# Pathobiology of ESKAPE Biofilms in implant infections: current understanding and implications for future therapeutic strategies

## TL;DR

This review discusses how ESKAPE pathogens form biofilms on medical implants, leading to infections and implant failure, and highlights new strategies to prevent and treat these infections.

## Contribution

The paper provides a comprehensive overview of ESKAPE biofilm-related implant infections and evaluates emerging therapeutic strategies.

## Key findings

- Biofilm formation by ESKAPE pathogens on implants increases the risk of infection and antimicrobial resistance.
- Current diagnostic methods struggle to detect ESKAPE biofilm infections effectively.
- Emerging therapies like antimicrobial coatings and phage therapy show promise in combating these infections.

## Abstract

In the modern era, the expanding demand for implants has transformed the healthcare system by restoring and enhancing the function of various biological structures, thereby increasing the patients’ quality of life. These include urinary catheters, dental, orthopedic, cardiovascular implants, and sutures designed to perform various functions. However, these devices are more prone to microbial attack, contributing to biofilm formation mainly caused by multidrug-resistant ESKAPE pathogens, thereby increasing the risk of implant-associated infections and implant failure. This review summarizes the diverse array of implants available on the market and their associated infections caused by biofilm-producing pathogens, with a particular emphasis on the ESKAPE pathogen. Specific keywords were used to conduct a literature review using Google Scholar, Web of Science, PubMed, and Scopus databases. The data were then screened and integrated to explore the underlying principles of biofilm formation, its consequences, diagnostic approaches, and therapeutic studies. Currently, various methods are employed to diagnose these infections, including culture-based methods (tissue swab, culture, sonication) and non-culture methods (Dithiothreitol, XTT (2,3-bis-(2-methoxy-4-nitro-5-sulfophenyl)-2H-tetrazolium-5-carboxanilide), Resazurin, BioTimer assays, and PCR). However, these studies indicate an increased difficulty in detecting infections caused by ESKAPE pathogens due to biofilm formation, highlighting the need for developing novel strategies. The recent advancements in the development of antimicrobial coatings, implant surface modifications, phage therapy, nanoparticles, antimicrobial peptides, and quorum-sensing inhibitors have shown promise in controlling these infections. Thus, these findings underscore the importance of research on innovative approaches and the development of infection-resistant implants, thereby reducing the clinical burden and improving patient outcomes.

Illustration showing the process of pathogen adhesion and biofilm formation on medical implants, listing implant types, ESKAPE pathogens, and consequences such as implant failure, antimicrobial resistance, hospitalization costs, and economic loss.