Light-activated quantum dot potentiation of antibiotics to treat drug-resistant bacterial biofilms

CdTe-2.4 eV quantum dots (QDs) show excellent efficacy due to their tunability and photo-potentiation for sterilizing drug-resistant planktonic cultures without harming mammalian cells but this QD fabrication has not been tested against biofilms. While the QD attack mechanism—production of superoxide radicals—is known to stimulate biofilm formation, here we demonstrate that CdTe-2.4 eV QD-antibiotic combination therapy can nearly eradicate Escherichia coli, methicillin-resistant Staphylococcus aureus, and Pseudomonas aeruginosa biofilms. CdTe-2.4 eV QD versatility, safety, and ability to potentiate antibiotics makes them a potential treatment strategy for biofilm-associated infections.

Antimicrobial resistance already threatens our ability to treat infections, perform surgery, and manage immunocompromising conditions, effects which are compounded by improper use of existing antibiotics and insufficient research into new treatments for multi-drug resistant (MDR) bacteria. [1][2][3][4] Many treatment options are tested against planktonic bacterial cultures but at least 60% of clinical infections involve biolms, a common bacterial growth form contributing to increased resistance to immune and antibiotic attack. [5][6][7] Current strategies for biolm-associated infections include antibiotic combinations or elevated doses, perpetuating the development of MDR bacteria while risking increased toxicity and secondary infections for the patient. 8,9 These challenges underscore the need for alternative, dynamic therapies for MDR bacteria which are also capable of clearing bacterial biolm-associated infections. 10 Superoxide-generating light-activated quantum dots (QDs) can potentiate antibiotic treatments in vitro without harming mammalian cells. 11,12 Upon QD absorption of a photon, a generated electron-hole pair collapses via an oxidationreduction reaction, generating intracellular superoxide. 13 Like macrophage oxidative burst, concomitant reactive oxygen species (ROS) damage cellular DNA and metabolic pathways. 14 Fig. 1 Method & experimental design. (A) Biofilms were grown for 48 hours from 1 : 1 Â 10 5 dilutions of each bacterial strain. Antibiotics (ABX) and CdTe-2.4 eV quantum dot (QD) treatments in growth medium were added for 8 hours with white LED light to activate the QDs. (B) Post-treatment wells were rinsed 3 times with phosphatebuffered saline (PBS) to remove planktonic cells and waste. Biofilms were measured via 1 of 3 methods: (1) crystal violet (CV) staining, (2) Resazurin metabolic assay, or (3) counting colony forming units (CFU). CV stains were solubilized in 70% ethanol and absorbance (abs) measured at 595 nm. Biofilms metabolized Resazurin for 2 hours before being measured at excitation (ex) 530-570 nm and emission (em) 580-620 nm. Absorbance and fluorescence was measured with a TECAN GENios Microplate reader. Biofilms were manually scraped off of each well using a pipette tip, then diluted in PBS and plated for CFU.
QD fabrication also allows for selection of materials, oxidation and reduction potentials, size, and surface chemistry, making QDs modiable as needed to address a variety of infectious agents. 12 Their small size and tunable properties facilitate diffusion through tissues and cellular uptake enabling unparalleled control over localized treatment. 12 While various QD fabrications have been used as nanotherapeutics for eradication of bacterial biolms, they are predominantly carbon-based and cannot be localized in the host to the site of infection. [15][16][17][18][19] The cadmium telluride (CdTe) QDs characterized by Courtney et al. and used in these experiments are approximately 2-4 nm in diameter with a 2.4 eV bandgap and conduction band aligned with the reduction potential of dissolved oxygen. 11,12,20 These features make CdTe-2.4 eV QDs excitable by #517 nm light to produce only localized superoxide which specically targets bacteria. 11,13,21 Only nanomolar concentration of CdTe-2.4 eV QDs are necessary to kill bacteria, making them safe and nontoxic to mammalian cells. 11,14,22,23 The exibility and safety of CdTe-2.4 eV QDs make them particularly well-suited for antimicrobial applications.
Despite the promise of CdTe-2.4 eV QDs, biolms present unusual challenges. Resident bacteria diversify their gene expression-improving their response to environmental stressors such as antibiotic treatment through horizontal gene transfer of resistance genes-and surround themselves with an extracellular polymeric matrix, which may impede diffusion. 6,7,24 The CdTe-2.4 eV QD killing mechanism (superoxide generation) also may encourage biolm formation rather than eradication. [25][26][27][28] Here, we explore the QD-biolm interaction to reveal an alternative option for treating clinically-relevant bacterial infections that form biolms.
We demonstrate synergy between 2.4 eV CdTe QDs and sub-Clinical & Laboratory Standards Institute (CLSI) breakpoint antibiotic treatments to early-stage, static Escherichia coli (E. coli) MG1655, methicillin-resistant Staphylococcus aureus (MRSA), and Pseudomonas aeruginosa (PAO1) biolms. Used separately, effective concentrations of CdTe-2.4 eV QDs and antibiotics enhanced biolm growth in clinical isolate strains compared to no treatment controls. Each strain, however, showed susceptibility to at least one CdTe-2.4 eV QD-antibiotic combination treatment (QD-ABX).
Biolms were grown from 1 : 1 Â 10 5 overnight cultures for 48 hours in 96-well U-bottom plates as described by O'Toole 29 in conditions ideal for each strain (ESI Table S1 †), summarized in Fig. 1a. The biolms were incubated with treatment brought to concentration in growth medium at 37 C then illuminated with white LED-light for 8 hours to activate the CdTe-2.4 eV QDs. Post-treatment wells were screened for viability via (1) crystal violet (CV) staining, (2) 2 hour incubation with Resazurin metabolic assay, or (3) counting colony forming units (CFU) (Fig. 1b). Normalized Relative Fluorescence Units (RFU), CFU, and CV absorbances were calculated relative to untreated controls for each strain, respectively.
We used E. coli MG1655-a well-established model strainto inspect correlation among the 3 biolm viability assays. A signicant correlation (R ¼ 0.88993, p ¼ 0.01751) between normalized RFU and CFU measurements for increasing CdTe-2.4 eV QD doses, provides evidence for the use of Resazurin as an accurate, high-throughput assay of biolm viability (Fig. 2a). While CV-stained post-treatment biolms show a trend consistent with that captured by Resazurin, CV stains any organic matter, resulting in articially elevated measurements that did not represent viable cells. We analyzed QD-ABX synergy with S-values, which were calculated using the Bliss independence model by subtracting normalized RFU of QD-ABX measurements from the product of their component monotherapies (S > 0 indicates synergy, S < 0 indicates antagonism). [30][31][32][33][34] CdTe-2.4 eV QD-monotherapies were effective for E. coli MG1655 showing dose-dependent effects (Fig. 2a-c). An 800 nM CdTe-2.4 eV QD dose cleared biolms nearly to the same degree as 16 mg mL À1 kanamycin. Though low doses of CdTe-2.4 eV QD (100-200 nM) and antibiotic (4-8 mg mL À1 ampicillin, 2-4 mg mL À1 gentamicin) monotherapies achieved little killing (Fig. 2c), in combination their effects were amplied, signicantly killing 48 hour biolms with high synergy. Overall, E. coli MG1655 S-values were small since biolms responded well to monotherapies (Fig. 2c). Fig. 2d shows that QD-ABX can negate the biolm stimulation of sub-breakpoint ampicillin monotherapy. Though E. coli MG1655 already responded to CdTe-2.4 eV QD and antibiotic monotherapies, we achieved more robust killing with lower QD-ABX combination. We conrmed that the QD-ABX treatments were killing resident bacteria rather than triggering dispersal by testing the viability of media posttreatment ( Fig. S2-S5 †).
Aer demonstrating experimental proof-of-concept with E. coli MG1655, we tested QD-ABX on clinical isolates MRSA (for its relevance in dermal infections) and PAO1 (for its prevalence in lung infections). 35,36 Bacteria establish biolms in response to environmental stressors, including ROS. MRSA established signicantly larger biolms with CdTe-2.4 eV QD or subbreakpoint gentamicin treatments compared to the untreated control (Fig. 3a). In combination, however, CdTe-2.4 eV QDs with 2 mg mL À1 gentamicin signicantly reduced MRSA biolm mass with high synergy (S ¼ 2.46 in Fig. 3b).
CdTe-2.4 eV QD-monotherapy showed no signicant variation in PAO1 biolms (Fig. 3c). Furthermore, sub-breakpoint doses of gentamicin (2 mg mL À1 ) showed dramatic variation (visualized in Fig. 3d by the large error associated with 2 mg mL À1 gentamicin monotherapy), suggesting that effects of antibiotic monotherapy may vary with the bacterial population, making their efficacy difficult to predict. QD-ABX showed far more consistent results, even at mild concentrations, with reasonably high S-values.
As tested antibiotic concentrations increased, S-values decreased as antibiotic monotherapies were sufficient for bio-lm clearance. For both clinical isolates, CdTe-2.4 eV QDs potentiated lower concentrations of antibiotics to eradicate established biolms. Similar to E. coli MG1655, we conrmed killing rather than dispersal of biolm bacteria by measuring the viability of post-treatment media (MRSA in Fig. S7-S9, PAO1 in Fig. S11-S13 †). CdTe-2.4 eV QD and sub-breakpoint monotherapies risk inadvertent biolm stimulation, but CdTe-2.4 eV QD-antibiotic potentiation eliminates this concern, with synergy suggesting enhancement or reversal of CdTe-2.4 eV QD or sub-breakpoint antibiotic monotherapies.
CdTe-2.4 eV QDs show potential not only for alternative therapies but also sterilization of surfaces prone to biolm growth (such as faucets and implanted medical devices). This research lays a foundation for future work in treating late-stage biolms with ow (to more accurately model clinical and industrial conditions). CdTe-2.4 eV QDs are activated by visible light, which limits their application to surface infections. Future work will explore the application of near-infrared lightactivated indium phosphide quantum dots to establish similar foundational work for the treatment of deep-tissue biolm-associated infections. 37 QD-ABX eradicate biolms with milder dosages (protecting patient microbiomes) and holistic disruption of cellular function (slowing MDR development). The versatility, safety, and ability to potentiate antibiotics makes CdTe-2.4 eV QDs a prime therapeutic candidate for persistent bacterial biolm-associated infections.

Conflicts of interest
A. C. and P. N. have a patent on QD technology. D. F. S. declares no competing interests.