Published Online | : | Jun 28, 2019 |
eBbook | : | Research Trends of Microbiology |
Publisher | : | MedDocs Publishers LLC |
Online edition | : | http://meddocsonline.org |
Cite this article: Bhushan I, Kour M, Kour G, et al. Alzheimer’s disease: Causes and treatment – A review. Ann Biotechnol. 2018; 1(1): 1002.
Wound healing is a fundamental process to re-establish tissue integrity. Microbial infections, however, may hinder this process and compromise our health. The increasing resistance of microorganisms colonizing infections to con-ventional antibiotics has raised many concerns. Hence, new treatment options have been researched and new biomol-ecules uncovered. As known, multicellular organisms are endowed with an arsenal of host-defense molecules, the Antimicrobial Peptides (AMPs) that fight microbial invaders and modulate the host’s immune response. In recent years, research has been focused on the development of such mol-ecules with lower toxicity and improved activity compared to their endogenous counterparts for potential applications in wound healing. The present work offers a review over AMPs involved in wound healing and used against infected wounds, their potentialities and limitations, and highlights their mode of action. The challenges with the use of AMPs and the current strategies to prevent those challenges are also enumerated.
Keywords: Bacterial infections; Antimicrobial action; Surface functionalization; Wound dressings; Wound healing.
Skin is the largest organ in the human body. It works as a physical barrier, protecting our integrity from environmental threats. Inevitably wounds and traumas occur, compromising the skin defenses against pathogens and putting at risk our health [1]. In normal conditions, the skin heals by following a well-organized set of stages, hemostasis, inflammation, prolif-eration and remodeling, in a process that may last few hours or days. However, under certain diminished health conditions, such as diabetes, infection, etc., the healing process may be de-layed in a stage, usually at inflammation, and lead to the appear-ance of chronic wounds. Chronic wounds are a result of gradual tissue degradation in which biochemical agents, like proteolytic enzymes, are involved becoming very difficult to treat. Chronic wounds are characterized by flawed tissue, debris impair heal-ing, bacterial colonization (biofilms), prolonged inflammation, and moisture imbalance [2,3]. Hence, accelerate healing is vital to the human body as a mean to prevent wound chronicity and treat chronic wounds.In many chronic wound patients, the immune system is com-promised. As such antimicrobial agents must be added to their treatment to fight infections. Traditional wound healing drugs include antiseptics, ointments, antibiotics, growth factors, cy-tokines, plant derivates and even metal nanoparticles. Howev-er, these have been proven difficult to translate into successful therapies for chronic wounds [4]. Considering the limitations of the previous strategies, such as high cost, low availability, re-duced stability, specific and low antimicrobial activity, and re-lease/delivery issues, Antimicrobial Peptides (AMPs) have been established as potential biomolecules for the healing of infected wounds [5,6].AMPs are cationic, low molecular weight molecules and an integral part of the innate immune system, being present in many multicellular organisms, including insects, bacteria, ver-tebrates, plants and humans. AMPs display a broad spectrum of antimicrobial activity, including microorganisms from resistant strains, are bactericidal, their activity is not inhibited by biologi-cal fluids, exudates or biofilms, and act quickly at multiple sites within microbial cells reducing chance of resistance. Since most microorganisms frequently found colonizing the wounded site are potentially pathogenic, infection control is critical [7-10].The present work offers a review over the most common AMPs involved in wound healing and used against infected wounds, their potentialities and limitations. It also uncovers the most problematic aspects with skin infections and highlights the AMPs mode of action towards the pathogens colonizing the wounded site. Finally, a reflection over the recent advances in wound healing and the expectations for the future is provided.
At each stage of the healing process, the wounded site is in-vaded by biomolecules responsible for inducing the consecutive phases. Between those, many antimicrobial agents that are part of our innate immune system, including AMPs, are attracted and activated to protect our system against foreign invaders. Upon tearing of the skin, proteases are activated and release Heparin Binding-Epidermal Growth Factors (HB-EGF) and am-phiregulin that possess antimicrobial activity and are responsi-ble for instigating the expression of epidermal AMPs later in the healing process [11]. During hemostasis, the complement and coagulation cascades are activated which results in the cleavage of many proteins like fibrinogen or thrombin. Fragments from those proteins give rise to many AMPs including the C3a, known for its antimicrobial activity [12].
In the inflammatory stage, the wounded site is invaded by neutrophils followed by monocytes and lymphocytes. Neu-trophils are the most important “producers” of AMPs during inflammation; they contain α-defensins (human neutrophil peptides, HNPs) in azurophil granules, cathelicidins in specific granules (or large granules in rudiments), and calgranulins in the cytosol [2,13]. The defensins antibacterial and antiviral ac-tivity is mainly exerted in the neutrophil phagolysosome, but they are also responsible for boosting bacterial phagocytosis by macrophages and possess chemotactic activity towards mono-cytes, T cells and immature dendritic cells [14,15]. After release from the granules, cathelicidins are processed by the protei-nase 3 into the antimicrobial peptide hCAP-18 or more com-monly known the LL37, which is endowed with great antimicro-bial activity [16]. Cathelicidins are also responsible for recruiting monocytes to the wounded site, for inducing the expression of the Vascular Endothelial Growth Factor (VEGF), and for causing the transactivation of the Epidermal Growth Factor (EGFR) and thus promoting keratinocytes migration [17-19]. The most com-mon calgranulins found in the cytosol is the potent antifungal agent S100A8/S100A9 [20]. This AMP enhances phagocytosis and induces neutrophil chemotaxis and adhesion. It also me-diates pro-inflammation by binding to the toll-like receptor 4 (TLR-4) or the Receptor for Advanced Glycation End products (RAGE) and induces the expression of the cytokine interleukin 10 (IL-10) [21-24].
During proliferation, most AMPs are obtained from the epi-dermal keratinocytes, like hBD-2, hBD-3, RNase7 and psoriasin. At this stage the LL37 and S100A8/S100A9 together with the previous reach their peak of expression. As many defensins have the same ancestral gene, neutrophils (inflammation) and keratinocytes (proliferation) share many of the same AMPs and antimicrobial proteins. However, their expression is dependent on the healing phase [25,26]. For instance, the expression of hBD-3 is induced by the EGFR activation in epidermal keratino-cytes upon injure, while the expression of S100A8/S100A9 can be both induced by the activation of growth factors during injury or by pro-inflammatory cytokines, thus linking growth and tissue regeneration with AMPs expression [26,27]. Epidermal AMPs involved in wound healing display a broad spectrum of antibac-terial activity, with nBD-3 and RNase 7 being extremely effective against Staphylococcus aureus, psoriasin against Escherichia coli and calgranulins against Candida albicans [20,28,29]. Aside from protecting the wounded site from foreign invaders, the expression of these AMPs both during proliferation and inflam-mation points to the manifestation of other non-antimicrobial functions conducted by these AMPs. It has been reported that hBD-2 activates dendritic cells through TLR-4, being a chemoat-tractant towards immature dendritic cells and memory T cells, and has also been shown to stimulate proliferation, migration, and cytokine production of epidermal keratinocytes [30]. hBD-3 and psoriasin have also shown chemoattractant properties, with the first also being associated with the activation of mast cells with increase of vascular permeability and the second expres-sion of keratinocyte differentiation markers, promoting prolif-eration of endothelial cells [25,31]. Tissue remodeling is the last stage of the healing process. Even though currently there are no evidences of AMPs being produced during this phase, the increase expression of the highly antimicrobial collagen type VI, characteristic of this phase, protects the connective tissue of the skin [32]
Skin infections are some of the most common bacterial in-fections in humans. In hospitalized patients, bacterial skin in-fections are the 28th most common diagnosis, with some of those infections already revealing resistance to antibiotics [33]. However, not all wounds containing bacteria are considered in-fected; in fact, a wound that contains non-replicating bacteria is said to be contaminated, and those wounds containing replicat-ing bacteria, but without causing cellular damage to the host, are said to be colonized. A wound is only considered infected when replicating bacteria invade the tissue and cause damage. Indeed, a major advance in the prevention and management of wound infection has been this understanding, that the mere presence of organisms in a wound is not an indication of infec-tion and may not be more important than the level of bacterial growth. Bacterial infections can range from superficial, in which antibiotic administration may not be required, to complicated, in which biofilm formation is observed and systemic sepsis is a major problem with a lethal outcome [34,35]. In cases of skin rupture (most common in hospitalized patients recovering from surgery, burns or trauma), the chance of infection increases drastically. Wounds of surgical or traumatic origin, in which the host immune response is compromised, and the tissue is de-vitalized (i.e ischemic, hypoxic or necrotic), bacteria coloniza-tion is inevitable since these wounds offer optimal conditions for microbial growth. In these situations, infection has been defined as the product of entrance, growth, metabolic activity and resultant pathophysiologic effects of microorganisms in the wound bed. Since the human body is constantly surrounded by potentially pathogenic microorganisms, even in the absence of clinical infection, a delicate balance must exist between the host resistance and the actions of the bacteria to maintain our integrity. In fact, wound contaminants may originate from the environment, the surrounding skin (Staphylococcus epider-midis, micrococci, skin diphtheroids, and propionibacteria are common in the normal skin microflora), and even from endogenous sources involving mucous membranes [36-38]. In minor, healing wounds only a relatively small number of bacteria will take residence, while in devitalized tissues or chronic wounds colonization and establishment of a wide variety of endogenous microorganisms will occur, slowing the healing process. Bacte-ria loads in excess of 105 microorganisms/g of tissue are con-sidered to inhibit healing; this number depends, however, on the immune system of the host and the type of bacteria spe-cies. The primary microorganisms causing delayed healing and infection in both acute and chronic wounds are Staphylococcus aureus, Pseudomonas aeruginosa, Staphylococcus epidermidis and β-hemolytic Streptococcus bacteria [39]. Infected wounds may severely compromise the health of an individual. As such, efficient healing is essential in restoring the epidermal barrier natural characteristics and, with that, its bacterial resistance skills.
Over the years, to aid with the healing process different biomolecules, drugs and ointments together with appropriate dressings have been proposed and researched. Silver, in ionic or nanocrystalline forms, has been used as an antimicrobial agent in the treatment of burns. Lately, the incorporation of silver in dressings has widen its use to other wound types that are either colonized or infected [40]. Povidone or cadexomer iodine, chlo-rhexidine, polyhexamethyl biguanide and honey, all antiseptic agents, have also been used to impregnate dressings for acute and chronic wound care [41]. However, the rising of antibiotic-resistant infection agents has increased the need for new al-ternatives and more efficient therapies. Because of the AMPs ability to act at multiple sites within microbial cells in a very short time (smaller than the microorganism replicating cycle), bacteria are less likely to develop resistance; also AMPs display a broad spectrum, including resistant strains, are bactericidal and not just bacteriostatic, and their activity is not inhibited by body fluids, wound exudates or biofilms [2,7,10,42,43]. More importantly, AMPs are present in each phase of healing process contributing actively to the wound healing. Recently, studies have been conducted with the purpose of immobilizing AMPs onto the surface of wound dressings, to generate bioactive dressings, with promising results [10].
Over 2500 AMPs with different origins and applications have been identified. Even though they present a broad antimicrobial action, AMPs can be classified by their primary target micro-organisms: (i) Antibacterial, which target bacterial cell mem-branes; (ii) Antiviral, which penetrate the viral envelope neutral-izing their action; (iii) Antifungal, which act by targeting the cell wall or the intracellular organelles; and (iv) Antiparasitic, which kill by direct interaction with the cell wall. Most AMPs are small, cationic peptides composed of over 50% hydrophobic residues that enable them to fold into an amphiphilic conformation to better interact with the microorganisms’ cell membrane. AMPs mostly kill by disrupting the microorganism cell membrane in-tegrity, which task can be accomplished in a matter of seconds after initial contact. For most cases the AMPs action starts with electrostatic attraction between the anionic cell wall of the mi-croorganisms colonizing a wound and the cationic AMPs, which conformation then adapts to a cell membrane-water interface [2,44,45]. Once the interaction is established several models de-scribing the AMPs transmembrane mechanisms of action against pathogens have been proposed. Table 1 and Figure 1 provide spe-cific details describing the most common models used by AMPs.
Figure 1: Schematic representation of the most common AMPs transmembrane cell action models: Toroidal, barrel stave and car-pet-like [47].