# Combined Effects of Amikacin and Methylene Blue-Mediated Photodynamic Therapy on Pseudomonas aeruginosa Biofilms Mimicking Mono- and Polymicrobial Diabetic Foot Ulcer Infections

## TL;DR

This study shows that combining photodynamic therapy with antibiotics is more effective at killing Pseudomonas biofilms in diabetic foot ulcers than using either treatment alone.

## Contribution

The study introduces a sequential treatment combining photodynamic therapy and antibiotics to enhance antibiofilm activity against Pseudomonas aeruginosa.

## Key findings

- Antibiotics alone had limited effect on Pseudomonas biofilms, even at high concentrations.
- Combining antibiotics with photodynamic therapy significantly reduced Pseudomonas viability in both mono- and polymicrobial biofilms.
- Scanning electron microscopy showed structural damage to Pseudomonas cells after combined treatment.

## Abstract

Diabetic foot ulcer (DFU) infections frequently involve biofilm formation and exhibit limited responsiveness to conventional antibiotic therapy. In particular, Pseudomonas aeruginosa often participates in mono- and polymicrobial biofilms that display high tolerance to antimicrobial agents. This study evaluated the efficacy of methylene blue-mediated antimicrobial photodynamic therapy (aPDT), alone and in combination with antibiotics, against P. aeruginosa biofilms formed either as single-species or in mixed communities with Enterococcus faecalis, under conditions mimicking DFU infections. Macrocolony biofilms were challenged with amikacin alone (for single-species biofilms) or amikacin plus ampicillin (for mixed biofilms), aPDT, or sequential combinations of these treatments, and bacterial viability was quantified by colony-forming unit enumeration. Antibiotic treatment alone produced only modest reductions in P. aeruginosa viability, even at high concentrations, while aPDT using methylene blue was effective only at high photosensitizer concentrations. In contrast, sequential treatment with antibiotics followed by aPDT and a second antibiotic challenge resulted in a marked reduction in P. aeruginosa viability in both mono- and polymicrobial biofilms. Scanning electron microscopy revealed extensive structural damage in P. aeruginosa cells following combined treatments, whereas E. faecalis remained unaffected. Overall, our findings demonstrate that combining aPDT with antibiotics significantly enhances antibiofilm activity against P. aeruginosa, highlighting this approach as a promising alternative for the management of biofilm-associated DFU infections.