Gemini Cationic Amphiphiles Control Biofilm ...

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Sep 13, 2017 - Pinto4, Kathryn E. Uhrich3,and Michael L. Chikindas4,6∗. 4. 1Department of ...... Findlay B, Zhanel GG, Schweizer F. 2010. Cationic ...

AAC Accepted Manuscript Posted Online 11 September 2017 Antimicrob. Agents Chemother. doi:10.1128/AAC.00650-17 Copyright © 2017 American Society for Microbiology. All Rights Reserved.

Gemini Cationic Amphiphiles Control Biofilm Formation by

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Bacterial Vaginosis Pathogens

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Ammar Algburi1,2‡, Yingyue Zhang3, Richard Weeks4‡, Nicole Comito1, Saskia Zehm5, Juanita

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Pinto4, Kathryn E. Uhrich3, and Michael L. Chikindas4,6∗

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08901, USA, 2Department of Biology and Biotechnology, College of Science, Diyala University,

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Baqubah, Iraq, 3 Department of Chemistry and Chemical Biology, Rutgers State University,

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Piscataway, NJ, USA, 4School of Environmental and Biological Sciences, Rutgers State

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University, New Brunswick, NJ, USA, 5Department of Life Sciences and Technology, Beuth

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University of Applied Sciences, Berlin, Germany, 6Center for Digestive Health, New Jersey

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Institute for Food, Nutrition and Health, New Brunswick, NJ, USA

Department of Biochemistry and Microbiology, Rutgers State University, New Brunswick, NJ

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Authors with equal contribution

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∗For

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USA. Tel: +1-848-932-5405; E-mail: [email protected]

correspondence: Rutgers State University, 65 Dudley Road, New Brunswick, NJ 08901,

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ABSTRACT

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Antibiotic resistance and recurrence of bacterial vaginosis (BV), a polymicrobial infection,

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justify the need for novel antimicrobials to counteract microbial resistance to conventional

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antibiotics. Previously, two series of cationic amphiphiles (CAms), which self-assemble into

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supramolecular nanostructures with membrane-lytic properties, were designed with hydrophilic

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head groups and non-polar domains. The combination of CAms with commonly prescribed

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antibiotics is suggested as a promising strategy for targeting microorganisms that are resistant to

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conventional antibiotics. Activity of the CAms against Gardnerella vaginalis ATCC 14018, a

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BV representative pathogen, ranged from 1.1 to 24.4 µM. Interestingly, the tested healthy

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Lactobacillus species, especially L. plantarum ATCC 39268, were significantly more tolerant to

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CAms compared to the selected pathogens. In addition, CAms prevented biofilm formation at

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concentrations which did not influence the normal growth ability of G. vaginalis ATCC 14018.

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Furthermore, the minimum biofilm bactericidal activity (MBC-B) of CAms against G. vaginalis

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ATCC 14018 ranged between 58.8 and 425.6 µM while much higher concentrations (≥850 µM)

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were required to produce ≥3 log reduction in the number of biofilm-associated lactobacilli. The

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conventional antibiotic metronidazole strongly synergized with all tested CAms against

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planktonic cells and biofilms of G. vaginalis ATCC 14018. The synergism between CAms and

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the tested conventional antibiotic may be considered a new, effective, and beneficial method of

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controlling biofilm-associated bacterial vaginosis.

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Keywords: AMP mimics, antimicrobials, Gardnerella vaginalis, biofilm, bacterial vaginosis

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INTRODUCTION

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Bacterial vaginosis (BV) is a non-inflammatory, polymicrobial infection in women of

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reproductive age (1). Generally, the infection occurs due to a decrease in protective lactobacilli

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species, leading to the overgrowth of pathogenic, anaerobic bacteria that are naturally present in

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low concentrations within the vaginal lumen (2). The mechanism by which the loss of

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lactobacilli occurs is not yet clear (3), however, the decrease in the commensal lactobacilli

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population causes an increase in pH due to reduced lactic acid production and increased fatty

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acid production by anaerobic bacteria, making the vaginal environment more suitable for

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opportunistic pathogen growth and unfavorable for lactobacilli growth (4). BV affects between

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10% to 30% of women in developed nations (5), making it three to four times more common

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than urinary tract infections and three times more prominent than Trichomonas vaginalis

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infection (6). While often asymptomatic, BV can lead to serious complications including, but not

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limited to, abortion or premature birth in pregnant women, pelvic inflammatory disease,

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endometriosis, and infertility (2). During early pregnancy, the cost of screening and treating

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women for BV is quite high; total costs can amount to over $490,000 (7), not including

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recurrences. This issue calls for a safe, effective, and economically conscious treatment of the

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disease. Although no single bacteria can be considered as the sole causative agent of BV,

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Gardnerella vaginalis, an opportunistic anaerobic pathogen, is the predominant bacterial species

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isolated from BV infections; G. vaginalis forms a thick biofilm and produces toxins as effective

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virulence factors, increasing bacterial resistance to conventional antibiotics (8). The bacterium

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has been detected in over 98% of BV cases and often exhibits a symbiotic relationship with other

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anaerobes (9).

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Current treatment of bacterial vaginosis includes conventional antibiotics, most often 400 to 600 mg of metronidazole taken orally (10). Metronidazole is readily taken up by anaerobic

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bacteria through passive diffusion, where it is activated within the cytoplasm and then reduced to

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its active form by electron transport, causing inhibition of DNA synthesis (11). Despite its initial

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effectiveness against the unwanted bacteria, the antibiotic often fails to fully eradicate the

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pathogenic biofilm (2). Pathogenic polymicrobial biofilms are especially difficult to eradicate;

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such biofilms occur in infections like BV while carrying G. vaginalis as the predominant BV-

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associated pathogen (12).

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Antibiotic resistance is an impending issue concerning the overuse of antibiotics;

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Gardnerella strains are becoming increasingly resistant to both clindamycin and to a lesser

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extent, metronidazole (13,14,15). This leads to ineffective treatment of the infection and often a

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recurring infection: approximately 80% of treated women will have another episode of BV

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within one year of treatment (16,17). Therefore, resistance to antibiotics calls for alternative

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treatments, which leads to an interest in antimicrobial peptides. Antimicrobial peptides (AMPs)

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are proteinaceous substances with low molecular weights and broad spectrum antimicrobial

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activity against bacteria, fungi, and viruses (18). AMP-mimicking cationic amphiphilic

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compounds (CAms, either bola-like or gemini-like) effectively target the lipopolysaccharide

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(LPS) layer of the cell membrane in Gram-negative microorganisms; at the same time,

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eukaryotic cell membranes have a high cholesterol content and low anionic charge, making them

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out of the target range of most AMPs (19). AMPs can form pores in the cell membrane or disable

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the proton motive force, as discussed by Wimley and Hristova (20). By targeting the LPS layer

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of the cell membrane, the cationic AMPs interact with the negatively charged membranes of the

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bacteria and biofilm surface electrostatically, killing active and dormant cells or slowing their 4

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growth; the hydrophobic domain also interacts with and disrupts the hydrophobic membrane

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resulting in cell death (21). Previously, two series of CAms, which self-assemble into supramolecular nanostructures

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with membrane-lytic properties, were designed with hydrophilic heads and non-polar domains as

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AMP mimics. In this study, the antimicrobial and anti-biofilm activity of CAms with

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nomenclatures of G8 and G10 with ether or ester linkages (22) were determined against G.

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vaginalis ATCC 14018 and Lactobacillus species by establishing the minimum inhibitory

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concentration (MIC), minimum biofilm inhibitory concentration (MIC-B) and minimum biofilm

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bactericidal concentration (MBC-B) of each antimicrobial. The nature of antimicrobial

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interactions between the CAms and metronidazole against planktonic and biofilm cells was

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investigated as well.

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MATERIALS AND METHODS

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Synthesis of Gn formulations

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Ether-linked and ester-linked cationic gemini-like amphiphiles (Gn, where G stands for gemini

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and n denotes the total carbon number of each hydrophobic arm) with various hydrophobic chain

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lengths (Fig. 1) were synthesized in high yields following procedures described by Zhang et al.

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(22).

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Bacterial strains and growth conditions

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G. vaginalis ATCC 14018 was grown overnight in Brain Heart Infusion (Difco, Sparks, MD)

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supplemented with 3% horse serum (sBHI) (JRH Biosciences, KS), while BHI supplemented

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with 1% glucose (BHIG) was used for biofilm formation assays. Each experiment using G.

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vaginalis ATCC 14018 was performed anaerobically (10% hydrogen, 5% carbon dioxide, and

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85% nitrogen) within an anaerobic glove box (Coy Laboratory Products Inc., Grass Lake, MI,

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USA). Four species of vaginal Lactobacillus were used in this study to evaluate the possible

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harmful effects of CAms on beneficial bacteria: Lactobacillus plantarum ATCC 39268,

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Lactobacillus rhamnosus 160 (provided by Dr. Aroutcheva, Rush University Medical Center,

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1653 W. Congress Parkway, Chicago, IL 60612), Lactobacillus crispatus ATCC 33197 and

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Lactobacillus gasseri ATCC 33323; all were grown for 18-24 h in DeMan, Rogosa and Sharpe

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broth (MRS Difco BD, Franklin Lakes, NJ, USA) under aerobic conditions at 37°C. For

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lactobacilli biofilm formation, MRS broth supplemented with 1% glucose and 2% sucrose

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(Fisher Scientific, Waltham, MA, USA) was utilized.

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The antimicrobial activity of CAms was also tested against Peptostreptococcus

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anaerobius ATCC 27337, Mobiluncus curtisii ATCC 35241 and Prevotella bivia ATCC 29303,

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all of which, in addition to G. vaginalis ATCC 14018, are the most commonly isolated anaerobes

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from BV-infected women. These anaerobes were maintained within the anaerobic chamber and

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transferred daily into fresh sBHI.

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Stock solution preparation of CAm compounds

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To prepare a stock solution, the CAm compounds were dissolved in ddH2O and incubated at

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37°C with shaking at 250 rpm for 10 min. Then, the solution was serially diluted twofold with

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sBHI broth to determine the MIC and with BHIG broth to identify the MIC-B/MBC-B against

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planktonic and biofilm cells, respectively.

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Minimum inhibitory concentrations (MIC) of CAms

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According to the Clinical and Laboratory Standards Institute (CLSI 2016), the MIC is defined as

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the lowest concentration of antimicrobial compound producing no visible growth or complete

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inhibition of bacterial growth during 24 h. To determine MIC values, a broth microdilution assay

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was performed according to Algburi et al. (23) with minor modifications. Briefly, a 24 h culture

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of G. vaginalis ATCC 14018 was diluted with a suitable volume of culture medium to achieve

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~106 CFU/ml. The number of bacterial cells was identified using the spot plate method (24). The

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CAms were serially diluted twofold with sBHI into a non-tissue culture 96-well microplate plate

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(Falcon, Corning Incorporated, Corning, NY, USA) resulting in a final volume of 100 µl for each

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well. Aliquots of 100 µl of the diluted cell suspension (~106 CFU/ml) were added to each well of

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a microplate that was treated with different concentrations of CAms. To avoid culture medium

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evaporation, 75 µl of mineral oil (Sigma-Aldrich, St. Louis, MO) was added to each treated well.

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The microplate was then transferred to a plate reader (Model 550, Bio-Rad Laboratories,

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Hercules, CA, USA) and incubated anaerobically at 37°C for 24-36 h. The kinetic reading was

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statistically analyzed, and the MIC and sub-MIC concentrations for each CAm compound were

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determined.

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Minimum biofilm inhibition concentration (MIC-B)

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The MIC-B50 of an antimicrobial is defined as the lowest concentration of the antimicrobial that

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inhibits 50% of treated biofilm compared to the untreated one (control), while MIC-B90 was

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defined as the minimum biofilm inhibitory concentration that inhibits 90% (25). G. vaginalis

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ATCC 14018 cells were grown overnight in sBHI broth anaerobically at 37°C. The overnight

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culture was diluted in BHIG broth 1:100 (v:v) to achieve ~106 CFU/ml. The CAms were diluted

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twofold with BHIG into a 96-well tissue culture microplate (Falcon, Corning Incorporated,

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Corning, NY, USA) with a final volume of 100 µl in each well. Aliquots of 100 μl of diluted cell 7

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suspensions at 106 CFU/ml were added separately to different concentrations of CAms in a 96-

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well tissue culture microplate. The microplate was then incubated for 48 h at 37°C under

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anaerobic conditions. After incubation, the number of non-adherent bacterial cells was counted

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using a spot plate method and compared with the number of cells of the untreated control. Then,

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the intact biofilm was stained with 0.1% crystal violet.

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Biofilm staining using crystal violet (CV)

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This method was performed as described by Borucki et al. (26) with minor modifications.

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Briefly, after counting the non-adherent cells, the biofilm was fixed at 60°C for 60 min in an

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inverted position using an incubator (New Brunswick Scientific Co., Inc., NJ, USA). In each

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well, 125 μl of 0.1% CV was added and left at room temperature for 20 min. Each well was then

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rinsed three to four times with 200 μl of ddH2O and left for 15 min to dry at room temperature.

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To solubilize the biofilm-stained CV, 200 μl of 95% ethanol in water was added and the

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microplate was incubated at 4°C for 30 min. One hundred microliter samples of solubilized CV

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were then transferred to a new flat-bottomed 96-well microplate. The absorbance of each sample

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was measured using a plate reader at 595 nm (Model 550, Bio-Rad Laboratories, Hercules, CA,

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USA).

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Minimum biofilm bactericidal concentration (MBC-B)

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The minimum biofilm bactericidal concentration (MBC-B) is defined as the minimum

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concentration of an antibacterial agent that causes ≥3 log reduction in the number of viable cells

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as compared to the positive control (27). This assay was performed according to Algburi et al.

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(23) with minor modifications: a 24 h culture of G. vaginalis ATCC 14018 was diluted to 107

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CFU/ml. For the biofilm formation assay, aliquots of 200 μl were added into a 96-well tissue 8

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culture microplate, sealed by amplification tape (Nalge Nunc International, Rochester, NY,

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USA) and incubated for 24-36 h at 37°C. After incubation, the planktonic cells were removed by

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gently washing the biofilm twice with 200 μl of fresh broth. The biofilm was then treated with

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200 μl of a predetermined concentration of the tested compound. The microplate was incubated

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for 24 h at 37°C under anaerobic conditions. After incubation, the antimicrobials (supernatant)

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were discarded and the biofilm was washed twice with fresh BHIG broth. The biofilm was then

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disrupted by vigorous pipetting, in order to determine the number of biofilm-associated cells

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using the spot plate method.

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Checkerboard assay for antimicrobial combinations

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To evaluate the potential effectiveness of the CAms in combination with metronidazole on

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planktonic and biofilm cells, a checkerboard assay was performed following Algburi et al. (23)

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with minor modifications. For planktonic cells, a 24 h culture of G. vaginalis ATCC 14018 was

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diluted to achieve 106 CFU/ml. Each antimicrobial agent was diluted twofold with sBHI broth

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into two separate 96-well non-tissue culture microplates. From each dilution of antimicrobial B,

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50 μl was added horizontally over 50 μl of antimicrobial A. Then, 100 μl of bacterial suspension

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(106 CFU/ml) was separately added to the predetermined concentration of antimicrobial

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combinations. The MIC of each combination was determined after 24 h of incubation.

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For biofilm formation, the overnight culture of G. vaginalis ATCC 14018 was diluted to

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approximately 107 CFU/ml and 200 μl was transferred into a 96-well tissue culture microplate

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and incubated anaerobically at 37°C for 24-36 h. Following biofilm formation and removal of

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non-adherent cells by washing the biofilm twice with BHIG, each antimicrobial was diluted

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twofold separately with BHIG broth into two 96 deep well microplates. From each dilution of

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antimicrobial B, 125 μl was added horizontally over 125 μl of antimicrobial A (see Fig. 1 of

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(21)). From each combination, 200 μl samples were added to the biofilm in sequence, and the

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microplate was incubated for 24 h at 37°C under anaerobic conditions. The spot plate method

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was utilized for counting the number of CFU/ml and in evaluating the bactericidal activity

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(MBC-B) of each antimicrobial combination against biofilm-associated G. vaginalis ATCC

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14018. Isobolograms were used to analyze the nature of antimicrobial interaction, which is

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classified as synergistic, antagonistic or additive activity against the planktonic and biofilm cells.

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Checkerboard assay, data analysis

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Isobolograms were used to compare the MIC and MBC-B values of each antimicrobial alone

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with its MIC and MBC-B values in combination with other antimicrobials. The point on the axis

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(X) refers to MIC or MBC-B values of the first antimicrobial with the coordinates (0, x), and the

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point on the axis (Y) represents the MIC or MBC-B values of the second antimicrobial with the

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coordinates (y, 0) when they are used alone. The two MIC or MBCs-B values are connected by a

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dashed line (228). The MICs or MBCs-B of each antimicrobial combination are plotted as dots

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on the graph. Results are expressed according to the locations of these dots from the line that

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connects MICs or MBCs-B of the first and second antimicrobials. When the MIC or MBC-B

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values are located under the line, the combination of the two antimicrobials are synergized, but

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when these dots of interaction are above the line, the combination of the two antimicrobials

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antagonized against the tested microorganism. An additive effect is observed when these dots are

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located on the line.

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Scanning electron microscopy (SEM)

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SEM was used to visualize the anti-biofilm activity of the AMP mimics. As in the biofilm

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formation assay, G. vaginalis ATCC 14018 cells were diluted to 107 CFU/ml before 2 ml was

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transferred to each well of a 6-well tissue culture plate (Falcon, BD, Franklin Lakes, NJ, USA),

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which was then incubated for 24 h at 37°C with a glass slide in each well (12mm, Fisher

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Scientific, Waltham, MA). After incubation, the biofilms that formed on the glass slides were

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washed twice with fresh BHIG to remove the non-adherent bacteria. Then, antimicrobial(s) in

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BHIG were added, and the plate was incubated again for 24 h. Each well was washed twice with

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BHIG and fixed with 2.5% glutaraldehyde at room temperature for 1 h. The biofilms were

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dehydrated with a graded series of ethanol solutions (50%, 70%, 80%, 95% and 100%) followed

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by drying with graded hexamethyldisilazane (50%, 100%) in ethanol. Before being mounted on

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stubs and sputter-coated with 20 nm gold, the samples were further air-dried for an additional 2

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days. SEM images were taken with a Zeiss Sigma Field Emission SEM (Carl Zeiss, Ontario, CA)

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at 5 kV.

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Statistical analysis

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Each experiment was repeated at least three times, in duplicate. The error bars in the provided

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figures represent the standard deviation of each experiment's data. All calculations were

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performed in Microsoft Excel and then the statistical analysis was re-shaped with SigmaPlot 11.0

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(Systat Software Inc., Chicago, IL, USA). The Student's t-test (P ≤ 0.01 and P ≤ 0.05) was also

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calculated using SigmaPlot 11.0.

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RESULTS

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CAms effectively inhibit planktonic cells of BV-associated pathogens but not lactobacilli

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The antimicrobial potential of CAms against planktonic G. vaginalis ATCC 14018 was

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determined and compared to their activity against healthy vaginal lactobacilli. The results

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illustrated that G10 compounds were more active as compared to G8 compounds (Table 1). The

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MICs of CAms against G. vaginalis ATCC 14018 were lower than their MICs against two

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lactobacilli with significant differences (p < 0.05) for G10 compounds. However, no significant

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difference was detected between the susceptibility of G. vaginalis ATCC 14018 and L. gasseri

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ATCC 33323/L. crispatus ATCC 33197 for both compounds (Table 1).

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Since G. vaginalis ATCC 14018 is not the sole bacterial cause of BV, CAms were

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evaluated against the other most commonly isolated BV-associated pathogens: M. curtisii ATCC

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35241, Pep. Anaerobius ATCC 27337, and P. bivia ATCC 29303. Pep. Anaerobius ATCC

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27337 was more susceptible to CAms as compared to M. curtisii ATCC 35241 and P. bivia

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ATCC 29303 and again, G10 ether and G10 ester were more active against selected pathogens

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than G8 compounds (Table 1). The results showed that the MICs of G10 CAms against the three

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tested pathogens were significantly lower than their MICs against L. plantarum ATCC 39268

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and L. rhamnosus 160 (P < 0.01), while no significant differences were identified when G8

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compounds were used against the pathogens.

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MICs and sub-MICs of CAms inhibit G. vaginalis ATCC 14018 biofilm formation

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The anti-biofilm activity of the CAms was evaluated in vitro against BV-associated G. vaginalis

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ATCC 14018 using 96-well tissue culture microplates (Fig. 2). The MIC-B values of G8 ether

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(Fig. 2A) and G10 ether (Fig. 2B) were within their MIC ranges: 3.6 µM of G8 ether was

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required to inhibit >90% of biofilm formation, 1.6 µM of G10 ether and 3.2 µM of G10 ester

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prevented >50% of biofilm formation compared to the untreated control. G8 ester showed 50%

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biofilm inhibition when the sub-MIC concentration of 7.2 µM was used. Interestingly, MIC-B50

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and MIC-B90 of the CAms did not influence the growth of biofilm associated bacterial cells.

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Lactobacilli biofilms are tolerant to CAm concentrations that are bactericidal for G.

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vaginalis ATCC 14018 biofilms

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Despite being less active against planktonic G. vaginalis ATTC 14018 cells, G8 compounds

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were more active than G10 compounds when tested against pre-formed biofilms (Fig. 3).

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Specifically, G10 ether and G10 ester have an MBC-B of 425.6 µM against G. vaginalis ATCC

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14018 (Fig. 3B). At the same time, only 58.8 µM of G8 ether and 117.6 µM of G8 ester were

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sufficient to produce >3 log reduction in the number of biofilm-associated G. vaginalis ATCC

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14018 (Fig. 3A). The CAms’ effectiveness against biofilms of the studied Lactobacillus species

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was evaluated and compared to the bactericidal activity against G. vaginalis ATCC 14018

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biofilm. Data showed that the MBC-Bs of CAms against the G. vaginalis ATCC 14018 biofilm

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were less than their MBC-Bs against all of the tested Lactobacillus species with significant

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differences (P < 0.01, Table 2).

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CAms synergized with metronidazole against planktonic cells and biofilms of G. vaginalis

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ATCC 14018

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According to our results (Fig. 4 and 5), the CAms synergized with metronidazole against both

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planktonic cells and biofilms of G. vaginalis ATCC 14018. Metronidazole inhibited the growth

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of planktonic cells of G. vaginalis ATCC 14018 at an MIC of 37.4 μM, which was much lower

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than the concentration that inhibited the growth of vaginal lactobacilli (>1168.5 μM). The MIC

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of G8 ether, in combination with metronidazole, decreased more than fivefold compared to when

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it was used alone (0.45 μM in combination vs. 2.5 μM alone). Regarding biofilm inhibition, the

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MBC-B of G8 ether, in combination with metronidazole, decreased more than threefold

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compared to when it was used alone (11.1 μM in combination vs. 40.4 μM alone). Overall, when

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used in combination with the tested CAms, metronidazole’s MIC against planktonic cells was

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more than sevenfold lower, and its MIC-B against G. vaginalis ATCC 14018 was about threefold

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lower than the corresponding values for metronidazole alone (4.7 µM and 11.1 µM in

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combination instead of 37.4 µM and 40.4 µM for planktonic cells and biofilms, respectively).

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The MIC of G8 ester in combination with metronidazole decreased more than sevenfold from

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when it was used alone (3.4 μM in combination vs. 24.4 μM alone). For G. vaginalis ATCC

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14018 biofilms, the MBC-B of G8 ester in combination with metronidazole decreased more than

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threefold from when it was used alone (26.9 μM in combination vs. 92.7 μM alone). When G10

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compounds were used in combination with metronidazole, the MIC of G10 decreased more than

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fivefold from when it was used alone (0.2 μM in combination vs. 1.1 μM alone). In the same

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regards, the MBC-B of G10 ether, in combination with metronidazole, decreased more than 13-

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fold from when it was used alone (25.7 μM and 7 μM in combination vs. 340 μM alone).

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Furthermore, the MIC of G10 ester in combination with metronidazole decreased 50-fold from

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when it was used alone (0.2 μM in combination vs. 10 μM alone). Lastly, for G. vaginalis ATCC

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14018 biofilms, the MBC-B of G10 ester, in combination with metronidazole, decreased more

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than tenfold from when it was used alone (6.3 μM in combination vs. 67.7 μM alone).

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Mechanism of CAms action against G. vaginalis ATCC 14018 biofilms

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To confirm that CAms act as membrane-targeting compounds, biofilm-associated G. vaginalis

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ATCC 14018 was treated with G8 antimicrobial alone at its MBC-B, and in combination with

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metronidazole. Scanning electron microscopy (SEM) showed considerable morphological and

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ultrastructural changes in treated biofilm cells as compared to untreated cells (Figure 6). Prior to 14

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treatment with CAms, G. vaginalis ATCC 14018 cells within the biofilm showed a coccobacilli

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shape and smooth surfaces (Fig. 6A). On the contrary, open holes, deep craters, severe

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membrane deformation, and cellular debris were noticed within the G8 ether treated sample,

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indicating strong evidence of membrane disruption and damage (Fig. 6B), with fragmentation

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also observed in the polar regions of the biofilm cells. In addition, degradation and deformation

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of biofilm exopolysaccharide (EPS) structures was observed. A combination of G8 ether and

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metronidazole was also used against a biofilm of G. vaginalis ATCC 14018 (Fig. 6C); greater

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killing activity, in addition to EPS reduction, was observed, indicating the importance of

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antimicrobial combinations for the successful eradication of a biofilm and its biomass.

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DISCUSSION Traditional antibiotics are falling short when it comes to effectively treating bacterial

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infections. Biofilm-associated infections have become increasingly resistant to antibiotics, often

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resulting in recurrence that can lead to severe health consequences. Thus, there is an urgent need

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for alternative medications and treatment strategies. Bacterial vaginosis is one such infection that

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is often resistant to conventional antibiotics, primarily clindamycin and more rarely,

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metronidazole (16). The infection arises from a decrease in commensal lactobacilli and an

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increase in anaerobic pathogenic species, predominantly G. vaginalis, which is often the main

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causative agent of BV (12). Recurrence of bacterial vaginosis is common within three to twelve

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months, often due to failure of treatment with conventional antibiotics and therefore failed

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eradication and/or re-growth of pathogenic bacteria (16). In this study, we utilized cationic

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amphiphilic molecules (CAms) to control biofilm formation of BV-associated G. vaginalis

15

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302

ATCC 14018. As bacterial vaginosis is a polymicrobial infection, CAms were evaluated against

326

the most frequently isolated BV anaerobes including M. curtisii ATCC 35241, P. bivia ATCC

327

29303, and Pep. anaerobious ATCC 27337. The CAms were also evaluated against

328

Lactobacillus species to observe the possible effect of CAms on the commensal bacteria, which

329

are responsible for the stability and health of the vaginal microbiota (29).

330

Biofilm-associated BV is characterized by the overgrowth of opportunistic, pathogenic

331

bacteria, such as G. vaginalis, P. bivia, Pep. Anaerobius, and M. curtisii; all four pathogens have

332

shown increasing resistance to conventional antibiotics (30). When evaluated against planktonic

333

cells of the pathogens, the most effective CAms were the ether compounds, particularly G10

334

ether. As shown in Table 1, G10 ether had the lowest MIC out of the evaluated CAms against

335

each pathogen. When evaluated for biofilm inhibition of G. vaginalis ATCC 14018, G10 ether at

336

1.6 µM was quite effective (Fig. 2B), as was G8 ether at 3.6 µM (Fig. 2A). Overall, it was

337

observed that Pep. Anaerobius ATCC 27337 was the most sensitive out of the tested BV-

338

associated pathogens, and P. bivia ATCC 29303 and M. curtisii ATCC 35241 were more

339

resistant to the highest concentrations of each CAm (Table 1). The CAms used in this study (Fig.

340

1) consisted of hydrophilic head groups and non-polar domains on opposite ends of the

341

amphiphile’s backbone, resulting in a facially amphiphilic conformation (22). The CAms’ mode

342

of action against the persistent pathogens, by insertion and disruption of the cytoplasmic

343

membrane, makes them efficient as antibacterial agents (31). CAms have been found to be more

344

effective against Gram-positive bacteria, in contrast to Gram-negative organisms (22). Compared

345

to G. vaginalis ATCC 14018 and Pep. Anaerobius ATCC 27337, the higher MIC values of P.

346

bivia ATCC 29303 and M. curtisii ATCC 35241 can be attributed to the existence of an

347

additional lipopolysaccharide (LPS) layer in the Gram-negative organisms; the extra LPS layer 16

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325

forms a hydrophilic barrier, preventing the hydrophobic CAms from docking on the cytoplasmic

349

membrane (22). Resistance of M. curtisii to antibiotics, such as metronidazole and clindamycin

350

was reported in some studies (32,33). It was suggested that 67.9% of BV recurrence is due to M.

351

curtisii, which is frequently isolated from recurrent infections after initial treatment. M. curtisii,

352

P. bivia and Pep. Anaerobius co-exist with G. vaginalis to form a thick and adherent

353

multispecies biofilm, as reported recently (23, 24, 34, 35). G. vaginalis is often classified as a

354

Gram-variable bacterium, meaning it exhibits characteristics of both Gram-positive and Gram-

355

negative bacteria. The thickness of its peptidoglycan layer varies depending on which phase the

356

cell is at. G. vaginalis’s cell wall exhibits Gram-positive characteristics in its early exponential

357

phase, but as its life cycle advances, the peptidoglycan layer decreases in thickness and, the cell

358

stains as Gram-negative. Overall, cationic amphiphiles have shown to be quite effective against

359

anaerobes: in Sovadinova et al. (36), AMP mimetic amphiphilic polymethacrylate derivatives

360

were evaluated against the anaerobe Propionibacterium acnes and found to be highly effective in

361

eradicating the bacterium. In Algburi et al. (23), the natural antimicrobials subtilosin and

362

lauramide arginine ethyl ester (LAE) were evaluated against G. vaginalis ATCC 14018 as well.

363

The cationic LAE altered the permeability of the cytoplasmic membrane and was shown to

364

further enhance the antibiotic susceptibility of the bacterial cells, as did subtilosin A without

365

bactericidal effects on the healthy vaginal lactobacilli (23).

366

Lactobacilli are crucial to the stability and health of the vaginal microenvironment; they

367

play a pivotal role in controlling the pH, which allows for inhibition of overgrowth of

368

opportunistic pathogenic bacteria (34). Most studies that evaluate an antimicrobial agent against

369

pathogenic bacteria often neglect the effect of the agent on the protective microbiota. The CAms

370

used in this study were evaluated against four species of Lactobacillus: L. rhamnosus 160, L. 17

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348

plantarum ATCC 39268, L. gasseri ATCC 33323, and L. crispatus ATCC 33197 The most

372

effective CAm on G. vaginalis ATCC 14018, G10 ether, had much less effect on the

373

Lactobacillus species, L. plantarum ATCC 39268 and L. rhamnosus 160 especially. Overall, it

374

was observed that the MIC values of CAms for each species of Lactobacillus were significantly

375

greater than those of G. vaginalis ATCC 14018, leading us to propose that the CAms could be

376

selectively targeting pathogens while having little or no effect on the protective microbiota.

377

Most often, persistent infections arise from bacterial biofilms rather than solely

378

planktonic cells (37). Biofilms consist of a multitude of microbial cells that are associated with a

379

surface and enclosed in a matrix consisting of extracellular polymeric substances (EPS), which

380

often contributes to the antimicrobial-resistance properties of biofilms (38). Quorum sensing has

381

been attributed as being the main line of communication between microbial cells in a

382

community, allowing for the construction and/or dissolution of a biofilm (39). It has been

383

demonstrated that prevention of biofilm formation is more effective than treatment of a biofilm,

384

which includes the prevention of bacterial attachment and/or communication, or changing the

385

attached-surface properties, as demonstrated by Shah et al. (40). Preventing biofilm formation

386

can help lower the required antimicrobial concentration due to the easier targeting of planktonic

387

cells. In our study, we observed that biofilms of G. vaginalis ATCC 14018 were inhibited at the

388

sub-MIC concentrations of CAms without influencing bacterial growth (Figure 2A and B). One

389

possible explanation for this occurrence can be the interruption of quorum sensing by the CAms.

390

Fuente-Núñex et al. reported that the small synthetic cationic peptide 1037 significantly affected

391

the swarming motility (dependent on flagellin and quorum sensing) of bacterial cells and

392

inhibited biofilm formation (41). We tested the sub-MIC of the four most promising CAms for

393

their ability to inhibit quorum sensing. The Fe(III) reduction assay was utilized to evaluate all 18

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371

four compounds as quorum sensing inhibitors in Gram-positive bacteria. In Gram-negative

395

bacteria, The CAms were evaluated as quorum sensing inhibitors using Chromobacterium

396

violaceum as a microbial reporter (42). As a result of these experiments, no quorum sensing

397

inhibition was observed in either Gram-positive or Gram-negative bacteria by any of the four

398

compounds. Consequently, we speculate that there are different mechanisms involved in the

399

interactions of these compounds with bacterial cells.

400

Another possible explanation can be that CAms at sub-MIC concentrations coated the

401

attachment surface, preventing the bacterial cells from gathering on the surface, thereby

402

interfering with biofilm formation. Segev-Zarko et al. (43) demonstrated AMPs’ ability to reduce

403

bacterial adhesion to surfaces and inhibit biofilm formation, due to the AMPs’ capability of

404

coating either the surface of a biomaterial or the bacterium itself. The findings of Beckloff et al.

405

(44) seem to conflict with this observation. The AMP mimetic used in their study, meta-

406

phenylene ethynylene (mPE), required a very high concentration, nearly forty times the strength

407

of the concentration needed to eradicate a biofilm of Staphylococcus aureus, to inhibit the

408

biofilm.

409

Overall, the MIC-B of CAms against G. vaginalis ATCC 14018 were lower than the MIC

410

values against the tested Lactobacillus species, reinforcing the observation that the CAms seem

411

to be selectively targeting the pathogenic cells rather than the microorganisms of the healthy

412

commensal microbiota.

413

Biofilm bactericidal activity of CAms was evaluated against pre-formed biofilms of G.

414

vaginalis as well as Lactobacillus species. Unlike their activity against planktonic cells, G8

415

compounds were more effective against pre-formed biofilms of G. vaginalis ATCC 14018 and

19

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394

Lactobacillus strains compared to G10 compounds. In addition, the highly hydrophobic

417

compounds may aggregate within the biofilm matrix, delaying the delivery of antimicrobial to

418

the biofilm-associated cells.

419

All of the Lactobacillus biofilms were significantly more tolerant to CAms as compared

420

to the pathogenic biofilm of G. vaginalis ATCC 14018. It is important for the health of the

421

vaginal microbiota that lactobacilli biofilms are kept intact and are tolerant to antimicrobials.

422

Lactobacillus species ferment glycogen secreted by vaginal epithelial cells into lactic acid, which

423

controls the microenvironment of the vagina by maintaining a low pH and preventing the

424

overgrowth of pathogens (45). Biofilm formation by protective bacteria, such as lactobacilli,

425

enhances their beneficial properties and promotes their antimicrobial potential. Jones and

426

Versalovic (46) reported a promotion in cytokine and antimicrobial production by L. reuteri

427

growing in a biofilm. Moreover, the biofilm of L. reuteri may possibly eradicate and re-occupy

428

the biofilm of G. vaginalis (29), controlling pathogenic infection. Therefore, it is a crucial

429

observation that the CAms had very little, if any, bactericidal effect on the Lactobacillus

430

biofilms.

431

Metronidazole was used in this study because it is frequently prescribed by OB/GYN

432

(obstetrics/gynecology) doctors for the treatment of BV (10, 47). The synergistic activity of

433

metronidazole, when combined with natural antimicrobials, enhanced its antimicrobial potential

434

(23). In this study, the synergistic interactions between metronidazole and CAms against G.

435

vaginalis ATTC 14018, planktonic and biofilm cells, were investigated using isobolograms: all

436

CAms synergized with metronidazole against G. vaginalis ATCC 14018. Compared to other

437

combinations, G10 ester more effectively synergized with metronidazole than did G8, reducing

438

the required concentrations of each of the combined antimicrobials to kill planktonic and biofilm 20

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416

associated cells. Synergism of two or more antimicrobials can improve the efficacy of each

440

antimicrobial while lowering the risk of antimicrobial resistance, especially if the antimicrobials

441

each have different modes of action (48). Using natural or novel antimicrobials either alone or in

442

combination with conventional antibiotics does not carry the same consequences that come with

443

the use of conventional antibiotics, such as metronidazole, alone (23). The National Institutes of

444

Health has outlined a new approach in combating antibiotic resistance by combining

445

conventional antibiotics with complementary methods, i.e., natural-derived antimicrobials. (49).

446

As shown in the resulting isobolograms, metronidazole synergized with each of the CAms

447

against G. vaginalis ATCC 14018; G10 compounds were most strongly synergized with

448

metronidazole. The higher the CAm concentration, the lower the metronidazole concentration

449

needed for effective inhibition of G. vaginalis ATCC 14018.

450

The SEM data in this study, together with the findings of Zhang et al. (22), suggest that

451

the antimicrobial action of CAms is associated with the disruption of cellular membrane

452

permeability, ultimately reducing the opportunity for bacterial resistance to develop. These

453

promising results could potentially lead to a decrease in conventional antibiotic use when

454

treating bacterial vaginosis, thereby decreasing the risk for antibiotic-resistant infections.

455

CONCLUSION

456

Antibiotic resistance of persistent infections is an important challenge which requires significant

457

attention towards finding alternative antimicrobial treatments. Here, we reported on synthetic

458

cationic amphiphiles (CAms) and their antimicrobial and anti-biofilm activity against BV-

459

associated pathogens. The structure of CAms can be modified in several different ways and their

460

biocidal potential improved to counteract resistance to antibiotics. CAms have effectively

21

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439

prevented and eradicated biofilms of G. vaginalis with small concentrations at µM ranges

462

without any harmful effects on the protective vaginal microbiota. In addition, CAms have shown

463

synergistic activity with metronidazole against planktonic cells and biofilms of G. vaginalis

464

ATTC 14018. Taken altogether, CAms are promising new generation of antimicrobials with the

465

potential to transform modern therapeutic strategies for treating bacterial vaginosis.

466

Funding Information

467

The authors gratefully acknowledge NIH (R21 AI126053) for financial support.

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461

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TABLE 1: MICs of CAms (µM) with varying linker type (ether/ester), and hydrophobic arm length (n = 8,10) against G. vaginalis in comparison to healthy Lactobacillus species. G8 ester

G. vaginalis

2.5±0.98

18.5±7.9

L. rhamnosus L. plantarum L. gasseri L. crispatus P. bivia M. curtisii Pep. anaerobius

38.5±17.6 118±34.1 9.7±4.3 7±0.0 28.4 28.4 3.6

94.03±32.1 185+64.4 46.2±16.6 55.8±0.0 111.6 93.1 13.9

P value G. vaginalis vs lactobacilli P > 0.05 P ≤ 0.05 P > 0.05 P > 0.05

G10 ether

G10 ester

0.83±0.0

2.3±0.91

17.6±7.7 34.8±15.9 4.4±1.9 6.3±0 6.6 5.4 1.6

12.7±0.0 33.9±14.6 12.7±0.0 0.05 P > 0.05

616 617 618 619 620

TABLE 2: Minimum biofilm bactericidal concentrations (MBC-B) of CAms (µM) against G. vaginalis in comparison to healthy Lactobacillus species. Microorganisms

G. vaginalis L. rhamnosus L. plantarum L. gasseri L. crispatus

G8 ether

G8 ester

G10 ether

G10 ester

58.8 940 940 940 940

117.6 >890 >890 >890 >890

425.6 >850 >850 >850 >850

425.6 >810 >810 810 810

621 622

30

P value G. vaginalis vs lactobacilli P < 0.01 P < 0.01 P < 0.01 P < 0.01

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G8 Ether

Microorganisms

623

625 626

FIGURE 1: Structures of the tested CAms showing differences in liker type (ether/ester) and hydrophobic arm length (n = 8,10).

31

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624

627

FIG 2A

12

10

0.4

OD595

6 0.2 4 0.1

2

0.0

0 0

628

0.45

0.9

1.8

3.6

7.2

G8 CAm Concentration (µM)(M) Antimicrobial concentration

629 630 631 632 633 634 635 636 637 638 639 32

14.4

28.8

Log10 CFU/ml

8 0.3

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0.5

640

FIG 2B

OD595

0.20

6

0.15 4

Log10 CFU/ml

8

0.25

0.10 2 0.05

0.00

0 0

641 642 643 644 645

0.2

0.4

0.8

1.6

3.2

6.4

13.2

G10 CAm Concentration (µM) Antimicrobial concentration (M)

FIGURE 2: Minimum biofilm inhibitory concentration (MIC-B) of (A) G8 compounds and (B) G10 compounds (µM) against G. vaginalis biofilm. Biofilm formation ( █ ) and bacterial growth (●) after treatment with G8/G10 ether. Biofilm formation ( █ ) and bacterial growth (○) after treatment with G8/G10 ester.

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0.30

646

FIG 3A

Log10 CFU/ml

8

6

4

2

0 0

647

14.7

29.4

58.8

Antimicrobial concentration G8 CAm Concentration (µM) (M)

648 649 650

34

117.6

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10

651

FIG 3B

652

10

Log10 CFU/ml

8

6

4

2

0 0

53.2

106.4

212.8

425.6

Antimicrobial concentration G10 CAm Concentration (µM)(M)

653 654 655 656 657

FIGURE 3: Minimum biofilm bactericidal concentration (MBC-B) of (A) G8 compounds and (B) G10 compounds (µM) against preformed biofilm of G. vaginalis. Log10 CFU/ml of biofilm cells ( █ ) after treatment with G8/G10 ether. Log10 CFU/ml of biofilm cells ( █ ) after treatment with G8/G10 ester.

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12

658

FIG 4

2.5

25

G8 ester concentration (M)

G8 ether concentration (M

B 30

2.0

1.5

1.0

20

15

10

0.5

5

0.0

0 0

10

20

30

40

0

10

Metronidazole concentration (M Metronidazole vs G8ether Col 4 vs Col 5 12

1.0

10

0.8

0.6

0.4

40

8

6

4

2

0.2

0

0.0 0

10

20

30

0

40

10

20

30

40

Metronidazole concentration (M)

Metronidazole concentration (M)

659 660 661

30

D

1.2

G10 ester concentration (M)

G10 ether concentration (M)

C

20

Metronidazole concentration (M)

FIGURE 4: Isobolograms of metronidazole with CAms against planktonic cells of G. vaginalis. Combination of metronidazole with: (A) G8 ether, (B) G8 ester, (C) G10 ether and (D) G10 ester.

662

36

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A 3.0

663

FIG 5 B 100

G8 ester concentration (M)

G8 ether concentration (M)

50

40

30

20

10

0

80

60

40

20

0

0

10

20

30

40

50

0

10

Metronidazole concentration (M)

40

50

80

G10 ester concentration (M)

G10 ether concentration (M)

30

D

C 400

300

200

100

0

60

40

20

0 0

10

20

30

40

50

0

Metronidazole concentration (M)

664 665 666

20

Metronidazole concentration (M)

10

20

30

40

Metronidazole concentration (M)

FIGURE 5: Isobolograms of metronidazole with CAms against biofilm cells of G. vaginalis. Combination of metronidazole with: (A) G8 ether, (B) G8 ester, (C) G10 ether, and (D) G10 ester.

37

50

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A 60

FIG 6A 667

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668

669

670

671

672

673

674

675

676

677

678

679

38

FIG 6B 680

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681

682

683

684

685

686

687

688

689

690

39

691

FIG 6C

693 694 695

FIGURE 6: Scanning electron microscopy (SEM) images. (A) CAms-untreated G. vaginalis biofilm, (B) G. vaginalis biofilm treated with 58.8 µM of G8 ether, (C) G. vaginalis biofilm treated with a combination of 29.4 µM of G8 ether and 40.4 µM of metronidazole.

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692

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