35 Mobile +45 20 65 98 88 36 fax + 45 35 45 64 12 37 Tbjarnsholt@sund.ku.dk 38 www.sund.ku.dk 39 40 41 42 43 44 45 46 47 48 49 50 51 52 Abstract 53 Extracellular DNA (eDNA) plays an important role in both the aggregation of bacteria54 and in the interaction of the resulting biofilms with polymorphonuclear leukocytes 55 (PMNs) during an inflammatory response. Here, transmission electron and confocal 56 scanning laser microscopy were used to examine the interaction between biofilms of 57 Pseudomonas aeruginosa and PMNs in a murine implant model and in lung tissue from 3 58 chronically infected cystic fibrosis patients. PNA FISH, DNA staining, labeling of 59 PMN DNA with a thymidine analogue, and immunohistochemistry were applied to 60 localize bacteria, eDNA, PMN-derived eDNA, PMN-derived histone H3 (H3), 61 neutrophil elastase (NE), and citrullinated H3 (citH3). Host-derived eDNA was 62 observed surrounding bacterial aggregates but not within the biofilms. H3 localized to 63 the lining of biofilms while NE was found throughout biofilms. CitH3, a marker for 64 neutrophil extracellular traps (NETs) was detected only sporadically indicating that 65 most host-derived eDNA in vivo was not a result of NETosis. Together these 66 observations show that, in these in vivo biofilm infections with P. aeruginosa, the 67 majority of eDNA is found external to the biofilm and derives from the host. 68 69 70 71 Keywords: polymorphonuclear leukocytes/ neutrophil extracellular traps/ NETosis, 72 /Histone/ elastase 73 74 Author summary75 The role of extracellular DNA (eDNA) has been described in vitro to play a major role in 76 biofilm formation and antibiotic tolerance, but never for biofilm infections in vivo. 77 78 Two important characteristics of human chronic bacterial infections are aggregated 79 bacteria and white blood cells (WBC). Bacteria use eDNA to stabilize biofilms and WBC 80 use eDNA to trap bacteria. Given the importance of eDNA for both bacteria and WBC we 81 show here for the first time that bacterial biofilms do not co-localize with either bacterial 82 or WBC-derived eDNA during chronic infections. Our in vivo findings show eDNA is 83 located outside biofilms as opposed to incorporated within the biofilm as commonly 84 observed in vitro. 85 86 We believe that understanding the interplay between biofilms and WBC during chronic 87 infection is essential if we are to elucidate the mechanisms underlying persistent infection 88 and ascertain why WBC fail to eradicate bacteria; this will enable us to develop new 89 treatment strategies. 4 90 91 92 93