Is Increased Biofilm Formation Associated with Decreased Antimicrobial Susceptibility? A Systematic Literature Review

Biofilm formation is a key factor in microbial survival and persistence, often contributing to reduced antimicrobial susceptibility. This systematic literature review investigates whether increased biofilm formation correlates with decreased antibiotic susceptibility. The literature search was conducted in the Pubmed database and we identified and screened 328 studies, with 35 ultimately meeting the inclusion criteria for detailed analysis. Findings reveal that the relationship between biofilm size and antimicrobial susceptibility is highly variable and influenced by multiple factors, including microbial species, strain-specific traits, antibiotic type, and experimental methodologies. While some studies report a positive correlation between biofilm biomass and reduced susceptibility, others show weak or no such relationships, and statistical support for a correlation is often lacking (also due to small sample sizes). The lack of standardized biofilm quantification methods and susceptibility metrics further complicates cross-study comparisons. These findings underscore the need for standardized protocols and more comprehensive datasets to clarify the complex interplay between biofilm formation and antibiotic susceptibility. Regardless of these difficulties, the available data clearly indicate that 'bigger' biofilms are not by definition less susceptible. Future research should prioritize diverse and sufficiently large strain collections and consistent methodologies to better understand and address biofilm-associated antimicrobial tolerance.