Role of fosfomycin in a synergistic combination with ofloxacin against Pseudomonas aeruginosa growing in a biofilm.

We examined the combined effect of fosfomycin and ofloxacin against Pseudomonas aeruginosa biofilms of four clinical isolates with different susceptibilities to ofloxacin. A clear synergistic effect was detected in all four strains in accordance with their susceptibilities to ofloxacin. To clarify the mechanism of this synergistic action, changes in cellular accumulation of ofloxacin into fosfomycin-pretreated cells and morphological changes in cells treated with fosfomycin, ofloxacin, or fosfomycin plus ofloxacin were investigated. Pretreatment with fosfomycin significantly enhanced cellular uptake of labeled or unlabeled ofloxacin in biofilm cells as well as in floating cells. The accumulation of ofloxacin into fosfomycin-pretreated biofilm cells was further enhanced by treating cells simultaneously with ofloxacin and fosfomycin. Morphological studies using scanning electron microscopy (SEM), transmission electron microscopy (TEM), and confocal laser scanning microscopy (CLSM) demonstrated that fosfomycin induced dramatic changes in cell shape and the outer membrane structure responsible for the altered membrane permeability of both surface and embedded biofilm cells. The resulting increased accumulation of ofloxacin in multilayers of biofilm cells was correlated with the kinetics of biofilm cell eradication, and this synergistic killing effect was confirmed by a combined study using SEM, TEM, and CLSM.