines. This is because they induce a dose-, size- and time-dependent cytotoxicity, especially those with sizes of ≤10 nm [15].

Compared to other types of nanoparticles, titanium dioxide is particularly attractive for photocatalytic bactericidal activity because of its relatively low cost, natural abundance and superior chemical stability. Titanium dioxide (TiO2), generally known as titania, is an n-type semiconductor due to the presence of oxygen vacancies [28,29]. Those oxygen vacancies favor the formation of unpaired electrons or Ti3<sup>+</sup> centers, thus acting as electron donors in the electronic structure of TiO2 [28]. Furthermore, oxygen vacancies can influence the charge transport and electron–hole recombination processes by trapping charge carriers in the defect sites [30–33]. Titania also has a high dielectric permittivity (κ = 50–80) that finds application as a gate insulator in the microelectronic industry. However, TiO2 with a bandgap of 3.2 eV suffers from a large leakage current and low dielectric breakdown field. In contrast, HfO2 with a larger bandgap (5.3–5.7 eV) is widely used as a high-κ gate dielectric material in the microelectronic sector [34].

By irradiating photocatalytic semiconductors with a photon of sufficient energy (≥band gap energy), an electron in the valence band (VB) is excited to the conduction band (CB), leaving a positive hole in the VB. These charge carriers migrate to the photocatalyst surface and can generate highly reactive oxygen species (ROS) such as hydroxyl (•OH) and superoxide anion (O2 −) radicals, and hydrogen peroxide (H2O2) through the oxidative or reductive path with surface-adsorbed water and oxygen (Figure 1). Hydroxyl and superoxide species are highly reactive due to the presence of unpaired valence shell electrons, and can cause oxidative damage to biomolecules such as proteins, lipids and nucleic acids [25,35,36].

Matsunaga et al. first reported the antimicrobial and photoelectrochemical activities of platinum-loaded titanium oxide (TiO2/Pt) powders for killing Lactobacillus acidophilus, *Saccharomyces cerevisiae* and *Escherichia coli* (*E. coli*) in 1985 [37]. Nano-TiO2 exhibits excellent photocatalytic bactericidal activity against viruses and MDR bacteria under UV irradiation [38]. Accordingly, extensive efforts have been carried out by researchers to improve the photocatalytic bactericidal activity of TiO2 nanomaterials. TiO2 nanostructures have a wide spectrum of industrial, environmental and energy applications, including water purification, food preservation, degradation of dyes, chemical sensors, dye-sensitized solar cells, and antimicrobial agents. [39–57]. In particular, visible light-responsive TiO2 doped with metals and non-metals exhibit bactericidal activity against a wide variety of bacterial species including Gram-negative *E. coli*, Acinetobacter baumannii, Shigella flexneri, and Gram-positive *S. aureus*, Bacillus subtilis, Listeria monocytogenes, as well as Bacillus anthracis spores [58]. Those photocatalysts can be used for the disinfection of pathogenic bacteria, thereby preventing the spread of microbe-related diseases. Recently, Markov and Vidakovi´c reviewed

antimicrobial testing methods of TiO2 photocatalysts, including thin-film technique, petri-dish system, and polytetrafluoroethylene membrane-separated system. They also addressed the calculation methods for assessing the antimicrobial efficacy of TiO2 photocatalysts [35]. To avoid mechanical damage to TiO2 NPs, they are embedded in the polymeric matrices to form antibacterial nanocomposites [59–65]. The beneficial effects of polymers as the matrix materials of functional composites include ease of processing and good moldability, and they are inexpensive with a low density [66–72].

**Figure 1.** The possible mechanisms of antibacterial activities exhibited by different metal nanoparticles (NPs) and photocatalytic semiconductors. The activation of the photocatalytic semiconductor by visible light is depicted on the left-hand side of the figure. Reactive oxygen species created by various semiconductors destruct bacterial cell components, as indicated by red arrows. Ag, Cu, and Au nanoparticles also generate reactive oxygen species (ROS) for bacterial killing. The green arrow represents targets of Ag. Reproduced with permission from [22]. Copyright Frontiers, 2018.

Apart from bactericidal activity, TiO2 NPs also find attractive application in biomedical fields as photodynamic therapeutic agents for destroying human cancer cells from the skin to the internal organs under ultraviolet (UV) and visible light illumination [36]. This is due to the ROS created by TiO2. NPs can damage cellular respiration in mitochondria, thus releasing electron-transfer proteins and causing cell death. Moreover, light-activated TiO2 NPs can lead to DNA fragmentation as a result of the electron transfer mechanism. This approach shows promise for reprograming gene-coding either by deleting or by inserting gene codons. In addition, TiO2 nanotubes can be used for light-controlled delivery of drugs for treating the diseased tissues upon UV irradiation [36]. This article provides an update review on the current development, synthesis, photocatalytic bacterial inactivation, and cytotoxicity of TiO2 NPs and their nanocomposites, especially in a rapidly growing field of research, over the past five years.

#### **2. Crystal Structure of Titania**

Titanium dioxide generally exists naturally in three crystalline structures, i.e., anatase, rutile, and brookite [42,43]. Anatase exhibits the tetragonal structure with a space group of I41/amd (I: body centered). Body-centered tetragonal anatase has lattice parameters of a = 3.7845 Å and c = 9.5143 Å. Rutile belongs to the P42/mnm (P: primitive) space group, with the primitive tetragonal lattice having lattice parameters a = 4.5937 Å, and c = 2.9587 Å. Brookite is orthorhombic with a space group of Pbca, having lattice parameters of a = 9.1819 Å, b = 5.4558 Å, and c = 5.1429 Å, as shown in Figure 2. [43,73,74]. These polymorphs are formed by linking the chains of distorted TiO6 octahedra through corner- and edge-sharing in different ways. In the TiO6 octahedra, titanium cations (Ti4+) are coordinated to six oxygen anions (O2−). The octahedron shares two, three, and four edges with adjacent octahedra to give rutile, brookite and anatase, respectively [42]. Anatase and brookite are metastable, and transform irreversibly to a stable rutile phase by heating at 500–700 ◦C. Moreover, anion fluorine dopant also

stabilizes anatase at elevated temperatures (>1000 ◦C) [75]. Generally, anatase TiO2 is more photoactive than rutile and brookite. Anatase TiO2 absorbs ultraviolet light (UV) to create an electron–hole pair necessary for photocatalytic reaction. In the process, electron is excited from the valence band to the conduction band, leaving a positively charged hole in the valence band. This photogenerated electron–hole pair displays a high reducing and oxidizing capability. In this respect, the electron in the conduction band reacts with molecular oxygen to produce superoxide ion (O2 −) via a reductive process, while the hole in the valence band oxidizes adsorbed water or hydroxyl ions at the titania surface into hydroxyl radicals (•OH) [76]. The photocatalytic activity of TiO2 depends mainly on the crystal structure, shape, particle size and surface area. The equilibrium shape of anatase consists of a truncated bipyramid constructed by {101} and {001} facets. According to the Wulff construction, the {001} facets constitute nearly 6% of the total exposed surface of anatase TiO2, while stable {101} facets contribute to more than 94% of the surface area [42]. However, the {001} facets of anatase TiO2 have a higher photocatalytic performance than {101} facets [77–79]. TiO2 NPs with a larger surface area and smaller size than their bulk counterparts generate more ROS during photoexcitation [80]. Xu et al. indicated that anatase TiO2 NPs exhibit a higher phototoxicity and cytotoxicity in human keratinocyte cells than rutile TiO2 NPs [81]. Recently, Bartlet et al. indicated that one-dimensional titania nanotubes prepared by electrochemical anodization exhibit superhydrophobic behavior with a large water contact angle of >150◦. Such superhydrophobic titania nanotubes reduced bacterial adhesion on their surfaces [82].

**Figure 2.** Connecting the chains of distorted TiO6 octahedra by sharing edges and corners in different ways to form rutile, brookite and anatase polymorphs. Titanium atoms are blue; oxygen atoms are red. Reproduced with permission from [42]. Copyright Nature Publishing Group, 2017.

#### **3. Visible-Light Active TiO2**

TiO2 NPs with a large bandgap (anatase = 3.2 eV and rutile = 3.0 eV) can only be activated by UV light, which accounts for less than 5% of the solar spectrum compared to 45% of visible light [83]. The low photocatalytic efficiency of titania under visible light limits its practical applications. Extending the utilization of solar energy to the visible region has motivated researchers to improve the visible-light photocatalytic performance of TiO2 NPs. Moreover, TiO2 NPs have another drawback, due to a rapid recombination of photogenerated electron–hole pairs. Recombination occurs when the excited electron returns to the valence band without interacting with the adsorbed species under UV irradiation. Accordingly, the energy of recombination is dissipated in the form of light or heat. Therefore, it deems necessary to enhance the photocatalytic activity of TiO2 NPs by reducing both the bandgap and the recombination of electron–hole pairs under visible light irradiation. Many attempts have been made by researchers to design and synthesize visible light-active TiO2 photocatalysts. These include metal and non-metal doping, coupling with semiconductors, and modification with graphene oxide or carbon

nanotube [84–104]. The incorporation of those dopants into titania affects its electronic band structure greatly, thereby promoting visible light absorption and a red shift in the bandgap.

#### *3.1. Metal Doping*

The VB of titania is composed of hybridized states of O-2p and Ti-3d orbitals, while the CB consists of primarily Ti-3d orbitals. The electronic and optical properties of titania can be modified by doping. In this context, titanium or oxygen ions' sites of titania lattice can be substituted with either metal or nonmetal dopants to alter their optical and photocatalytic properties. The cationic doping of titania with transition metals, rare earth metals and noble metals is typically used to improve its photocatalytic performance under visible light excitation. The presence of metal ion dopants can alter the charge transfer properties of TiO2, thus improving the separation efficiency of photogenerated carriers, and producing a shift in its absorption edge to the visible regime. The dopant energy level is located below the CB of TiO2, acting as an electron or hole trap, and thus allowing more carriers to transport to the surface. The photocatalytic activity of metal-doped titania depends on several factors, including the dopant concentration, type of metal dopant, d-electron configuration and energy band level of dopant in the titania lattice [105]. Although metal dopants facilitate a red shift in optical absorption edges of titania, they can induce defect states, acting as carrier recombination centers, especially at very high dopant contents. Thus, the occurrence of a rapid recombination rate of photogenerated charge carriers arises from a reduction in the distance between the trapping sites by increasing the number of dopant ions.

Doping TiO2 with transition metals influences its electronic energy levels and narrows the bandgap, resulting in a shift in the absorption spectrum of titania to longer wavelengths. Titania can be self-doped with Ti3<sup>+</sup> ions to improve its visible-light absorption and avoid the incorporation of other impurities into its lattice. The introduction of Ti3<sup>+</sup> energy level and the creation of an oxygen vacancy (Ovac) in the bandgap are responsible for the shift in optical adsorption of TiO2 into the visible light region. As such, the electrons in the VB can be excited to the Ovac–Ti<sup>3</sup><sup>+</sup> defect states, and electrons from these defect sites can be excited to the CB upon visible light illumination [106,107]. In this respect, the Ovac–Ti<sup>3</sup><sup>+</sup> sites can trap photogenerated electrons under visible light, thereby inhibiting the recombination of electron–hole pairs and improving photocatalytic activity accordingly. Generally, oxygen vacancy is not stable in air, and it remains a challenge to develop a stable Ti3<sup>+</sup> self-doped titania with a high photocatalytic performance [108].

Apart from Ti3<sup>+</sup> ions, other transition metals, such as copper (Cu), vanadium (V), chromium (Cr), manganese (Mn), iron (Fe) and nickel (Ni), are typically employed to enhance the visible-light photocatalytic activity of titania [88–95,109–115]. The redshift effectiveness takes the following order: V > Cr > Mn > Fe > Ni [86]. The substitution of Ti4<sup>+</sup> in the TiO2 lattice by transition metal ions creates a new energy state in the bandgap of TiO2. Therefore, the localized d-electron state of transition metals introduced in the bandgap captures the excited electrons from the titania valence band, thereby suppressing the recombination of charge carriers. Figure 3a shows the typical charge transfer reactions involved during photocatalysis of Mn-doped TiO2. Mn2<sup>+</sup> displays an electronic configuration of 3d5 and changes to 3d<sup>6</sup> (Mn<sup>+</sup>) by trapping electrons, while it changes to 3d4 (Mn3<sup>+</sup>) as it traps the holes. Both Mn<sup>+</sup> and Mn3<sup>+</sup> species are unstable, and react with adsorbed O2 and surface hydroxyl molecules to yield ROS [92]. Similarly, Fe3<sup>+</sup> ions of Fe-doped TiO2 can also act as hole and electron traps in prohibiting the recombination of the electron–hole pair and promoting ROS generation [84–86]. These result in a red shift in the absorption edge and thus enhance photocatalytic activity (Figure 3b) [95]. Doping TiO2 with vanadium, molybdenum (Mo) and tungsten can also shift its absorption edge to the visible region [111,112]. By doping TiO2 NPs with 1% and 2% Mo, the bandgap of TiO2 NPs decreases from 3.05 to 2.94 and 2.73 eV, respectively. The ionic radius of Mo6<sup>+</sup> is 0.062 nm, while that of Ti4<sup>+</sup> is 0.068 nm. As such, Mo ions can readily replace Ti4<sup>+</sup> in the TiO2 lattice, as they have approximately the same ionic radii, resulting in a narrower bandgap [112]. This facilitates the charge transfer between the VB and Mo-3d orbitals, thereby promoting photocatalytic activity under visible light [112].

**Figure 3.** The charge transfer processes between excited electrons from the valence band of TiO2 with (**a**) Mn2<sup>+</sup> ions of Mn-doped TiO2, and (**b**) Fe3<sup>+</sup> ions of Fe-doped TiO2. CB and VB are the conduction and valence bands of TiO2, respectively. Reproduced with permission from [92,95], respectively. Copyright Elsevier, 2017; Copyright American Chemical Society, 2013.

From the literature, rare earth metal ions are effective in extending the recombination time of charge carriers and improving their separation efficiency. Rare earth metals, such as cerium (Ce), lanthanide (La), erbium (Er) and ytterbium (Yb), with 4f, 5d, and 6s electrons are good dopants for modifying the electronic structure and optical properties of titania [116,117]. Rare earth dopants introduce several impurity energy levels due to the introduction of orbitals between the conduction and valence bands. Moreover, lattice defects are generated in titania as a result of a large mismatch of both the charge and ionic radius between the dopant and Ti cations. The impurity energy levels act as trapping centers for photogenerated electrons and holes, thereby favoring charge separation and reducing the electron–hole recombination [118–121]. Among these, the La dopant in titania is studied most frequently, followed by Ce doping, in recent years [116–122]. Kasinathan et al. reported that cerium doping suppresses the recombination of photogenerated electron–hole pairs in titania and promotes a red-shift in its band gap transition. As such, Ce-TiO2 had strong antibacterial activity against *E. coli* due to its strong oxidation activity and superhydrophilicity [121].

Generally, two or more types of metal cations can be incorporated into the TiO2 lattice to further improve its photocatalytic performance. This is typically termed the 'co-doping'. The enhancement in the photocatalytic activity of co-doped TiO2 is attributed to the synergistic effect of the dopants in increasing visible light absorption, thus facilitating electron–hole generation and suppressing the recombination rate [90,113–115]. Very recently, Aviles-Garcia et al. synthesized W and Mo co-doped TiO2, and reported that the nanocomposite with the W:Mo = 1:1 ratio having a bandgap of 2.87 eV exhibits a synergistic effect between the dopants to generate more hydroxyl radicals for degrading 4-chlorophenol. This is because both the W6<sup>+</sup> and Mo6<sup>+</sup> ions are effective in trapping photogenerated electrons, thus extending the lifetime of electron–hole pairs and reducing their recombination rate. The holes can react with the adsorbed H2O or –OH groups on the TiO2 surface, giving rise to hydroxyl radicals. The photocatalytic reactions can be expressed as follows [114]

$$\text{W/Mo-TiO}\_2 + h\nu \to \text{e}^- + \text{h}^+\tag{1}$$

$$\rm{W}^{6+} + \rm{e}^{-} \rightarrow \rm{W}^{5+} \tag{2}$$

$$\text{MoO}^{6+} + \text{e}^- \rightarrow \text{Mo}^{5+} \tag{3}$$

$$\text{CH}\_2\text{O} + \text{h}^+ \rightarrow \text{"OH} + \text{H}^+ \tag{4}$$

$$\bullet \text{OH}^- + \text{h}^+ \rightarrow \bullet \text{OH}.\tag{5}$$

The visible light response of titania can also be achieved by doping with noble metals such as gold (Au), silver (Ag), platinum (Pt) and palladium (Pd) [123–126]. As recognized, a collective oscillation of conduction electrons can be induced in metal NPs by irradiating with light. This is because the collective oscillation of surface electrons resonates with the electromagnetic field of the incident light. This behavior is generally termed as the localized surface plasmon resonance (LSPR). LSPR covers a wide range of solar spectrum, particularly in the visible and near-infrared (NIR) regions [127,128]. After excitation, LSPR decays non-radiatively into hot electrons and holes through Landau damping, generating highly energetic charge carriers that are typically termed 'hot carriers' [129]. This ultrafast relaxation renders the hot carriers capable of rapidly separating and transferring into semiconductors to drive chemical reactions on adsorbed molecules [128–131]. The LSPR effect is more pronounced for Au and Ag nanoparticles compared with other metals.

Employing plasmonic NPs on semiconductors is considered to be effective in improving their photocatalytic performance. In this respect, noble metal NPs act as electron donors for titania by injecting hot electrons into the conduction band of TiO2 under visible light [132]. The holes created in plasmonic AgNPs can capture conduction electrons of TiO2, thereby reducing the charge recombination in titania. Therefore, plasmonic oscillation from Au and Ag nanoparticles to TiO2 under visible light has received considerable attention in recent years [133–138]. Moreover, AgNPs with well-established antibacterial properties are particularly attractive dopants for titatia in addition to their LSPR effect [15]. Figure 4 shows the UV-visible spectra of pristine TiO2 and Ag/TiO2 nanocomposites with different AgNP contents [126]. Pristine TiO2 exhibits a strong UV light absorption band due to the excitation of the electron–hole pair across the bandgap. The Ag/TiO2 nanocomposites display higher absorption values in the UV region, and the absorption intensity increases with increasing AgNP concentrations. The introduction of AgNPs into TiO2 results in an increase in the absorption towards the visible light region, i.e., 400–650 nm wavelength. This arises from the LSPR effect of AgNPs that promotes the absorption of Ag/TiO2 nanocomposites in the visible regime.

**Figure 4.** Ultraviolet-visible diffuse reflectance spectra of TiO2 and its nanocomposites. Reproduced with permission from [126]. Copyright Elsevier, 2019.

When a metal comes into contact with a semiconductor of a different work function, a large potential barrier is established at their interface, which is usually known as the Schottky barrier [137]. Such a barrier at the AgNPs/titania junction improves the charge separation or suppresses the charge recombination greatly [135,138]. Under UV irradiation and in the absence of plasmonic oscillation, electron transfer from the TiO2 conduction band to AgNPs is thermodynamically favorable, as the Fermi level of titania is higher than that of AgNPs. From this perspective, excited electrons are transferred from titania to AgNPs across the Schottky barrier at the Ag/TiO2 interface. Accordingly, AgNPs serve as an excellent electron accumulator, thus suppressing the charge recombination process. Under visible light irradiation, AgNPs experience the LSPR effect, and excite the conduction electrons for transfer to TiO2 to create ROS, as mentioned previously (Figure 5).

**Figure 5.** The creation of reactive oxygen species in Ag/TiO2 nanomaterials due to the localized surface plasmon resonance (LSPR) effect of AgNPs under visible light. After excitation, LSPR decays into hot electrons and holes through Landau damping, creating highly energetic charge carriers. On the other hand, AgNPs serve as an excellent electron accumulator for TiO2 under UV irradiation. Reproduced with permission from [138]. Copyright MDPI, 2019.

#### *3.2. Carbonaceous Nanomaterials Modified Titania*

Pure and high-quality graphene is an excellent electrical conductor as it has no bandgap. Graphene consists of a monolayer of sp2-bonded carbon atoms that are tightly organized into a two-dimensional (2D) honeycomb structure. Graphene has been reported to possess an excellent electrical mobility of <sup>2</sup> <sup>×</sup> <sup>10</sup><sup>5</sup> cm<sup>2</sup> <sup>V</sup>−<sup>1</sup> <sup>s</sup><sup>−</sup>1, a superior light transparency of 97.7%, a high specific surface area of 2600 m<sup>2</sup> <sup>g</sup><sup>−</sup>1, and good antibacterial activity [14,139,140]. In this context, graphene and its derivatives, such as graphene oxide (GO) and reduced graphene oxide (rGO), find attractive applications in electronic and optoelectronic devices, energy storage devices, chemical sensors and biomedical implants [141–143]. Moreover, a graphene sheet with a lateral dimension of several micrometers can serve as a template for anchoring TiO2 NPs onto its surface [102,144–146].

Large-area graphene sheets can be synthesized from chemical vapor deposition (CVD) [147]. However, the CVD approach is still an expensive process for manufacturing high-quality graphene sheets. To tackle this, GO can be prepared at a large scale by exposing the graphite flakes in a strong oxidizing solution, i.e., a mixture of sulfuric acid, sodium nitrate, and potassium permanganate, using a modified Hummers process [148]. As a result, GO bears oxygen functional groups having hydroxyl and epoxide on the graphene basal plane, with carboxyl and carbonyl groups at the edges [149]. Those oxygenated groups damage the conjugated structure of graphene, leading to poor electrical conductivity. To resume its electrical conducting properties, reducing agents, such as hydrazine and sodium borohydride, are used to reduce GO to form rGO [150]. The aforementioned reductants are toxic, so green reductants such as L-ascorbic acid, D-glucose and tea polyphenol can be used to

reduce GO to rGO [151]. Generally, all chemical reductants cannot remove oxygenated groups of GO completely, rendering rGO with a certain degree of residual oxygen levels. Accordingly, GO would change from insulating to conducting behaviors by regulating the C/O ratios. GO and rGO with a tunable band gap of 4.3–2.4 eV is dependent upon the oxygen level; the bandgap generally increases with increasing O levels [152]. In contrast, pure graphene exhibits no bandgap with excellent electron mobility.

For novel graphene/TiO2 nanostructures, the migration of photogenerated charge carriers from TiO2 to graphene or vice-versa depends upon the interfacial contact between them, and the photon energy or wavelength [153]. As is known, uniformly dispersed TiO2 NPs on a large-area graphene sheet and a close interfacial interaction between them are essential for efficient charge transport across the interface (Figure 6a). Under UV irradiation, photoexcited electrons from titania are injected into graphene as the conduction band minimum of TiO2 is higher than the Fermi level of graphene [32]. As such, highly conductive graphene acts as an electron acceptor for titania, and provides a network to facilitate the rapid transfer of excited electrons. These promote the separation between electron–hole pairs and inhibit their recombination [154]. Under visible light illumination, electrons located in high-energy graphene states are delocalized into the conduction band of TiO2. Consequently, electrons react with oxygen adsorbed on the TiO2 surface to form superoxide anion (Figure 6b) [153]. In general, a few layer graphene sheets of rGO/TiO2 photocatalyst facilitate a red shift in the optical absorption, thereby narrowing its bandgap and enhancing its photocatalytic efficiency [144,146]. Figure 7 shows the UV-vis spectra of anatase TiO2 and rGO/TiO2 nanocomposite. The inset displays the Tauc plot of the modified Kubelka–Munk (KM) function with a linear extrapolation to produce respective bandgap values of TiO2 and rGO/TiO2 materials, i.e., 3.2 eV and 2.9 eV.

**Figure 6.** Schematics displaying the (**a**) roles of graphene layers of graphene/TiO2 composite in photocatalysis, and (**b**) charge transfer mechanism under ultraviolet or visible light irradiation. Reproduced with permission from [145,153], respectively. Copyright MDPI, 2018 and 2017.

A single-walled carbon nanotube (SWNT) is formed by rolling-up a graphene sheet into a cylindrical or turbular shape, while several sheets rolls into a multi-walled nanotube (MWNT). The MWNTs with a large surface-area-to-volume ratio and remarkable electrical conductivity serve as the template for anchoring TiO2 NPs, facilitating the separation of electron–hole pairs and inhibiting the charge recombination by trapping photoexcited electrons from titania [154]. Accordingly, the bandgap of TiO2 NPs reduces from 3.25 to 2.71 eV with an increase in MWNTs content. This leads to a shift in the absorption edge into the visible region. The Ti–O–C bond extends the light absorption to longer wavelengths [155–157].

**Figure 7.** UV–vis diffuse reflectance spectra of (**a**) anatase TiO2 and (**b**) nanostructured rGO/TiO2. Inset: plot of transformed KM function [F(R).*hv*] <sup>1</sup>/<sup>2</sup> vs. *hv* for bandgap determination of anatase TiO2 and rGO/TiO2; R is reflectance and *hv* is photon energy. Reproduced with permission from [146]. Copyright Springer, 2013.

#### *3.3. Non-Metal Doping*

Metal doping has some drawbacks for enhancing the visible light response of titania. These include transition metals of high contents, which may serve as recombination sites for photogenerated charge carriers, the low thermal stability of photocatalysts, the formation of secondary phases and dopant insolubility [105,158,159]. Therefore, significant improvement in the photocatalytic performance of metal-doped titania can be achieved only at a low metal dopant concentration. Above an optimal dopant content, photocatalytic activity decreases owing to a higher recombination rate of charge carriers. Non-metal elements such as carbon, nitrogen and boron, with an atomic radius close to that of the O atom, can be utilized as anionic dopants for replacing lattice oxygen anions [76,97,159–164]. In this respect, non-metal doping appears to be an alternative route for enhancing visible light efficiency, due to the introduction of a new valence band associated with their localized 2p states lying above the valence band of TiO2 (Figure 8). As such, non-metal doping generates a hybridization of O-2p and N-2p orbitals, giving rise to an upshift in the valence band position. By irradiating with visible light, electrons are excited from the localized N-2p states to the CB, leaving behind holes on the localized states. The exception is fluorine with the highest electronegativity, having filled states below the O-2p valence band, leading to the formation of Ti3<sup>+</sup> ions as of result of the charge compensation [165].

**Figure 8.** Electronic band structure of titania due to non-metal doping. CB and VB represent conduction band and valence band, respectively. Reproduced with permission from [160]. Copyright Elsevier, 2013.

Among anionic dopants, nitrogen is widely employed to enhance the visible light response of titania. The N atom can occupy either the substitutional or interstitial site of the titania lattice. In the former case, the N atom substitute the O atom to yield TiO2−xNx, so that the doping energy state (N-2p) lies just above the valence band. Substitutional N doping reduces the bandgap of titania slightly, from 3.20 to ~3.06 eV. The interstitial N-doping reduces the bandgap to ~2.46 eV, in which the doping energy level lies in the midgap, i.e., at 0.74 eV above the valence band [166–168]. In an earlier study by Asahi et al., N-doping into substitutional sites of TiO2 is reported to be essential for bandgap reduction and efficient photocatalytic activity [166]. For the C-doped TiO2 photocatalyst, carbon dopant may replace oxygen or Ti in the substitutional lattice site. It may also occupy the interstitial site [169]. Therefore, C-doped TiO2 can have different photocatalytic behaviors, depending on the synthesis process employed. Density functional theory (DFT) calculations predict that substitutional (to oxygen) carbon and oxygen vacancies are formed at low carbon contents and oxygen-poor conditions. Under oxygen-rich conditions, interstitial and substitutional (to Ti) C atoms are favored [170]. Similarly, the B dopant can substitute for either the O or Ti atom, or can occupy the interstitial position. DFT simulations indicate that a B substitution for Ti is unlikely to take place. In contrast, the boron atom tends to either replace an oxygen atom or occupies the interstitial site [171]. From the X-ray photoelectron spectroscopic (XPS) results, Patel et al. reported that B preferentially occupies the interstitial site at low concentrations (up to 1%), while it occupies the substitutional O site as the concentration increases (≥2%) [172].

Recently, Sotelo-Vazquez et al. reported that phosphorus (P)-doping can result in the formation of both cationic (P5+) and anionic (P3−) states of anatase TiO2 films on the basis of XPS results. The P3<sup>−</sup> state of P-doped TiO2 exhibited inferior photocatalytic activity compared to undoped TiO2 film. Transient absorption spectroscopic results revealed that charge carrier concentrations increased by several orders of magnitude in films containing P5<sup>+</sup> species [173]. From the XPS measurements, Gopal et al. demonstrated that the P dopant exists in a P5<sup>+</sup> state which can replace part of Ti4<sup>+</sup> through the formation of Ti–O–P bonds, i.e., forming P cation-doped TiO2 [174]. As a result, the photocatalytic activity of P-doped titania for degrading methylene blue was much enhanced and superior to undoped TiO2. Moreover, X-ray diffraction results indicated that P-dopant increases the thermal stability of TiO2 NPs, and retards the phase transition from anatase to rutile.

From the literature, fluorine doping stabilizes anatase TiO2 at elevated temperatures up to 1200 ◦C [75]. The substitution of fluorine for oxygen in TiO2 NPs leads to the creation of an oxygen vacancy [175]. Fluorine doping converts Ti4<sup>+</sup> to Ti3<sup>+</sup> in TiO2 NPs by charge compensation. The presence of Ti3<sup>+</sup> suppresses the recombination of the electron–hole pairs and enhances the photocatalytic activity accordingly [165]. Co-doping TiO2 NPs with F and N is considered to be very effective in tuning the bandgap to further enhance visible-light photocatalytic activity. Multiple charge transfer transitions occur in the Ti3<sup>+</sup> localized state, oxygen vacancy and N midgap state of the F–N, co-doped TiO2 NPs [176]. Table 1 summarizes visible-light active TiO2 NPs doped with metals and non-metals.

#### *3.4. Coupling of Semiconductors*

The poor photocatalytic efficiency of titania under visible light can be overcome through the formation of a heterojunction structure by coupling with other semiconductors with a suitable energy band level. Titania can be coupled with metal oxides (e.g., Cu2O, Fe2O3, WO3) and chalcogenides (e.g., CdS, MoS2 and WS2) to form a heterojunction for the charge separation in enhanced visible light absorption. Those coupled semiconductors acting as sensitizers should be nontoxic, and exhibit visible light photocatalytic activity, with a bandgap smaller than that of titania [177–183]. In this respect, photoexcited electrons in the CB and holes in the VB of a sensitizer semiconductor can be transferred to the CB and VB of TiO2 NPs [180]. Zinc oxide with good antimicrobial property is unsuitable to form visible-light active ZnO/TiO2 nanostructures due to its wide bandgap of 3.37 eV. Cadmium sulfide is toxic and carcinogenic, so it is unfavorable to form CdS/TiO2 heterojunction for practical applications. Nontoxic molybdenum disulfide (MoS2) with a direct band-gap of 1.9 eV can be coupled with titania to form MoS2/TiO2 nanocomposites, having excellent visible photocatalytic activity [181]. Oxide semiconductors, such as α-Fe2O3 and Cu2O with a respective small bandgap of 2.2 eV and 2.17 eV,

can also form composite photocatalysts, with TiO2 having good antibacterial properties under visible light [177,179,182,183]. Inexpensive and nontoxic Cu2O, with its efficient electron injection to the conduction band of TiO2, is particularly suitable for forming heterojunction photocatalysts [182,183].


**Table 1.** Visible-light active TiO2 NPs doped with metals and non-metals.

#### **4. Synthesis of Titania Nanomaterials**

Titania can be fabricated in the form of thin films, powders, or nanocrystals. Physical deposition techniques such as thermal evaporation, reactive sputtering and pulsed laser deposition, chemical gas-phase atomic layer deposition (ALD) process, and wet chemical deposition methods such as dip-coating, spin-coating, spray coating and sol-gel, have been employed by researchers to prepare TiO2 thin films [184–189]. Those homogeneous films deposited by physical deposition techniques are beneficial for use in dye-sensitized solar cells, microelectomechanical systems and electroluminescent devices [185,189]. In ALD, chemical precursors react sequentially on various substrate surfaces including carbon nanotubes, forming nanometer-sized films of metal oxides (e.g., TiO2 and HfO2) [190–192]. It offers the advantages of nanometer-level control of both thickness and film composition. For bactericidal applications, wet chemical processing is the most convenient, simple and effective synthesis route for preparing TiO2 NPs and nanocomposites. Moreover, the solution chemical synthesis process is capable of producing titania nanomaterials in larger quantities in comparison with the physical processing route. Solution processing techniques include the sol-gel, wet impregnation, photoreduction, hydrothermal and solvothermal processing, electrochemical anodization and electrospinning.

#### *4.1. Solution Processing Route*

#### 4.1.1. Sol-Gel Method

Titania colloids can be synthesized through the hydrolysis and condensation reaction of titanium alkoxide in the presence of water, and these reactions are catalyzed by an acid [193–196]. The sol-gel process involves the transformation of metal alkoxide or metal salt into a solid by adding an excess of water to give a metal–oxo linkage (M–O–M). The hydrolysis facilitates the formation of original nuclei TiO2, and the subsequent condensation promotes the growth of a crosslinked network of TiO2 nuclei. This strategy allows the formation of TiO2 NPs with a high level of chemical purity [196,197]. From an earlier study of Padmanabhan et al., the sol-gel process involved the reaction of titanium

tetraisopropoxide (TTIP) with trifluoroacetic acid (TFA), followed by hydrolysis, gelation, drying, and finally calcination at high temperatures. The sol was dried at 90 ◦C to obtain the gel, and then calcined at 500–900 ◦C to remove organic substances to form nano-TiO2 with a high photocatalytic activity [194]. In a recent study, Lusvard et al. employed different precursors and procedures for synthesizing TiO2 NPs with the preparation conditions compatible with the industrial scale for water purification [196]. Three different kinds of precursors were utilized for the synthesis of TiO2 NPs, including: titanium tetrachloride (TiCl4) and ethanol, titanium isopropoxide (C12H28O4Ti) and urea (CO(NH2)2), as well as titanium isopropoxide, isopropyl alcohol (C3H8O), acetic acid (CH3COOH) and methanol (CH3OH). They reported that TiO2 NPs, synthesized from molar TTIP: urea in a ratio of 2:1 at 50 ◦C, have the best photocatalytic activity for degrading methyl blue and bromothymol blue [196].

For fabricating metal-doped TiO2 nanopowders, an additional metal source reagent is needed, and added to titanium precursors during the sol-gel process [197–200]. For instance, Marami et al. prepared Fe-doped TiO2 powders by introducing FeSO4·7H2O into the TTIP, and the ethanol solution followed with the addition of acetic acid under vigorous stirring. Thereafter, the temperature of mixture was increased to 70 ◦C, and ethylene glycol was added, acting as a stabilizer. The product was dried and finally calcined at 600 ◦C for 4 h to yield Fe-doped TiO2 nanopowders [198]. In the case of Ag-doped TiO2, a desired amount of silver salt precursor, i.e., silver nitrate was added to the TTIP−methanol solution [50,199]. Reducing agents such as NaBH4 are employed to reduce silver ions to AgNPs. For the synthesis of N-doped TiO2, an organic compound with nitrogen (such as trimethylamine, 1,3-diaminopropane, ethylmethylamine), or ammonium salt bearing nitrogen (e.g., ammonium carbonate, ammonium chloride, ammonium nitrate), is added to the sol-gel solution during the synthesis process [200–204].

#### 4.1.2. Hydrothermal/Solvothermal Synthesis

The hydrothermal/solvothermal method is a useful tool for fabricating TiO2 nanostructures involving chemical reactions in a solvent (water/nonaqueous) medium at an elevated temperature >100 ◦C and a pressure higher than 1 atm, within a closed system using an autoclave. As the sol-gel process generally produces amorphous or low crystalline materials, a subsequent annealing at high temperatures for crystallization is needed. In this context, hydrothermal or solvothermal processing is beneficial for improving the crystallinity of titania synthesized by the sol-gel technique. For example, Yanagizawa and Ovenstone investigated the effect of hydrothermal treatment on the crystallinity and phase structure of sol-gel prepared, TiO2 amorphous powders [205]. In their study, hydrothermal treatment was performed at 250 ◦C for 1 h in the presence of several inorganic salts under acidic and basic conditions. Acidic conditions led to the formation of anatase, brookite, and rutile, whereas basic conditions and/or the presence of sulfate ions favored the crystallization of anatase [205]. In addition, the hydrothermal approach can also be used to synthesize rGO/TiO2 nanocomposites [206].

The organic solvents in solvothermal treatment help to control the morphology of synthesized nanocrystals. Thus, this process enables better control of the shape, size distribution and crystallinity of TiO2 NPs in comparison with the hydrothermal method. TiO2 nanostructures of different morphologies can be obtained and tailored by manipulating several processing parameters, including the type of solvent and titanium precursor, molar ratio of reagents, addition of surfactant, reaction temperature and time [207–212]. For instance, TiO2 nanorods can be synthesized in TTIP, benzyl alcohol (BzOH) and acetic acid (AA) at 150 ◦C for 8 h. The molar ratio of TTIP/AA is kept at 1: 4 [208]. Recently, Falentin-Daudré et al. synthesized highly crystalline sphere and rod-shaped TiO2 nanostructures using TTIP, benzyl alcohol (BzOH) and AA reagents. The shape of the TiO2 nanostructure can be tuned by varying the concentration molar ratios of TTIP/BzOH and AA/BzOH (Figure 9) [209]. The X-ray diffraction patterns for TiO2 nanospheres and nanorods display well-defined peaks associated with pure anatase, thus revealing TiO2 nanospheres and nanorods with a high crystallinity.

**Figure 9.** Transmission electron micrographs of solvothermally synthesized TiO2 with nanospheres (NP1–NP2) and nanorods (NP3–NP4) morphologies. Reproduced with permission from [209]. Copyright Elsevier, 2017.

For preparing rGO/TiO2 nanocomposite, Tan et al. first obtained a mixed solution of tetrabutyl titanate, ethylene glycol and acetic acid, and then added it dropwise into a chilled GO solution under vigorous stirring. Thereafter, an autoclave filled with the GO–TiO2 solution was heated at 180 ◦C for 8 h. The greyish-black precipitate was obtained by centrifugation [146]. During the solvothermal synthesis, GO was reduced to rGO accordingly. Figure 10a,b show the respective field-emission scanning electron microscopic (FESEM) image and transmission electron micrograph (TEM) of the rGO/TiO2 nanocomposite. It is apparent that titania nanoparticles with an average size of 12 nm are dispersed and anchored on the rGO surface. The high-resolution TEM (HRTEM) images of a selected rGO-TiO2 heterojunction are shown in Figure 10c,d. The lattice fringes can be seen in titania nanoparticles, especially in the high magnification image shown in Figure 10d, implying that the TiO2 nanocrystals exhibit good crystallinity. The lattice spacing of TiO2 is determined to be 0.35 nm, which corresponds to the (101) plane of anatase TiO2. Moreover, the rGO–TiO2 interface is clean and free from the impurity products. The intimate connection enables photoinduced electrons to flow readily from rGO to TiO2 NPs, thereby enhancing the photocatalytic activity.

**Figure 10.** (**a**) Field-emission scanning electron image and (**b**) transmission electron micrograph of the solvothermally synthesized rGO/TiO2 nanocomposite. (**c**,**d**) Enlarged images of high-resolution transmission electron micrographs showing the lattice fringes of TiO2 and a clean interface between TiO2 and rGO. Reproduced with permission from [146]. Copyright Springer, 2013.

#### 4.1.3. Electrochemical Anodization

Transition metals like iron and chromium can form a thin oxide film on their surface upon electrochemical polarization in the anodic region [213,214]. Therefore, titanium and its alloys can also form anodic films on their surfaces during the anodizing process. Ti-based alloys are widely used as load-bearing bone prostheses and dental implants in clinical sectors. However, bacterial

infection due to biofilm formation is the main cause of implant failures. In recent years, there has been a clinical demand for functional Ti-prostheses with enhanced bone cell adhesion/growth, and excellent antibacterial properties. To improve the biocompatibility of Ti-implants with the host-tissues, titania coating is formed on their surfaces through the anodization technique [215]. One-dimensional titania nanotubes' (TNTs) high surface area to volume ratio and enhanced bone–cell adhesion ability makes them suitable for biomedical applications [216–219]. TNTs promote the osseointegration of bone implants more effectively than titanium alloys. Compared with TiO2 NPs, TNTs bear a stronger negative surface charge [55], enabling them to repel bacteria with a negatively charged membrane. Thus, TNTs show bactericidal effects to a lesser degree. By incorporating AgNPs into TNTs, the bactericidal performance of anodized Ti-alloys is improved significantly [218]. The TNTs fabricated from the sol-gel or hydrothermal methods are randomly oriented [220]. In contrast, ordered and self-organized titania nanotubes can be prepared by electrochemical anodization [219]. Anodization offers the additional advantages of simplicity, and ease of fabrication and scaling-up. The tube diameter, length and wall thickness can be properly manipulated by processing parameters including electrolyte composition, applied voltage, pH, temperature, and time [221]. In general, the applied voltage regulates the nanotube diameter, and the anodizing time controls the tube length.

Titanium anodization can be simply performed in a two-electrode cell system connected to a power supply (Figure 11a). The oxide film formation involves an anodic oxidation of metal at the metal surface, outward migration of Ti4<sup>+</sup> ions toward the metal/oxide interface and field-assisted dissolution of oxide at the oxide/electrolyte interface [219]. The oxide layer generally has a low conductivity, which restricts the migration of oxygen and Ti ions accordingly. As such, continued oxide growth is assisted by an electric field, and a compact oxide layer is formed on the Ti surface. The electrochemical reactions occurring during anodization are given as follows

$$\text{Ti} + 2\text{H}\_2\text{O} + 4\text{e} \rightarrow \text{TiO}\_2 + 4\text{H}^+ \text{ Anodic oxidation} \text{.}\tag{6}$$

$$2\ 4\text{H}^+ + 4\text{e} \to 2\text{H}\_2\text{Cathodic reaction.}\tag{7}$$

**Figure 11.** Schematic illustration displaying (**a**) the set-up for anodization and (**b**) frmation of compact titania layer on the Ti substrate in electrolytes without fluoride, and self-organized titania nanotube arrays in electrolytes with fluoride. Reproduced with permission from [222]. Copyright Elsevier, 2007.

To form TNTs on Ti foil substrate, aqueous fluoride-containing electrolytes such as (NH4)2HPO4/NH4F or (NH4)2SO4/NH4F, and organic electrolytes, e.g., ethylene glycol, formamide, or dimethylsulfoxide containing F− anions, are needed (Figure 11b). The presence of F− anions in the electrolyte results in the chemical dissolution of oxide at the electrolyte/oxide interface to yield [TiF6] <sup>2</sup><sup>−</sup> and F− rich layers. In other words, F<sup>−</sup> ions etch the oxide layer to form water-soluble [TiF6] 2− complexes. The chemical reaction associated with the F− ions etching is given by [222]

$$\text{TiO}\_2 + 6\text{F}^- + 4\text{H}^+ \rightarrow \text{[TiF}\_6\text{]}^{2-} + 2\text{H}\_2\text{O} \tag{8}$$

Accordingly, small pits are produced at the electrolyte/oxide interface due to the chemical dissolution of oxide. These pits gradually grow into nanopores, as shown in Figure 12a,b. The pores grow into tubular features and form TNT arrays as the anodizing process continues to its final stage (Figure 12c,d). The growth of TNT arrays is described as the competition between electrochemical oxide formation and chemical dissolution of oxide by F− ions of sufficient concentrations [222–224]. Figure 13a,b shows the formation of TNT arrays by anodizing Ti in a mixed ethylene glycol/NH4F and water solution [223,225]. At a low applied voltage of 5 V, an SEM image shows the formation of the rough Ti surface together with inhomogeneous TNTs. However, uniform and well-aligned TNTs are produced by increasing the applied voltage from 15 to 20 V (Figure 13a). The as-anodized TiO2 nanotubes generally exhibit an amorphous structure. Therefore, post-annealing treatment is typically performed to enhance their crystallinity.

**Figure 12.** Schematic showing the formation of titania nanotube (TNT) arrays: (**a**) an initial development of a compact oxide layer on the surface of Ti, (**b**) small pits formation due to the etching of oxide by F− ions, (**c**) local growth of nanopores into well-aligned TNT arrays, and (**d**) the shape and wall thickness of a nanotube. Reproduced with permission from [223]. Copyright MDPI, 2019.

**Figure 13.** (**a**) Top-view scanning electron micrographs of TNT arrays prepared by anodizing Ti in a mixed ethylene glycol/NH4F and water solution under applied voltages of 5, 15 and 20 V for 5 h. Reproduced with permission from [225]. Copyright IOP Publishing, 2014. (**b**) Cross-sectional SEM image (inset) and top view of TNTs fabricated by anodizing Ti in a mixed ethylene glycol/NH4F and water solution at 30 V for 1 h. Reproduced with permission from [223]. Copyright MDPI, 2019.

To introduce AgNPs into TNTs, Lan et al. deposited a thin Ag layer on anodized TNTs via electron-beam evaporation. AgNPs were directly coated onto inner- and outer-tube surfaces [226]. Figure 14A is the TEM image of AgNP-decorated TNTs, showing the uniform distribution of AgNPs along the tubes. High-magnification TEM images reveal that the sizes of AgNPs range from 5 to 20 nm (Figure 14B,C). The corresponding energy dispersive X-ray spectrum (EDS) reveals the presence of Ag in addition to Ti from the TNT (Figure 14D). Alternatively, the wet chemical synthesis route using TNT and silver nitrate mixed solution can yield Ag-decorated TNTs. Thereafter, UV illumination is employed to reduce Ag<sup>+</sup> ions to AgNPs through the photoreduction process without using reducing agents. As such, photo-assisted deposition can bind AgNPs closely to TNTs [53].

**Figure 14.** (**A**) TEM image of a single, Ag-decorated TiO2 nanotube with a diameter of 100 nm. The white arrow indicates the growth direction of a nanotube. (**B**) High-magnification image of the selected are, as marked by a dashed square in (**A**). (**C**) Enlarged view of a single AgNP, and (**D**) the corresponding EDS spectrum of AgNP and TiO2 nanotubes. Reproduced with permission from [226]. Copyright Public Library of Science, 2013.

#### 4.1.4. Electrospinning

Electrospinning is a simple and versatile tool to form microfibers and nanofibers (NFs) from different materials including polymers, metal oxides and their nanocomposites. This process has been used extensively for fabricating nanofibers derived from polymers and polymer nanocomposites [27,72,227,228]. In the process, a high electric field is applied to the polymer/solvent solution. Beyond a critical voltage, the repulsive electrostatic force overcomes the surface tension of the polymer droplet, resulting in the ejection of a charged jet from the nozzle towards the collector. Several processing parameters affect the fiber diameter and porosity of electrospun polymer mats, including the type of solvent used, polymer concentration, applied voltage, flow rate, needle-to-collector distance, etc. [227,228]. Very recently, Feng et al. incorporated commercial Degussa P25 (70–80% anatase and 20–30% rutile) with a diameter of 20 nm into polylactic acid (PLA) using the electrospinning method [229]. They reported that the PLA/TiO2 composite nanofibers with 0.75 wt% TiO2 exhibit good bactericidal activity upon exposure to UV-A (360 nm) radiation.

In general, two approaches have been employed to prepare electrospun metal oxide NFs, i.e., a polymer-assisted spinning method and direct electrospinning without using a polymer [230–234]. The former strategy involves the mixing of metal alkoxide sol with a polymer solution in which the polymer controls the rheology during electrospinning. Without a polymer solution, the viscosity of the sol varies with time, causing a difficulty in controlling the rheological properties of a sol. In addition, the diameter of the as-spun ceramic fibers falls in the micrometer scale [232]. To improve solution spinnability, poly (vinyl pyrrolidone) (PVP) is added to the sol to obtain continuous ceramic NFs. As such, the diameter of titania fibers can be tuned from the micrometer to nanometer scale by regulating

the concentration of PVP and the Ti alkoxide to PVP ratio. For example, Tekmen et al. electrospun TiO2 with a diameter of 54–78 nm, employing a mixture solution of PVP and TTIP [231].

Albetran et al. studied the effect of calcination treatment on the bandgap reduction in electrospun titania nanofibers exposed to pure argon, air, and air–argon mixtures at 900 ◦C [233]. The spinning solution was prepared by mixing TTIP, ethanol, and acetic acid in a fixed volume ratio of 3:3:1, followed by the addition of 12 wt% PVP. The nanofibers heated in 100% argon exhibit an uneven or rough surface in comparison with the as-spun amorphous fibers due to the formation of crystalline grains of anatase and rutile (Figure 15a,b). In general, the anatase phase is stable in TiO2 up to 500–700 ◦C, and transforms to rutile with an increase in temperature [75]. Calcination at 900 ◦C led to a reduction in the diameter of NFs due to the removal of PVP and the densification of TiO2. The degree of crystallinity of calcined titania NFs was 73.4%. Moreover, calcination of the as-spun NFs in 100% argon induced the formation of a high amount of oxygen vacancies, thereby creating a localized state below the conduction band, and reducing the bandgap accordingly. The creation of oxygen vacancies was reported to be effective to enhance visible light absorption as the oxygen vacancy states were located 0.75 to 1.18 eV below the conduction band minimum of TiO2. Those oxygen vacancies were generated in titania by heating in an oxygen-poor environment, such as a N2, Ar or a vacuum at elevated temperatures (>400 ◦C) [235]. From Figure 15c, the as-spun mat calcined at 900 ◦C in a 100% argon atmosphere had the highest absorbance in the visible light region compared with the as-spun mats with and without calcination in air and air–argon gaseous mixtures. The bandgap of as-electrospun amorphous nanofibers determined from the UV-vis spectra reduced from 3.33 to 3.09, 2.91 and 2.18 eV through calcination in air, 25% air/75% argon and 100% argon, respectively. Nasr et al. electrospun (2%–7 wt%) rGO/TiO2 NFs, followed by annealing at 500 ◦C [236]. The rGO sheets reduced the bandgap of TiO2 NFs from 3.2 to 2.9 eV, thus suppressing the recombination of electron–hole pairs, and increasing visible-light photocatalytic activity for degrading methylene blue. Very recently, Chapman et al. successfully obtained TiO2 NFs with average diameters of ~70 nm without using a polymer through mixing an alkoxide precursor, solvent, water, and an acid [234]. They introduced TTIP in ethanol, aged under nitric acid condition, and then added *N,N*-dimethylformamide to obtain a sol needed for the continuous spinning of TiO2 NFs.

**Figure 15.** Scanning electron micrographs of (**a**) electrospun titania nanofibers before heating, and (**b**) after heating in 100% argon atmosphere at 900 ◦C. (**c**) UV-visible spectra of as-spun titania nanofibers without calcination, and with calcination at 900 ◦C in 100% air, 50% air–50% argon, 25% air–75% argon and 100% argon. Reproduced with permission from [233]. Copyright Elsevier, 2016.

#### **5. Bactericidal Activities**

Titania NPs are negatively charged at the point of zero charge (pzc) at pH = 6.2. Therefore, they exhibit low bactericidal activity in neutral and alkaline solutions by repelling negatively charged bacteria in the absence of light. At acidic pH, positively charged TiO2 NPs strongly interact with the bacterial cells, resulting in bacterial membrane penetration and inducing oxidative damage accordingly [57]. Kiwi et al. reported that TiO2 NPs tend to kill *E. coli* by direct contact in the dark condition, thus damaging their cell walls, due to the electrostatic attraction between the TiO2 NPs and the negatively charged bacterial cell wall at a pH close to but below pzc [237]. On the contrary, the bactericidal effect is caused by the creation of ROS species on the TiO2 NPs under UV irradiation. This means that the bactericidal activity is due to the radiation itself and is not caused by the titania NPs [238]. TiO2 NPs can kill multidrug-resistant bacteria such as MRSA, vancomycin-resistant Enterococcus faecalis (VRE) and *P. aeruginosa* through the reactive radicals generated by electron–hole pairs upon UV excitation [239,240]. The photocatalytic inactivation of MRSA and VRE strains depends on the power and irradiation time of UV-A light [239]. Therefore, the disinfection process requires a high-power UV source to excite TiO2 NPs. Apparently, TiO2 NPs do not reach their full potential for bactericidal applications owing to their ineffective photoexcitation under visible light irradiation. As a result, TiO2 NPs have limited efficiency against microorganisms in indoor environments where the fraction of UV light is small. From this perspective, the development of a visible-light active TiO2 with excellent antibacterial performance is of crucial importance in medical and industrial sectors.

#### *5.1. Metal Doping*

Transition metals like Cr, Fe, Ni, Cu, and RE metals can be used to enhance the photocatalytic activity of nanocrystalline titania, and this in turn improves its bactericidal performance. Those metal cations substitute Ti4<sup>+</sup> ions in the titania lattice, leading to a reduction in the bandgap and promoting the formation of charge carriers under visible light. As a result, ROS are generated on the titania surface, and they are very effective at killing bacteria through lipid peroxidation, the depletion of glutathione, DNA damage and the final disintegration of the cell membrane. This results in a leakage of cellular contents, thus causing cell lysis and eventual cell death [241,242]. Negatively charged superoxide and hydroxyl radicals generally reside on the membrane and do not penetrate into the bacterial cytoplasm, while electrically neutral H2O2 can pass through the cell membrane. Hydrogen radicals can abstract hydrogen atoms from the fatty acids of bacterial membrane lipids, causing lipid peroxidation and damaging the respiratory electron transport chain located in the membrane [242]. As is known, most transition and RE metals are toxic to humans. In terms of environmental and public health considerations, Cu is more suitable than other transition metals and RE metals for doping nanocrystalline titania. Copper metal is widely used in hospitals for preventing spread of bacteria among the patients because of its antimicrobial activity [243]. Therefore, copper can be used to dope titania for antibacterial purposes [244–247]. As an example, TiO2–Cu films exhibit bacterial inactivation for *E. coli* and MRSA under indoor visible light irradiation [244,245].

#### 5.1.1. Doped Titania NPs

Yadav et al. fabricated Ni-doped TiO2 NPs using the sol-gel process through the addition of NiSO4(H2O)6 to a mixture solution containing TTIP, acetic acid and sodium dodecyl sulfate. The resulting powders were dried and calcined at 500 ◦C for 5 h [248]. Figure 16a,b shows the photocatalytic bactericidal activity against *E. coli* and *S. aureus* of Ni-doped TiO2 NPs with 1.0 mol %, 2.0 mol % and 3.0 mol % Ni dopants, denoting Ni1–TiO2, Ni2–TiO2 and Ni3–TiO2, respectively. In dark (with doped TiO2 NPs) and visible light (without doped TiO2 NPs) environments, both bacterial strains grow into a high density of cell populations, expressed as colony-forming units (CFU)/mL. The photocatalytic inactivation of *E. coli* and *S. aureus* takes place by illuminating Ni-doped TiO2 NPs with visible light. The Ni3–TiO2 sample shows the highest photocatalytic inactivation because it can generate a higher

ROS level with an increase in Ni content. Moreover, the photocatalytic inactivation efficiency of Ni-doped TiO2 NPs toward Gram-positive *S. aureus* is somewhat faster than Gram negative *E. coli*. In the case of Gram-negative salmonella abony, complete inactivation takes 360 min of light irradiation (data not shown). The time required for the full inactivation of S. abony is higher than that for *E. coli* inactivation. Using the same approach, they also fabricated Cu-doped TiO2 NPs with 1.0 mol %, 2.0 mol % and 3.0 mol % Cu by adding different concentrations of CuSO4·5H2O to a solution containing TTIP and acetic acid. The catalysts were calcined in air at 500 ◦C for 5 h [247]. The 3%Cu/TiO2 NPs photocatalyst exhibits a higher bactericidal activity than those doped with 1.0 mol %, and 2.0 mol % Cu. The 3%Cu/TiO2 NPs catalyst shows 100% inhibition for *S. aureus* within 120 min, but it requires 240 min for the complete inactivation of *E. coli*. This implies that the rate of bacterial inactivation for *E. coli* is much slower than for *S. aureus*. This is caused by a difference in the cell wall structures between these two bacterial strains. As is known, bacteria exhibit a negative charge on their cell wall surface. The cell wall of Gram-positive bacteria is relatively porous and thick (20–80 nm) consisting of several layers of peptidoglycan, interspersed with teichoic and lipoteichoic acids. Peptidoglycan is negatively charged due to the presence of carboxyl and amino groups [249]. In contrast, the cell wall of Gram-negative bacteria is thinner (<10 nm) with a single peptidoglycan layer, surrounded by an outer membrane with a very complex structure. Lipopolysaccharides (LPS) and lipoproteins are located in the outer leaflet, while phospholipids are found in the inner leaflet of the outer membrane. The phosphate groups of LPS increase the overall negative charge. Thus Gram-negative bacteria have a higher negative charge than Gram-positive bacteria [250–252]. The structural variations in the cell walls between these two bacterial strains lead to their different interactions with photocatalysts. As such, Gram-negative bacteria is more resistant to attack from the superoxide anion and hydroxy radical with a negative charge. Moreover, LPS also creates a permeability barrier at the cell surface, thus contributing to its resistance against many antibiotics and substances [250–252].

**Figure 16.** Inactivation of (**a**) *E. coli* and (**b**) *S. aureus* by Ni-doped TiO2 NPs as a function of time. Reproduced with permission from [248]. Copyright Elsevier, 2014.

Very recently, Pillai and coworkers prepared Cu-doped TiO2 NPs by adding a copper sulfate solution to a mixture solution containing TTIP, and isopropanol [109]. The resulting gel was dried, and doped titania powders were calcined at 500, 600, 650 and 700 ◦C, respectively. Pure TiO2 powders were prepared from TTIP and isopropanol without copper sulphate addition. The obtained TiO2 powders were calcined at 500 and 700 ◦C to yield anatase and rutile, respectively. Their results showed that Cu doping is very effective to retain the anatase phase of TiO2 at calcined temperatures up to 650 ◦C. X-ray Photo-electron Spectroscopy (XPS) spectra reveals the presence of Cu<sup>+</sup> and Cu2<sup>+</sup> in Cu-doped TiO2 where the Cu<sup>+</sup> state predominates. Figure 17a,b shows the photocatalytic bactericidal activity of 0.5 wt% Cu/TiO2, anatase TiO2 and rutile TiO2 against *E. coli* and *S. aureus* under dark and visible light illumination, respectively. In the dark, both bacteria strains grow quickly and their survival rate reaches a high plateau value. However, a 5-Log pathogen reduction (99.999%) is observed in both bacterial strains exposed to 0.5 wt% Cu/TiO2 following visible light irradiation for 30 min (Figure 18). In this respect, 0.5 wt% Cu/TiO2 photocatalyst exhibits a strong antibacterial effect against *E. coli* and S. aureous under visible light irradiation. The enhanced antibacterial performance of 0.5 wt% Cu/TiO2 photocatalyst calcined at 650 ◦C is attributed to the formation of a heterojunction between TiO2 and Cu2O, inducing hydroxyl radicals through the interfacial charge carrier transfer mechanism, to the copper ions killing effect. The replacement of Ti4<sup>+</sup> with Cu2<sup>+</sup> also induces the creation of oxygen vacancies. This gives rise to the high absorption rate of visible light as a result of a bandgap reduction from 3.17 to 2.8 eV. It is noted that some Cu<sup>+</sup> ions may react with a transient metabolic byproduct of cellular respiration, i.e., H2O2 through the Fenton reaction, resulting in the formation of hydroxyl radicals and Cu2<sup>+</sup> ions. The Fenton reaction for generating hydroxyl radicals due to the presence of Cu<sup>+</sup> ions is given by [246]

$$\text{Cu}^+ + \text{H}\_2\text{O}\_2 \rightarrow \text{Cu}^{2+} + \text{OH}^- + \text{^\bullet OH.} \tag{9}$$

**Figure 17.** Photocatalytic inactivation of (**a**) *E. coli* and (**b**) *S. aureus* with 0.5% Cu/TiO2 calcined at 650 ◦C, pure anatase and rutile specimens. N/No is the reduction in the concentration of the bacteria. Reproduced with permission from [109]. Copyright MDPI, 2018.

**Figure 18.** Photocatalytic bactericidal efficacy of 0.5% Cu/TiO2, pure anatase and rutile with *E. coli* and *S. aureus* upon visible light irradiation for 30 min. Reproduced with permission from [109]. Copyright MDPI, 2018.

Silver nanoparticles with an additional function as a bactericidal agent can be used to modify titania photocatalyst to further enhance its antibacterial performance. From the literature, AgNPs exhibit excellent antibacterial activity against various microorganisms, including *S. aureus*, MRSA, Bacillus subtilis, *E. coli*, *Pseudomonas aeruginosa*, *Klebsiella pneumonia*, and *Acinetobacter baumanii* [253]. Whether metallic Ag0 or ionic Ag<sup>+</sup> released from AgNPs exerts killing effects on bacteria is still unknown [15,253–255]. The former mechanism involves the adhesion of AgNPs to the cell membrane, leading to membrane damage, the generation of oxidative stress and leakage of cellular contents. Moreover, AgNPs can move into the cytoplasm and interact with biomolecules such as protein and DNA. In some cases, they inactivate and destabilize ribosome, thus inhibiting protein synthesis and generating ROS accordingly. In the case of silver-ion induced toxic effects, released silver ions would interact with the thiol groups of respiratory chain proteins on the membrane, resulting in the disruption

of the bacterial cell wall and the creation of ROS. The electron transport chain for bacterial respiration is located at the bacterial cytoplasmic membrane, since bacteria have no mitochondria (Figure 1). Silver ions can also penetrate into the cytoplasm and react with the thiol groups of cytoplasmic proteins [15,253–255].

As mentioned, AgNPs can induce a collective oscillation of surface electrons under visible light irradiation, thereby creating a hot electron–hole pair and inducing ROS for bacterial inactivation. Thus, AgNPs serve as electron donors for titania, since plasmonic hot electrons are injected into the conduction band of TiO2 and trigger a photocatalytic disinfection reaction to generate superoxide anion, as shown in Figure 6. Accordingly, AgNPs play the dual role of antibacterial agent and electron donor for Ag-doped TiO2 NPs [124]. Gupta et al. fabricated Ag-doped TiO2 NPs with 3% and 7% AgNPs using the sol-gel process. The resulting powders were dried in an oven followed by annealing at 450 ◦C for 30 min [256]. The photocatalytic activities of the as-synthesized TiO2, annealed TiO2, and annealed Ag-doped TiO2 materials were assessed against Gram negative *E. coli*, Pseudomonas aeruginosa and Gram positive *S. aureus* under visible light. Figure 19a,b shows the viability of *E. coli* and *S. aureus* versus the concentration of catalyst nanoparticles, respectively. The as-synthesized TiO2 NPs with an amorphous structure inactivates some *E. coli* and *S. aureus* because their negatively charged surface can repel bacteria, resulting in a net negative charge on the cell wall [57]. Annealing treatment at 450 ◦C induces the crystallization of the anatase phase in TiO2 NPs. The bactericidal performance of annealed Ag-doped TiO2 NPs is markedly improved in comparison with the as-synthesized and annealed TiO2 NPs. The Ag-doped TiO2 NPs with 7% AgNPs exhibits toxicity to both bacterial strains at 60 mg/30 mL, and at 40 mg/30 mL culture in the case of *P. aeruginosa*.

**Figure 19.** Viability of (**a**) *E. coli* and (**b**) *S. aureus* against the concentration of as-synthesized TiO2 NPs, annealed TiO2 NPs, and Ag-doped TiO2 NPs with 3% AgNPs (dash–dot curve) and 7% AgNPs (dot curve; blue). Reproduced with permission from [256]. Copyright Beilstein-Institut, 2013.

#### 5.1.2. Doped Titania Nanotubes

The photocatalytic activity of one-dimensional TNTs is considerably higher than that of TiO2 NPs because of their large surface area, high aspect ratio, and good light-harvesting properties [257,258]. Recently, Podporska-Carroll et al. reported that TNTs exhibit very high bactericidal efficiency against *E. coli* (97.53%) and *S. aureus* (99.94%) under 24 h of UV irradiation [259]. Moreover, anodic TNTs exhibit a higher photocatalytic inactivation of bacteria than commercial Degussa P25 TiO2 powders. To extend the optical absorbance to the visible-light region and improve bactericial performance in this optical regime, noble metal dopants are added to TNTs accordingly. For instance, Viet et al. demonstrated that the 2 wt% Ag/TNTs photocatalyst exhibits higher bactericidal activity against *S. aureus* than pristine TNTs when exposed to sunlight at noontime [53].

Rtimi and coworkers prepared TNTs of different diameters by varying applied voltages from 20 V–70 V during anodizing process. The anodized TNTs were air-dried, annealed for 3 h at 400 ◦C, and then immersed in a 0.1 M AgNO3; Ag<sup>+</sup> ions were reduced to AgNPs on TNTs using the photoreduction method [260]. A low voltage of 20 V was not favorable for the formation of TNTs. The average diameters of TNTs under applied voltages of 40, 50, 60 and 70 V were 59.6, 93.6, 96.6 and 100. 9 nm, respectively. The tube diameter increased with increasing applied voltage. Figure 20a shows the bacterial survival rate of *E. coli* on pristine TNTs and Ag-decorated TNTs of different diameters upon exposure to solar-simulated light (50 mW/cm2). The used light intensity corresponds with the overcast daylight dose. Pristine TiO2–NTs inactivate 1.6log E coli within 180 min. Negatively charged TNTs tend to repel *E. coli* with a negative surface charge, giving rise to a low level of antibacterial activity. From this figure, a stronger *E. coli* inactivation can be achieved by increasing the diameter of TNTs. The Ag/TNTs with diameters of 96.6 nm and 100.9 nm exhibit excellent bacterial inactivation compared with neat TNTs. These two samples require 90 min for inactivating 99.99% *E. coli* upon exposure to solar-simulated light. The bacterial inactivation is attributed to the generation of ROS as a result of the plasmonic oscillation of surface electrons of AgNPs caused by solar-simulated light irradiation. This, in turn, leads to the generation of an electron–hole pair in TNTs to create ROS (Figure 20b). Free radicals abstract electrons from the lipid molecules of bacterial membrane, leading accordingly to lipid peroxidation and membrane damage.

**Figure 20.** (**a**) Bacterial inactivation on neat TiO2–NT and Ag/TNTs photocatalysts exposed to solar-simulated light (50 mW/cm2, 310–800 nm). Error bars: standard deviation; *n* = 5. (**b**) Bacterial inactivation mechanism of Ag/TNTs, as described by Reaction (1–6). Reproduced with permission from [260]. Copyright Elsevier, 2018.

The AgNPs of silver-decorated TNTs also play the role of antibacterial agent through the released Ag<sup>+</sup> ions. Uhm et al. fabricated Ag-doped TNTs by depositing a thin silver layer onto anodized TNTs via magnetron sputtering for different time periods [261]. The TNTs samples coated with silver for 60, 120 and 180 s were designated as ANS 60, ANS 120 and ANS 180, respectively. A longer sputtering time induced more AgNPs formation on the nanotubes, as expected. To assess the silver-ion induced toxic effect on the *S. aureus*, Ag<sup>+</sup> ion, released in phosphate-buffered saline (PBS) and plate counting methods was employed in their study (Figure 21a,b). From Figure 21a, all Ag-doped TNTs samples showed excellent antibacterial activity compared to commercially pure Ti (cpTi) and pristine TNTs. This was attributed to the released Ag<sup>+</sup> ions from the Ag-doped TNTs for bacterial inactivation (Figure 21b). Such an antibacterial effect was unrelated to photoactivity. A profound difference in bacterial reduction in terms of CFU was seen between neat TNTs and Ag-doped TNTs.

**Figure 21.** (a) Photographs showing the spread of *S. aureus* on commercially pure titanium (cpTi), titanium nanotubes (NTs) and Ag-doped TNTs samples. (**b**) Antibacterial efficacy of all samples immersed in PBS for 3 h and 7 d. The error bars are the standard deviation (*n* = 5); \* denotes *p* < 0.05 compared with cp-Ti at a 3 h ion extraction time, # denotes *p* < 0.05 compared with cp-Ti at 7 days ion extraction time. Reproduced with permission from [261]. Copyright Wiley, 2014.

#### *5.2. Non-Metal Doping*

Non-metal dopants such as nitrogen, carbon, and boron are typically employed to replace lattice oxygen anions of titania, in order to narrow its bandgap and extend the optical absorption edge to the visible regime, thereby increasing photocatalytic activity. This in turn leads to an improvement in its antibacterial properties under visible light [161,202,246,262–265]. The visible light response originates from the presence of localized energy levels of the dopant lying above the valence band, thus shifting the VB level upward (Figure 8) [97,159–164]. Among those dopants, nitrogen has a size comparable to oxygen, so it can be readily doped into the TiO2 lattice in either substitutional or interstitial sites. The N-2p orbital hybrids with the O-2p state, leading to the band gap narrowing. Recently, Ananpattarachai et al. prepared N-doped TiO2 NPs using the sol-gel technique with diethanolamine acting as the N source. For the purposes of comparison, they also prepared Ni-doped TiO2 NPs by adding NiSO4(H2O)6 to the Ti-sol. The as-synthesized N- and Ni- doped TiO2 NPs powders were calcined at 600 ◦C [161]. The bandgaps of N-doped TiO2 NPs and Ni-doped TiO2 NPs were determined to be 2.1 eV and 2.97 eV, respectively. The antibacterial activities of the photocatalysts

were assessed using *S. aureus* and *E. coli* strains under visible light irradiation. Figure 22 shows the photocatalytic inactivation of *S. aureus* with neat TiO2, N-doped TiO2 NPs and Ni-doped TiO2 NPs. Apparently, N-doped TiO2 NPs are more effective than Ni-doped TiO2 NPs for *S. aureus* inactivation due to their smaller bandgap. Nearly 90% of *S. aureus* cells are inactivated by N-doped TiO2 NPs within 300 min. The complete inactivation time for *S. aureus* is 360 min. In contrast, the complete inactivation time for *E. coli* is 420 min (not shown). Figure 23 displays the photocatalytic inactivation of *S. aureus* with different concentrations of N-doped TiO2 NPs and Ni-doped TiO2 NPs. The survival of *S. aureus* with N-doped TiO2 NPs under visible light is smaller than with Ni-doped TiO2 NPs. Figure 24 shows the photocatalytic inactivation of *E. coli* with different concentrations of N-doped TiO2 NPs. The inactivation efficacy of Gram-positive *S. aureus* using N-doped TiO2 NPs is higher than that of Gram-negative *E. coli* under visible light illumination. According to the literature, carbon dopant is also beneficial in improving the visible light absorption of TiO2 NPs and photocatalytic inactivation of anthrax, a fatal bacterial disease that occurs in animals and can transmit to humans, and is caused by Gram-positive Bacillus anthracis [264].

**Figure 22.** Survival ratio (C/Co) of *S. aureus* with neat TiO2, N-doped TiO2 NPs and Ni-doped TiO2 NPs under an 18 W visible light irradiation for different time periods. *S. aureus* without TiO2 in the dark is used as a control. Statistically significant at *p* < 0.05. Reproduced with permission from [161]. Copyright Springer, 2016.

**Figure 23.** Photocatalytic inactivation of *S. aureus* with N- and Ni-doped TiO2 NPs of different contents under visible light. Statistically significant at *p* < 0.05. Reproduced with permission from [161]. Copyright Springer, 2016.

**Figure 24.** Photocatalytic inactivation of *E. coli* with N-doped TiO2 NPs of different concentrations under an 18 W visible light. Statistically significant at *p* < 0.05. Reproduced with permission from [161]. Copyright Springer, 2016.

He et al. fabricated N-doped TiO2 NPs (30 nm) using the sol-gel technique. The photocatalytic and bactericidal behaviors of N-doped TiO2NPs against *E. coli* under dark and simulated-sunlight conditions were investigated [265]. The bacterial inactivation of this catalyst reaches 90% under simulated sunlight for 2 h, much higher than in the dark. Figure 25 displays photographs of neat TiO2 and N-doped TiO2 NPs treated with *E. coli* in the dark for 24 h, and under visible light for 2 h. Bacteria grows into colonies on these samples in the dark (top panel). However, N-doped TiO2 can inactivate *E. coli* by irradiating with simulated-sunlight for 2 h (bottom panel).

**Figure 25.** Photographs of *E. coli* colonies developed on agar plates treated with (**A**) control, (**B**) TiO2 and (**C**) N-doped TiO2 samples in the dark for 24 h. (**a**–**c**) are the images of *E. coli* colonies under visible light irradiation for 2 h. (**a**): control, (**b**): neat TiO2, and (**c**) N-doped TiO2. Reproduced with permission from [265]. Copyright Springer, 2013.

From the literature, fluorine doping does not shift the bandgap of TiO2. Fluorine dopant stabilizes anatase TiO2 up to 1200 ◦C [75,266]. The replacement of lattice oxygen with fluorine in TiO2 converts Ti4<sup>+</sup> to Ti3<sup>+</sup> as a result of the charge compensation between F<sup>−</sup> and Ti4<sup>+</sup> [165]. The Ti3<sup>+</sup> ions suppress the recombination rate of photogenerated charge carriers, thereby enhancing photocatalytic activity. The substitution of fluorine for oxygen in the titania lattice gives rise to a dramatic increase in oxygen vacancy concentrations [175,267]. The visible-light photocatalytic activity of F-doped TiO2 can be further enhanced by co-doping with N [268]. Thus, the co-doping approach is an effective route to tune the energy band level of TiO2 NPs to enhance photocatalytic reactions. Figure 26a shows the charge-transfer mechanism for visible-light excitation of N−F co-doped TiO2. A series of charge transfer events take place during visible light irradiation. In the process, electrons are excited from the N midgap state to the conduction band, and the corresponding holes generated in the N-state are filled by electrons from the Ti3<sup>+</sup> level. Oxygen vacancies (Ovac) also donate electrons to the empty N-state. Moreover, the conduction band can transfer electrons to the oxygen vacancies. This cascade effect

facilitates the continuous generation of superoxide anion and hydroxide radical species [268,269]. The ROS then cause the destruction and death of microorganisms accordingly.

**Figure 26.** (**a**) Visible light excitation of N−F codoped TiO2 and subsequent filling of empty N state by electron transfer from either Ti3<sup>+</sup> or oxygen vacancies (Ovac). Reproduced with permission from [268]. Copyright American Chemical Society, 2014. (**b**) Survival rate of *E. coli* treated with N-doped P25 (P25-N-HT), F-doped P25 (P25-F-HT) and (3) F-N codoped P25 (P25-F&N-HT) under simulated light illumination. Reproduced with permission from [270]. Copyright MDPI, 2017.

Milosevic et al. fabricated N-doped and F-doped TiO2 by wet milling Aeroxide® P25 (21 nm) powders in the presence of glycine (N source) or polytetrafluoroethylene (PTFE; fluorine source), respectively [270]. For the preparation of F−N-co-doped P25, both glycine and PTFE were added during wet milling. The resulting N-doped P25 was heat-treated at 500 ◦C for 1 h, while F-doped P25 and F−N-doped P25 were calcined at 600 ◦C for 1 h. Figure 26b shows the survival rate of *E. coli* treated with F-doped P25, N-doped P25, and F−N-co-doped P25 under visible light irradiation. The complete bacterial inactivation times for F-doped P25, N-doped P25 and F−N-co-doped P25 catalysts are 120 min, 90 min and 60 min, respectively. Apparently, codoping P25 with F and N leads to the F−N-doped P25 catalyst with the best bactericidal performance. This is attributed to a synergistic effect between F and N dopants, creating a series of charge transfer reactions, thereby inducing ROS for bacterial inactivation (Figure 26a). In another study, Milosevic et al. prepared F-doped TiO2 NPs by means of solution precipitation through the hydrolysis of titanium oxychloride, using urea and ammonia as the precipitation agents, and potassium fluoride as the fluorine source. This was followed by wet milling in glycine, and the resulting F−N-doped TiO2 powders were calcined at 500 ◦C for 1h[271]. The complete bacterial inactivation times for F-doped TiO2 and F-N codoped TiO2 are 75 min and 60 min, respectively.

#### *5.3. Graphene and MWNT Modified Titania Nanocomposites*

A graphene sheet with sharp edges can act as a 'nanoknife' for killing microorganisms during the direct contact of bacteria with the sheet edges. In addition, graphene with a lateral dimension of several micrometers can effectively wrap and isolate bacteria from the environment, thus stopping the supply of nutrients [272,273]. A direct contact of the bacterial cell wall with graphene may also lead to the induction of oxidative stress, resulting in the physical disruption of lipid bilayers and the generation of ROS [274,275]. In this respect, the inclusion of rGO to TiO2 NPs can produce novel photocatalysts with improved antibacterial performance. There are few studies in the literature reporting bacterial inactivation of rGO/TiO2 photocatalysts [101,102,276,277].

More recently, Wanag et al. fabricated (0.5–2.5 wt%) rGO/TiO2 NPs using hydrothermal process at 180 ◦C for 4 h. The resulting products were finally heated in a furnace at 100 ◦C for 4 h [101]. Figure 27A,B shows the survival rate of *E. coli* treated with (0.5–2.5 wt%) rGO/TiO2 NPs in the dark and under artificial solar light irradiation, respectively. Little change in the bacterial populations is seen in the dark condition. The complete bacterial inactivation times for TiO2 NPs, 0.5% rGO/TiO2 NPs, 1.5% rGO/TiO2 NPs, and 2.5% rGO/TiO2 NPs samples are 105, 90, 75 and 85 min, respectively. It appears that the 1.5% rGO/TiO2 NPs photocatalyst exhibits the best bacterial inactivation effect.

**Figure 27.** Inactivation of *E. coli* in the presence of rGO, TiO2 and (0.5–2.5 wt%) rGO/TiO2 samples in (**A**) dark contition and (**B**) under artificial solar light irradiation. Reproduced with permission from [101]. Copyright Elsevier, 2018.

Nica et al. determined the minimum inhibitory concentration (MIC) and minimum biofilm eradication concentration (MBEC) values of rGO/1%Fe–N-doped TiO2 nanocomposites prepared by a hydrothermal synthesis of mixed 1%Fe–N-doped TiO2 and GO solutions at 150 ◦C for 2 h [277]. Two different precipitation strategies were adopted to yield 1%Fe–N-doped TiO2 powders. Sample A solution was prepared through a simultaneous precipitation of Ti3<sup>+</sup> and Fe3<sup>+</sup> ions by mixing desired amounts of TiCl3 and FeCl3.6H2O in water, with a subsequent addition of NH4OH to maintain an alkaline pH of 9. This solution was hydrothermally treated at 200 ◦C for 2 h, and the resulting powders were calcined at 400 ◦C for 2 h. Sample B solution was made via a sequential precipitation of these two cations. The Ti3<sup>+</sup> ions were first precipitated and oxidized to Ti4<sup>+</sup> followed by the addition of Fe3<sup>+</sup> ions in an alkaline reaction medium. The purpose of this was to attain a higher iron concentration on the surfaces of synthesized powders [242]. The antibacterial activity of rGO/1%Fe–N-doped TiO2 nanocomposites was assessed with *S. aureus*, *E. coli*, *P. aeruginosa* and Candida albicans (a type of fungus). Figure 28 shows the the MIC and MBEC values of rGO/1%Fe–N-doped TiO2 nanocomposites irradiated with visible light. MIC is generally defined as the lowest antimicrobial agent concentration inhibiting visible growth of bacteria, whereas MBEC is the lowest concentration of an antimicrobial agent needed to kill a bacterial biofilm [278,279]. Compared with commercial P25, rGO/1%Fe–N-doped TiO2 nanocomposites made from the respective Sample A and Sample B solutions exhibit a much higher antibacterial activity under visible light exposure than Gram-positive *S. aureus*, Gram-negative *E. coli*, and *P. aeruginosa*. The MIC value of rGO/doped TiO2 nanocomposites for *E. coli* and *S. aureus* is 2.5 μg/mL, four times smaller than that of P25.

Akhavan et al. prepared MWNT/TiO2 thin films with 2–40 wt% MWNTs by sol-gel technique. The films were deposited on the glass slides by the dip coating method followed by annealing at 450 ◦C in air for 1 h to yield anatase phase, thereby forming Ti–C and Ti–O–C bonds [155]. The 20 wt% MWNT/doped TiO2 film inactivated *E. coli* completely under visible light irradiation for 60 min. They attributed bactericidal effects of 20 wt% MWNT/doped TiO2 nanocomposite to an efficient charge transfer between the MWNTs and TiO2 due to the formation of a Ti–C and Ti–O–C bond, and a reduction in the electron–hole recombination rate, leading to an increase in the production of hydroxyl radicals for photocatalytic inactivation. Very recently, Koli et al. fabricated (0.1–0.5 wt%) MWNT/doped TiO2 nanocomposites using the solution-mixing method. The final products were centrifuged and calcinated in air at 450 ◦C for 5 h [156]. The 0.5 wt% MWNT/doped TiO2 nanocomposite exhibited complete

killing for *S. aureus* and *E. coli* under visible light irradiation for 180 and 300 min, respectively. However, nanocomposites with 0.3 wt% and 0.1 wt% MWNTs only showed 80% and 90% inhibition for *S. aureus*. In another study, Koli et al. prepared (0.1–0.5 wt%) MWNT/Fe-doped TiO2 nanocomposites using the sol gel process. The 0.5 wt% MWNT/Fe-doped TiO2 nanocomposite showed 100% inactivation for Gram-positive Bacillus subtilis under visible light illumination for 120 min. However, nanocomposites with 0.1 wt% and 0.3 wt% MWNTs exhibited complete inhibition at 180 min [157]. In the case of Gram-negative Pseudomonas aeruginosa, MWNT/Fe-doped TiO2 nanocomposites with 0.1, 0.3 and 0.5 wt% MWNTs required 240 and 300 min, respectively, for complete bacterial killing. The photocatalytic inactivation of these bacterial strains derived from the effective generation of ROS under visible light irradiation.

**Figure 28.** MIC and MBEC values of rGO/1%Fe-N-doped TiO2 nanocomposites and commercial P25 TiO2 treated with *S. aureus*, *E. coli*, *P. aeruginosa* and fungal C. albicans under visible light at 37 ◦C for 24 h. Reproduced with permission from [277]. Copyright MDPI, 2017.

#### *5.4. Coupled Semiconductors*

Limited studies are available in the literature on the visible-light photocatalytic bactericidal activity of oxide semiconductor heterojunctions [177,179]. Recently, Janczarek et al. studied the antibacterial performance of cuprous oxide/titania nanocomposites prepared by mechanically mixing Cu2O with TiO2 powders of different structures including pure anatase TiO2 (8 nm), pure rutile TiO2 (16 nm) and Aeroxide® TiO2 P25 in an agate mortar [177]. Figure 29a–d shows the antibacterial performance of pure Cu2O and Cu2O/TiO2 nanocomposites against *E. coli* in the dark, under UV and visible light irradiation, respectively. Pure Cu2O displays high bactericidal activity under UV or visible light irradiation due to the intrinsic activity of Cu<sup>+</sup> ions (Figure 29a). Pure anatase TiO2 NPs with a negative charge surface show little bacterial inactivation in the dark as they repel negatively charged bacteria to a lesser degree [44,57]. However, their antibacterial activity improves substantially under UV light irradiation as a result of the ROS generation. By coupling anatase TiO2 with Cu2O, the Cu2O/anatase shows enhanced antibacterial activity in the dark, under UV or visible light irradiation (Figure 29b; solid curve). The bactericidal activity of Cu2O/anatase in the dark is caused by the Cu<sup>+</sup> ions in Cu2O. The enhanced bactericidal activity of this sample under visible light is attributed to the interfacial charge transfer of electrons from Cu2O to TiO2 across the heterojunction interface. This prolongs the lifetime of charge carriers, such that they can take part in photocatalytic reactions. Cu2O generates electron–hole pairs readily under visible light irradiation due to its small bandgap of 2.17 eV. Under UV light irradiation, the interfacial charge transfer from TiO2 to Cu2O, and the inhibition of charge carriers' recombination contribute to an enhancement in bactericidal activity. In contrast, unmodified rutile and Cu2O/rutile show slower antibacterial activity under UV or visible light irradiation (Figure 29d).

**Figure 29.** Survival of *E. coli* in CFU/mL treated with (**a**) Cu2O, (**b**) Cu2O/anatase TiO2, (**c**) Cu2O/P25, and (**d**) Cu2O/rutile TiO2 in solid curves with circle symbols; grey color (dark condition), violet (UV irradiation) and green (visible light). Umodified anatase TiO2, P25 and rutile TiO2 results are shown in dashed curves with diamond symbols in grey (dark condition), violet (UV irradiation) and green (visible light). Error bars in Cu2O: standard deviation determined from two or three independent measurements. Reproduced with permission from [177]. Copyright MDPI, 2018.

#### *5.5. Polymer*/*Titania Nanocomposites*

Novel polymer nanocomposites with enhanced chemical, thermal and mechanical properties can be designed and developed by adding functional nanofillers of unique properties [26,26,68–72,280,281]. Such polymer nanocomposites show great potential for structural, electronic, environmental and biomedical engineering applications. The polymeric matrix of nanocomposites immobilizes nanofillers and offers protection to the fillers from mechanical damage. The extent of property enhancement in the polymer nanocomposites depends greatly on the homogeneous dispersion of the fillers, and good interfacial bonding between the filler and polymer matrix [280]. The polymers employed for forming nanocomposites can be either degradable or nondegradable, depending on their intended application. Degradable polymers such as PLA, polyvinyl alcohol (PVA), poly(ε-caprolactone) (PCL) and chitosan are generally used to form scaffolds and wound dressings [26,65,282–285]. These polymers should have the ability to degrade with time and to heal the wounds.

Titania nanomaterials have been incorporated into polymers to form antibacterial coatings, food packaging materials, medical implants, wound dressings and scaffolds [59–65,229,286,287]. However, those studies are mainly focused on the bactericidal properties of the polymer nanocomposites with TiO2 nanomaterials under UV irradiation. However, it is impractical to use a UV source to excite electron–hole pairs in the polymer–TiO2 NP system for applications in theb medical sector and food industry. Therefore, the development of visible-light active polymer–TiO2 nanocomposites is considered of technological interest and practical importance [288–293].

The bactericidal activity of polymer–TiO2 nanocomposites under visible light also depends on the type of polymers employed. In particular, natural chitosan (CS) with biodegradable behavior can bind to TiO2 NPs through its amino and hydroxyl groups, thereby extending the optical absorption of TiO2 NPs into the visible region. The CS/TiO2 nanocomposites exhibit a red shift in absorption in their UV-vis spectra [289,292,294]. The bandgap of TiO2 NPs in CS/TiO2 nanocomposites is then reduced from 3.20 to 3.00 eV [292]. As such, CS/TiO2 nanocomposites exhibit the photocatalytic inactivation of microorganisms under visible light. Accordingly, CS/TiO2 films find useful application as antimicrobial wrapping films for vegetables and fruits under visible light. Thus, TiO2 nanofillers can delay the ripening process of fresh produce [289,295]. Very recently, Zhang et al. fabricated a CS/TiO2 nanocomposite film for wrapping red grapes. They assessed the antimicrobial activity of the film against food-borne pathogenic microbes, including *E. coli*, *S. aureus*, C. albicans, and Aspergillus niger (mold) [289]. They found that the film exhibited a good microbial inactivation effect, with complete sterilization for all microbial strains within 12 h. The composite film was very effective in protecting red grapes from microbial attack, thereby extending their shelf-life and improving the quality of fresh fruit accordingly (Figure 30a–c). Moreover, pure CS film also shows antibacterial effect to a certain degree. In contrast, grapes were spoiled and mouldy in the plastic wrap, as expected.

**Figure 30.** Photographs showing the preservation of red grapes wrapped with (**a**) plastic film, (**b**) chitosan film, and (**c**) chitosan-TiO2 film at 37 ◦C for six days. Reproduced with permission from [289]. Copyright Elsevier, 2017.

It is noteworthy that CS/TiO2 nanocomposites also find medical applications as antibacterial scaffolds in the presence of visible light. Biodegradable chitosan has been used as a scaffold in orthopedics, particularly for bone tissue engineering. The hydrophilic behavior of CS facilitates the adhesion and growth of bone cells (osteoblasts) on its surface [296]. However, a pure chitosan scaffold suffers from poor mechanical strength, so it is unable to provide sufficient mechanical support for the proliferation of osteoblasts during the bone healing process. Therefore, TiO2 NPs and AgNPs are added to CS to improve mechanical strength [65]. Recently, Raut et al. enhanced the visible-light bacterial inactivation of the CS/TiO2 NPs nanocomposite by including a Cu dopant into TiO2 NPs (denoting as CT) through the sol-gel process. The CT nanofillers were then solution-mixed with CS to yield CS/Cu-doped TiO2, denoted as CS-CT [288]. Figure 31a shows the bactericidal activity of CS, CT and CS–CT samples against *E. coli* under visible light. A 100% bacterial inactivation time is achieved in 240 min by CT and 120 min by CS–CT. Therefore, a synergistic effect exists between Cu-doped TiO2 NPs (CT) and C, thereby giving rise to a faster bacterial reduction time of 120 min. Figure 31b shows the effect of an \*OH radical, generated by the photoexcitation of an electron–hole pair, in destroying *E. coli*.

Antibacterial polymer/TiO2 nanocomposites also find attractive applications in textile industries for producing odorless and self-cleaning fabrics. Clothing fabrics are prone to microbial contamination, and can spread infections accordingly. The clothes generate a warm and humid environment on human skin, causing the secretion of sweat and bacterial growth [297]. Cotton consists of natural cellulosic fibers that absorb more sweat than synthetic polymer fabrics. Thus, cotton clothes tend to keep the body dry while absorbing sweat. Very recently, Zahid et al. prepared Mn-doped TiO2 NPs (150 nm) by the sol-gel method, and then applied the spray coating technique to apply Mn-doped TiO2 NPs on cotton fabrics. NPs0, NPs10, NPs25 and NPs50 were designated to the cotton fabrics with zero, 10, 25 and 50 wt% Mn-doped TiO2 NPs, respectively [298]. The fabrics with and without Mn-doped TiO2 NPs in the dark exhibited no bactericidal effect because no photocatalytic excitation occurred in the absence of light. The NPs10 and NPs 25 reduced the *S. aureus* population by 80% and 90% within the first 60 min, respectively, while NPs50 and NPs50W reduced nearly ~100% *S. aureus* population in the same period under sunlight (Figure 32a). A lower bacterial inactivation rate was found for the fabrics with Mn-doped TiO2 NPs and treated with *K. pneumoniae* in the first 60 min (Figure 32b). The presence of Mn ions dopant promoted the generation of an electron–hole pair in TiO2 fillers for creating ROS under visible light, as shown in Figure 32a,c. Apart from its antimicrobial activity, the photocatalytic

effect also removed or degraded color stains on the fabrics, thus performing self-cleaning, as shown in Figure 32c. The visible-light antibacterial activity of modified titania nanomaterials is summarized in Table 2.

**Figure 31.** (**a**) Antibacterial activity of CS, CT and CS–CT samples against *E. coli* under visible light illumination. (**b**) Mechanism of antibacterial activity of CS/Cu-doped TiO2 nanocomposite. Reproduced with permission from [288]. Copyright Elsevier, 2011.

**Figure 32.** Bacterial reduction in percentage of (**a**) *S. aureus* and (**b**) *K. pneumoniae* on cotton fabrics with and without Mn-doped TiO2 NPs in the dark and under natural sunlight. NPs0, NPs10, NPs25 and NPs50 are cotton fabrics with zero, 10, 25 and 50 wt% Mn-doped TiO2 NPs; NPs50W is the NPS50 after 10 washing cycles. (**c**) Schematic of visible light induced the photocatalytic inactivation of bacteria and degradation of stain residues on contaminated fabric with Mn-doped TiO2 NPs. Reproduced with permission from [298]. Copyright American Chemical Society, 2018.



#### **6. Biocompatibility and Cytotoxicity**

Antibacterial materials and coatings have been a focus of global research topics for the past decade in orthopedics, due to an increasing incidence of implant-related infections caused byMDR bacteria [299]. Medical devices and implants are easily contaminated with microorganisms, leading to the formation of biofilms on their surfaces. Therefore, titania coating is an attractive solution for controlling implant infection by decreasing bacteria adhesion through the introduction of metal nanoparticles (e.g., AgNPs or CuNPs) to the coating [300,301]. Furthermore, titania coating formed on the medical devices should exhibit good biocompatibility with the host tissues. As an example, titania film deposited on polyetheretherketone (PEEK) spinal implant exhibits superior compatibility compared to uncoated PEEK in terms of osteoblastic adhesion, proliferation, and differentiation [302]. Similarly, anodic TNTs of large surface areas formed on Ti-based alloys have been reported to provide anchoring sites for osteoblasts and fibroblasts, thereby promoting cell proliferation effectively [217–219,303–305]. Ti-based alloys (e.g., Ti-6%Al-4%V and Ti-6%Al-7%Nb) are commonly used as the load-bearing prostheses in orthopedics and tooth implants in dentistry. The optimal diameter of TNTs for osteoblastic adhesion and growth is typically below 100 nm [217,218]. Recently, Radtke et al. reported that anodic TNTs formed on the Ti-6%Al-4%V alloy, especially at lower anodic potentials with diameters of 25–35 nm, were effective in promoting the growth of murine fibroblasts L929 [303]. Xu et al. investigated the

biocompatibility of periodontal ligament cells on anodized TNTs of different diameters. Periodontal ligament cells (PDLCs) are the key cells responsible for periodontal tissue regeneration [304]. They demonstrated that the TNTs formed on thin Ti foil substrate favor the adhesion and growth of PDLCs. Furthermore, TNTs promoted the osseointegration of Ti substrate more effectively than untreated Ti foil, as evidenced by the high gene expression levels of alkaline phosphatase, osteocalcin and osteopontin.

#### *6.1. Cytotoxicity*

Advanced nanomaterials, prepared by emerging nanotechnology, pose toxicity to humans to a large/lesser extent depending on their structure, chemical composition, shape, distribution, etc. [14,15,306]. Wadhwa et al. reported that hydrothermally synthesized TNTs and TiO2 NPs exhibit no toxic effect towards the human alveolar carcinoma epithelial cell line (A549) [307]. Standalone and detached TNTs from Ti foil substrate were toxic to human dermal fibroblasts as a result of the ROS generation, leading to DNA damage and chromosomal aberration [308]. Allegri et al. reported that electrospun TiO2 nanofibers were toxic towards A549 and murine macrophage cell lines (Raw 264.7). The cytotoxic effects were dose-dependent, with larger effects on A549 than on Raw 264.7. However, TiO2 NPs exert no cytotoxic effect on these two cell lines [309].

As mentioned, TiO2 NPs have been produced commercially in large quantities for applications in paints, pharmaceutical, food, drug and cosmetic industries [39–56]. The synthesis and handling of TiO2 NPs during the production process can release a tremendous amount of these nanomaterials into the environment, including air, soil and water. The wastewater of titania production plants is the major source pollutant that leaks into the environment. The nanomaterials are discharged in the sewage sludge and can enter the soil and water ecosystem [310]. Therefore, the disposal and treatment of wasterwater, as well as the recycling of titania from water treatment plants, are considered of technological importance [311]. Moreover, the widespread use of products with TiO2 NPs would also release such nanoparticles into the environment. For instance, auto-manufacturing plants consume large quantities of titania pigment paints for coating car bodies. Therefore, plaint sludge is always found in the paint-bearing wastewaters. The recycling and reproduction of TiO2 NPs from the paint sludge are beneficial to both the environmental and industrial sectors for minimizing pollution [312]. Furthermore, embedded TiO2 NPs in the paint of buildings, bridges and traffic railings could be lost and released into the aquatic environment due to a lengthy outdoor weathering [313]. Some consumer titania products such as food-packages and textiles could also end up as waste, and are disposed of in incinerators and landfills [314]. The wastewater treatment plants remove most TiO2 NPs in the influent sewage; however, the residual nanoparticles would discharge to natural water ecosystems. In this respect, TiO2 NPs could potentially induce harmful effects to aquatic organisms, such as impaired metamorphosis and growth, teratogenicity, and mortality of fish larvae [315,316].

#### 6.1.1. Neat TiO2 NPs

TiO2 NPs can enter the human body through exposure to workplace atmospheres, the use of commercial products, the ingestion of food and pharmaceuticals. The main routes of entry include skin contact, inhalation, ingestion and medical implants [317]. Accordingly, public concerns have been raised related to the safe use of TiO2 NPs, and their effects on human health and the environment. Conflicting results are reported in the literature regarding the biocompatibility and cytotoxicity of TiO2 NPs. Some studies indicate a good biocompatibility of TiO2 NPs with mammalian cells [166,201,309,318], while others reveal the toxic effects of TiO2 NPs [319–325]. The discrepancy is attributed to the biological and materials factors involved during in vitro studies. The former factors include the type of culture cells, cell cultivation time and cell-based assays used, while the latter factors include the size, shape, crystal structure (anatase or rutile), and dose of TiO2 NPs in the assay tests [326].

Wang et al. investigated cytotoxicity in A549 cells induced by TiO2 NPs (5 nm) using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT), quantitative real-time PCR (qRT-PCR) and comet assays, as well as rhodamine 123 staining [323]. From the MTT results, the cytotoxic effect of TiO2 NPs was time- and concentration-dependent (in a range from 50 to 200 μg/mL). Comet assay revealed DMA damage in cells exposed to 50 to 200 μg/mL TiO2 NPs for 48 h. TiO2 NPs also decreased the mitochondrial membrane potential as determined by rhodamine 123 (Rh123) staining. The qRT-PCR analysis demonstrated that the expression of caspase-3 and caspase-9 messenger RNA (mRNA) increased dramatically upon exposure to 100 and 200 μg/mL TiO2 NPs for 48 h. As is known, caspases play the key role in executing apoptosis. Caspase-3 tends to induce DNA bond cleavage and inactivate cytoskeletal proteins. From this perpective, TiO2 NPs inhibit A549 proliferation, and induce DNA damage and eventual cell apoptosis through the activation of the intrinsic mitochondrial pathway [323].

TiO2 NPs can penetrate the human body through inhalation, then translocate from the lungs into the bloodstream, and the subsequent uptake in other organs like the heart, liver, spleen and brain. Huerta-Garcia et al. investigated the in vitro toxicity of TiO2 NPs on rat cardiomyoblasts (H9c2) [327]. They found that the cellular uptake of TiO2 NPs by H9c2 cells reduces their metabolic activity and cell growth, thus causing mitochondrial dysfunction due to a marked reduction in mitochondrial membrane potential. Furthermore, TiO2 NPs increase the ROS level and membrane permeability of H9c2 cells greatly, leading to final cell death. Therefore, the internalization and building up of TiO2 NPs in cardiomyoblasts would induce cardiac damage and pose threats to human health upon inhalation of those nanoparticles. More recently, Mottola et al. studied the genotoxic effect of TiO2 NPs on human amniotic fluid cells in vitro. The TiO2 NPs exposure caused DNA strand fragmentation, a loss of viability, and apoptosis of the cells [325].

Yin et al. studied the phototoxicity of TiO2 NPs (<25 nm, 31 nm, <100 nm, and 325 nm) in human skin keratinocytes (HaCaT) under UVA irradiation [328]. TiO2 NPs induced photocytotoxicity and cell membrane damage in a UVA dose- and TiO2 NPs dose-dependent manner. The smaller the size of TiO2 NPs, the higher the cell damage was. The induced photocytotoxic damage was attributed to the ROS generation during UVA irradiation, leading to lipid peroxidation of the plasma membrane. TiO2 NPs with a large surface-to-volume ratio enhanced biological reactivity by generating ROS. The degree of photocytotoxicity and cell membrane damage depends greatly on the level of ROS generated. More recently, Ren et al. also reported a similar finding on the phototoxicity of TiO2 NPs in HaCaT cells under UV irradiation [329].

The adverse effects of TiO2 NPs on mammalian cells, such as DNA damage, the generation of ROS, and apoptosis, addressed in in vitro studies, are supported by in vivo animal models [330–334]. Grassian et al. exposed mice to TiO2 NPs (2–5 nm; 8.88 mg/m3;4h/day for 10 days) through inhalation. Exposure for 1–2 weeks led to pulmonary inflammation with high cell counts of alveolar macrophages in bronchoalveolar lavage (BAL) fluid [330]. To evaluate the potential respiratory system toxicity, Liu et al. studied the biodistribution of TiO2 NPs (5, 21 and 50 nm) in rats via intratracheally instillation at doses of 0.5, 5, and 50 mg/kg body weight (bw). Rats were then sacrificed one week post-instillation [331]. Histopathological evaluation of lung tissues revealed a dose-dependent inflammatory lesion. At a specific dose, the pulmonary toxicity induced by 5 nm TiO2 NPs was more severe than that caused by 21 and 50 nm TiO2 NPs. In the case of dermal exposure, Wu et al. reported that TiO2 NPs can penetrate through the skin of hairless mice, and finally reach the liver following a prolonged exposure of 60 days. This led to a remarkable change in malondialdehyde (MDA) level [332]. MDA is a marker of liquid peroxidation and oxidation stress of cells. Therefore, an increase in free radicals produces high levels of MDA. Disdier et al. intravenously administrated P25 TiO2 NPs of 1 mg/kg into male Fisher F344 rats. They analyzed the biodistribution of Ti level in internal organs of rats using inductively coupled plasma mass spectrometry [333]. Biopersistence of Ti in the main target organs, i.e., the liver, lungs, spleen and kidneys, was observed after intravenous administration for up to 365 days (Figure 33a–d). Jia et al. intraperitoneally injected TiO2 NPs (5, 10, 60, 90 nm) and TiO2 microparticles at doses of 5, 10, 50, 100, 150, and 200 mg/kg (once a day for 14 days) into rats (half male and half female). TiO2 NPs were found to accumulate in the liver, kidney, spleen, lung, brain, and heart through the circulatory system [335]. The liver was damaged seriously due to mitochondrial dysfunction and the ROS generation at TiO2

NPs doses ≥10 mg/kg, leading to hepatocyte apoptosis. Furthermore, TiO2 NPs were more toxic than TiO2 microparticles, as expected. The distribution of TiO2 NPs in the brain tissue suggested that nanoparticles can enter directly into the central nervous system without crossing the blood–brain barrier. Finally, TiO2 NPs also caused genotoxicity in the ex vivo mouse embryo models [335].

**Figure 33.** Biopersistence of titanium level in (**a**) liver, (**b**) lungs, (**c**) spleen and (**d**) kidneys after intravenous injection of 1 mg/kg TiO2 NPs in rats for 365 days. Grey and white bars are treated and control mice, respectively. Error bars represent the mean ± SD and *n* = 6. Statistical comparison is performed by two-way ANOVA, \* *p* < 0.05; \*\* *p* < 0.01; \*\*\* *p*< 0.001. Reproduced with permission from [333]. Copyright BioMed Central, 2015.

#### 6.1.2. Metal-Doped TiO2 NPs

We now consider the effect of metal doping on the cytotoxicity of TiO2 NPs in human cells. Doping TiO2 NPs with transition metals and noble metals is an efficient strategy for improving the photocatalytic inactivation of bacteria in the visible region. However, this approach has its own drawback as metal dopants can induce cytotoxicity in human cells. Therefore, metal-doped TiO2 NPs photocatalysts can fulfill the requirement of bactericidal performance, but they pose potential human health and safety hazards following long-term exposure. Recently, Ahamed et al. employed MTT and neutral red uptake (NRU) assays to assess the metabolic and lysosomal activities of human liver cancer (HepG2) cells exposed to Ag (0.5–5%)-doped TiO2 NPs [318]. Their results showed that Ag-doped TiO2 NPs reduce the cell viability in a dose-dependent manner, as shown in Figure 34a,b. Apparently, TiO2 NPs display no toxic effect to the HepG2 cell. In contrast, Ag (0.5–5%)-doped TiO2 NPs are toxic, as the Ag-dopant can release zero valent Ag<sup>0</sup> or Ag<sup>+</sup> ion to reduce cell viability through ROS generation [15]. This leads to the leakage of intracellular components at Ag (0.5–5%)-doped TiO2 NPs doses of ≥25 μg/mL, as evidenced by lactate dehydrogenase (LDH) assay (Figure 34c). Furthermore, cell viability decreases with increasing Ag content in Ag-doped TiO2 NPs, from 0.5% to 5%, while the ROS level increases with increasing Ag content (Figure 34d).

**Figure 34.** (**a**) MTT, (**b**) NRU, and (**c**) lactase dehydrogenase leakage results of human liver cancer (HepG2) cells exposed to TiO2 NPs and Ag-doped TiO2 NPs of different concentrations. (**d**) ROS level of HepG2 cells exposed to pure TiO2 NPs and Ag-doped TiO2 NPs of 25, 50 and 100 μg/mL. Reproduced with permission from [318], Copyright Nature Publishing Group, 2017.

#### 6.1.3. rGO-Modified TiO2 NPs

Jin et al. demonstrated that rGO/TiO2 NPs would separate independently into TiO2 NPs and GO after entering A549 cells. The rGO/TiO2 NPs composite could induce cytotoxicity in A549 due to the generation of oxidative stress [336]. More recently, Prakash et al. prepared rGO (10–50%)/TiO2 nanocomposites using hydrothermal synthesis, and studied their toxicity in zebrafish embryos and larvae [337]. The toxicity of rGO (10–50%)/TiO2 nanocomposites was highly dependent on the rGO concentrations and doses. At low concentration and dose levels (10%, 20%, and 30% rGO; 0.25–30 μg/mL), rGO (10–30%)/TiO2 nanocomposites exhibited no toxicity to the zebrafish embryos. At high doses of 0.125–1.0 mg/mL, all the rGO (10–50%)/TiO2 nanocomposites induced teratogenicity and cardiotoxicity due to the generation of ROS. Zebrafish (Danio rerio) are aquatic species commonly employed to detect toxicological effects due to their known physiology having a high degree of genetic similarity with mammals, and the optical transparency of the tissues.

#### **7. Prospects and Challenges**

Titania has been considered an inert and nontoxic material. It is typically used as a color additive for foods up to 1 wt%, and was approved by the Food and Drug Agency of the United States under Title 21 of the Code of Federal Regulations [338]. The additive contains TiO2 NPs as described by the E171, European Food Safety Authority (EFSA) of the European Union [339]. Titania is also widely used in toothpaste as a white pigment with a small fraction of TiO2 NPs. These nanoparticles are also detected in sweets containing E 171, e.g., chewing gum, colored candy, chocolate and cake-icing. The approximate oral ingestion of TiO2 NPs for the Dutch is 0.19 mg/kg bw/day for elderly, 0.55 mg/kg bw/day for 7–69 year old people, and 2.16 mg/kg bw/day for young children [340]. Very recently, Hwang et al. demonstrated that commercial TiO2 additive as outlined by the E171 contains particles with mean size values of 118–169 nm. The TiO2 additive created ROS and inhibited long-term colony formation in human intestinal epithelial Caco-2 cells at concentrations >125 μg/mL. The additive slightly induced apoptosis at a very high content of 1000 μg/mL upon exposure for 24 h [341]. This result raises a safety concern about the toxic impact of TiO2 food additives on human health [342]. Heringa et al. reported the presence of TiO2 NPs in 15 post-mortem human livers and spleens of Caucasians. Those human subjects followed a West European diet and used toothpaste, so this may have resulted from oral intake of TiO2 NPs [343].

Most in vitro cell cultivation and in vivo animal models tests clearly indicate that TiO2 NPs are toxic to mammalian cells, since they induce DNA damage, ROS generation, and apoptosis. In particular, Ag-doped TiO2 NPs act as a double-edged sword, having beneficial and adverse effects. The plasmonic effect of surface electrons of AgNP-decorated TiO2 NPs promotes light-harvesting in the visible region, as mentioned previously. This inhibits bacterial growth of *E. coli* and *S. aureus* effectively when compared to pure TiO2 NPs, as shown in Figure 20. Therefore, there exists a synergistic bactericidal effect of TiO2 and AgNPs through the photocatalytic reaction and Ag0/Ag<sup>+</sup> species released from the AgNPs. However, metallic Ag0 and ionic Ag<sup>+</sup> released from AgNPs can elicit a toxic effect on HepG2 cells through ROS generation (Figure 34). Furthermore, AgNPs have been found to induce a toxic effect on mammalian cells in a dose-, size- and time-dependent manner. In vivo animal studies reveal that AgNPs locate preferentially in murine target organs including the liver, spleen, kidney and brain after intratracheal instillation, intravenous or intraperitoneal injection [15].

Standalone and detached TNTs exhibit poor compatibility to human dermal fibroblasts due to ROS generation, leading to DNA damage and chromosomal aberration [308]. Ultrasonication was employed to detach TNTs from the Ti substrate. Standalone TNTs were able to pierce and penetrate through the membrane of fibroblasts, resulting in cytotoxicity. Without ultrasonication, intact TNTs adhered firmly on the Ti substrate, acting as the adhesion and growth sites for murine osteoblasts (MC3T3-E1) and human fibroblasts [226,261]. As such, anodic TNTs exhibited higher osteoblastic viability than pure Ti (Figure 35). After sputtered coating TNTs with silver for 60, 120 and 180 s (designated as ANS 60, ANS 120 and ANS 180), the ANS 60 sample still showed better biocompatibity than pure Ti. However, the cell viability of ANS 120 and ANS 180 samples decreased markedly because a longer sputtering time favored more AgNP formation on the nanotubes. Thus the ANS 180 sample exhibited the lowest cell proliferation. From Figure 21, ANS 60 showed a similar antibacterial actitvity to ANS 120 and ANS 180 samples. Therefore, a balance between bactericidal activity and cellular viability can be reached by monitoring the Ag content in ANS 60. In general, Ti-based alloy implants have inadequate antibacterial activity, so much effort has been made to improve their compatibility and antibacterial properties for clinical applications. Ti-based alloy implants with enhanced antibacterial activity and biocompatibility can be achieved by forming an Ag-doped TNTs surface layer with an optimal Ag content through anodization and sputtering. The modified TNTs formed on Ti-based implants can reduce bacterial colonization on their surfaces accordingly. Alternatively, antibacterial CuNPs can be used to replace AgNPs for doping TNTs with improved biocompatibility [98,99]. CuNPs are less toxic than AgNPs to human and bovine mammary epithelial cells [344].

However, it remains a big challenge for chemists and materials scientists to design novel nanomaterials for technological and medical applications utilizing TiO2 NPs and doped TiO2 NPs. With the increasing need for antibacterial scaffolds and wound dressings in tissue engineering, biodegradable polymers are ideal materials to immobilize TiO2 NPs to form polymer nanocomposites with improved biocompatibility and photocatalytic activity. It is of primary importance to select a proper polymeric material, suitable for those applications. As previously mentioned, mixing chitosan with TiO2 NPs can yield a biodegradable plastic film with visible light photocatalytic bactericidal activity. The film functions effectively for preserving fresh fruits and vegetables, and for prolonging shelf-life [289]. Such a plastic film can also be used as a food packaging material for killing pathogenic bacteria that causes food poisoning or food spoilage. In addition, biodegradable CS-TiO2 NPs

film also finds potential applications as antibacterial scaffolds and wound dressings in orthopedics. By incorporating Cu dopant into TiO2 NPs, the resulting CS/Cu-doped TiO2 NPs shows higher photocatalytic bactericidal activity, as expected [288].

**Figure 35.** The viability of MC3T3-E1 murine osteoblasts obtained from the MTT assay. Error bars indicate the standard deviation (*n* = 5); # *p* < 0.05 compared with commercial pure Ti (cp-Ti). Reproduced with permission from [261]. Copyright Wiley, 2014.

Finally, antibacterial and self-cleaning fabrics have received considerable attention in hospitals and clinics due to the increased risk of healthcare-associated infections. Those fabrics are particularly useful against nosocomial bacteria to protect patients from harmful microorganisms [298,345]. The fabrics made from cotton/Mn-doped TiO2 NPs have been reported to exhibit full inactivation of *S. aureus* and *K. pneumoniae* within 120 min under sunlight (Figure 32a,b) [298]. However, one can see that such fabrics need at least 25 wt% Mn-doped TiO2 NPs for achieving antibacterial properties. Those fillers can be removed from the fabrics upon several washing cycles, and then discharged into rivers and lakes. The recent literature data indicate the toxicity of rGO/TiO2 NPs in inducing teratogenic effects on zebrafish, although at doses considerably higher than those in aquatic environments [337]. The release of large amounts of Mn-doped TiO2 NPs would inevitably pollute the aquatic environment, and harm aquatic life in the ecosystem [346]. Moreover, Mn is a heavy metal that is toxic to mammalian cells. Manganese can induce toxicity in human bronchial epithelial cells, leading to caspase-9-mediated cell death [347,348]. Therefore, non-noble metal doped TiO2 NPs such as the N-doped TiO2 NPs photocatalyst is considere a potential replacement for Mn-doped TiO2 NPs for reducing environmental toxicity.

Thanks to the efforts of researchers, visible-light active TiO2 NPs and their nanocomposites have been found to exhibit a bactericidal effect against drug-resistant bacteria including salmonella abony, *S. aureus*, *K. pneumoniae*, *P. aeruginosa* and anthrax. However, it still requires substantial time and effort to develop visible-light active TiO2 NPs photocatalysts with both antibacterial activity and good cytocompatibility. Long-term, in vivo animal studies relating to the biocompatibility and cytotoxicity of those photocatalysts are required. More research studies are needed to design the toxic free, green synthesis of visible-light active TiO2 NPs with bactericidal activity for industrial, environmental and medical applications.

#### **8. Conclusions**

This review gives a summary of the synthesis, photocatalytic bacterial inactivation, biocompatibility and cytotoxic effects of visible-light active TiO2 NPs and their nanocomposites, especially over the past five years. The photocatalytic bactericidal effect of TiO2 NPs with a wide bandgap depends on the creation of an electron–hole pair under UV irradiation to generate ROS. The created radicals then interact with microorganisms, causing damage to the structure of the cell membrane and the subsequent leakage of intracellular components. However, UV-responsive TiO2 NPs

exhibit poor photocatalytic efficiency under visible light. It is of practical importance to employ visible light to induce the photocatalytic bactericidal activity of TiO2 NPs. Considerable progress has recently been made in the development of TiO2 nanostuctures with good photocatalytic bactericidal activity under visible light irradiation. Visible-light active TiO2 nanomaterials can be synthetized through several techniques including sol-gel, hydrothermal/solvothermal, electrochemical anodization, and electrospinning. Among these, sol-gel is commonly used for preparing TiO2 NPs, while electrochemical anodization is an effective method for fabricating TNTs.

Doping TiO2 NPs with metal and non-metal elements can lead to a red shift in the optical absorption edge into the visible region, resulting in a reduction of the bandgap accordingly. Transition metal elements, such as Mn, Fe, V and Cu, can create a localized d-electron state in the bandgap of TiO2 NPs, thereby promoting the separation of photogenerated electron–hole pair and suppressing the recombination of charge carriers. However, defect states in the bandgap of titania would also serve as charge recombination centers under experimental conditions of high dopant concentrations. Noble metal dopants such as AgNPs exhibit plasmonic oscillation of surface electrons under visible light irradiation. As such, hot-electron transfer from excited AgNPs into the conduction band of TiO2 NPs creates ROS for bactericidal activity. In addition to photocatalytic bactericidal activity, AgNPs of Ag-doped TiO2 NPs can inactivate bacteria through the release of Ag<sup>+</sup> ions. These cations strongly interact with the thiol groups of microorganisms and inhibit DNA replication, resulting in apoptosis. Furthermore, AgNPs also induce a toxic effect on human cells. In this respect, we must be cautious when using AgNPs as a dopant for TiO2 NPs. Taking account of the adverse effects of metal dopants, visible-light active, anion-doped TiO2 NPs using non-metal elements have attracted increasing attention as agents against pathogenic bacteria.

Given the important uses of visible-light active TiO2 NPs for various applications, their impact on human health poses a serious concern worldwide. In vitro cell cultivation and in vivo animal models studies have reported the cytotoxic effects of TiO2 NPs and Ag-doped TiO2 NPs in mammalian cells by inducing an inflammatory response, DNA damage, ROS generation, and apoptosis. For long-term safety, more research studies are needed to properly design a toxic free, green synthesis of visible-light active TiO2 NPs with bactericidal activity.

**Author Contributions:** S.C.T. conceived and directed the research. C.L., Y.L. and S.C.T. contributed to the writing of this review article. All authors have read and agree to the published version of the manuscript.

**Funding:** National Youth Science Foundation, China (Grant Number: 21703096), and Natural Science Foundation of Shandong Province, China (Grant Number: ZR2019MB053) provided the funding of this research.

**Conflicts of Interest:** The authors declare no conflict of interest.

#### **References**


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*Letter*
