Microbial Virulence, Biofilm Formation, and Antimicrobial Resistance Mechanisms Challenges and Emerging Therapeutic Strategies
Author(s):
Alaa Subhi Hammoud ,Aula Saad Jumaa
Date: 09/10/2026
doi: https://doi.org/10.5281/zenodo.8425890
Abstract
Background: Biofilm-associated infections and the spread of Antimicrobial Resistance (AMR) alongside
the virulence of microorganisms are one of the world's most concerning challenges in health at present.
Biofilm communities of bacteria resist both the host immune response and antibiotics, leading to treatment
failures, extended hospital stays and mortality, especially in infections linked to medical devices and/or
chronic infections – these organisms collectively are referred to as multidrug-resistant (MDR), extensively
drug-resistant (XDR) and pandrug-resistant (PDR) pathogens.
Aim: In this context, this objective aims to look critically at the link between virulence traits, biofilm
formation, AMR and consider whether it is a mono-dimensional expression of the bacterial virulence or
three different research areas.
Methods: This narrative review used Scopus, PubMed, Web of Science, ScienceDirect and SpringerLink
to search for peer-reviewed journals across a range of years from 2015 to 2026 adhering to the PRISMA
reporting guidelines. The study identification and screening followed a structured Boolean search with
pre-defined inclusion/exclusion criteria, and the search protocol was not registered.
Results: There were 58 studies included. The production of a biofilm matrix is a process co-regulated by
pathogen quorum systems and adhesins, along with secreted toxins and immune-evasion molecules, across
pathogens. Stronger horizontal gene transfer (HGT) ability was always associated with resistance
phenotypes and was linked to the EPS biofilm components, persister cells, and the presence of mobile
genetic elements (MGEs) in the organisms frequently together. Consistently, HGT ability was associated
with resistance phenol types and to the EPS biofilm components, to persister cells and to HGE in the
organisms often together as was also the occurrence of mobile genetic elements (MGEs).
Conclusions: The interconnection of virulence and biofilm formation, with common networks of
regulation and resistance. Some of the potentially promising but mostly pre-clinical methods that may
regain antibiotic activity and alleviate the burden of MDR/XDR/PDR pathogens include bacteriophages,
anti-biofilm compounds, CRISPR-Cas antimicrobials, nanoparticle-based antimicrobial delivery and
quorum-sensing inhibitors.
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