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Ann Surg. Author manuscript; available in PMC 2021 June 01.
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Published in final edited form as:

Ann Surg. 2020 June ; 271(6): 1174–1185. doi:10.1097/SLA.0000000000003053.

Staphylococcus aureus Biofilm Infection Compromises Wound

Healing by Causing Deficiencies in Granulation Tissue Collagen
Sashwati Roy, PhD*,†,‡, Suman Santra, PhD*,†,‡, Amitava Das, PhD*,†,‡, Sriteja Dixith, MS†,‡,
Mithun Sinha, PhD*,†,‡, Subhadip Ghatak, PhD*,†,‡, Nandini Ghosh, MS*,†,‡, Pradipta
Banerjee, PhD*,†,‡, Savita Khanna, PhD*,†,‡, Shomita Mathew-Steiner, PhD*,†,‡, Piya Das
Ghatak, MS*,†,‡, Britani N. Blackstone, PhD§, Heather M. Powell, PhD§,¶,∥, Valerie K.
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Bergdall, DVM**, Daniel J. Wozniak, PhD††,‡‡, Chandan K. Sen, PhD*,†,‡,§§

* Department of Surgery, IU Health Comprehensive Wound Center, Indiana Center for

Regenerative Medicine and Engineering, Indiana University School of Medicine, Indianapolis, IN

† Comprehensive Wound Center, The Ohio State University, Columbus, OH
‡ Department of Surgery, The Ohio State University, Columbus, OH
§ Department of Materials Science and Engineering, The Ohio State University, Columbus, OH
¶ Department of Biomedical Engineering, The Ohio State University, Columbus, OH
∥ Research Department, Shriners Hospitals for Children, Cincinnati, OH
** Department of Veterinary Preventive Medicine, The Ohio State University, Columbus, OH
††
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Department of Microbial Interface Biology, The Ohio State University, Columbus, OH

‡‡Department of Microbial Infection and Immunity, Microbiology, The Ohio State University,
Columbus, OH
§§ Lead contact, Indianapolis, IN.

Abstract
Objective—The objective of this work was to causatively link biofilm properties of bacterial
infection to specific pathogenic mechanisms in wound healing.

Background—Staphylococcus aureus is one of the four most prevalent bacterial species

identified in chronic wounds. Causatively linking wound pathology to biofilm properties of
bacterial infection is challenging. Thus, isogenic mutant stains of S. aureus with varying degree of
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biofilm formation ability was studied in an established preclinical porcine model of wound biofilm
infection.

Reprints: Chandan K. Sen, PhD, 975 W Walnut Street, Suite 454, Medical Research Library Building, Indiana University School of
Medicine, Indianapolis, IN 46202. [email protected].
C.K.S., S.R., D.J.W., S.K., H.M.P., and V.K.B. conceived and designed the work. S.S., A.D., T.D., M.S., S.G., N.G., P.B., S.K., S.R.,
S.M.-S., H.M.P. P.D.G., and B.B. collected, analyzed data for this work and participated in the preparation of the manuscript. C.K.S.,
S.R., A.D., and S.S. wrote the manuscript. All authors reviewed the manuscript.
The authors report no conflicts of interest.
Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML
and PDF versions of this article on the journal’s Web site (www.annalsofsurgery.com).
 Roy et al. Page 2

Methods—Isogenic mutant strains of S. aureus with varying degree (ΔrexB > USA300 > ΔsarA)
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of biofilm-forming ability were used to infect full-thickness porcine cutaneous wounds.

Results—Compared with that of ΔsarA infection, wound biofilm burden was significantly higher
in response to ΔrexB or USA300 infection. Biofilm infection caused degradation of cutaneous
collagen, specifically collagen 1 (Col1), with ΔrexB being most pathogenic in that regard. Biofilm
infection of the wound repressed wound-edge miR-143 causing upregulation of its downstream
target gene matrix metalloproteinase-2. Pathogenic rise of collagenolytic matrix
metalloproteinase-2 in biofilm-infected wound-edge tissue sharply decreased collagen 1/collagen
3 ratio compromising the biomechanical properties of the repaired skin. Tensile strength of the
biofilm infected skin was compromised supporting the notion that healed wounds with a history of
biofilm infection are likely to recur.

Conclusion—This study provides maiden evidence that chronic S. aureus biofilm infection in
wounds results in impaired granulation tissue collagen leading to compromised wound tissue
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biomechanics. Clinically, such compromise in tissue repair is likely to increase wound recidivism.

Keywords
biofilm; extracellular matrix; wound

Systematic review and meta-analysis of several hundred wound studies reported a 78.2%
prevalence of biofilms in chronic wounds.1 A rapidly growing body of evidence establishes
biofilm infection as a major cause of delayed wound healing.2–5 Staphylococcus is one of
the predominant (65%) causes of persistent infections in chronic wounds.6 Bacteria of the
Staphylococcus genus are highly efficient in establishing biofilms resulting in persistent
infection.7 Gram-positive Staphylococcus is a nonmotile, and nonspore-forming bacteria
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that readily adheres to highly proteinaceous surfaces of chronic wounds and forms matrix-
encased communities resulting in persistent chronic wound infection that is recalcitrant to
antibacterial therapies.8

Despite substantial evidences linking biofilm infection with impaired wound healing,
mechanisms underlying impairments in wound healing caused by biofilm infections have
only recently started to unfold.4,5 Majority of studies investigating mechanisms underlying
the pathogenicity of biofilm utilize in vitro biofilm models.9 While this approach provides
the opportunity of elegant traceability, the absence of host factors compromises the
relevance of such studies to wound infection in vivo.10 Although of a lesser magnitude,
similar concerns apply to the study of biofilm grown on tissue explants lacking immune
surveillance. Recent studies demonstrated a clear role of the host immune system in shaping
microbial mechanisms relevant to biofilm pathology.11,12 Such mechanisms unfold over
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time.13,14 Thus, to understand the cascade of mechanisms following biofilm infection of the
cutaneous wound, a long-term model involving deliberate infection of clinically isolated
bacteria is necessary. It is widely accepted that porcine skin wound healing most closely
resembles the human healing process. Furthermore, the human immune system has a higher
similarity to the porcine immune system compared with rats or mice, making it a better
suited model for studies on the host interactions that are integral to the complexities of the

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pathological biofilm in wound infections.10 The Wound Healing Society recommends the
porcine model as the most relevant preclinical model of skin wound healing.15
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Our interest in understanding the mechanism underlying biofilm infection in wound healing
led to the development of a preclinical porcine persistent biofilm infection wound model.4,5
Using this model, we provided first evidence that biofilm-inducible microRNAs specifically
silence tight junction proteins resulting in impaired barrier function of the neo-epidermis at
the wound-site.5 Furthermore, our recent work underscores the significance of the
preclinical porcine persistent biofilm infection model to study novel interventions.4
Staphylococcus aureus (SA) is one of the four most prevalent bacterial species identified in
chronic wounds.16 While there are numerous studies testing the efficacy of a specific
treatment for management of SA biofilm, understanding of molecular mechanisms
explaining the pathogenicity of SA biofilm is scantly studied.17 While there is limited
information from short-term rodent studies, there is a clear void in time-dependent
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understanding of molecular mechanisms in the porcine or human systems.

The current work is the first to specifically address the biofilm component of SA
pathogenicity by the comparative use of three isogenic mutant strains of SA. Importantly,
each of these strains is known to possess varying degrees of biofilm-forming ability. Well-
characterized S. aureus USA300LAC (USA300) served as the model strain for wound
infection. The biofilm-forming capability of this strain is well documented.18 The isogenic
mutant strains USA300::-sarA (ΔsarA) and USA300::rexB (ΔrexB) were used as hypo- and
hyperbiofilm-forming mutants, respectively.19,20 Staphylococcal accessory regulator (sarA)
is one of the global regulators implicated in biofilm formation.20 Biofilm-forming capacity
is compromised in sarA mutants,19,20 The Δrex B is a transposon mutant that was created by
disruption of rexB, which encodes for an ATP-dependent helicase/nuclease subunit that is
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important in DNA repair of double-stranded breaks. We report the hyperbiofilm activity of

this strain. This work represents the maiden effort to utilize mutant bacterial strains of
graded biofilm-forming ability to interrogate biofilm-dependent mechanisms of action in the
healing wound.

METHODS
Ethics Statement
The Ohio State University Institutional Animal care and Use Committee approved all animal
experiments.

Porcine Full-thickness Burns and Biofilm Infection

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Porcine infections were carried out as previously described.5 In brief, under general
anesthesia, reproducible, full-thickness burn wounds were created bilaterally on the
dorsolateral trunk. After hair removal with clippers, the dermis was prepped using
alternating chlorhexidine and alcohol wipes. A total of six, 2″ × 2″ wounds were generated
using a pressure and temperature controlled metallic dice. Wounds were individually
covered with Tegaderm™ (3 M) dressing and the entire wound area secured with
consecutive bandaging with V.A.C drape (Owens & Minor), VetWrap™, and Elasticon (3

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M). After 3 days, the bandages were removed under general anesthesia to allow for bacterial
inoculation of the burn wounds. A total of 108 CFU of S. aureus (SA) mutants sarA and
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rexB and wild-type SA, USA300 was inoculated onto the wounds topically and dispersed
across the surface with sterile spatula. Control wounds were inoculated with vehicle only.
The wounds were covered individually after bacterial inoculation and bandaged as described
above. Full-thickness, excisional wound biopsies (oriented in the sagittal plane) were
removed at days 7, 14, and 35 postbacterial inoculation and placed in 10% neutral-buffered
formalin for >72 hours. Normal/nonburned skin (~1 cm) from each side of the wound was
included in the biopsy. Skin samples were placed on wooden tongue depressors to maintain
skin shape prior to fixation.

Histopathology, Immunocytochemistry, and Imaging

Histopathology immunocytochemistry and imaging was performed as described previously.4
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Scanning Electron Microscope Imaging

Sample processing and imaging was performed as previously described.4

Secondary-intention Excisional Murine Dermal Wound Model

Young male (8 wk of age) C57BL/6 mice were used. Two 8 × 16-mm full-thickness
excisional wounds21 were placed on the dorsal skin, equidistant from the midline and
adjacent to the 4 limbs. Each of the 2 wounds was topically infected with isogenic strains of
S. aureus USA300, USA300::rexB (ΔrexB) or USA300::sarA (ΔsarA). The animals were
euthanized d5 postwound closure, and the wound areas excised for further analyses.

Skin Biomechanics
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Tensile strength of the healed murine skin was quantified using tensile testing to failure.
Mouse fur was removed from the excised, healed full-thickness skin, being careful to
exclude the panniculus. Samples were obtained using a dog bone shaped punch (gauge
length of 9.35 mm, gauge width of 3 mm) with the center of the wound positioned in the
central region of the punch. Each skin sample was placed into the grips of the tensile tester
(TestResources 100R, Shakopee, MN) outfitted with a 2.2lb load cell. Skin was placed in
between 2 squares of gauze prior to manual tightening of the grips and subsequently strained
at a rate of 2 mm/s until failure. If samples did not fail within the gauge length, data was
discarded (note: in this study all samples failed within the gauge length). Maximum load at
failure for each sample was extrapolated from the load (N)-position (mm) plot.

RNA Isolation and Quantitative Real-time PCR

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Total RNA, including the miRNA, was isolated using mirVana RNA isolation kit followed
by quantitative PCR assay as previously reported.22,23

Enzyme-linked Immunosorbent Assay

Levels of matrix metalloproteinase-2 (MMP-2) were measured using commercially available
enzyme-linked immunosorbent assay kit following manufacturer’s protocol as previously
described.22,23

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miR-target 3′—UTR Luciferase Reporter Assay

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miRIDIAN mimic-miR-143 were transfected to human Fibroblast cells followed by

transfection with pmiR target MMP-2 3’UTR plasmids. Luciferase assays were performed
using Gaussian luciferase reporter assay (Genecopia). Normalization was achieved by seap
value. Data were presented as ratio of Gaussian luciferase to secreted alkaline phosphatase.

Hydroxyproline Assay
Collagen content of wound edge tissue was assessed by determining the amount of
hydroxyproline using a commercially available hydroxy proline assay kit (MAK008 Sigma
Aldrich) following manufacturers protocol. In brief, frozen wound tissue was pulverized
under liquid nitrogen followed by acid hydrolysis using 12N hydrochloric acid (HCl) and
water (1:1) for 3 hrs at 110°C. The hydrolyzed material was dehydrated overnight was at
60°C. For the assay, a mixture of Chloramine T and oxidation buffer was added to reaction
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and incubated at room temperature for 5 minutes. p-dimethylaminobenzaldehyde, percholic

acid and isopropanol mixture was added to each well and incubated at 60°C for 90 minutes.
The samples were cooled to room temperature and absorbance was measured at 562 nm, and
the amount of hydroxyproline present in samples was determined by comparison to a
standard curve.

Zymography
Gelatin zymography was performed. For each sample, 30 μg of total serum protein was
loaded in 10% zymogram gels (Novex). Electrophoresis was carried out using the minigel
slab apparatus Mini Protean 3 (Biorad) at a constant voltage of 150 V, until the dye reached
the bottom of the gel. Following electrophoresis, gels were washed in renaturation buffer
(2.5% Triton X-100 in 50 mM Tris–HCl (pH 7.5)) for 1 hour in an orbital shaker. Then the
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zymograms were incubated for 18 hours at 37°C in incubation buffer (0.15M NaCl, 10mM
CaCl2, 0.02% NaN3 in 50mM Tris–HCl (pH 7.5)). Gels were then stained with Coomassie
blue and destained with 7% methanol and 5% acetic acid. Areas of enzymatic activity
appeared as clear bands over the dark background.

Cell Culture
Human immortalized fibroblasts were grown under standard culture conditions (at 37°C in a
humidified atmosphere consisting of 95% air and 5% CO2) in DMEM growth medium
supplemented with 10% FBS, 100 IU/mL antimicrobial-antimycotic, 10 mmol/L L-
glutamine.

Preparation of Conditioned Media

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Mutants and wild-type strains of S. aureus, ΔsarA, ΔrexB and USA300 (108 CFU/mL)
bacterial biofilms were grown on a membrane and after 48 hours of growth the membranes
were incubated with fibroblast media without antibiotics for 18 hours and filtered through
0.2 μm filter.

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Statistics
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In vitro data are reported as mean ± SEM of 3 to 8 experiments as indicated in the respective
figure legends. Comparisons among multiple groups were tested using analysis of variance.
For animal studies, data are reported as mean ± SEM of 3–6 animals as indicated. Student t
test (2-tailed) was used to determine significant differences between means. Comparisons
among multiple groups were tested using analysis of variance. P < 0.05 was considered
statistically significant.

RESULTS
Biofilm-forming Ability of S. aureus (SA) Transposon Mutants in Porcine Burn Wounds
Day 3 porcine burn wounds were infected by isogenic strains of S. aureus USA300, ΔsarA
or ΔrexB. The wounds were harvested at specific time points and biofilm formation ability
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was evaluated using 2 standardized approaches: 1) anti-SA antibody and confocal laser
scanning microscopy (CLSM), and 2) Scanning Electron Microscopy (SEM) imaging.
CLSM imaging studies revealed thick biofilm (Z section, 20 μm) at day 7 produced by all 3
strains. On day 14 and day 35 postinfection, USA 300 and Δrex B showed thick biofilm and
large green SA aggregates. In contrast, biofilm by ΔsarA mutant was diminished at these
latter time-points (Fig. 1A, C). Interestingly on day 14, SEM imaging show SA cocci
embedded in thick Extracellular Polymeric Substance (EPS) in the case of ΔrexB mutant.
Although a large number of cocci persisted in USA300 infected wounds, these cells were
not embedded in thick EPS (Fig. 1B). A markedly diminished number of cocci not
embedded in EPS were noted in ΔsarA supporting the CLSM data (Fig. 1B).

The gene expressions of RNAIII and agrA in day 35 wound-edge tissue were consistent with
observations on magnitude of biofilm as observed by SEM. The expression of RNAIII and
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agrA genes were highly upregulated in ΔrexB as compared with ΔsarA mutant (Fig. 1D).
CLSM and SEM imaging of in vitro SA biofilms developed on polycarbonate membrane
supported the in vivo wound observations (Fig. 1E, S1, http://links.lww.com/SLA/B514)
establishing ΔrexB as hyperbiofilm forming and ΔsarA as hypobiofilmforming USA300
mutant strains both in vitro and in vivo. Following the characterization of these mutant
strains for their biofilm-forming ability, these mutants were used for investigating host
wound healing responses.

Compromised Wound Epithelialization and Granulation Tissue Collagen Biosynthesis

Wound closure, as determined by digital planimetry, was comparable among 3 types of
infections studied (Fig. 2A). However, significant attenuation (~50%) of re-epithelialization
was noted in whole wound cross-section histological images in hyperbiofilm-forming ΔrexB
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infected wounds compared with ΔsarA or USA300 infections (Fig. 2B–D). Masson’s
trichrome staining revealed a marked reduction in granulation tissue collagen content (blue
stain) in burn wounds infected with ΔrexB (hyperbiofilm) or USA300 infected wounds
compared with group infected with ΔsarA (hypo-biofilm; Fig. 3A, C). The detection and
analysis of collagen fibers in granulation tissue were additionally performed using
Picrosirius red staining. This staining, under polarized light, allows the visualization of
collagen bundles as green, red, or yellow that are clearly distinct from the black background

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allowing for quantitative analysis (Fig. 3B).24 Marked reduction in granulation tissue
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collagen level in ΔrexB (hyperbiofilm) and USA300 infected wounds were noted when
compared with ΔsarA (hypo-biofilm) infected burn wounds (Fig. 3B, D). Hydroxyproline
assay was performed to quantify collagen levels in wound-edge tissue. Significant loss of
collagen in hyperbiofilm infected wounds was noted compared with hypobiofilm-infected
SA mutant (Fig. 3E). To test the functional significance of this observation, tensile strength
of the healed skin was studied in murine wounds infected with USA300, ΔsarA or ΔrexB.
Concomitant with significantly compromised tensile strength following hyperbiofilm
infection, the murine model recapitulated hyperbiofilm infection mediated loss of Collagen
1, repression of miR-143 and de-silencing of MMP-2 expression (Fig S3, http://
links.lww.com/SLA/B514) as observed in the porcine model.

Loss of Collagen Type I (Col1) in Granulation Tissue

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Significant reduction in both Col1 mRNA and protein expression were noted in USA300 as
well as ΔrexB infected compared with the ΔsarA infected wounds (Fig. 4A–C). Levels of the
immature collagen Col3 were higher in the granulation tissue of wounds infected with
ΔrexB (hyperbiofilm; Fig. 4A–C). Findings with Col1 and Col3 were further characterized
using Herovici staining (Fig. 4D–E). This polychrome staining specifically identifies and
quantifies the expression and distribution of types I (purple/red) and III (blue) collagen.25

miR-143 and MMP-2 Expression and Activity in Wound Fibroblasts Is Regulated by SA

Biofilm Infection
In our search for mechanisms silencing Col1 in the granulation tissue, we hypothesized that
biofilm infection induces host and/or bacterial collagenases at the wound-site. Thus,
bacterial collagenase activity was measured from SA-biofilm-infected wounds using a
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bacterial collagenase-specific synthetic peptide FALGPA (N-[3-(2-Furyl)acryloyl]-Leu-Gly-

Pro-Ala). Bacterial collagenases, compared with vertebrate collagenases, show broader
substrate specificity and make multiple cleavage within the triple helical region.26 No
significant change was noted in the bacterial collagenase activity in wounds infected with
any of the three isogenic strains of bacteria (Fig S5, http://links.lww.com/SLA/B514).
Zymography is routinely employed for measurement of collagenolytic activity of tissue
extracts.27 Zymography of denatured Col1, also referred to as gelatin, demonstrated a
marked increase in activated MMP-2 expression in ΔrexB and USA 300 infected wounds as
compared with ΔsarA (hypobiofilm) infected burn wounds (Fig. 5A). A significant induction
in the transcript and protein expression of MMP-2 was observed in hyperbiofilm-infected
wounds (Fig. 5B, C). We identified miR-143 as a S. aureus biofilm-sensitive miRNA which
when repressed leads to the desilencing of MMP-2 and loss of collagen. miR-143 is
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abundantly expressed in vascular smooth muscle cells and fibroblasts. Interestingly, ΔrexB
and USA300 biofilm infection in burn wounds downregulated miR-143 (Fig. 5D). In
wounds, fibroblasts are the primary cell type of the granulation tissue. We used hTERT
immortalized cultured human fibroblasts (hFb) and exposed these cells to conditioned media
(CM) from in vitro mature biofilms from the three isogenic strains of SA studied in this
work (Fig. 5E). Exposure of hFb to CM from hyperbiofilm-forming ΔrexB resulted in
increased MMP-2 and loss of miR-143 (Fig. 5F, G). The translational significance of the
findings in porcine and murine wounds was tested in human engineered (HE) skin. HE skin

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was treated with CM from in vitro mature biofilms. Exposure of HE skin to CM from
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hyperbiofilm-forming ΔrexB suppressed miR-143, desilenced MMP-2 causing loss of

Collagen 1 protein (Figs S6, http://links.lww.com/SLA/B514). This observation supports the
notion that part of the biofilm-induced loss of Col1 in wounds could be attributed to the
effect of biofilm-released soluble factors on wound-site fibroblasts.

MMP-2, a Direct Target of miR-143 in Fibroblasts

Bioinformatics analyses using RNAHybrid28 recognized miR-143 with potential binding
sites on MMP-2 mRNA (Fig. 6A). Using MMP-2 3’-UTR firefly luciferase expression
constructs the effect of miR-143 on MMP-2 transcription was tested (Fig. 6B). To directly
test the significance of this miR on MMP-2 and collagen expression, studies using miRidian
miR-143 mimic and inhibitors (Fig. 6C, D) were performed (Fig. 6C–G). Delivery of
miR-143 mimics or their corresponding inhibitors showed that the miRNA was inversely
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associated with the expression of corresponding MMP-2 protein (Fig. 6E, F). Bolstering
miR-143 levels in hFb using mimic resulted in strong induction of cellular collagen
expression (Fig. 6G, H). Knockdown of MMP-2 using siRNA significantly increased
collagen 1 protein (Fig. 6I, J). Thus, lowering of miR-143 as observed following ΔrexB
hyperbiofilm infection desilenced and thus upregulated MMP-2 resulting in lowering of
collagen 1 (Fig. 7).

DISCUSSION
Collagenopathies, caused by genetic defects in collagen formation, have substantial health
impact affecting almost each and every tissue system.29 Collagenopathy of the skin
markedly changes the biomechanical properties of the skin such that they are easily torn by
the slightest trauma.30 In wound healing, this poses the risk of wound recidivism which
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represents a major threat to the growing cost of wound care.31 This work compares three
isogenic mutant strains of SA with graded biofilm-forming ability to come to the conclusion
that wound biofilm infection causes significant reduction in collagen type I in the wound bed
compromising tensile strength of the repaired tissue. Such outcomes increase the risk of
wound recidivism.32 Given the high incidence of biofilm infection reported in chronic
wounds, the current work is of extraordinary significance drawing attention to the quality of
closure of biofilm infected wounds. Our previous work has reported that although the effects
of chronic biofilm infection on wound closure may be marginal over a period of two months,
such infection results in failure of the skin barrier function at the site of healing.4,5 The
current work demonstrates that biofilm infection impairs granulation tissue collagen
deposition leading to increased risk of wound recurrence as predicted by compromised
tensile strength of the repaired tissue. Skin fibroblasts are critical in contributing the
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extracellular matrix (ECM) to support physiological wound healing. Collagen is one of the
most abundant ECM proteins in skin as well as in a healing wound.33 In a healing wound,
Col3 appears first as an early collagen in granulation tissue which is then gradually replaced
by Col1, a central protein that is responsible for the wound tensile strength.34 The counter
balance of ECM synthesis is provided by matrix MMPs. On one hand, MMPs are essential
for physiological wound healing. MMPs break down ECM, thus allowing migration of cells
and remodeling of the injured tissue. On the other hand, excessive MMPs in the wound

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milieu could be detrimental, resulting in nonhealing chronic wounds. High levels of MMPs
are a common characteristic property of chronic wounds.35
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This study utilizes a unique approach of in vivo graded biofilm infection in a preclinical
porcine burn wounds to establish a direct cause and effect relationship between methicillin-
resistant S. aureus (MRSA) biofilm infected wound and defective collagen levels via a novel
miRNA-MMP axis. S. aureus is one of the most common causes of hospital/community
acquired wound infections. In our efforts to establish an in vivo preclinical burn chronic
biofilm infection model where the host responses to SA biofilm infection may be causatively
linked to specific host wound healing response, we utilized USA300 and isogenic mutant
strains ΔsarA and ΔrexB, with varying biofilm-forming capabilities. In 1959, with the
introduction of semisynthetic penicillin, methicillin, the wave of resistance emerged with
MRSA that gained considerable attention due to invasive nature of the infection.36 MRSA is
capable of forming robust biofilm and persists in host contributing to relapsing chronic
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infections in wound tissue.3 USA300, the model organism used in the current study is a
specific MRSA lineage that was first reported by McDougal et al37 in 2003. USA300 is a
predominant strain in US hospitals.38

Fibroblasts from chronic wounds have been reported to produce defective collagen.39
Consistently, we noted that in hyper-biofilm-infected wounds there was a marked reduction
in both Col1 transcript as well as protein indicative of blocked Col1 synthesis. Col1 is a
predominant collagen in mature dermis as well as in late phase of wound healing.34 In the
wound granulation tissue, fibroblasts differentiate to form myofibroblasts which deposit
collagen.40 Soluble factors released from SA biofilm are known to limit migration and
differentiation of fibroblasts.41 In this work, we observed that exposure of isolated
fibroblasts to secreted products from SA biofilms blunted Col1 expression. Collagen
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biosynthesis involves: 1) expression of polypeptides and posttranslational modification, 2)

folding into a triple helix, and 3) secretion and maturation of procollagen to collagen.42
Post-transcriptional control plays a pivotal role in the synthesis and production of Col1
polypeptides.43 miRNA are about 18 to 24 nucleotide long, single-stranded RNA molecules
that have emerged as key post-transcriptional regulators of gene expression.44 A number of
miRNA, including miR-29 and 143/145 clusters, regulate collagen expression.45,46 While
miR-29 was nonresponsive to biofilm-infection in burn wounds, this study reports potent
inhibition of miR-143 expression in response to hyperbiofilm infection. miR-143/145 is
abundantly expressed in cells of mesenchymal origin.47 A major role of this cluster in
intestinal wound repair is evident.48 Under conditions of hypertrophic scarring, miR-143–3p
attenuates ECM production-associated proteins including the expression of Col1 and 3. This
is achieved by targeting CTGF via the Akt/mTOR pathway.49 In fibroblasts, direct inverse
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regulation of Col3 by miR-143 has been reported.46 Increased Col3 expression in hyper-
biofilm infected wounds may be explained by the loss of miR-143 in wound granulation
tissue fibroblasts. Tight control of collagen levels in physiological wound healing is
maintained by a fine balance of biosynthesis and breakdown. In the wound
microenvironment, MMPs contribute to the breakdown of collagen.35 This work recognizes
S. aureus MRSA biofilm infection as a potent inducer of MMP-2 activity. Such regulation is
indirect and caused by biofilm-dependent depletion of miR-143. miR-143 is directly
implicated in posttranscriptional silencing of MMP-2. Thus, this work provides a

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mechanistic explanation to the common observation that chronic wounds are rich in
MMP-2.50
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Taken together, this study utilized SA strains with graded biofilm-forming ability to
specifically dissect the biofilm-dependent pathogenic mechanisms in the healing wound.
Long-term outcomes studied in an established porcine model of biofilm infection, show
striking collagen 1 deficiency in the wound granulation tissue. Such deficiency compromised
wound re-epithelialization. Biofilm inhibited collagen synthesis and induced collagenolytic
MMP-2 by lowering miR-143. Low collagen 1, a major structural protein of ECM, in
wounds culminated in poor wound tensile strength of the repaired skin. Clinical studies
looking for higher wound recidivism of closed wounds with a history of biofilm infection
are warranted.

Supplementary Material
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Refer to Web version on PubMed Central for supplementary material.

ACKNOWLEDGMENTS
The following reagent was provided by the Network on Antimicrobial Resistance in Staphylococcus aureus
(NARSA) for distribution by BEI Resources, NIAID, NIH: Staphylococcus aureus subsp. aureus, Strain JE2,
Transposon Mutant NE1012 (SAUSA300_0869), NR-47555, NE1193 (SAUSA300_0605), NR-47736. Technical
help from Dr Kasturi Ganesh Barki is acknowledged for pig experiments and tissue collection.

This work was partly supported by National Institute of Health NR015676, NR013898 and Diacomp, NIDDK
(Augusta University). In addition, it benefited from the following National Institutes of Health awards: GM077185,
GM069589, GM108014, DK076566, DK114718, AI097511, and NS42617.

REFERENCES
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FIGURE 1.
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Evidence of hyperbiofilm formation by S. aureus, transposon mutant USA300::rexB while

USA300::sarA mutant is a hypobiofilm-forming strain in porcine burn wound infections. Six
2 × 2 sq inch size burn wounds were created on back of pigs. On day 3 post-burn, the
wounds were infected by isogenic strains of S. aureus USA300: USA300, USA300::rexB
(ΔrexB) or USA300::sarA (ΔsarA). A, Representative confocal laser scanning microscopy
images from burn wounds on days 7, 14, and 35 postinfection showing S. aureus (anti-SA,
green) aggregates. Counterstaining was performed using DAPI (blue, nucleus). Z-stack

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images of tissues sections (20 μm) from burn wound are shown. Scale bar = 50 μm. B,
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Representative scanning electron microscopy (SEM) images from SA infected burn wounds
on days 7 and 14 postinfection. Scale bar = 5 μm. C, Quantifications of S. aureus aggregates
for images shown in (A). Data are mean ± SEM (n = 3), *P < 0.05 compared with ΔsarA. D,
Quantification of mRNA levels of biofilm/virulence specific genes in biofilm infected burn
wound tissue was determined using real-time PCR. The data was normalized against 16 s
rRNA. Data are mean ± SEM (n = 6), *P < 0.05 compared with ΔsarA. E, SEM images of in
vitro SA biofilms developed on polycarbonate filters. Scale bar = 5 μm.
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FIGURE 2.
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Effects of S. aureus (SA) biofilm infection on burn wound healing evaluated using 3 strains
of USA300 with varying degrees of biofilm-forming capability. On day 3 postburn, the
wounds were infected by isogenic strains of S. aureus USA300, USA300::rexB (ΔrexB) or
USA300::sarA (ΔsarA). A, Representative digital images of biofilm infected burn wounds
on days 0, 7, 14, and 35 postinfection. The wound area on the day of burn has been
demarcated with white dashed line. B, hematoxylin and eosin stained whole mount cross
sections of infected burn wounds show re-epithelialization. The wound edges have been

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shown with dash black lines while the tip of migrated epithelium is shown with black
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arrows. WE indicates wound edge. Scale bar = 200 μm. C, rate of re-epithelialization (%)
quantified from H&E stained images shown in (B). D, Immunofluorescence images of anti-
K14 (green) stained biofilm infected burn wound tissue sections. Counter staining was
performed with DAPI (blue, nucleus). Scale bar = 200 μm. Insets, zoom of the boxed area.
Scale bar = 50 μm.
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FIGURE 3.
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Hyperbiofilm infection by S. aureus USA::ΔrexB in burn wounds severely compromises

granulation tissue collagen content. A–C, On day 3 postburn, the porcine wounds were
infected by isogenic strains of S. aureus USA300, USA300::rexB (ΔrexB) or USA300::sarA
(ΔsarA). A, Representative images of formalin-fixed paraffin-embedded (FFPE) biofilm
infected day 35 burn wound biopsy sections (5 μm) were stained using Masson Trichrome
(MT). MT staining results in blue-black nuclei, blue collagen, and light red or pink
cytoplasm. Epidermal cells appear reddish. Scale bar = 200 μm. The edges of the wound

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have been shown with black/white arrows. Right panels are the zoom in images of the boxed
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areas within the images in the left panels. Scale bar, 50 μm. B, Representative images of
formalin-fixed paraffin- embedded (FFPE) biofilm infected day 35 burn wound biopsy
sections (5 μm) were stained using Picrosirius red (PS) staining. Scale bar = 200 μm. Insets
zoom of the box area. Scale bar = 50 μm. C, Bar graph shows quantitation of collagen
abundance using MT stains. Data are mean ± SEM (n = 6), *P < 0.05 compared with ΔsarA.
D, Bar graph shows quantitation of collagen abundance using PS stains. Data are mean ±
SEM (n = 3), *P < 0.05 compared with ΔsarA. E, Granulation (d35 postinfection) tissue
collagen content was determined using hydroxyproline assay. Data are mean ± SEM (n = 6),
*P < 0.05 compared with ΔsarA.
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FIGURE 4.
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Dysregulation of Col1 and Col3 at wound-site granulation tissue in S. aureus biofilm-

infected burn wounds. On day 3 post-burn, the wounds were infected by isogenic strains of
S. aureus USA300, USA300::rexB (ΔrexB) or USA300::sarA (ΔsarA). Wound biopsies were
collected at specified time-points after inoculation with S. aureus USA300 isogenic strains:
USA300, USA300::rexB (ΔrexB), or USA300::sarA (ΔsarA). A, Expressions of Col1 and
Col3 mRNA in wound biopsies collected on day 35 post-inoculation. Data presented as
mean ± SEM (n = 4), * P < 0.05 compared with ΔsarA. B, Representative images of Col1

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(red, anti-col1) and Col3 (green, anti-Col3) stained sections on days 35 post-inoculation.
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The sections were counterstained using DAPI (nuclear, blue). Scale bar = 100 μm. C, Bar
graphs present quantitation of Col1 and Col3 signal intensity and their ratio in (B). Data are
presented as mean ± SEM (n = 4), *P < 0.05 compared with ΔsarA. D, Herovici stained
images of biofilm infected burn wound tissue sections from d35 post-infection burn wounds.
Herovici stains young collagen reticulum blue (Col3) and mature collagen red (Col1) while
providing a yellow cytoplasm counterstain. Nuclei are stained to black with Weigert
Hematoxylin. E, Bar graphs present quantitation of Col1 and Col3 signal intensity and their
ratio in (D). scale bar = 50 μm. Data are presented as mean ± SEM (n = 4), *P < 0.05
compared with Col1 of ΔsarA +P < 0.05 compared with Col3 of ΔsarA.
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FIGURE 5.
miR-143 and MMP-2 expression/activity in wounds fibroblasts is regulated by SA biofilm
infection. Wound biopsies were collected at specified time points post-inoculation with S.
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aureus USA300 isogenic strains: USA300, USA300::rexB (ΔrexB) or USA300::sarA

(ΔsarA). A, Representative, gelatin zymogram of d35 porcine infected burn wounds tissue.
Based on molecular weight, pro- (70 kDa) and active MMP-2 (62 kDa) bands have been
indicated. Quantification of active MMP-2 (62 kDa) band using densitometry. Data are mean
± SEM (n = 4) *P < 0.05 compared with ΔsarA. B, MMP-2 mRNA in d35 post-inoculation
porcine infected burn wounds tissues quantified using real-time PCR. Data was normalized
against 18S RNA as housekeeping gene. Data are mean ± SEM (n = 6) *P < 0.05 compared

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with ΔsarA. C, MMP-2 protein in d35 post-inoculation porcine infected burn wounds tissues
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quantified using ELISA. Data are mean ± SEM (n = 6). *P < 0.05 compared with ΔsarA. D,
miR-143 expression in d35 post-inoculation porcine infected burn wounds tissues quantified
using real-time PCR. Data was normalized against U6 snRNA as housekeeping genes. Data
are mean ± SEM (n = 6) *P < 0.05 compared with ΔsarA. E-G, Human fibroblasts (hFb)
were cultured with overnight conditioned media from SA biofilms. Mature biofilms
developed on polycarbonate membrane in vitro were placed in cultured dish and incubated
with fibroblast (Fb) culture media overnight. The conditioned media was harvested,
centrifuged, filtered and then added to hFb. E, Schematic presentation of the experimental
model. F, MMP-2 mRNA expression in hTERT immortalized cultured human fibroblasts
(hFb) with conditioned media from biofilms cultured in vitro. Data are mean ± SEM (n = 6)
*P < 0.05 compared with ΔsarA. G, miR-143 expression in hTERT immortalized cultured
human fibroblasts (hFb) with conditioned media from biofilms cultured in vitro. Data are
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mean ± SEM (n = 3) *P < 0.05 compared with ΔsarA.

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FIGURE 6.
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MMP-2 is a direct target of miR-143 and regulates fibroblast collagen levels. A, miR-143
predicted to target MMP-2 3’UTR based on RNA Hybrid algorithm. MMP-2 transcript is
NM_004530. Binding position of miR-143 (green) corresponds to position 604–602 of 3′-
UTR of MMP-2 (red). B, Luciferase activity in human fibroblasts after transfection with
mimic miR-143 and mimic control. Data are mean ± SEM (n = 6) *P < 0.05 compared with
mimic control. C and D, Expression of miR-143 in human fibroblasts transfected with (C)
miR-143 inhibitor (D) miR-143 mimic. E and F, Expression of MMP-2 in human fibroblasts

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transfected with (E) miR-143 mimic (F) miR-143 inhibitor. G, Fluorescence microscopy
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images of collagen 1 (green) Col1 expression in hFb following bolstering of miR143 with
mimic miR-143 (upper panel) and knockdown of MMP-2 with siMMP2. Counterstaining
was performed using DAPI (blue, nuclear). H, Bar graph presents quantitation of Col1 from
(G, upper panel). Data are mean ± SEM (n = 3). *P < 0.05 compared with mimic control. I–
J, Knockdown of MMP-2 with siMMP2. Data are mean ± SEM (n = 4). *P < 0.05 compared
with si control.
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FIGURE 7.
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S. aureus biofilm results in loss of Col1 and reduces tensile strength through a miR-143-
MMP-2-dependent pathway. Solid lines indicate pathways based on data from this work.
Broken lines are based on literature (Eleswarapu SV et al, Tensile properties, collagen
content, and crosslinks in connective tissues of the immature knee joint. PLoS One 2011;
6(10):e26178. Lodish H et al., Collagen: The Fibrous Proteins of the Matrix. In: Lodish H,
Berk A, Zipursky Sea, eds. Molecular Cell Biology. New York: W. H. Freeman;2000.
Roeder BA et al., Tensile mechanical properties of three-dimensional type I collagen

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extracellular matrices with varied microstructure. J Biomech Eng - Transactions of the Asme
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2002; 124(2):214–222.
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