In vitro assessment of the anti-biofilm activity of ethanol alone and in combination with enoxaparin 60IU. 
Catheter-related bloodstream infection (C-RBSI) can sometimes be managed without catheter removal by combining systemic therapy with catheter lock therapy.  Most antiseptic lock solutions are made up of ethanol combined with an anticoagulant.  However, data regarding the anti-biofilm activity of ethanol combined with enoxaparin are scarce.  We aimed to assess the efficacy of ethanol at different concentrations combined with enoxaparin 60IU as a lock solution for eradication of the biofilm of different microorganisms.  Using a static 96-well plate in vitro model, we tested 30%, 35%, and 40% ethanol alone and combined with 60IU of enoxaparin against 24-h-old biofilm from the following microorganisms: Staphylococcus aureus, Staphylococcus epidermidis, Enterococcus faecalis, Escherichia coli, and Candida albicans.  Time of exposure was assessed during a 2-h and 24-h regimen.  We analysed the percentage reduction in metabolic activity using the XTT assay.  We considered therapy to be successful when metabolic activity was reduced by >90%.  In the 2-h regimen, the therapy was successful against all microorganisms at 35% and 40% ethanol without enoxaparin (p<0.001).  In the 24-h regimen, the therapy was successful against all microorganisms at all ethanol solutions without enoxaparin (p<0.001).  When ethanol was combined with enoxaparin, the therapy was only successful in the 24-h regimen in biofilms of S. epidermidis, C. albicans and E. coli at all concentrations of ethanol assessed.  Our in vitro model demonstrated that when ethanol is combined with enoxaparin in a lock solution, it negatively affects ethanol anti-biofilm activity after both short and long exposures.