Using biofilm-targeting local antibiotics to treat recalcitrant medical device–associated infections: driveline infection as a model

Driveline infection, exemplifying medical device-associated infection, is a difficult-to-treat complication of ventricular assist device implantation in which biofilm formation underlies both infection onset and recurrence. Although clinical experience remains limited, treatment success has been reported in cases where local antibiotics at high concentrations were used in combination with surgical debridement and/or device reimplantation. We recently identified the low metabolic state of biofilm cells as the central mechanism underlying the high antimicrobial resistance of staphylococcal biofilms and as a potential therapeutic target for driveline infections. We hypothesize that rationally combining weakly and strongly metabolism-dependent antibiotics at high concentrations for an extended period may eradicate staphylococcal biofilms, including the embedded tolerant and persister cells. If clinically validated, this strategy may hold the key to achieving long-term treatment success in many medical device-associated infections, including the driveline infection.