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Healthcare-associated infections (HAIs) are among the most critical and worrisome public health challenges worldwide1. Alarmingly, they are strongly associated with the spread of multidrug-resistant (MDR) microorganisms and the persistence of bacterial bioburden on hospital surfaces, often due to inappropriate or ineffective disinfection practices2,3. Moreover, the cross-contamination between patients, healthcare staff, and medical equipment further amplifies this issue4,5. In Europe, for instance, it has been estimated that nearly 80,000 hospitalized patients suffer from at least one HAI on any given day, accounting for approximately 16 million additional hospital days each year2. The COVID-19 pandemic has further complicated this issue, contributing to a surge in MDR bacterial infections due to the high usage of antimicrobial agents/disinfectants and increased hospitalizations6,7. The rise of antibiotic-resistant bacteria, including extended-spectrum β-lactamase (ESBL)-producing Escherichia coli and methicillin-resistant Staphylococcus aureus (MRSA), has led to a growing health and economic burden worldwide. In fact, these strains underscore the urgency of developing innovative solutions for infection prevention and control1,8,9.
With that in mind, biocides became crucial tools to control the spread of resistant bacteria and bacterial infections, being extensively applied to disinfect hospital surfaces, sterilize equipment, treat water systems, and prevent contamination of medical devices10,11. Unlike antibiotics, which act on specific microbial targets12, biocides disrupt multiple cellular structures simultaneously, including membranes, enzymes, ribosomal RNA, and metabolic pathways13,14,15. This broad-spectrum action was initially thought to reduce the risk of resistance. However, evidence shows that microorganisms can adapt to biocide exposure, leading to tolerance, persistence, and even cross-resistance to antibiotics10,16. For example, exposure of Pseudomonas aeruginosa to benzalkonium chloride selected for variants resistant to ciprofloxacin and novobiocin through the overexpression of efflux pumps17. Similarly, triclosan has been shown to activate efflux pumps in Stenotrophomonas maltophilia, while chlorhexidine exposure has been associated with increased antibiotic resistance in S. aureus18.
Furthermore, quaternary ammonium compounds (QACs), chlorhexidine, diamidines, acridines, and triclosan have been implicated as possible causes for the selection and persistence of bacterial resistance to several antibiotics19,20. Resistance genes such as qacA/B and smr are known to confer tolerance to QACs, and clinical failures such as bacteremia linked to catheters stored in contaminated QAC solutions and intrinsic microbial contamination of iodophors have also been reported16,17,21. These findings highlight the urgent need for optimized biocide use, supported by mechanistic studies and rational disinfection strategies.
Biofilms, which are high-cell-density and well-structured bacterial communities embedded in an extracellular matrix of polysaccharides, proteins, and nucleic acids, pose an additional and significant obstacle to infection control22,23. They exhibit remarkable tolerance to antibiotics and biocides, contributing to the persistence of infections in patients. Moreover, biofilms are also often associated with the persistent contamination of medical devices, surgical instruments, and hospital surfaces24. Despite their clinical importance, biofilms have only been recognized as major contributors to chronic infections and antimicrobial resistance in recent decades. Their resilience is such that even aggressive disinfecting agents often fail to eradicate them, leaving behind persister cells capable of reseeding infection20,25,26. Therefore, finding effective antibiofilm strategies is crucial to controlling HAIs and reducing the public health and economic burden of MDR pathogens27,28.
As a promising solution, phytochemicals, which are secondary metabolites produced and extracted from plants, represent a largely untapped resource for novel antimicrobial and antibiofilm agents29. However, no phytochemical is used as an antibiotic, due to its modest antimicrobial activity compared to conventional antibiotics. Phytochemicals are routinely classified as antimicrobials based on susceptibility tests that produce the minimum inhibitory concentration (MIC) in the range of 100 to 1000 µg/mL, which are values much higher than those of conventional antibiotics30,31. Importantly, phytochemicals have already demonstrated antibiofilm activity when used alone or as potentiators of conventional biocides. For example, quercetin may inhibit alginate production, leading to decreased adhesion during biofilm development32,33,34. Emodin inhibited the development of biofilms by P. aeruginosa, E. coli, and S. aureus through the decrease of expression of key genes involved in biofilm formation35. Combining phytochemicals with conventionally used yet increasingly ineffective biocides, as resistance-modifying agents, represents a promising strategy to enhance antimicrobial efficacy36. Such synergistic interactions can interfere with microbial resistance mechanisms, lowering the minimum effective concentrations of biocides required to achieve satisfactory disinfection37. This approach optimizes the biocidal performance, reduces selective pressure for resistance development, and reduces the ecological and toxicological impacts associated with excessive biocide application15,20. Phytochemicals are structurally diverse38,39,40, widely available38,39,41, inexpensive38,39,42, and often less toxic to humans and the environment than synthetic biocides38,39. They are natural products that are often derived from renewable plant sources and, in some cases, have been reported to exhibit lower environmental persistence and reduced toxicity profiles compared with certain synthetic biocides43,44,45. While their cost, availability, and toxicity profiles vary depending on the compound and extraction process, several phytochemicals have demonstrated favorable safety and environmental characteristics compared with certain conventional biocides46,47.
This protocol aims to evaluate the potential of phytochemicals, individually and in combination with conventional biocides, for healthcare disinfection. In brief, the protocol evaluates biocide-phytochemical interactions across broad concentration ranges. Biocides were initially tested across 0.1–500 mg/L and phytochemicals across 50–10,000 mg/L to determine minimum bactericidal concentrations (MBCs) (Table 1). For dual combinations, sub-bactericidal concentrations were selected as follows: benzalkonium chloride (BAC) at 0.1, 0.5, and 0.75 mg/L; peracetic acid (PAA) at 0.1, 0.3, and 0.5 mg/L; salicylic acid (SAL) at 50, 100, and 250 mg/L; and eugenol (EUG) at 100, 250, and 750 mg/L (Table 1). Triple combinations were conducted using BAC (0.75 mg/L) or PAA (0.5 mg/L) combined with SAL (100 or 250 mg/L) and EUG (250 or 750 mg/L) (Table 1). Time-response assays were performed over 1–90 min, followed by a 24 h bacterial regrowth assessment. Antimicrobial interactions are quantified using the fractional bactericidal concentration index (FBCI) and analyzed with Combenefit software, while disinfection kinetics are modeled using the Chick-Watson and Weibull models to characterize concentration dependence and inactivation dynamics.
The innovation lies in the rational design of stable dual and triple interactions between phytochemicals and biocides, optimizing the disinfection activity while minimizing toxicity and environmental impact due to a decreased use of conventional biocides. Mathematical approaches such as calculating the FBCI and synergy evaluation were also used to quantify phytochemical-biocide interactions in microbial control. While FBCI offers a categorical interpretation of interaction (synergy, antagonism, or indifference) at specific concentration combinations, Combenefit enables a more comprehensive, response-surface-based evaluation of interaction patterns across a broader concentration range. This allows visualization and quantification of concentration-dependent interaction effects that may not be captured by single-point indices48,49. Moreover, disinfection kinetics are modeled using the Chick-Watson (for dose-response) and Weibull (for time-response) models50. These models provide kinetic modeling of microbial inactivation, offering quantitative parameters describing disinfection rates and survival curve behavior50. They help characterize whether killing follows log-linear or non-linear dynamics and allow more mechanistic interpretation of treatment effects, which extends beyond the descriptive of FBCI51,52.
This protocol ensures the systematic identification of promising phytochemical-biocide combinations and the development of an efficient, sustainable strategy for healthcare disinfection. Unlike classical MIC or checkerboard assays that provide static endpoint measurements, this protocol integrates dynamic bactericidal modeling and interaction analyses to capture the magnitude and kinetics of potentiation. While classical checkerboard assays provide valuable information on inhibitory interactions based on MIC endpoints, they are limited to growth measurements and single interaction indices. The protocol described here advances beyond this framework by quantifying bactericidal activity rather than growth inhibition, assessing post-treatment regrowth to evaluate sustained antimicrobial effects, evaluating both dual and triple biocide-phytochemical(s) combinations, modeling disinfection kinetics through Chick-Watson and Weibull approaches, and applying concentration-response surface analysis using Combenefit. This multidimensional strategy enables a more robust and predictive assessment of biocide-phytochemical potentiation.