Sub-Minimum Inhibitory Concentrations of Amoxicillin Modulate Biofilm Formation and the Expression of Biofilm-Associated Genes in Enterococcus faecalis

Abstract

Background: Enterococcus faecalis is one of the most frequent causes of catheter-associated urinary tract infections, largely due to its ability to form biofilms on indwelling urinary catheter surfaces, which enhance bacterial persistence and antimicrobial tolerance. Sub-minimum inhibitory concentrations (sub-MICs) of antimicrobials frequently occur in clinical settings, and growing evidence suggests that such suboptimal exposures can induce bacterial biofilm formation. We hypothesized that exposure to sub-MICs of amoxicillin, ciprofloxacin, and nitrofurantoin, antimicrobials commonly employed in the treatment of urinary tract infections, would enhance the biofilm-forming capacity of E. faecalis strains. Objective: To investigate the effects of sub-MICs of amoxicillin, ciprofloxacin, and nitrofurantoin on biofilm formation and biofilm-associated gene expression. The study focused on key biofilm-related genes, including those encoding aggregation substance protein (asa1), collagen adhesin (ace), E. faecalis surface protein (esp), gelatinase (gelE), cytolysin activator A (cylA), endocarditis antigen A (efaA), and the endocarditis- and biofilm-associated pili subunit A (ebpA) in E. faecalis. Methods: Two strains, E. faecalis ATCC 29212 and strain 54, were exposed to 1/8× and 1/4× MIC of amoxicillin, ciprofloxacin, and nitrofurantoin in either artificial urine medium (AUM) or tryptone soya broth (TSB). Bacterial growth kinetics were monitored by optical density measurements, while biofilm formation was quantified using a microtiter plate biofilm assay. The expression of biofilm-associated genes was analyzed using quantitative reverse transcription PCR (RT-qPCR) at 24 and 48 h following exposure to sub-MICs of amoxicillin under flow conditions mimicking the urinary tract milieu. Results: Exposure to sub-MICs of the three antimicrobials did not significantly affect bacterial growth in either strain or culture medium. Sub-MICs of amoxicillin significantly enhanced biofilm formation, with the most pronounced effect observed at 1/4× MIC in both AUM and TSB. In contrast, ciprofloxacin and nitrofurantoin exerted inhibitory effects on biofilm formation across both media. Gene expression analysis demonstrated time- and strain-dependent responses to amoxicillin exposure. E. faecalis ATCC 29212 exhibited a moderate, coordinated upregulation of adhesion- and biofilm-associated genes, particularly at 48 h. By comparison, E. faecalis strain 54 showed a stronger and more dynamic transcriptional response, characterized by early and sustained induction of key biofilm-related genes, including esp and gelE, as well as a pronounced late upregulation of ebpA. Conclusions: These findings emphasize the importance of maintaining therapeutically effective antimicrobial concentrations, as sub-inhibitory amoxicillin exposure may promote biofilm-associated persistence and potentially compromise treatment efficacy.