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Bacterial biofilms in patients with indwelling urinary catheters

Nature Clinical Practice Urology volume 5, pages 598–608 (2008)Cite this article

Abstract

Bacteria have a basic survival strategy: to colonize surfaces and grow as biofilm communities embedded in a gel-like polysaccharide matrix. The catheterized urinary tract provides ideal conditions for the development of enormous biofilm populations. Many bacterial species colonize indwelling catheters as biofilms, inducing complications in patients' care. The most troublesome complications are the crystalline biofilms that can occlude the catheter lumen and trigger episodes of pyelonephritis and septicemia. The crystalline biofilms result from infection by urease-producing bacteria, particularly Proteus mirabilis. Urease raises the urinary pH and drives the formation of calcium phosphate and magnesium phosphate crystals in the biofilm. All types of catheter are vulnerable to encrustation by these biofilms, and clinical prevention strategies are clearly needed, as bacteria growing in the biofilm mode are resistant to antibiotics. Evidence indicates that treatment of symptomatic, catheter-associated urinary tract infection is more effective if biofilm-laden catheters are changed before antibiotic treatment is initiated. Infection with P. mirabilis exposes the many faults of currently available catheters, and plenty of scope exists for improvement in both their design and production; manufacturers should take up the challenge to improve patient outcomes.

Key Points

  • Many bacterial species colonize indwelling catheters, growing as biofilm communities embedded in a gel-like polysaccharide matrix, and induce complications in patients' care

  • The most troublesome biofilms are crystalline biofilms, generated by urease-producing bacteria, particularly Proteus mirabilis; crystalline biofilms can occlude the catheter lumen and trigger episodes of pyelonephritis and septicemia

  • Urease raises the urinary pH and drives the formation of calcium and magnesium phosphate crystals in the biofilm

  • All types of catheter, including those coated in antimicrobial agents, are vulnerable to encrustation by these biofilms, and there is a clear clinical need to develop prevention strategies

  • Bacterial cells in the biofilm mode of growth are resistant to antibiotics, and evidence indicates that treatment of symptomatic urinary tract infection is more effective if biofilmladen catheters are changed before antibiotic treatment is initiated

  • Infection with P. mirabilis exposes the many faults of current catheters; crystalline biofilms can lead to potentially disastrous consequences for patients and substantial financial implications for health-care services

  • Plenty of scope exists for improving both the design and production of catheters; manufacturers should take up this challenge

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Figure 1: Conceptualization of biofilm development and dynamic behaviors.
Figure 2: Examples of crystalline biofilms on blocked catheters taken from patients.
Figure 3: Scanning electron micrographs of encrustation on the surface of a silver–hydrogel-coated latex catheter that had been indwelling for 14 days.
Figure 4: Scanning electron micrographs of the surfaces of unused hydrogel-coated latex catheters.
Figure 5: Electron micrographs illustrating the colonization of a hydrogel-coated latex catheter by Proteus mirabilis in a laboratory model of the bladder.
Figure 6: Electron micrographs of catheters removed from bladder models with varying citrate concentrations and nucleation pHs.
Figure 7: An early stage in the formation of a crystalline biofilm on a hydrogel-coated latex catheter.
Figure 8: A crystalline biofilm developing around the eyehole of a silver–hydrogel-coated latex catheter.
Figure 9: Examples of mucoid, noncrystalline biofilms formed on all-silicone catheters after 4 days of incubation in a laboratory model of the bladder.

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Acknowledgements

The author would like to thank Dr Rob Broomfield, Dr Sheridan Morgan and Dr Rob Young, who are members of Dr Stickler's research team, for providing the previously unpublished images shown in this Review. Charles P Vega, University of California, Irvine, CA, is the author of and is solely responsible for the content of the learning objectives, questions and answers of the Medscape-accredited continuing medical education activity associated with this article.

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  1. Cardiff School of Biosciences, Main Building, Cardiff University, Museum Avenue, Cardiff CF10 3TL, UK stickler@cardiff.ac.uk

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  1. DJ Stickler is a Reader in Medical Microbiology at The Cardiff School of Biosciences, Cardiff University, Cardiff, UK.,

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Stickler, D. Bacterial biofilms in patients with indwelling urinary catheters. Nat Rev Urol 5, 598–608 (2008). https://doi.org/10.1038/ncpuro1231

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