Antibiotic Resistance and Bacterial Biofilm: Causes and Threats

What are antibiotics?

Antibiotics are medicines used to treat or prevent infections caused by any of the following
organism
 Bacteria
 Virus
 Fungi
 Parasite
 Protozoa
 Yeast
 Molds, etc.

What is antibiotic resistance?

Antibiotic resistance (AR) is the ability of organisms (bacteria, virus, yeast, fungi, parasites) to
nullify the effect of antimicrobial drugs resulting in these drugs becoming ineffective. Antibiotic
resistance happens when organisms like bacteria, virus, yeast, parasites and fungi develop the
ability to defeat the drugs designed to kill them. Microorganisms that develop antimicrobial
resistance are sometimes referred to as “superbugs”.
Antibiotic resistant organisms are free to grow, multiply and cause infection within the host even
when exposed to antibiotics. Antibiotic resistance is a major obstacle in the treatment of
infectious diseases caused by bacteria. Resistance to antimicrobial agents has become a major
source of threat, morbidity and mortality worldwide(1)(2).
Typical resistance mechanism against antibiotics

Intrinsic Adaptive Acquired

resistance resistance resistance
Ribosomal mutation Biofilm matrix Chromosomal mutation
Ribosomal modification Persister cells Gene mutation
Antibiotic modiflying Physiological changes Uptake of resistance gene
enzymes Swarming motility Uptake of resistance plasmid
Change in membrane
permeability
Efflux pump
Membrane protease

Causes of antibiotic resistance

Antibiotic resistance happens when bacteria change and become resistant to the antibiotics used
to treat the infections they cause.
 Over-prescribing of antibiotics
 Patients not finishing their treatment
 Over-use of antibiotics in livestock and fish farming
 Poor infection control in hospitals and clinics
 Lack of hygiene and poor sanitation
 Lack of new antibiotics being developed

Antibiotic Resistance in Bacterial Biofilms

What is Biofilm?
A biofilm is composed of living, reproducing microorganisms, such as bacteria, that exist as a
colony, or community. In other words, biofilms are alive and have a complex social structure that
scientists and engineers are still trying to unravel, a structure that both protects them and allows
them to grow.
A biofilm comprises any syntrophic consortium of microorganisms in which cells stick to each
other and often also to a surface that provide protection for bacteria and make them more suitable
for the external environment under certain conditions. Biofilms are populations of bacteria that
adhere to surfaces and exist as organized structures which are held together in a liquid matrix
that provides stability and structural integrity. When bacteria grow as biofilms, they become
resistant to antibiotics and other agents that would generally have a bacteriostatic or bactericidal
effect. Bacteria can proliferate either as independent cells singularly or in organized aggregates
as biofilms(3)(4).
Antibiotic resistance and biofilm tolerance are naturally and inextricably linked, and together
create a formidable threat and catalyst in chronic infections
The formation of biofilms is found to be one of the leading causes of antimicrobial resistance.
Early research revealed that bacterial biofilms exist as clusters in a liquid matrix composed of
proteins, polysaccharides, and extracellular DNA (cDNA), which constitute the extracellular
polymeric substances. Biofilm formation is considered the core reason why antimicrobial
treatment fails, and it is estimated that about 65–80% of all infections are biofilm-related; this
presents a grim trial. These biofilms are the reason for certain chronic infections being more
common in cystic fibrosis and delayed wound healing and are often associated with medical
instruments such as heart valves, prostheses, catheters, implants, contact lenses, pacemakers, and
ventricular assist devices. Several species of bacteria such as Staphylococcus aureus and
Pseudomonas aeruginosa are implicated as the cause of many chronic infections, due to their
resistance to antibiotics and the formation of biofilms(5).

Fundamental Basis for Bacterial Biofilm Formation

Bacteria form biofilms in response to environmental stresses such as UV radiation, desiccation,
limited nutrients, extreme pH, extreme temperature, high salt concentrations, high pressure, and
antimicrobial agents.
Why form bacterial biofilm? Reasons behind the formation of bacterial biofilm
Given below some potential incentives behind the formation of biofilms by bacteria during
infection are considered:
 Resists phagocytosis by protozoa and immune cells
 Collect nutrients from flowing liquid
 Nutrient exchange
 Resists penetration of drug (e.g. antibiotics), this leads to antibiotic resistance
 Genetic exchange
 Protection from harmful conditions in the host (defense)
 Sequestration to a nutrient-rich area (colonization)
 Utilization of cooperative benefits (community)

Threats of Bacterial biofilm

Bacterial biofilm is important concern in Healthcare issues, Plant diseases, Food safety and the
Food industry, Drinking Water Distribution Systems, Marine Biofouling etc.
Bacterial biofilm formation, a threat to health issues and its Impact on
Antibiotic Resistance: The emergence and spread of antimicrobial resistance among
bacteria are the most important health problems worldwide. Antibiotic resistance is one of the
consequences of the bacterial biofilm communities which contribute to chronic infections.
Biofilm is recalcitrant to antibiotic therapy and a major cause of persistent and recurrent
infections by clinically important pathogens worldwide. This is because the formation of
biofilms and subsequent encasement of bacterial cells in a complex matrix can enhance
resistance to antimicrobials and sterilizing agents making these organisms difficult to eradicate
and control(4).
The extracellular polymeric substances (EPS) matrix protects bacteria from antibiotics, avoiding
drug penetration at bactericidal concentrations. Bacteria within a biofilm are several orders of
magnitude more resistant to antibiotics, compared with planktonic bacteria. For instance,
biofilms can tolerate antimicrobial agents at concentrations of 10–1000 times that needed to
inactivate genetically equivalent planktonic bacteria.
The nature of biofilm structure and other physiological changes such as slow growth rate assists
them to be resistant to antimicrobial agents. Microorganisms in a biofilm are resistant due to the
following suggested factors(6):

Polymeric matrix that can restrict diffusion of antibiotics

Interaction of antibiotics with a polymeric matrix which lowers their activity

Enzyme-mediated resistance such as β-lactamase

Changes in metabolic activity inside the biofilm

Genetic changes on target cells or hiding the target sites

Extrusion of antibiotics using efflux pumps

The presence of outer membrane structure such as in Gram-negative bacteria

These mechanisms are critical for antibiotic resistance and survival of biofilm bacteria. The
antibiotic resistance used by bacteria in biofilm is distinct and different from natural or innate
resistance mechanisms.
As similar findings revealed bacteria within biofilm develop different molecular strategies to
protect their cells from hostile conditions such as the interaction of biofilm matrix with
antibiotics that can retard or lower their activities, slow growth rates in which antibiotics will not
be effective, genetic related resistance, and producing persistent cells which are tolerant to
different antibiotics. In biofilm-forming bacteria, there is a high rate of mutation that enables
them to develop resistant mechanisms, and this, in turn, gives an opportunity for their genes to
produce enzymes that inactivate the antibiotics or expel the antibiotics using efflux pumps.
Bacteria within biofilm produce persister cells that are metabolically inert and it is one of their
mechanisms to escape from antibiotics and even they have the ability to survive in high
concentration of antibiotics. Biofilm plays a critical role in the spread of antibiotic resistance.
Within the high dense bacterial population, efficient horizontal transfer of resistance and
virulence genes takes place. The number of microorganisms within the matrix is too dense so
that there is close contact between different microorganisms which enable them to exchange
resistant genes and finally, the whole community may acquire that resistant gene.
Therefore, genetic diversification of microorganisms in biofilm is largely responsible for shaping
antibiotic resistance. As studies have suggested that biofilm is important for the transfer of
conjugative plasmids due to the high proximity of cells within this multicellular structure. The
resistance of biofilm to antibiotics depends on different factors such as physical, physiological,
and gene-related factors. Thus, this multifactorial nature of biofilm development and drug
tolerance imposes great challenges for the use of conventional antimicrobials(4)(5).
To sum up, bacterial biofilm is a key player in the development of antimicrobial resistance
and leads to cause disease of different body system (Table-1)
References:
1. Yelin I, Kishony R. Antibiotic Resistance. Cell [Internet]. 2018;172(5):1136-1136.e1.
Available from: http://dx.doi.org/10.1016/j.cell.2018.02.018
2. Frieri M, Kumar K, Boutin A. Antibiotic resistance. J Infect Public Health [Internet].
2017;10(4):369–78. Available from: http://dx.doi.org/10.1016/j.jiph.2016.08.007
3. Eze EC, El Zowalaty ME, Pillay M. Antibiotic resistance and biofilm formation of
Acinetobacter baumannii isolated from high-risk effluent water in tertiary hospitals in
South Africa. J Glob Antimicrob Resist [Internet]. 2021;27:82–90. Available from:
https://doi.org/10.1016/j.jgar.2021.08.004
4. Joseph HA, Swamy SS, Solomon AP. Antibiotic Resistance in Biofilms. ACS Symp Ser.
2019;1323:205–24.
5. Bowler PG. Antibiotic resistance and biofilm tolerance: A combined threat in the
treatment of chronic infections. J Wound Care. 2018;27(5):273–7.
6. Antimicrobial resistance : a global threat. Essent Drugs Monit. 2000;(28 & 29):36.