Contact-free inactivation of Candida albicans biofilms by cold atmospheric air plasma.
ABSTRACT Candida albicans is one of the main species able to form a biofilm on almost any surface, causing both skin and superficial mucosal infections. The worldwide increase in antifungal resistance has led to a decrease in the efficacy of standard therapies, prolonging treatment time and increasing health care costs. Therefore, the aim of this work was to demonstrate the applicability of atmospheric plasma at room temperature for inactivating C. albicans growing in biofilms without thermally damaging heat-sensitive materials. This so-called cold atmospheric plasma is produced by applying high voltage to accelerate electrons, which ionize the surrounding air, leading to the production of charged particles, reactive species, and photons. A newly developed plasma device was used, which exhibits a large plasma-generating surface area of 9 by 13 cm (117 cm(2)). Different time points were selected to achieve an optimum inactivation efficacy range of ≥3 log(10) to 5 log(10) reduction in CFU per milliliter, and the results were compared with those of 70% ethanol. The results obtained show that contact-free antifungal inactivation of Candida biofilms by cold atmospheric plasma is a promising tool for disinfection of surfaces (and items) in both health care settings and the food industry, where ethanol disinfection should be avoided.
Article: Biofilm formation by the fungal pathogen Candida albicans: development, architecture, and drug resistance.[show abstract] [hide abstract]
ABSTRACT: Biofilms are a protected niche for microorganisms, where they are safe from antibiotic treatment and can create a source of persistent infection. Using two clinically relevant Candida albicans biofilm models formed on bioprosthetic materials, we demonstrated that biofilm formation proceeds through three distinct developmental phases. These growth phases transform adherent blastospores to well-defined cellular communities encased in a polysaccharide matrix. Fluorescence and confocal scanning laser microscopy revealed that C. albicans biofilms have a highly heterogeneous architecture composed of cellular and noncellular elements. In both models, antifungal resistance of biofilm-grown cells increased in conjunction with biofilm formation. The expression of agglutinin-like (ALS) genes, which encode a family of proteins implicated in adhesion to host surfaces, was differentially regulated between planktonic and biofilm-grown cells. The ability of C. albicans to form biofilms contrasts sharply with that of Saccharomyces cerevisiae, which adhered to bioprosthetic surfaces but failed to form a mature biofilm. The studies described here form the basis for investigations into the molecular mechanisms of Candida biofilm biology and antifungal resistance and provide the means to design novel therapies for biofilm-based infections.Journal of Bacteriology 10/2001; 183(18):5385-94. · 3.83 Impact Factor
Contact-free inactivation of Candida albicans biofilm by Cold-Atmospheric Air
Tim Maisch*1, Tetsuji Shimizu2, Georg Isbary3, Julia Heinlin1, Sigrid Karrer1, Tobias
G. Klämpfl², Yang-Fang Li2, Gregor Morfill2 and Julia L. Zimmermann2
1 Department of Dermatology, Regensburg University Hospital, Germany
2 Max Planck Institute for Extraterrestrial Physics, Garching, Germany
3 Department of Dermatology, Allergology, and Environmental Medicine, Hospital
Running title: Candida biofilm inactivation by plasma
Candida albicans, disinfection, cold atmospheric plasma
* Correspondent footnote:
Tim Maisch, Ph.D.
Department of Dermatology, Regensburg University Hospital
Copyright © 2012, American Society for Microbiology. All Rights Reserved.
Appl. Environ. Microbiol. doi:10.1128/AEM.07235-11
AEM Accepts, published online ahead of print on 30 March 2012
Candida albicans is one of the main species which is able to form a biofilm on almost
every surface, causing both skin and superficial mucosal infections. Worldwide
increase of antifungal resistance led to a decrease in the efficacy of standard
therapies, prolonging treatment time and increasing healthcare costs. Therefore the
aim of this work is to demonstrate the applicability of atmospheric plasma at room
temperature for inactivating biofilm growing Candida albicans without thermally
damaging heat-sensitive materials. This so-called cold atmospheric plasma is
produced by applying high voltage to accelerate electrons which ionize the
surrounding air - leading to the production of charged particles, reactive species and
A newly developed plasma device was used, which exhibits a large plasma
generating surface area of 9 x 13 cm2 (117 cm2). Different time points were selected
to achieve an optimum inactivation efficacy range of ≥ 3log10 to 5log10 reduction of
CFU/ml and compared with 70% ethanol.
The obtained results show that contact-free antifungal inactivation of Candida
biofilms by cold atmospheric plasma is a promising tool for disinfection of surfaces
(and items) in both health care settings and foodstuff industry where ethanol
disinfection should be avoided.
Candida albicans is one of the main fungal species which has the ability to grow as a
biofilm on almost all surfaces, such as medical devices as well as human epithelial
surfaces (31, 32). In the last decade, biofilm growing Candida showed increased
levels of resistance to a wide spectrum of conventional antifungal drugs used in
clinical practice, such as amphotericin B and fluconazole (15). Chandra and
colleagues demonstrated that C. albicans biofilms can be up to 20-times more
resistant to amphotericin B and more than 100-times more resistant to fluconazole
compared with their planktonic counterparts (4, 5). Environmental contamination by
microbes which originate in dust and soil is a major problem where the maintenance
of high level hygiene is indispensable such as in clinics or in foodstuff facilities.
Several studies demonstrated that conventional methods to inactivate free-floating
microorganisms through antimicrobial agents or disinfection solutions are often less
effective against pathogens within a biofilm (6, 9, 13). Furthermore Vazquez et al.
demonstrated the possibility of exogenous nosocomial colonisation of Candida,
including the possible acquisition from the hospital environment (33). Transmission
may be by indirect contact since identical strains of Candida were recovered from
patients who were not in direct contact but temporally associated via a transmission
route of indirect contact between the patients. Adherence of Candida species to host
tissues and non-biological materials is not a problem (28). Mucosal cells, fibrin-
platelet matrices, vascular endothelial cells or plastic materials can be colonized by
Candida. Radford et al. showed that rough surfaces on e.g. denture-base materials
promote the adhesion of Candida albicans (26).
Therefore research efforts have led to the development of new antimicrobial
strategies, especially for killing of biofilm growing microorganisms (10, 11, 16).
Another new approach in combating biofilm growing organisms is cold atmospheric
plasma which has demonstrated its bactericidal, virucidal and fungicidal properties
due to the generation of reactive species, charged molecules and photons (20, 29,
34). Numerous studies so far have demonstrated the effectiveness of gas-discharges
or cold atmospheric plasmas in killing planktonic microorganisms only (14, 17, 18,
29). The killing efficacies were dependent on the plasma exposure-time (10 sec up to
10 min), the material the microorganisms were located on and the cell density. Only
recently the bactericidal effect of a non-thermal argon plasma was shown in vitro and
also in biofilms (8). Furthermore Koban et al. showed inactivation of Candida biofilm
using different plasma devices (19). An atmospheric plasma jet pen showed only
minimal antifungal effects on Candida biofilms, whereas an argon dielectric barrier
discharge plasma device showed a reduction of CFU/ml of up to 5 log10. The
disadvantage of these dielectric barrier discharge plasmas is the fact that the surface
of the growing Candida biofilm acts as the counter electrode for the plasma
generation. This means that the electric current flows through the biofilm, which
increases the electric field strength of the plasma, which in turn increases the
bacteria killing efficacy of the biofilm. This is critical for in vivo applications. In the
study presented here we used the Surface Micro-Discharge (SMD) plasma
technology to generate plasma in ambient air (25) to inactivate Candida albicans
biofilm via a contact-free disinfection procedure. The plasma is produced indirectly
and transported to the biofilm on the surface via diffusion. The surface does not serve
as a counter electrode and complications with electric currents are avoided and
"safe" applications in vivo are possible. The SMD plasma device operates at
approximately room temperature and produces so-called electrical micro-discharges.
This plasma discharge is generated by applying high voltage to accelerate electrons
to ionize the surrounding air molecules. Due to the high electric field (voltage), the
electrons have high energies and therefore do not only produce ions but also
chemically reactive atoms/molecules (O3, OH, O, NO, etc.). In addition to these
particles, light - including UV - is emitted.
Our study on contact-free inactivation of Candida albicans biofilm with cold
atmospheric pressure plasma indicates efficient disinfection of inanimate surfaces
where liquid disinfectants fail, because protection of corrosive material is mandatory.
Materials and Methods
SMD Plasma Device
The SMD (Surface Micro-Discharge) plasma device is incorporated in a box made
out of plastic (Teflon and polyoxymethylene). The electrode for producing the plasma
is located inside the box which is shown in figure 1. On one side of the box a door is
installed so that the produced plasma gas is confined inside (Fig. 1). The plasma
device is designed for the efficient treatment of a 96-well plate – therefore, the
maximum area to treat is large and equals 9 x 13 cm2. The electrode, which
produces the plasma, is located above the respective samples to treat and the
distance between the electrode and the sample is adjustable. In this study, the
distance was set to approximately 6 mm. The electrode for plasma production
consists of a 0.5 mm thick Teflon plate sandwiched by a brass planar plate and a
stainless steel mesh grid (line width 2 mm, opening 10 mm, height 1.5 mm). By
applying a high sinusoidal voltage of 9 kVpp with a frequency of 1 kHz between the
brass plate and the mesh grid the plasma is produced homogenously in ambient air
by many micro-discharges (25). The plasma discharge is sustained through
ionization processes with electrons accelerated by applying the high voltage. These
electrons produce electron/ion pairs. In addition to these pairs, chemically reactive
species (O3, O, NO, etc.) are produced by approximately 600 chemical reactions
driven by the electrons (dissociation of molecules, recombination, etc.). Furthermore,
due to activated molecules/atoms, light emission can also be detected. The UV light
emitted by plasma is mainly observed from the N2 positive system between 280 and
420 nm in wavelength (see spectrum in fig. 2). Furthermore peaks in the UVC region
of the spectrum resulting from the NO γ system can be detected. The UV power
density measured with a power meter (HAMAMATSU UV-Power Meter C8026,
Japan) equalled 25 nW/cm2. This value is far below ICNIRP (International
Commission Non-Ionizing Radiation Protection) safety levels. The measurement of
ozone was performed by using an UV absorption spectroscopy, NO2 concentration
was measured using a gas detector (Dräger AG, Multiwarn II, Germany) (table 1).
The power consumption for the plasma discharge was approximately 0.02 W/cm2
measured with the Lissajous method using a 1 μF capacitance.
In order to obtain well isolated discrete colonies, Candida albicans were streaked on
a Sabouraud dextrose agar plate and cultured at 37°C. A single colony of Candida
albicans (ATCC-MYA-273) was picked up using a sterile inoculation loop and
suspended in 5 ml of Sabouraud dextrose broth (SDB) (Sigma Chemical Co., St.
Louis, Mo, USA). The suspension was cultured overnight at 37°C on a shaker
platform (200 rpm). When the cultures reached the stationary phase of growth, the
cells were harvested by centrifugation (1800 rcf, 5 min) and washed once with PBS
(Dulbecco's phosphate-buffered saline without Ca2+ and Mg2+, PAA Laboratories
The Candida cell density was determined using a microscope counting chamber. For
biofilm formation, C. albicans were diluted to 106 cells ml-1 in 25% of fetal bovine
serum (FBS) and 2.5 ml were added to sterile flat-bottomed 6-well polystyrene plates
for cell culture and incubated at 37°C for 24 h without shaking.
Cold atmospheric plasma treatment
In a first step a proof of concept study was adopted from Shimizu et al. (29).
Suspensions of free-floating Candida cells with a density of 2 x 106/ml were prepared
in PBS. 3 x 20 µl of serially diluted samples were dropped out on Sabouraud
dextrose agar plates and kept at RT under laminar flow for 30 min to dry the surface.
After treatment with plasma, the agar plates were incubated at 37°C for 24 h until
surviving Candida colonies were counted.
Second, 24 h after biofilm generation, the samples were washed twice with PBS to
remove free-floating Candida cells. The 6-well plates containing the biofilm were
placed inside the device and treated for different time intervals as follows: 0 min, 2, 5,
6, 7, 8, 9, 10 and 15 min. As controls, non plasma-treated samples were placed as
well in the SMD device for the respective time points.
Furthermore the disinfectant efficacy of 70% Ethanol was tested on the Candida
biofilm as recently published by Théraud et al. (30).
Quantification of inactivation efficacy
Post plasma treatment the biofilm was scraped out of the 6-well plate using a sterile
cell scraper (Sarstedt, Newtonk, NC, USA). Each sample was sonicated for 3 min in
an ultrasonic bath sonicator (Merck Eurolab, USR 30H, Germany) at a frequency of
35kHz to disrupt the biofilm, because the colony forming unit assay was used to
determine the survivors by the Miles and Misra technique for viable counts (24).
Serially diluted aliquots (20 µl) of treated and untreated samples were plated on
Sabouraud dextrose agar, and the number of CFU per millilitre was counted after 24
h of incubation at 37°C.
All results are shown as medians, including the 25% and 75% quartiles, which were
calculated from the values of at least three independent experiments. Each
experiment was conducted in triplicates (three wells of a 6-well-plate corresponding
to a biofilm area of 28.9 cm2), with Prism 4 for Windows (GraphPad Software Inc.,
San Diego, CA, U.S.A). The calculation (reduction of CFU/ml) was then compared
with the untreated controls (non plasma treated). In figures 3-4, medians on or below
the dotted horizontal line in red or green represent ≥ 99.9% efficacy or ≥ 99.999% of
Candida cell killing corresponding to at least more than three magnitudes or five
magnitudes of log10 reduction compared with the matching untreated controls (non
plasma treated). A reduction of at least three magnitudes of log10 of viable median
numbers of Candida cells was stated as biologically relevant with regard to the
guidelines of hand hygiene (3).
SMD Plasma device
A SMD plasma device was used for all experiments. During the experiments, the
door (as shown in figure 1) of the plasma device was closed, i.e. almost no gas
exchange was able to take place. Thermal effects on the Candida biofilm can be
ruled out in this study because the increase of the gas temperature during 10 min
application did not exceed 4°C (data not shown). As mentioned in Materials and
Methods the UV light emission was mainly observed from the N2 positive system
between 280 and 420 nm (Fig. 2). Furthermore, emission in the UVC region resulting
from the NO γ system was detected. Nevertheless the main content of the measured
UV radiation refers to the UV-A wavelength range between 320 to 400 nm. The UV
power density of the plasma equalled 25 nW/cm2. The main components produced
by the SMD plasma device are shown in table 1 which are relevant for biomedical
applications. The ozone concentration in the device (inside the box, door closed)
after 60 seconds of plasma production was approximately 500 ppm. The NO2
concentration was approximately 3 ppm.
Plasma rapidly kills planktonic Candida cells: A proof of concept
First the susceptibility of the SMD plasma device was determined by applying plasma
to planktonic Candida cells plated on Sabouraud Dextrose agar plates. The fungicidal
effect of plasma is shown in figure 3. A killing efficacy of 99.9% of viable Candida
cells was achieved upon a plasma treatment time of 40 sec. The reduction of viable
Candida cells was increased further up to 5 log10 steps when the plasma treatment
time was 5 min. No fungicidal effect was observed for the untreated controls.
Killing efficacy of Plasma against Candida biofilms
The Candida biofilms formed on inanimate surfaces were exposed to different
plasma treatment times (Fig. 4). A biofilm surface area of 28.9 cm2 was treated with
plasma corresponding to three single wells of a 6-well plate. The plasma application
of Candida biofilms resulted in a successful inactivation of Candida cells within the
biofilm, which increased with increasing treatment time (Fig. 4). After 7 min, more
than 99.9% of Candida cells were inactivated. 8 min results in a reduction of 6 log10
steps which corresponds to a killing efficacy of 99.9999%. Again no fungicidal effect
was observed for the untreated controls. Here we also want to mention, that the
inactivation efficacy also depends on the distance between the electrode and the
biofilm (data not shown). The tested distances ranged from 6 to 10 mm. All the
results in this study refer to the most effective distance of 6 mm. In a second set of
experiments, 70% ethanol was tested on biofilm inactivation. A reduction efficacy of
only 1.5 log10 , 2.8 log10 and >3 log10 was achieved within a treatment time of 5 min,
7min and 10 min, respectively (data not shown).
Candida growing as a biofilm produces a broad range of infections, ranging from non
life-threatening mucocutaneous illnesses to severe invasive diseases (4, 27). This
study demonstrates the efficacy of SMD plasma for killing biofilm growing C.
albicans. The results of this study clearly show, that cold atmospheric plasma
treatment is an attractive potential approach for Candida biofilm inactivation growing
on inanimate surfaces. A reduction of up to 99.9999% was achieved in a time-
dependent manner (8 min) without any direct contact to the biofilm. A biofilm surface
area of 28.9 cm2 was efficiently inactivated. This area is 72-times greater than the
biofilm surface area of a 96-well plate, which was used in other studies (19). The
possibility of removing large areas of biofilm in one step, without screening the
surface, clearly exhibits advantages for industrial applications. Koban et al. measured
a reduction factor of 5.2 log10 steps of a Candida biofilm grown in a 96-microtitre
plate upon 10 min plasma treatment using the dielectric barrier discharge (DBD)
plasma device (19). As already stated in the introduction, the great advantage of
SMD plasma compared to DBD is that there is no direct contact to the surface
necessary and no current passes through the plate and the biofilm.
The main species which contribute to the inactivation of the biofilm using SMD
plasma in ambient air are reactive species and charged particles. As indicated
earlier, the density of the charged particles which interact with the biofilm is low due
to excitation, dissociation, attachment and recombination processes on their way
from the electrode to the sample (25). Therefore the main impact on the biofilm
results from the produced reactive species: Measurements of the produced ozone in
the device after a treatment time of 60s showed a value of approximately 500 ppm.
The NO2 concentration was approximately 3 ppm. Concerning the ozone
concentration, Kowalski et al. reported that 15 s with 1500 ppm of ozone were
necessary for a 3 log10 reduction of E. coli plated on agar (21). In our study, the
reduction of even Candida albicans (and E.coli (data not shown)) is faster with a
smaller amount of ozone. This leads to the conclusion that the produced plasma
agents have synergetic effects and therefore result in a faster inactivation of
pathogens. Various inactivation experiments with bacteria showed that the UV
photons (gained by treating a planktonic bacteria sample with plasma filtered by a
quartz glass) do not have any bactericidal property up to 120 s (data not shown).
Therefore we conclude that the UV radiation alone does not contribute to the
fungicidal property as well. The electric field produced by the plasma can cause
stress on the cell wall of fungi. However, we could not observe any inactivation of
fungi due to the electric field produced by the plasma (data not shown). As stated
earlier the electrical current through the sample is negligibly small.
In recent years opportunistic pathogens from the genera Candida are the main cause
of fungal infections, especially as biofilm-mediated infections (4, 23). Therefore
contamination of inanimate surfaces by Candida may lead to the formation of
Candida biofilm and if left untreated or not disinfected it may become a risk in health
care services. Candida biofilms are more resistant to standard antifungal agents than
free-floating Candida cells (7). This study supports this statement as we clearly
showed that planktonic Candida cells can be easier killed using shorter plasma
treatment times than biofilm growing cells. Therefore we conclude that not only the
amount of cells per ml limits the inactivation but also the growing conditions:
planktonic or biofilm. Single Candida cells can survive for a longer time embedded in
a biofilm and grow with slower rates, and their metabolic and antifungal responses
are often different from their planktonic counterpart. Furthermore we were able to
show that the disinfectant ethanol (70%) was less effective in killing the Candida
biofilm which is in agreement with already published data (30). Théraud et al.
demonstrated that the overall efficacy of antiseptics and disinfectants on yeast
isolates is different when the cells are grown in planktonic or biofilm conditions (30).
Eight out of nine agents investigated (10% iodine polyvinylpyrrolidone, 2% sodium
lauryl sufate, 0.5% and 0.05% chlorhexidine digluconate, 3% hydrogen peroxide,
70% ethanol, 0.5% alkylamine, 0.5% alkylamine + sodium hypochlorite and UV
radiation at 365 nm were ineffective against biofilm growing Candida (30).
Chlorhexidine digluconate at a concentration of 0.5% was the only antifungal agent
which was active both on planktonic Candida cells suspension and biofilm growing
Candida albicans. Today chlorhexidine digluconate is used as a “gold standard”
antiseptic in the oral cavity, but some risks must be considered (12). Chlorhexidine
has a mutagenic potential, possesses a neurotoxic side effect and can induce
hypersensitiveness (22). The Japanes Ministry of Health recommended in 1984 to
avoid the use of chlorhexidine. Therefore the long-term use of chlorhexidine has to
be questioned (1).
As stated in the introduction, the high antifungal resistance of biofilms is a multifactor
process where an antifungal drug with just one single mechanism of action is unlikely
to be effective (2). In contrast, the mechanism of action of cold atmospheric plasma is
different from that of an antifungal agent. Typically an antifungal drug acts using the
lock-and-key principle. This means that a specific antifungal agent has to fit in a
certain way inside or outside of a Candida cell to induce an antifungal effect. In
contrast cold atmospheric plasma produced by this device results in the generation of
reactive oxygen and nitrogen species as well as atomic O and N and hydrogen
peroxide interacting with water vapour. All these species are capable to induce
oxidative and radical damage of the biofilm immediately during the plasma treatment.
Therefore a rapid fungicidal disinfection is possible. In this case no specific
interaction is necessary to induce the antifungal effect.
Overall the use of cold atmospheric plasma for disinfection of inanimate surfaces
could lead to a major development preventing biofilm-associated Candida infections
in the future. Therefore the advantage of a concept of a contact-free application of
plasma to sterilize Candida biofilm contaminated surfaces (and items) in health care
settings might have a positive impact on preventing community-acquired and
nosocomial infections in the medical field, but also in foodstuff industry where time
saving is a critical point to achieve efficient disinfection in the future.