www.acsabm.

org Article

Multifunctional, Low Friction, Antimicrobial Approach for

Biomaterial Surface Enhancement
Nicola J. Irwin,* Michael G. Bryant, Colin P. McCoy, Johann L. Trotter, and Jonathan Turner

Cite This: https://dx.doi.org/10.1021/acsabm.9b01042 Read Online

ACCESS Metrics & More Article Recommendations

See https://pubs.acs.org/sharingguidelines for options on how to legitimately share published articles.

ABSTRACT: Poly(vinyl chloride) (PVC) biomaterials perform a host

of life-saving and life-enhancing roles when employed as medical
devices within the body. High frictional forces between the device
Downloaded via UPPSALA UNIV on March 10, 2020 at 15:17:45 (UTC).

surface and interfacing tissue can, however, lead to a host of

complications including tissue damage, inflammation, pain, and
infection. We herein describe a versatile surface modification method
using multifunctional hydrogel formulations to increase lubricity and
prevent common device-related complications. In a clinically relevant
model of the urinary tract, simulating the mechanical and biological
environments encountered in vivo, coated candidate catheter surfaces
demonstrated significantly lower frictional resistance than uncoated
PVC, with reductions in coefficient of friction values of more than 300-
fold due to hydration of the surface-localized polymer network.
Furthermore, this significant lubrication capacity was retained following
hydration periods of up to 28 days in artificial urine at pH 6 and pH 9, representing the pH of physiologically normal and infected
urine, respectively, and during 200 repeated cycles of applied frictional force. Importantly, the modified surfaces also displayed
excellent antibacterial activity, which could be facilely tuned to achieve reductions of 99.8% in adherence of common hospital-
acquired pathogens, Staphylococcus aureus and Proteus mirabilis, relative to their uncoated counterparts through incorporation of
chlorhexidine in the coating matrix as a model antiseptic. The remarkable, and pH-independent, tribological performance of these
lubricious, antibacterial, and highly durable surfaces offers exciting promise for use of this PVC functionalization approach in
facilitating smooth and atraumatic insertion and removal of a wide range of medical implants, ultimately maintaining user health and
dignity.
KEYWORDS: functional surfaces, tribology, biomaterials, medical devices, infection

1. INTRODUCTION Patients who undergo repeated catheterization with poorly

Poly(vinyl chloride) (PVC) is one of the most widely lubricated indwelling and/or intermittent devices have,
employed biomaterials in medical implants and devices, however, been reported to experience urethral bleeding,
including endotracheal tubes, urinary catheters, and medical trauma, pain, and inflammation as a result of high frictional
tubing. The diverse healthcare applications result from its forces between the biomaterial surface and interfacing tissues,
relatively low cost, biological and chemical stability, and ready which can ultimately result in infection and formation of
processability.1 Insertion and removal of these devices can, urethral strictures.5−8
however, adversely affect tissue integrity as a result of high Increased lubricity of the device surface is anticipated to
frictional forces between the interfacing surfaces.2 While the prevent associated pain and tissue trauma by decreasing
tribological behavior of artificial limbs, fraction fixation devices, frictional forces between the catheter surface and the urethral
and joint, cardiovascular, and dental implants against human tissue upon device insertion and removal.9 A common
tissues has been extensively studied, the tribology of urinary approach to promote smooth catheterization and reduce
catheter surfaces has, in contrast, received comparatively less
attention to date, even though urinary catheters are the most Received: November 12, 2019
frequently deployed medical device in clinical care.3 Accepted: January 6, 2020
Urinary catheters may be inserted intermittently to drain
urine from the bladder when required or remain in situ for up
to three months between scheduled device changes when
employed for the long-term management of incontinence.4

© XXXX American Chemical Society https://dx.doi.org/10.1021/acsabm.9b01042

A ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

interfacial friction involves the application of lubricating agents negative urinary pathogen P. mirabilis and the common Gram-
or jelly like materials, for example, glycerin or lidocaine gels.10 positive nosocomial pathogen Staphylococcus aureus.
An alternative strategy to enhance the usability of these devices
and ensure sufficient robustness of the lubricious surface 2. MATERIALS AND METHODS
throughout the entire catheterization process involves the The coating components: ethylene glycol dimethacrylate (EGDMA),
application of hydrophilic coatings.5,11,12 These coatings have 2-hydroxy-4′-(2-hydroxyethoxy)-2-methylpropiophenone, 2-hydrox-
been widely applied to a range of implantable medical devices, yethyl methacrylate (2-HEMA), chlorhexidine, and isopropanol; the
such as endovascular catheters and guidewires, to minimize artificial urine components: potassium dihydrogen orthophosphate,
soft tissue damage upon interfacial contact with the vessel wall magnesium chloride hexahydrate, urea, calcium chloride dihydrate,
and chicken ovalbumin; and the neutralizer components: Tween 80
or urethra.5,13 As a result of their lubricious properties, they and azolectin, were obtained from Sigma-Aldrich (Dorset, UK).
have also been applied in many industrial applications to Kollidon 90F was supplied by BTC Europe (Germany). Poly(vinyl
reduce frictional forces and associated component wear.13 chloride) (PVC) sheets (unplasticized, 0.2 mm thickness) were
Previous studies involving both in vitro and in vivo models for purchased from Goodfellow Ltd. (Cambridge, UK). Phosphate-
investigation of frictional properties of catheter surfaces have buffered saline (PBS), quarter-strength Ringer’s solution (QSRS),
reported significantly lower interfacial frictional forces with the tryptone soya broth (TSB), agar, glycerol, and Mueller-Hinton broth
use of hydrated hydrophilic-coated catheters relative to their (MHB) were obtained from Oxoid Ltd. (Hampshire, UK). Proteus
uncoated counterparts.11,12,14,15 This effect is, however, mirabilis ATCC 35508 and Staphylococcus aureus ATCC 6538 (LGC
Standards, Middlesex, UK) were maintained on cryopreservative
commonly short-lived due to ready delamination of the
beads (Protect Bacterial Preservation System, Technical Service
coating as a result of high interfacial stresses between the Consultants Ltd., UK) in 10% glycerol at −80 °C and cultured by
device surface and the urethral tissue.5 inoculation into MHB and incubation at 37 °C when required for the
In addition to the reported tissue damage, catheter surfaces in vitro microbiological assessments.
also provide an attractive niche for colonization of infecting 2.1. Preparation of Hydrogel-Coated PVC. The coating
pathogens, of which the urease producer Proteus mirabilis, formulation with a final component composition of 37% w/v was
which has been identified as one of the most common causes prepared by dissolving the cross-linker EGDMA (3.7 g L−1), the
of catheter-associated urinary tract infections, is a notable hydrogel monomer 2-HEMA (248 g L−1), the thickening agent
example.16,17 Infection with this pathogen results in elevation Kollidon 90F (111 g L−1), and the photoinitiator 2-hydroxy-4′-(2-
hydroxyethoxy)-2-methylpropiophenone (7.4 g L−1) gradually, with
of urinary pH to levels up to pH 9.1 as a result of urease- stirring at ambient temperature, in a solvent mixture of isopropanol:-
catalyzed hydrolysis of urea in the urine to ammonia, leading water (2:1), under protection from light. In addition, chlorhexidine-
to precipitation of calcium and magnesium ammonium loaded hydrogel (CLH) coatings were prepared for in vitro
phosphates.18,19 Accumulation of these crystals within the microbiological testing by the incorporation of chlorhexidine (1 g
surface-attached bacterial biofilm leads to recurrent blockages L−1) to the previously described coating formulation. Substrates of
of the catheter lumen in a reported 50% of all chronically PVC, as a model biomedical and catheter material, were etched in
catheterized patients, necessitating device replacement and, ethanol for 30 s and coated by a dip coating procedure using a
furthermore, increasing the risk of urinary retention and withdrawal speed of 200 mm min−1. Samples were then dried at 60 °C
for 20 min and cured by irradiation with UVA light.
associated problems of pyelonephritis and septicemia.20 The
2.2. Preparation of Artificial Urine. Artificial urine (AU) was
development of lubricious and durable surfaces which resist prepared using a composition based on that described by Cox et al.
bacterial colonization and retain their friction-lowering proper- (1987), with the components listed in Table 1.23 Two solutions (A
ties within environments of varying pH is therefore urgently
needed. Despite the wide variation in urinary pH, resulting not Table 1. Composition of Artificial Urine
only from infection but also from diet and drug therapy, the
effect of pH on the tribological performance of coated catheter concentration solution B concentration
solution A components (g L−1) components (g L−1)
surfaces has, until now, never been examined.21,22
Herein, we describe the development of a robust and widely potassium dihydrogen 7.6 calcium chloride 3.6
orthophosphate dihydrate
applicable method to enhance the functionality of PVC
magnesium chloride 3.6 chicken 0.2
surfaces and resultant medical devices, including intermittent hexahydrate ovalbumin
urinary catheters. The tribological and microbiological urea 16
performance of the modified surfaces was evaluated under
mechanically and biologically relevant conditions to inform the
capacity of this approach for reducing frictional forces and and B) were prepared and mixed immediately before use in order to
ultimately preventing device-associated tissue trauma, infec- avoid precipitation of calcium phosphate in the form of brushite,
which would lead to a corresponding reduction in the concentration
tion, and pain. PVC, representing the most widely employed of calcium and phosphate ions.
biomaterial, was coated with a hydrogel formulation by a dip AU was adjusted to pH values of pH 6 and 9 to simulate the pH of
coating and UV curing process. Coefficients of friction (COF) normal physiological and infected urine, respectively, by the addition
of the modified surfaces were measured using a biologically of 1 M HCl or NaOH, and sterilized by membrane filtration (pore
representative in vitro model of the tribological conditions size of 0.45 μm).
experienced in the urinary tract in vivo after varying periods of 2.3. Surface Characterization. 2.3.1. Fourier Transform Infra-
incubation in deionized water (dH2O) and artificial urine of red (FTIR) Spectroscopy. Functional groups of uncoated and coated
pH 6 and pH 9, representing normal and infected urinary pH, sample surfaces were characterized by attenuated total reflectance
(ATR) Fourier transform infrared (FTIR) spectroscopy using a
respectively, against a polydimethylsiloxane (PDMS) probe. PerkinElmer Spectrum Two spectrophotometer equipped with a
The tribological behavior of the coated surfaces was, in diamond ATR accessory at a resolution of 4.0 cm−1. Spectra are an
addition, evaluated over 200 repeated frictional cycles to assess average of 128 scans recorded over the range 4000−650 cm−1 1.
coating durability. Resistance to bacterial colonization was 2.3.2. Contact Angle Analysis. Static contact angles of dH2O
studied by challenging modified surfaces with the Gram- droplets (4.0 μL) on the surface of coated and uncoated PVC

B https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

substrates were measured using an Attension Theta optical water was prepared for use in microbiological assessments of the CLH
tensiometer (Biolin Scientific, Sweden) mounted with a digital coatings to inhibit any residual antibacterial agent and ensure no
video camera and OneAttension software for image analysis. Samples inhibitory effects on microorganisms recovered from the sample
were previously hydrated for 24 h in dH2O, and values are reported as surfaces, following the designated periods of bacterial challenge. First,
the mean ± standard deviation of five measurements collected 1−1.5 the absence of toxicity of the neutralizer toward the bacterial cells was
s following droplet placement on ten replicate samples. confirmed by adding 1 mL of the bacterial suspension (1 × 108 cfu
2.3.3. Kinetics of Coating Hydration and Dry-Out. The kinetics of mL−1) to the neutralizer solution (9 mL), vortexing, and counting
coating hydration and dry-out at ambient temperature were viable cell density after 10 min incubation. Controls were prepared
determined by measuring coating thickness from cross-sectional using PBS in place of the neutralizer. Viable counts of the bacterial
images acquired using a Keyence VHX-2000E microscope every 10 suspensions were performed by serial dilution, with plating onto
min for 4 h, with a final measurement at 24 h, during hydration in or MHA and low-swarm agar for S. aureus and P. mirabilis, respectively.
following removal from, respectively, an aqueous solution of The neutralizer was considered nontoxic if colony counts for the test
Toluidine blue O (TBO). Mean ± standard deviation values were suspensions were ≤1 log10 lower than the counts observed for the
calculated from a minimum of five measurements at each time point. control suspensions.
2.4. Tribological Assessment. Pin-on-plate reciprocating sliding Second, efficacy of the neutralizer in quenching the activity of
friction tests on coated and uncoated PVC substrates were performed chlorhexidine was tested by adding 1 mL of chlorhexidine solution
with an Anton-Paar Nano Tribometer in conjunction with InstrumX (1% w/v) to the neutralizer solution (8 mL). The solution was
software. In this case, the counter surface pin was a PDMS vortexed, and after 10 min, 1 mL of the bacterial suspension (1 × 108
hemisphere (Sylgard 184, DowCorning, USA) with a diameter Ø of cfu mL−1) was added, vortexed again, and incubated for 10 min.
6 mm and surface roughness Ra < 20 nm. Figure 1 shows a schematic Controls were similarly prepared with the use of PBS instead of
of the test arrangement used in this study. neutralizer. Viable counts of the test and control bacterial suspensions
were performed, and the neutralizer was considered effective if ≤1
log10 reduction was observed in the neutralized bacterial suspension.25
2.5.3. Bacterial Adherence Assessments. Resistance of the
hydrogel- and CLH-coated surfaces to bacterial colonization was
assessed by challenging coated samples with P. mirabilis and S. aureus
by incubation in infected AU. Suspensions of the respective bacteria
with density of 1 × 108 cfu mL−1 were prepared in PBS as described
above, and a 1 in 100 dilution was carried out using AU supplemented
with 0.5% TSB. Coated samples (1 cm × 1 cm) and uncoated PVC, as
controls, were placed into individual wells of a sterile 24-well flat
bottom tissue culture plate (Corning Inc., Corning, NY). Aliquots of
bacterial suspension (1 mL) with a density of 1 × 106 cfu mL−1 were
added to each well, and the plates were shaken in an orbital incubator
at 100 rpm at 37 °C. After designated 4 or 24 h incubation periods,
samples were removed from the bacterial suspension and rinsed three
times in QSRS to remove nonadherent bacteria. Adherent bacteria
were then removed by sonicating samples for 10 min in neutralizer
solution and vortexing for approximately 30 s. The sonication
Figure 1. Schematic of the tribometer test arrangement. technique has previously been demonstrated not to affect bacterial
viability or morphology.26 Viable counts of the resulting neutralizer
The frictional properties of control and coated surfaces were solution were performed by the Miles and Misra serial dilution
quantified following incubation in dH2O and AU (pH 6 and pH 9) technique, with plating onto MHA and low-swarm agar for
for 30 s, 24 h, 5 days, and 28 days. Immediately before tribological subsequent enumeration of adherent S. aureus and P. mirabilis,
assessments, 100 μL of the relevant media (dH2O or AU) was respectively, per sample.27 Five replicates were assessed for each
dropped onto the surface as a lubricant. The PDMS counter probe period of incubation, and numbers of adherent bacteria on the coated
was slowly lowered until a monotonic increase in force and then samples have been expressed as percentage values relative to uncoated
zeroed to mitigate any additional buoyancy forces. A normal load of PVC controls.28
10 mN was applied to the coated and uncoated PVC surfaces. Sliding 2.6. Statistical Analysis. Statistical differences in COF values and
was simulated via reciprocation of the PVC surfaces and the frictional sessile contact angles between coated surfaces and uncoated PVC
forces quantified as a function of cycle position. The tests were controls were evaluated by an unpaired t test. Time-dependent
conducted at a constant sliding speed of 2 mm/s at a sliding measurements of coating thickness during hydration and dry-out were
amplitude of 1 mm for 200 cycles, representing a total sliding distance statistically analyzed by a two-way analysis of variance. Resistance to
of 400 mm. This exceeds the distances expected during urinary bacterial colonization between hydrogel-coated, CLH-coated, and
catheterization, which are reported to be in the region of 40 and 200 uncoated PVC controls was evaluated by a one-way analysis of
mm for females and males, respectively.24 The instantaneous variance, whereas the effect of media pH and duration of hydration on
coefficient of friction (COF), μ, was calculated by taking an average COF values of the coated surfaces was statistically assessed by a two-
of frictional forces measured within the middle 20% of forward and way analysis of variance. Posthoc comparisons between means of
reverse portions of the sliding cycle. The mean steady state COF was individual groups were performed using Tukey’s honestly significant
determined from data from the last 50 cycles when the transient difference (HSD) test, and in all cases differences were considered
behavior had stabilized. Each tribological test was performed with five significant when p < 0.05. All statistical calculations were performed
replicate samples to obtain the mean ± standard deviation values. with the use of GraphPad Prism 7 software.
2.5. Microbiological Assessment. 2.5.1. Preparation of
Challenge Inocula. Overnight broth cultures of respective bacteria, 3. RESULTS AND DISCUSSION
P. mirabilis and S. aureus, were centrifuged at 3000g for 10 min, and
after discarding the supernatant, the resulting bacterial pellet was The findings from the experimental work are reported below,
resuspended in PBS to an optical density equivalent to an inoculum and their relevance is discussed to inform widespread use of
concentration of 1 × 108 cfu mL−1, as verified by viable count. this surface modification technique for engineering low
2.5.2. Neutralizer Toxicity and Efficacy Tests. A neutralizer friction, infection-resistant medical devices for optimal clinical
composed of Tween 80 (30 g L−1), azolectin (3 g L−1), and deionized use within environments of varying pH.
C https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

3.1. Characterization of Coated Surfaces. 3.1.1. FTIR hydrophobicity (∼90 °C) relative to their more hydrophilic
Spectroscopy. Overlaid ATR-FTIR spectra of uncoated PVC, counterparts due to the promotion of adherence by hydro-
hydrogel-coated PVC, and CLH-coated PVC are presented in phobic interactions between the substrate and bacterial
Figure 2. membrane.33,34
3.1.3. Kinetics of Coating Hydration and Dry-Out. The
thickness of the coatings was measured at regular intervals
during hydration in, and following removal from, an aqueous
solution of TBO using optical microscopy. Representative
cross-sectional images of hydrogel-coated PVC stained with
TBO and hydration and dehydration profiles of the hydrogel
coating at ambient temperature are shown in Figures 4 (a) and
(b), respectively.
The stained hydrogel coating can be seen in Figure 4(a) as a
uniform and distinct layer on the PVC surface. The significant
increase in coating thickness upon hydration, as shown in
Figure 4(b), was attributed to the rapid uptake of water and
resultant swelling of the hydrogel layer. A rapid and significant
Figure 2. ATR-FTIR spectra of (a) uncoated PVC, (b) CLH-coated increase in coating thickness was observed after a 20 min
PVC, and (c) hydrogel-coated PVC from 1800 to 1100 cm−1. Spectra period of hydration, and the values appeared to plateau after 90
have been offset vertically for clarity.
min when the thickness of the coating had increased by 45.5%.
An increase in surface lubricity has previously been reported
Spectral differences due to the presence of the coating with increased thickness of hydrophilic-coated layers as a result
include additional bands at 3400−3300, 1650, and 1290 cm−1 of the greater capacity for imbibement of water.32 With regards
attributed to stretching vibrations of O−H, CO, and C−N to coating dry-out, no significant differences in coating
moieties, respectively, within the HEMA and PVP components thickness were observed until 200 min after removal from
at the coated surface.29 Additional bands within the spectra of the wetting media when the coating had decreased in thickness
the coated PVC at 2930 cm−1 and 1450−1420 cm−1 were by 15.7%. The slower rates of coating dry-out demonstrate the
ascribed to the alkyl backbones of HEMA and PVP moieties ability of the hydrogel coating to retain the imbibed water,
within the coating.30 which is highly beneficial in clinical applications. Rapid loss of
3.1.2. Contact Angle Analysis. To investigate the effect of water from hydrophilic coatings has previously been found to
these differences in chemical composition on wettability of the increase resultant tissue damage as a result of the higher
surface, the angles made by droplets of dH2O in contact with frictional forces between dried-out, “sticky” coated surfaces and
the solid surface were measured, and representative images of interfacing tissue.35,36
these angles are displayed in Figure 3. 3.2. Tribological Assessment. Tribological performance
of the modified surfaces was assessed by measuring COF
values of coated and uncoated PVC surfaces against a PDMS
counterprobe under a normal applied load of 10 mN. COF
values measured after varying periods of hydration in dH2O
and AU (pH 6 and pH 9) are shown in Figure 5.
Under all testing conditions, coated PVC surfaces
demonstrated significantly lower COF values than their
uncoated counterparts, with mean COF values as low as
0.0045 against the PDMS probe following a five-day hydration
period in AU pH 6, thereby revealing the lubricious properties
of the applied hydrogel coatings. The low frictional forces
Figure 3. Contact angles of dH2O on surfaces of uncoated PVC and characteristic of hydrophilic surfaces are commonly associated
hydrogel-coated PVC. Values represent the mean ± standard with the presence of surface-localized lubricating layers of
deviation of five measurements collected 1 to 1.5 s following droplet water and the corresponding increase in smoothness and
placement on ten replicate samples. **** denotes significant
difference in contact angle (p < 0.0001).
lubricity of the surface.30 In this case, the significant reductions
in COF values relative to uncoated controls were attributed to
the presence of the highly solvated hydrogel network resulting
The significantly lower contact angles measured herein for from the absorption of water molecules by the hydroxyl and
the coated surfaces relative to their uncoated PVC counter- carboxyl groups of the HEMA and PVP moieties.13 In
parts (11.9° ± 14.8° and 87.9° ± 1.8°, respectively) reveal the agreement with previous reports where friction was reported
enhanced hydrophilicity of the surface upon application of the to be dependent on the degree of polymer solvation, this
hydrogel coating, with dH2O almost completely wetting the hydrated network was found to modify interfacial contact
coated surface, as shown in Figure 3. This increased wettability mechanics leading to lower contact pressures during sliding of
was due to the presence of hydrophilic hydroxyl and carboxyl the probe over the coated surface, with significant reductions
groups of the HEMA and PVP moieties within the coating.13,31 in frictional forces.13,37,38
Surface wettability has previously been reported to play an COF values of the coated surfaces were, in addition,
important role in resulting lubricity and friction.13,32 In demonstrated to be independent of media pH after up to 5
addition, a higher degree of protein adsorption and bacterial days hydration in AU of pH 6 and pH 9. In contrast, rapid
adhesion has been observed on surfaces with moderate swelling of poly(acrylic acid) (PAA) hydrogels as pH of the
D https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

Figure 4. (a) Digital microscopy images of hydrogel-coated PVC (i) 0 h and (ii) 4 h posthydration at 200× magnification. The coating was stained
with TBO dye. (b) Relative change in coating thickness (%) during hydration in, and following removal from, an aqueous solution of TBO. Values
displayed are the mean of five replicate measurements, and error bars represent standard deviations of the mean values.

wetting media was increased from pH 3 (below the pKa of changes.35 Importantly, as shown in Figure 5, the frictional
PAA) to pH 10 (above the pKa of PAA) resulted in pH- response of coated surfaces was again more than 85-fold lower
responsive frictional properties of the artificial cartilage than for uncoated PVC controls after a four-week incubation
materials, namely, high friction and superlubrication in acid period. In the case of immersion in dH2O (Figure 5), an
conditions and alkaline media, respectively.39 While the effect increased immersion time resulted in an increased COF,
of pH on tribological performance of hydrophilic catheter although significantly lower than the uncoated surfaces. This
coatings has not previously been explored, the pH-independent may be a result of dissolution of coating components upon
frictional behavior of the coatings developed herein from the prolonged incubation, with an accompanying change in coating
nonionic monomer, HEMA, is of significant importance in integrity, osmotic pressure, and resultant lubricity.40 A similar
consideration of their potential clinical application within the observation was demonstrated for the coated surfaces
urinary tract, which maintains a normal physiological pH range immersed in AU (Figure 5), although the trends were not
between pH 4.8 and pH 8, with elevations up to pH 9.1 consistent with immersion time or pH.
reported during infection.18,19 Furthermore, no significant differences in frictional behavior
In order to assess coating stability, tribological tests were of the coated surfaces were observed following hydration in
performed with samples which had been incubating in dH2O AU or dH2O, despite the osmotic differences between these
or AU at 37 °C for extended periods of up to 28 days, two solutions. This is in contrast to alternative hydrogel
representing the duration that indwelling urinary catheters may systems of polyvinyl alcohol/polyvinylpyrrolidone (PVA/
be in situ within the bladder between scheduled device PVP), where significantly lower COF values were observed
E https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

related to degradation of films and exposure to charged species

within the different hydration media and could affect the
mechanical and swelling properties of the coatings, sub-
sequently affecting the tribological properties. Further work
will be conducted to elucidate the links between coating
degradation and tribological properties.
3.3. Microbiological Assessment. Chlorhexidine, as a
model antiseptic, was incorporated within the coating
formulation to impart antibacterial properties and reduce the
risk of device-associated infections.43 Neutralizer toxicity
testing revealed that the prepared neutralizer was not toxic
to P. mirabilis or S. aureus, with ≤1 log10 reductions in the test
suspensions relative to the controls as shown in Table 2.
Figure 5. Cycle average COF values of coated and uncoated PVC
surfaces following hydration in dH2O and AU. COF values have been Table 2. Viable Counts from Neutralizer Toxicity and
averaged over the last 50 sliding cycles. Columns and error bars Efficacy Testing
represent mean values ± standard deviations (n ≥ 5). **** denotes
significant difference in COF values relative to uncoated control (p < P. mirabilis S. aureus
0.0001). §COF values were too high to be measured without test solution (log10 cfu mL−1) (log10 cfu mL−1)
damaging the counterprobe. inoculum density at 7.21 ± 0.065 7.51 ± 0.020
t=0h
toxicity test 7.40 ± 0.115 7.36 ± 0.125
after swelling in polyethylene glycol (PEG)-based osmotic
toxicity control 7.26 ± 0.038 7.32 ± 0.046
solution for 28 days relative to values obtained for their
efficacy test 7.31 ± 0.137 6.89 ± 0.058
counterparts swollen in a nonosmotic PBS solution. These
efficacy control <1.7 <1.7
differences were attributed to deswelling of the PVA/PVP
hydrogel in the former ionic environment and the correspond-
ing decreased contact area between the two counterfaces Importantly, the neutralizer was also shown to effectively
during sliding.40 quench the activity of chlorhexidine, with ≤1 log10 reductions
Durability of the coated surfaces following hydration in in bacterial densities observed in the neutralized suspensions of
dH2O and AU for periods from 30 s to 28 days was assessed chlorhexidine.
using the same tribological parameters outlined above. The Device-associated infections and associated biofilm forma-
COF values of surfaces following incubation in dH2O and AU tion result from the initial adhesion of bacteria to implant
have been plotted against cycle number in Figure 6(a) and (b), surfaces.44,45 To establish the capacity of the CLH-coated
respectively. surfaces to prevent catheter-associated urinary tract infections,
Coating delamination would be expected to cause an we herein evaluated the in vitro resistance of hydrogel-coated
increase in frictional forces, with COF values ultimately PVC and CLH-coated PVC to adherence of P. mirabilis and S.
approximating those obtained for uncoated surfaces.5,39,41 In aureus relative to uncoated PVC in AU media. Samples of each
contrast, as shown in Figure 6, the COF values remained material were challenged with inoculi of P. mirabilis and S.
relatively stable for the duration of all tests, highlighting the aureus (1 × 106 cfu mL−1) over incubation periods of 4 and 24
impressive wear performance of the coated surfaces.42 With h. Bacterial adherence to surfaces of the coated samples relative
increasing incubation time, an increase in the COF was seen to uncoated PVC controls is displayed in Figure 7.
for surfaces “aged” in dH2O (Figure 6(a)). A similar As shown in Figure 7(a), significant reductions in bacterial
observation was also seen for surfaces “aged” in AU, albeit to colonization of up to 66% were observed on hydrogel-coated
a higher extent compared to sample surfaces hydrated in PVC relative to their uncoated counterparts. Reduced
dH2O. In addition to time, the pH of the AU was also seen to adherence of a range of common nosocomial pathogens,
affect the COF after extended periods of immersion time. including S. aureus, Pseudomonas aeruginosa, and Escherichia
These differences with time and hydration media may be coli, to hydrophilic-coated surfaces relative to uncoated

Figure 6. Mean COF values over 200 repeated sliding cycles on coated sample surfaces following hydration in (a) dH2O and (b) AU. Error bars
have been omitted for clarity; however, SD values were on average 7-fold lower than their associated mean values.

F https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

Figure 7. (a) Adherence (%) of (i) S. aureus and (ii) P. mirabilis to the hydrogel- and CLH-coated PVC samples relative to uncoated PVC controls
after 4 and 24 h incubation at 37 °C. Columns and error bars represent mean values ± standard deviations (n ≥ 5). *Denotes significant reduction
in bacterial adherence relative to PVC control (**p < 0.01, ****p < 0.0001). (b) Viable counts of planktonic bacterial suspensions of (i) S. aureus
and (ii) P. mirabilis after 4 and 24 h incubation at 37 °C in the presence of PVC, hydrogel-coated PVC, and CLH-coated PVC. Error bars represent
standard deviations of the mean values.

catheter substrates has previously been reported.30,46,47 This relative to the bacterial population in contact with the
lower degree of bacterial colonization is a result of the uncoated PVC, and after 24 h the logarithmic reductions in
hydration layer formed from interactions of the hydrogel planktonic P. mirabilis approximated 6.0 in the presence of
chains with water, which effectively acts as a hydrophilic barrier CLH-coated PVC. Chlorhexidine solutions and dressings are
to bacterial adhesion.34 Moreover, Figure 7(a) demonstrates routinely used to cleanse central venous catheter exit sites
that incorporation of chlorhexidine provided an effective toward the prevention of catheter-associated bloodstream
mechanism of increasing resistance of the coated surfaces to infections, and while similar solutions have been used for
bacterial adherence, with significant logarithmic reductions in periurethral cleansing before indwelling catheterization, there
adherence of S. aureus and P. mirabilis relative to PVC controls are to-date no marketed catheters containing this agent
approximating 2.42 and 2.72, respectively, after 24 h localized at the surface.49−51 The facile manipulation, drug
incubation. This resistance was attributed to the surface- incorporation, and drug-releasing capabilities of the lubricious
localized release of chlorhexidine, a cationic bisbiguanide surfaces engineered herein offer exciting potential for
antiseptic, with reported bactericidal activity against both increasing resistance of biomaterial surfaces to colonizing
Gram-positive and Gram-negative bacteria.43 Chlorhexidine bacteria and ultimately preventing associated infections.
functions by disruption of bacterial membranes. Insertion of
this agent between phospholipid headgroups, with associated 4. CONCLUSIONS
displacement of membrane-localized divalent cations, Mg2+ The multifunctional biomaterial surfaces engineered herein
and Ca 2+ , leads to loss of membrane fluidity and displayed significant tribological performance, with COF
osmoregulation and at higher concentrations loss of structural values more than 300-fold lower than uncoated PVC. This
integrity and cellular contents.48 behavior was, furthermore, independent of pH and, impor-
In addition to their observed resistance to bacterial tantly, maintained after prolonged incubation and repeated
adherence, the CLH coatings formulated herein demonstrated applications of frictional force. In addition, microbiological
significant antimicrobial activity against the planktonic testing confirmed the promising capacity of the CLH-coated
bacterial cultures, as shown in Figure 7(b). After 4 h surfaces to resist colonization of common clinical pathogens.
incubation with CLH-coated PVC, logarithmic reductions of These findings thereby highlight the promising potential of this
up to 2.0 in the planktonic S. aureus suspension were achieved robust and widely applicable surface modification approach to
G https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

reduce device-related complications of tissue trauma, pain, and literature review. International Journal of Clinical and Experimental
infection. Medicine 2017, 10 (2), 1995−2005.

■
(11) Stensballe, J.; Looms, D.; Nielsen, P. N.; Tvede, V.
Hydrophilic-coated catheters for intermittent catheterisation reduce
AUTHOR INFORMATION urethral microtrauma: A prospective, randomised, participant-blinded,
Corresponding Author crossover study of three different types of catheters. Eur. Urol. 2005,
Nicola J. Irwin − School of Pharmacy, Queen’s University 48 (6), 978−983.
Belfast, Belfast BT9 7BL, Northern Ireland, U.K.; orcid.org/ (12) Waller, L.; Jonsson, O.; Norlen, L.; Sullivan, L. Clean
0000-0003-1336-3823; Phone: +44 28 9097 2117; intermittent catheterization in spinal-cord injury patients - long-
term follow-up of a hydrophilic low-friction technique. J. Urol. 1995,
Email: n.irwin@qub.ac.uk 153 (2), 345−348.
Authors (13) Niemczyk, A.; El Fray, M.; Franklin, S. E. Friction behaviour of
hydrophilic lubricious coatings for medical device applications. Tribol.
Michael G. Bryant − School of Mechanical Engineering, Int. 2015, 89, 54−61.
University of Leeds, Leeds LS2 9JT, United Kingdom (14) Chai, T.; Chung, A. K.; Belville, W. D.; Faerber, G. J.
Colin P. McCoy − School of Pharmacy, Queen’s University Compliance and complications of clean intermittent catheterization in
Belfast, Belfast BT9 7BL, Northern Ireland, U.K.; orcid.org/ the spinal-cord injured patient. Paraplegia 1995, 33 (3), 161−163.
0000-0002-6468-2018 (15) De Ridder, D.; Everaert, K.; Fernandez, L. G.; Valero, J. V. F.;
Johann L. Trotter − School of Pharmacy, Queen’s University Duran, A. B.; Abrisqueta, M. L. J.; Ventura, M. G.; Sotillo, A. R.
Belfast, Belfast BT9 7BL, Northern Ireland, U.K. Intermittent catheterisation with hydrophilic-coated catheters (Spee-
Jonathan Turner − School of Pharmacy, Queen’s University diCath) reduces the risk of clinical urinary tract infection in spinal
Belfast, Belfast BT9 7BL, Northern Ireland, U.K. cord injured patients: A prospective randomised parallel comparative
trial. Eur. Urol. 2005, 48 (6), 991−995.
Complete contact information is available at: (16) Armbruster, C. E.; Forsyth-DeOrnellas, V.; Johnson, A. O.;
https://pubs.acs.org/10.1021/acsabm.9b01042 Smith, S. N.; Zhao, L.; Wu, W.; Mobley, H. L. T. Genome-wide
transposon mutagenesis of Proteus mirabilis: Essential genes, fitness
Notes factors for catheter-associated urinary tract infection, and the impact
The authors declare no competing financial interest. of polymicrobial infection on fitness requirements. PLoS Pathog.
Supporting data are openly available at https://doi.org/ 2017, 13 (6), No. 1006434.
(17) Armbruster, C. E.; Prenovost, K.; Mobley, H. L. T.; Mody, L.
10.17034/d5148116-3dcf- 4998-b75d-0ef99dd650f2.

■
How often do clinically diagnosed catheter-associated urinary tract
infections in nursing homes meet standardized criteria? J. Am. Geriatr.
ACKNOWLEDGMENTS Soc. 2017, 65 (2), 395−401.
This work was supported by the EPSRC-NIHR HTC (18) Stickler, D. J.; Morgan, S. D. Modulation of crystalline Proteus
Partnership IMPRESS Network (EP/N027345/1) and the mirabilis biofilm development on urinary catheters. J. Med. Microbiol.
2006, 55 (5), 489−494.
Department for the Economy (Northern Ireland).

■
(19) Irwin, N. J.; McCoy, C. P.; Carson, L. Effect of pH on the in
vitro susceptibility of planktonic and biofilm-grown Proteus mirabilis
REFERENCES to the quinolone antimicrobials. J. Appl. Microbiol. 2013, 115 (2),
(1) McCoy, C. P.; Irwin, N. J.; Hardy, J. G.; Kennedy, S. J.; 382−389.
Donnelly, L.; Cowley, J. F.; Andrews, G. P.; Pentlavalli, S. Systematic (20) Milo, S.; Hathaway, H.; Nzakizwanayo, J.; Alves, D. R.;
optimization of poly(vinyl chloride) surface modification with an Esteban, P. P.; Jones, B. V.; Jenkins, A. T. A. Prevention of
aromatic thiol. Eur. Polym. J. 2017, 97, 40−48. encrustation and blockage of urinary catheters by Proteus mirabilis via
(2) Prokopovich, P.; Perni, S. Prediction of the frictional behavior of pH-triggered release of bacteriophage. J. Mater. Chem. B 2017, 5 (27),
mammalian tissues against biomaterials. Acta Biomater. 2010, 6 (10), 5403−5411.
4052−4059. (21) Liak, T. L.; Po, A. L. W.; Irwin, W. J. The effects of drug-
(3) Jin, Z.; Zheng, J.; Li, W.; Zhou, Z. Tribology of medical devices. therapy on urinary pH - excipient effects and bioactivation of
Biosurface and Biotribology 2016, 2 (4), 173−192. methenamine. Int. J. Pharm. 1987, 36 (2−3), 233−242.
(4) Clark, J. F.; Mealing, S. J.; Scott, D. A.; Vogel, L. C.; (22) Remer, T.; Manz, F. Potential renal acid load of foods and its
Krassioukov, A.; Spinelli, M.; Bagi, P.; Wyndaele, J. J. A cost- influence on urine pH. J. Am. Diet. Assoc. 1995, 95 (7), 791−797.
effectiveness analysis of long-term intermittent catheterisation with (23) Cox, A. J.; Hukins, D. W. L.; Davies, K. E.; Irlam, J. C.; Sutton,
hydrophilic and uncoated catheters. Spinal Cord 2016, 54 (1), 73−77. T. M. An automated technique for in vitro assessment of the
(5) Ho, S. P.; Nakabayashi, N.; Iwasaki, Y.; Boland, T.; LaBerge, M. susceptibility of urinary catheter materials to encrustation. Engineering
Frictional properties of poly(MPC-co-BMA) phospholipid polymer in Medicine 1987, 16 (1), 37.
for catheter applications. Biomaterials 2003, 24 (28), 5121−5129. (24) Lanigan, J.; Fatima, S.; Charpentier, T.; Neville, A.; Dowson,
(6) Wyndaele, J. J. Complications of intermittent catheterization: D.; Bryant, M. Lubricious ionic polymer brush functionalised silicone
their prevention and treatment. Spinal Cord 2002, 40 (10), 536−541. elastomer surfaces. Biotribology 2018, 16, 1−9.
(7) Vapnek, J. M.; Maynard, F. M.; Kim, J. A prospective (25) Knapp, L.; Rushton, L.; Stapleton, H.; Sass, A.; Stewart, S.;
randomized trial of the LoFric hydrophilic coated catheter versus Amezquita, A.; McClure, P.; Mahenthiralingam, E.; Maillard, J. Y. The
conventional plastic catheter for clean intermittent catheterization. J. effect of cationic microbicide exposure against Burkholderia cepacia
Urol. 2003, 169 (3), 994−998. complex (Bcc); the use of Burkholderia lata strain 383 as a model
(8) Newman, D. K.; Wilson, M. M. Review of intermittent bacterium. J. Appl. Microbiol. 2013, 115 (5), 1117−1126.
catheterization and current best practices. Urologic Nursing 2011, 31 (26) Jones, D. S.; McGovern, J. G.; Woolfson, A. D.; Gorman, S. P.
(1), 12−29. Role of physiological conditions in the oropharynx on the adherence
(9) Nickel, J. C.; Olson, M. E.; Costerton, J. W. In vivo coefficient of of respiratory bacterial isolates to endotracheal tube poly(vinyl
kinetic friction - study of urinary catheter biocompatibility. Urology chloride). Biomaterials 1997, 18 (6), 503−510.
1987, 29 (5), 501−503. (27) Miles, A. A.; Misra, S. S.; Irwin, J. O. The estimation of the
(10) Aygin, D.; Usta, E. The effect of lubricants used in indwelling bactericidal power of the blood. Epidemiol. Infect. 1938, 38 (6), 732−
bladder catheterization through urethra on procedure-related pain: a 749.

H https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX
ACS Applied Bio Materials www.acsabm.org Article

(28) McCoy, C. P.; Irwin, N. J.; Brady, C.; Jones, D. S.; Carson, L.; (46) Kristinsson, K. G. Adherence of Staphylococci to intravascular
Andrews, G. P.; Gorman, S. P. An infection-responsive approach to catheters. J. Med. Microbiol. 1989, 28 (4), 249−257.
reduce bacterial adhesion in urinary biomaterials. Mol. Pharmaceutics (47) Bridgett, M. J.; Davies, M. C.; Denyer, S. P.; Eldridge, P. R. In
2016, 13 (8), 2817−2822. vitro assessment of bacterial adhesion to hydromer(r)-coated
(29) Coates, J. Interpretation of infrared spectra, a practical cerebrospinal-fluid shunts. Biomaterials 1993, 14 (3), 184−188.
approach. In Encyclopedia of Analytical Chemistry, 1st ed.; Meyers, (48) Wand, M. E.; Bock, L. J.; Bonney, L. C.; Sutton, J. M.
R. A., Ed.; John Wiley and Sons Ltd.: Chichester, 2000; pp 10815− Mechanisms of increased resistance to chlorhexidine and cross-
10837. resistance to colistin following exposure of klebsiella pneumoniae
(30) Yang, S.-H.; Lee, Y.-S. J.; Lin, F.-H.; Yang, J.-M.; Chen, K.-S. clinical isolates to chlorhexidine. Antimicrob. Agents Chemother. 2017,
Chitosan/poly(vinyl alcohol) blending hydrogel coating improves the 61 (1), 1−12.
surface characteristics of segmented polyurethane urethral catheters. J. (49) McCann, M.; Fitzpatrick, F.; Mellotte, G.; Clarke, M. Is 2%
Biomed. Mater. Res., Part B 2007, 83B (2), 304−313. chlorhexidine gluconate in 70% isopropyl alcohol more effective at
(31) Okano, T.; Nishiyama, S.; Shinohara, I.; Akaike, T.; Sakurai, Y.; preventing central venous catheter-related infections than routinely
Kataoka, K.; Tsuruta, T. Effect of hydrophilic and hydrophobic used chlorhexidine gluconate solutions: A pilot multicenter
microdomains on mode of interaction between block polymer and randomized trial (ISRCTN2657745)? Am. J. Infect. Control 2016,
blood-platelets. J. Biomed. Mater. Res. 1981, 15 (3), 393−402. 44 (8), 948−949.
(32) Hanssen, H. H. L.; Wetzels, G. M. R.; Benzina, A.; van der (50) Karpanen, T. J.; Casey, A. L.; Whitehouse, T.; Nightingale, P.;
Veen, F. H.; Lindhout, T.; Koole, L. H. Metallic wires with an Das, I.; Elliott, T. S. J. Clinical evaluation of a chlorhexidine
adherent lubricious and blood-compatible polymeric coating and their intravascular catheter gel dressing on short-term central venous
use in the manufacture of novel slippery-when-wet guidewires: catheters. Am. J. Infect. Control 2016, 44 (1), 54−60.
Possible applications related to controlled local drug delivery. J. (51) Duzkaya, D. S.; Uysal, G.; Bozkurt, G.; Yakut, T.; Citak, A.
Biomed. Mater. Res. 1999, 48 (6), 820−828. Povidone-iodine, 0.05% chlorhexidine gluconate, or water for
(33) Yuan, Y.; Hays, M. P.; Hardwidge, P. R.; Kim, J. Surface periurethral cleaning before indwelling urinary catheterization in a
characteristics influencing bacterial adhesion to polymeric substrates. pediatric intensive care: a randomized controlled trial. Journal of
RSC Adv. 2017, 7 (23), 14254−14261. Wound Ostomy and Continence Nursing 2017, 44 (1), 84−88.
(34) Ngo, B. K. D.; Grunlan, M. A. Protein resistant polymeric
biomaterials. ACS Macro Lett. 2017, 6 (9), 992−1000.
(35) Irwin, N. J.; McCoy, C. P.; McCullough, A. R.; Corbett, D. J.
Use of in vitro and haptic assessments in the characterisation of
surface lubricity. Proc. Inst. Mech. Eng., Part H 2019, 233 (1), 84−90.
(36) Fader, M.; Moore, K. N.; Cottenden, A. M.; Pettersson, L.;
Brooks, R.; Malone-Lee, J. Coated catheters for intermittent
catheterization: smooth or sticky? BJU Int. 2001, 88 (4), 373−377.
(37) Rudy, A.; Kuliasha, C.; Uruena, J.; Rex, J.; Schulze, K. D.;
Stewart, D.; Angelini, T.; Sawyer, W. G.; Perry, S. S. Lubricous
hydrogel surface coatings on polydimethylsiloxane (PDMS). Tribol.
Lett. 2017, 65 (1), 3−3.
(38) Pitenis, A. A.; Uruena, J. M.; Schulze, K. D.; Nixon, R. M.;
Dunn, A. C.; Krick, B. A.; Sawyer, W. G.; Angelini, T. E. Polymer
fluctuation lubrication in hydrogel gemini interfaces. Soft Matter 2014,
10 (44), 8955−8962.
(39) Ma, S. H.; Scaraggi, M.; Wang, D. A.; Wang, X. L.; Liang, Y. M.;
Liu, W. M.; Dini, D.; Zhou, F. Nanoporous substrate-infiltrated
hydrogels: a bioinspired regenerable surface for high load bearing and
tunable friction. Adv. Funct. Mater. 2015, 25 (47), 7366−7374.
(40) Shi, Y.; Xiong, D. S.; Liu, Y. T.; Wang, N.; Zhao, X. D. Swelling,
mechanical and friction properties of PVA/PVP hydrogels after
swelling in osmotic pressure solution. Mater. Sci. Eng., C 2016, 65,
172−180.
(41) Anil, M.; Ahmed, S. F.; Yi, J. W.; Moon, M. W.; Lee, K. R.;
Kim, Y. C.; Seok, H. K.; Han, S. H. Tribological performance of
hydrophilic diamond-like carbon coatings on Ti-6Al-4V in biological
environment. Diamond Relat. Mater. 2010, 19 (4), 300−304.
(42) Dunn, A. C.; Sawyer, W. G.; Angelini, T. E. Gemini interfaces
in aqueous lubrication with hydrogels. Tribol. Lett. 2014, 54 (1), 59−
66.
(43) Cassir, N.; Thomas, G.; Hraiech, S.; Brunet, J.; Fournier, P. E.;
La Scola, B.; Papazian, L. Chlorhexidine daily bathing: Impact on
health care-associated infections caused by gram-negative bacteria.
Am. J. Infect. Control 2015, 43 (6), 640−643.
(44) Irwin, N. J.; McCoy, C. P.; Jones, D. S.; Gorman, S. P.
Infection-responsive drug delivery from urinary biomaterials con-
trolled by a novel kinetic and thermodynamic approach. Pharm. Res.
2013, 30 (3), 857−865.
(45) Xu, X.; Li, Y. L.; Wang, L. X.; Li, Y.; Pan, J. J.; Fu, X. M.; Luo,
Z. Y.; Sui, Y.; Zhang, S. Q.; Wang, L.; Ni, Y. F.; Zhang, L.; Wei, S. C.
Triple-functional polyetheretherketone surface with enhanced bacter-
iostasis and anti-inflammatory and osseointegrative properties for
implant application. Biomaterials 2019, 212, 98−114.

I https://dx.doi.org/10.1021/acsabm.9b01042
ACS Appl. Bio Mater. XXXX, XXX, XXX−XXX