Microorganisms universally attach to surfaces and produce extracellular polysaccharides, resulting in the formation of a
biofilm. Biofilms pose a serious problem for public health because of the increased resistance of biofilm-associated organisms
In nature, microorganisms exist primarily by attaching to and susceptible organisms in the biofilm). The susceptibility of bio-
growing upon living and inanimate surfaces. These surfaces films to antimicrobial agents cannot be determined by means
may take many forms, including those found in soil and aquatic of standard microdilution testing, since these tests rely upon
systems, those on the spectrum of indwelling medical devices, the response of planktonic (suspended) rather than biofilm
and those of living tissues such as tooth enamel, heart valves, (surface-associated) organisms. Instead, susceptibility must be
or the lung, and middle ear. The common feature of this at- determined directly against biofilm-associated organisms, pref-
tached growth state is that the cells develop a biofilm. Biofilm erably under conditions that simulate conditions in vivo.
formation is a process whereby microorganisms irreversibly Many bloodstream infections and urinary tract infections
attach to and grow on a surface and produce extracellular poly- are associated with indwelling medical devices and, therefore,
mers that facilitate attachment and matrix formation, resulting (in most cases) biofilm associated. The most effective strategy
in an alteration in the phenotype of the organisms with respect for treating these infections may be removal of the biofilm-
to growth rate and gene transcription. Figures 1 and 2 show contaminated device. A better understanding of the process of
scanning electron micrographs of biofilms. biofilm formation may impact clinical decision-making by af-
Biofilms have great significance for public health, because fecting the way blood samples and catheter-tip samples are
biofilm-associated microorganisms exhibit dramatically de- collected and examined or by providing a clearer picture of
creased susceptibility to antimicrobial agents. This susceptibility the limitations of conventional therapies for treating biofilm-
may be intrinsic (as a natural outcome of growth in the biofilm) associated infections. This article presents an overview of the
or acquired (due to transfer of extrachromosomal elements to process of biofilm formation and its implications for the health
care practitioner.
Received 16 March 2001; revised 23 May 2001; electronically published 20 September
2001.
This is the first of 3 reviews based on presentations made at the 38th Annual Meeting THE NATURE OF BIOFILMS ON MEDICAL
of the Infectious Diseases Society of America (710 September 2000), in Symposium 100, DEVICES
Device-Associated Infections: New Insights into Pathogenesis and Prevention. The second
review, Device-Associated Infections: A Macroproblem That Starts with Microadherence,
by Dr. Rabih O. Darouiche, and the third, Preventing Vascular CatheterRelated Infections: Table 1 provides a partial listing of medical devices on or in
Current Controversies by Dr. Barry M. Farr, will appear in the next 2 issues of Clinical which biofilms have been shown to develop. Evidence of the
Infectious Diseases.
occurrence of biofilms on medical devices has come from stud-
Publication of the CID Special Section on Healthcare Epidemiology is made possible by
an educational grant from Pfizer, Inc. ies in which the devices either were examined upon removal
Reprints or correspondence: Dr. Rodney M. Donlan, CDC Mail Stop C-16, 1600 Clifton Rd. from the patients or were tested in animal or laboratory sys-
NE, Atlanta, GA 30333 (rld8@cdc.gov).
tems. Raad et al. [1] used the scanning electron microscope to
Clinical Infectious Diseases 2001; 33:138792
2001 by the Infectious Diseases Society of America. All rights reserved.
demonstrate that central venous catheters removed from pa-
1058-4838/2001/3308-0020$03.00 tients were universally colonized by biofilms. These and other
BIOFILM FORMATION