## 4 Biofilm-Associated Infections  
A significant proportion of microbial infections (65 to 80%) are caused by biofilms [50]. Those infections include tissue (non-device-associated) and device-associated infections, \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Method** & **Advantages** & **Disadvantages** & **References** \\ \hline \multirow{4}{*}{Total protein determination} & Provides a holistic view of the & Protein levels vary depending on & \\  & biofilm composition by quantifying & the species, age, and culture & \\  & all proteins present. & conditions, resulting in fluctuations & \\  & & in the data obtained. & \\ \hline \multirow{4}{*}{Quartz Crystal} & Enables continuous monitoring of & & \\  & biofilm growth. Offers detailed & & \\  & insights into how biofilms interact & & \\  & with surfaces. Allows for easy & & \\  & adjustment of variables like flow rate & & \\  & and temperature. Provides a quick & temperature and pressure can affect & [28; 40; 41; 42] \\  & and non-invasive way to study & the resonant frequency and thus & \\  & biofilms. Highly sensitive for & impact data collection. & \\  & tracking the accumulation of & & \\  & mass (ng/cm\({}^{2}\)) over time. & & \\ \hline \multirow{4}{*}{Resazurin assay} & Enables determination of cells’ & & \\  & metabolic activity by measuring the & & \\  & reduction of resazurin, indicating & & \\  & whether cells are active & & \\  & metabolically or not. & & \\ \hline \hline \end{tabular}
\end{table} 
Table 2: _Cont._which represent a hard medical challenge, in terms of infection diagnosis and treatment, since they exhibit greater recalcitance to antimicrobial therapies relative to planktonic organisms [28; 32]. The non-device-associated category encompasses biofilm formation on host tissues like epithelial and mucosal surfaces, as well as teeth. These biofilms can cause infections in individuals with cystic fibrosis, diabetic foot ulcers, chronic otitis media or rhinosinusitis, chronic prostatitis, osteomyelitisitis, recurrent urinary tract infections, and dental issues such as cavities and gum disease [51; 52]. Device-associated infections happen when microorganisms colonize non-living surfaces, including medical devices like central venous or urinary catheters, joint or dental prostheses, heart valves, endotracheal tubes, intrauterine devices, and dental implants [53]. Microorganisms can disaggregate from these biofilms, spreading to nearby tissues or entering the bloodstream, worsening the infection [1]. Frequently, hospital-acquired infections are linked to medical devices [54]. Independently of the biomedical implants' and tissue engineering constructs' complexity, all medical devices are vulnerable to microbial colonization, eventually leading to infections [55]. Biofilm formation on these devices is notoriously difficult to eliminate, often leaving few options for treatment, such as removing the infected device or administering high doses of antibiotics [56]. These approaches, however, increase treatment costs and may contribute to the development of antibiotic resistance and cytotoxicity [1]. Furthermore, removing medical devices is often not an option for patients who depend on essential medical devices such as pacemakers. The substantial clinical impact of biofilm-associated infections and their inherent resistance to antimicrobials underscore the urgent need to develop new anti-biofilm strategies. The primary challenge in eradicating biofilms stems from their intricate three-dimensional architecture [57]. Firstly, the biofilm matrices serve as mechanical barriers, safeguarding bacterial cells from forces like fluid shear and attacks by neutrophils [58; 59]. Secondly, EPS can neutralize antimicrobials through direct interactions [60]. Thirdly, bacterial cells in various regions of a biofilm exhibit different metabolic states, with dormant cells being less susceptible to many antimicrobial agents, leading to tolerance [61].