Finally, even these established criteria are having problems accommodating new molecular technologies and how to implement them. Although a useful adjunct suggests that the biofilm paradigm better explains the clinical realities of certain infections, this falls short of specific guidelines that are necessary to satisfy evidence-based clinical medicine. The biofilm research community Afatinib must also address that conventional Koch’s postulates using culture may not provide the best evidence

for BAI. Therefore, notwithstanding future developments such as the discovery of a universal biofilm marker, the biofilm and medical community needs to provide guidance to the clinician using existing techniques. Ultimately, the goal is to agree on a set of guidelines that lead to what Fredricks and Relman call ‘scientific concordance of evidence’ in the absence of the absolute fulfillment of Koch’s Postulates (Fredricks & Relman, 1996). Therefore, we propose a set of guidelines for the differential diagnosis of biofilm and planktonic infections (see Table 4). These guidelines combine both research criteria for biofilms and clinical criteria for infection and are proposed as a diagnostic

algorithm. A combination of positive results from Table 4 should be agreed upon by clinicians and researchers working with BAI, leading to a score that correlates with the probability of BAI that could be evaluated epidemiologically. Table 4 represents a systematic, substantive set of guidelines by which to diagnose BAI that is evidence-based rather than anecdotal. SCH727965 supplier Much research remains to be carried out, however. First, the development of imaging-based diagnostic approaches

to BAI is important, because a primary feature of BAI is currently the presence of aggregated microorganisms. One of the most convincing diagnostic approaches demonstrating the presence of microbial aggregates is FISH, accompanied by CSLM that provides the ability to spatially resolve microorganisms three dimensionally Racecadotril and show that they are aggregated. Unfortunately, this approach is expensive and time consuming and not useful for all diagnostic laboratories, although Gram-stained smears that show the aggregates, but do not directly identify the species, can also demonstrate biofilm (Fig. 3). Future development may facilitate the diagnostic use of CSLM, particularly at large diagnostic labs. All those involved in the diagnostic process should collaborate in differentially diagnosing these complex infections accompanied by a robust diagnostic algorithm and good communication. Problematically, in our experience, H&E staining of thin sections is ill-suited to showing biofilm aggregates (Fig. 4). Differential staining with carbohydrate stains such as alcian blue (Hoffmann et al., 2005) or ruthenium red or calcofluor (Yang et al.