Titanium implants are widely used in medicine but have a risk of biomaterial-associated infection (BAI), of which traditional antibiotic-based treatment is affected by resistance. Antimicrobial peptides (AMPs) are used to successfully kill antibiotic-resistant bacteria. Herein, a supramolecular coating for titanium implants is developed which presents the synthetic antimicrobial and antibiofilm peptide SAAP-148 via supramolecular interactions using ureido-pyrimidinone supramolecular units (UPy-SAAP-148GG). Material characterization of dropcast coatings shows the presence of UPy-SAAP-148GG at the surface. The supramolecular immobilized peptide remains antimicrobially active in dropcast polymer films and can successfully kill (antibiotic-resistant) Staphylococcus aureus, Acinetobacter baumannii, and Escherichia coli. Minor toxicity for human dermal fibroblasts is observed, with a reduced cell attachment after 24 h. Subsequently, a dipcoat coating on titanium implants is developed and tested in vivo in a subcutaneous implant infection mouse model with S. aureus administered locally on the implant before implantation to mimic contamination during surgery. The supramolecular coating containing 5 mol% of UPy-SAAP-148GG significantly prevents colonization of the implant surface as well as of the surrounding tissue, with no signs of toxicity. This shows that supramolecular AMP coatings on titanium are eminently suitable to prevent BAI.

<p>The use of medical devices has grown significantly over the last decades, and has become a major part of modern medicine and our daily life. Infection of implanted medical devices (biomaterials), like catheters, prosthetic heart valves or orthopaedic implants, can have disastrous consequences, including removal of the device. For still not well understood reasons, the presence of a foreign body strongly increases susceptibility to infection. These so-called biomaterial-associated infections (BAI) are mainly caused by <em>Staphylococcus aureus</em> and <em>Staphylococcus epidermidis</em>. The risk of infection might even be higher in so-called <em>in situ</em> tissue engineering applications, where population or infiltration of the scaffold material by endogenous cells and thereby the formation of new/healed tissue occurs as a spatiotemporal process. Since the porous scaffold materials can form a niche for invading bacteria, the intended in situ production of novel tissue may be severely compromised by infection.</p> <p>Our work focuses on the development and characterization of novel antimicrobial agents and delivery systems, and their effectiveness in the prevention of BAI and other difficult-to-treat biofilm infections. The scarcity of current antibiotic-based strategies to prevent infections and their risk of resistance development prompted us to develop novel synthetic antimicrobial and anti-biofilm peptides (SAAPs) based on the primary sequences of the human antimicrobial proteins Thrombocin-1<sup>1</sup> and LL-37<sup>2</sup>, and to test their potential in the fight against implant-associated and wound infections by multidrug-resistant bacteria. The lead peptide, SAAP-148, kills multidrug-resistant pathogens without inducing resistance, prevents biofilm formation and eliminates established biofilms and persister cells, and is effective against both acute and established skin infections<sup>1</sup>. As a next step, we aim to develop a new polymeric supramolecular<sup>3</sup> scaffold material, exerting two important functions: preventing microbial adhesion - by incorporating SAAP-148 - and thereby preventing biofilm formation, and inducing endogenous (eukaryotic) cells to adhere and propagate, as a first step towards functional tissue repair.</p> <p>This work is supported by FP7-HEALTH-2011 grant 278890, Biofilm Alliance and by NWO NEWPOL grant SuperActive (Project No. 731.015.505) in collaboration with the Dutch Polymer Institute (DPI, P.O. Box 902, 5600 AX Eindhoven, the Netherlands).</p> <p><sup>1</sup>Riool M. & de Breij A. <em>et al.</em>, BBA – Biomembranes (2020); <sup>2</sup>de Breij A. & Riool M. <em>et al.</em>, Sci. Transl. Med. (2018); <sup>3</sup>Dankers P.Y.W. <em>et al.</em>, Nat. Mater. (2005).</p>