The frequency of persisters in Escherichia coli reflects the kinetics of awakening from dormancy

Metabolic and transcriptional activities of Staphylococcus aureus challenged with high-doses of daptomycin

Treatment of stationary growth phase Staphylococcus aureus SA113 with 100-fold of the MIC of the lipopeptide antibiotic daptomycin leaves alive a small fraction of drug tolerant albeit genetically susceptible bacteria. This study shows that cells of this subpopulation exhibit active metabolism even hours after the onset of the drug challenge. Isotopologue profiling using fully (13)C-labeled glucose revealed de novo biosynthesis of the amino acids Ala, Asp, Glu, Ser, Gly and His. The isotopologue composition in Asp and Glu suggested an increased activity of the TCA cycle under daptomycin treatment compared to unaffected stationary growth phase cells. Microarray analysis showed differential expression of specific genes 10 min and 3 h after addition of the drug. Besides factors involved in drug response, a number of metabolic genes appear to shape the signature of daptomycin-tolerant S. aureus cells. These observations will be useful toward the development of new strategies against persisters and related forms of bacterial cells with downshifted physiology.

The HicA toxin from Burkholderia pseudomallei has a role in persister cell formation

TA (toxin-antitoxin) systems are widely distributed amongst bacteria and are associated with the formation of antibiotic tolerant (persister) cells that may have involvement in chronic and recurrent disease. We show that overexpression of the Burkholderia pseudomallei HicA toxin causes growth arrest and increases the number of persister cells tolerant to ciprofloxacin or ceftazidime. Furthermore, our data show that persistence towards ciprofloxacin or ceftazidime can be differentially modulated depending on the level of induction of HicA expression. Deleting the hicAB locus from B. pseudomallei K96243 significantly reduced persister cell frequencies following exposure to ciprofloxacin, but not ceftazidime. The structure of HicA(H24A) was solved by NMR and forms a dsRBD-like (dsRNA-binding domain-like) fold, composed of a triple-stranded β-sheet, with two helices packed against one face. The surface of the protein is highly positively charged indicative of an RNA-binding protein and His24 and Gly22 were functionality important residues. This is the first study demonstrating a role for the HicAB system in bacterial persistence and the first structure of a HicA protein that has been experimentally characterized.

The role of metabolism in bacterial persistence

Bacterial persisters are phenotypic variants with extraordinary tolerances toward antibiotics. Persister survival has been attributed to inhibition of essential cell functions during antibiotic stress, followed by reversal of the process and resumption of growth upon removal of the antibiotic. Metabolism plays a critical role in this process, since it participates in the entry, maintenance, and exit from the persister phenotype. Here, we review the experimental evidence that demonstrates the importance of metabolism to persistence, highlight the successes and potential of targeting metabolism in the search for anti-persister therapies, and discuss the current methods and challenges to understand persister physiology.

Persisters, persistent infections and the Yin-Yang model

Persisters are a small fraction of quiescent bacterial cells that survive lethal antibiotics or stresses but can regrow under appropriate conditions. Persisters underlie persistent and latent infections and post-treatment relapse, posing significant challenges for the treatment of many bacterial infections. The current definition of persisters has drawbacks, and a Yin–Yang model is proposed to describe the heterogeneous nature of persisters that have to be defined in highly specific conditions. Despite their discovery more than 70 years ago, the mechanisms of persisters are poorly understood. Recent studies have identified a number of genes and pathways that shed light on the mechanisms of persister formation or survival. These include toxin–antitoxin modules, stringent response, DNA repair or protection, phosphate metabolism, alternative energy production, efflux, anti-oxidative defense and macromolecule degradation. More sensitive single-cell techniques are required for a better understanding of persister mechanisms. Studies of bacterial persisters have parallels in other microbes (fungi, parasites, viruses) and cancer stem cells in terms of mechanisms and treatment approaches. New drugs and vaccines targeting persisters are critical for improved treatment of persistent infections and perhaps cancers. Novel treatment strategies for persisters and persistent infections are discussed.

Fast detection and quantification of Escherichia coli using the base principle of the microbial fuel cell

Escherichia coli is an important microbial indicator of fecal contamination, making accurate quantitative detection of E. coli a key to ensuring public health. In this study, a microbial fuel cell (MFC) was used as a detection unit of an E. coli sensor, and specific enzymes expressed in E. coli, such as β-D-galactosidase (GAL) and β-D-glucuronidase (GUS), were exploited as biological detection elements. As substrates, 4-aminophenyl-β-D-galactopyranoside (4-APGal) were used for GAL detection, whereas 8-hydroxyquinoline glucuronide (8-HQG) and 4-nitrophenyl β-D-glucuronide (PNPG) were used for GUS detection. Once these substrates were hydrolyzed by GAL or GUS, they became electrochemically active products, which were, in turn, oxidized on the anode of the MFC reactor. The power output of the MFC reactor increased sharply when E. coli in the reactor reached the critical concentration. Accordingly, the time required to reach the highest voltage output was recorded as a detection time (DT), and a negative linear relationship was established between DT and the logarithm of the initial concentration of E. coli in the samples studied. The DTs of laboratory samples were 140 min and 560 min for initial concentrations of 1.9 × 10(7) CFU/mL and 42 CFU/mL at 44.5 °C. Moreover, the DTs for GUS assays were further shortened by induction with methyl β-D-glucuronide sodium salt (MetGlu). The quantitative relationship between DTs and initial E. coli concentrations established from replicate laboratory sample assays allowed estimation of the E. coli concentration in environmental samples, but with approximately 100 min of lag time. The lag time was also observed with E. coli samples that were prepared by starving cells in a laboratory.

Bacterial persister cell formation and dormancy

Bacterial cells may escape the effects of antibiotics without undergoing genetic change; these cells are known as persisters. Unlike resistant cells that grow in the presence of antibiotics, persister cells do not grow in the presence of antibiotics. These persister cells are a small fraction of exponentially growing cells (due to carryover from the inoculum) but become a significant fraction in the stationary phase and in biofilms (up to 1%). Critically, persister cells may be a major cause of chronic infections. The mechanism of persister cell formation is not well understood, and even the metabolic state of these cells is debated. Here, we review studies relevant to the formation of persister cells and their metabolic state and conclude that the best model for persister cells is still dormancy, with the latest mechanistic studies shedding light on how cells reach this dormant state.

Salmonella typhimurium intercepts Escherichia coli signaling to enhance antibiotic tolerance

Bacterial communication plays an important role in many population-based phenotypes and interspecies interactions, including those in host environments. These interspecies interactions may prove critical to some infectious diseases, and it follows that communication between pathogenic bacteria and commensal bacteria is a subject of growing interest. Recent studies have shown that Escherichia coli uses the signaling molecule indole to increase antibiotic tolerance throughout its population. Here, we show that the intestinal pathogen Salmonella typhimurium increases its antibiotic tolerance in response to indole, even though S. typhimurium does not natively produce indole. Increased antibiotic tolerance can be induced in S. typhimurium by both exogenous indole added to clonal S. typhimurium populations and indole produced by E. coli in mixed-microbial communities. Our data show that indole-induced tolerance in S. typhimurium is mediated primarily by the oxidative stress response and, to a lesser extent, by the phage shock response, which were previously shown to mediate indole-induced tolerance in E. coli. Further, we find that indole signaling by E. coli induces S. typhimurium antibiotic tolerance in a Caenorhabditis elegans model for gastrointestinal infection. These results suggest that the intestinal pathogen S. typhimurium can intercept indole signaling from the commensal bacterium E. coli to enhance its antibiotic tolerance in the host intestine.

Establishment of a method to rapidly assay bacterial persister metabolism

Bacterial persisters exhibit an extraordinary tolerance to antibiotics that is dependent on their metabolic state. Although persister metabolism promises to be a rich source of antipersister strategies, there is relatively little known about the metabolism of these rare and transient phenotypic variants. To address this knowledge gap, we explored the use of several techniques, and we found that only one measured persister metabolism. This assay was based on the phenomenon of metabolite-enabled aminoglycoside killing of persisters, and we used it to characterize the metabolic heterogeneity of different persister populations. From these investigations, we determined that glycerol and glucose are the most ubiquitously used carbon sources by various types of Escherichia coli persisters, suggesting that these metabolites might prove beneficial to deliver in conjunction with aminoglycosides for the treatment of chronic and recurrent infections. In addition, we demonstrated that the persister metabolic assay developed here is amenable to high-throughput screening with the use of phenotype arrays.

Dormancy is not necessary or sufficient for bacterial persistence

The antibiotic tolerances of bacterial persisters have been attributed to transient dormancy. While persisters have been observed to be growth inhibited prior to antibiotic exposure, we sought to determine whether such a trait was essential to the phenotype. Furthermore, we sought to provide direct experimental evidence of the persister metabolic state so as to determine whether the common assumption of metabolic inactivity was valid. Using fluorescence-activated cell sorting (FACS), a fluorescent indicator of cell division, a fluorescent measure of metabolic activity, and persistence assays, we found that bacteria that are rapidly growing prior to antibiotic exposure can give rise to persisters and that a lack of replication or low metabolic activity prior to antibiotic treatment simply increases the likelihood that a cell is a persister. Interestingly, a lack of significant growth or metabolic activity does not guarantee persistence, as the majority of even "dormant" subpopulations (>99%) were not persisters. These data suggest that persistence is far more complex than dormancy and point to additional characteristics needed to define the persister phenotype.

Quantitative analysis of persister fractions suggests different mechanisms of formation among environmental isolates of E. coli

BACKGROUND

Bacterial persistence describes a phenomenon wherein a small subpopulation of cells is able to survive a challenge with high doses of an antibiotic (or other stressor) better than the majority of the population. Previous work has shown that cells that are in a dormant or slow-growing state are persistent to antibiotic treatment and that populations with higher fractions of dormant cells exhibit higher levels of persistence. These data suggest that a major determinant of the fraction of persisters within a population is the rate at which cells enter and exit from dormancy. However, it is not known whether there are physiological changes in addition to dormancy that influence persistence. Here, we use quantitative measurements of persister fractions in a set of environmental isolates of E. coli together with a mathematical model of persister formation to test whether a single general physiological change, such as cell dormancy, can explain the differences in persister phenotypes observed in different strains.

RESULTS

If a single physiological change (e.g. cell dormancy) underlies most persister phenotypes, then strains should exhibit characteristic fractions of persister cells: some strains will consistently have high fractions of persisters (dormant cells), whereas others will have low fractions. Although we found substantial variation in the fraction of persisters between different environmental isolates of E. coli, these fractions were not correlated across antibiotics. Some strains exhibited high persister fractions in one antibiotic, but low persister fractions in a second antibiotic. Surprisingly, no correlation in persister fractions was observed between any two drugs, even for antibiotics with nearly identical modes of action (ciprofloxacin and nalidixic acid).

CONCLUSIONS

These data support the hypothesis that there is no single physiological change that determines the persistence level in a population of cells. Instead, the fraction of cells that survive antibiotic treatment (persist) depends critically on the specific antibiotic that is used, suggesting that physiological changes in addition to dormancy can underlie persister phenotypes.

Interplay between population dynamics and drug tolerance of Staphylococcus aureus persister cells

Population dynamics parameters of Staphylococcus aureus strain SA113 were quantified based on growth and killing experiments with batch culture cells in rich medium. Eradication kinetics and the concomitant isolation of a subpopulation of drug-tolerant SA113 persisters upon treatment with super-minimal inhibitory concentrations of antibiotics such as ciprofloxacin, daptomycin, and tobramycin served as a basis for mathematical analyses. According to a two-state model for stochastic phenotype switching, levels of persister cells and their eradication rates were influenced by the antibiotics used for isolation, clearly indicating a heterogeneous pool of S. aureus persisters. Judging from time-dependent experiments, the persisters' degree of drug tolerance correlated with the duration of antibiotic challenge. Moreover, cross-tolerance experiments with cells consecutively treated with two different antibiotics revealed that multi-drug tolerance is not a necessary trait of S. aureus persisters isolated by antibiotic challenge. In some cases, the results depended on the order of the two antibiotic treatments, suggesting that antibiotic tolerance may be achieved by a combination of preexisting persisters and an adaptive response to drug exposure. Counts of live cells which had endured drug treatment increased only after lag phases of at least 3 h after the shift to non-selective conditions. Thus, this study provides quantitative insights into population dynamics of S. aureus persisters with regard to antibiotic challenge.

Pharmacodynamics, population dynamics, and the evolution of persistence in Staphylococcus aureus

When growing populations of bacteria are confronted with bactericidal antibiotics, the vast majority of cells are killed, but subpopulations of genetically susceptible but phenotypically resistant bacteria survive. In accord with the prevailing view, these “persisters” are non- or slowly dividing cells randomly generated from the dominant population. Antibiotics enrich populations for pre-existing persisters but play no role in their generation. The results of recent studies with Escherichia coli suggest that at least one antibiotic, ciprofloxacin, can contribute to the generation of persisters. To more generally elucidate the role of antibiotics in the generation of and selection for persisters and the nature of persistence in general, we use mathematical models and experiments with Staphylococcus aureus (Newman) and the antibiotics ciprofloxacin, gentamicin, vancomycin, and oxacillin. Our results indicate that the level of persistence varies among these drugs and their concentrations, and there is considerable variation in this level among independent cultures and mixtures of independent cultures. A model that assumes that the rate of production of persisters is low and persisters grow slowly in the presence of antibiotics can account for these observations. As predicted by this model, pre-treatment with sub-MIC concentrations of antibiotics substantially increases the level of persistence to drugs other than those with which the population is pre-treated. Collectively, the results of this jointly theoretical and experimental study along with other observations support the hypothesis that persistence is the product of many different kinds of errors in cell replication that result in transient periods of non-replication and/or slowed metabolism by individual cells in growing populations. This Persistence as Stuff Happens (PaSH) hypothesis can account for the ubiquity of this phenomenon. Like mutation, persistence is inevitable rather than an evolved character. What evolved and have been identified are genes and processes that affect the frequency of persisters.

Because of its importance to therapy, a great deal of effort has been devoted to understanding the mechanisms responsible for and the genetic basis of persistence in inherently susceptible but phenotypically antibiotic-resistant subpopulations of bacteria. Much of this research is based on the premise that persisters are produced at random from the susceptible population and the antibiotics used to detect them play no role in their generation. The results of this jointly theoretical and experimental study are inconsistent with this hypothesis. These results, along with observations reported by other investigators, including the failure to find bacteria that do not produce persisters but an abundance of genes modifying their frequency, support the hypothesis that there are many mechanisms responsible for persistence. Based on these collective theoretical and experimental results, along with evolutionary considerations, we postulate that persistence is analogous to mutation. It is an inevitable product of errors and glitches in cell replication and metabolism rather than an evolved character.

Microbial scout hypothesis, stochastic exit from dormancy, and the nature of slow growers

We recently proposed a scout model of the microbial life cycle (S. S. Epstein, Nature 457:1083, 2009), the central element of which is the hypothesis that dormant microbial cells wake up into active (so-called scout) cells stochastically, independently of environmental cues. Here, we check the principal prediction of this hypothesis: under growth-permissive conditions, dormant cells initiate growth at random time intervals and exhibit no species-specific lag phase. We show that a range of microorganisms, including environmental species, Escherichia coli, and Mycobacterium smegmatis, indeed wake up in a seemingly stochastic manner and independently of environmental conditions, even in the longest incubations conducted (months to years long). As is implicit in the model, most of the cultures we obtained after long incubations were not inherently slow growers. Of the environmental isolates that required ≥7 months to form visible growth, only 5% needed an equally long incubation upon subculturing, with the majority exhibiting regrowth within 24 to 48 h. This apparent change was not a result of adaptive mutation; rather, most microbial species that appear to be slow growers were in fact fast growers with a delayed initiation of division. Genuine slow growth thus appears to be less significant than previously believed. Random, low-frequency exit from the nongrowing state may be a key element of a general microbial survival strategy, and the phylogenetic breadth of the organisms exhibiting such exit indicates that it represents a general phenomenon. The stochasticity of awakening can also provide a parsimonious explanation to several microbiological observations, including the apparent randomness of latent infections and the existence of viable-but-nonculturable cells (VBNC).

Vancomycin tolerance in Gram-positive cocci

Vancomycin, a glycopeptide antimicrobial agent, represents the last line of defence against a wide range of multi-resistant Gram-positive pathogens such as enterococci, staphylococci and streptococci. However, vancomycin-resistant enterococci and staphylococci, along with vancomycin-tolerant clinical isolates, are compromising the therapeutic efficacy of vancomycin. It is conceivable that tolerance may emerge during prolonged vancomycin use. It has not been until recently, however, that the molecular basis of this tolerance began to be understood. Superoxide anions might be involved in the bactericidal activity of vancomycin in enterococci, and recent evidence suggests that the stringent response is partly responsible for vancomycin tolerance in Enterococcus faecalis. The mechanism of vancomycin tolerance in Staphylococcus aureus and Streptococcus pneumoniae is sometimes associated with a reduction of autolysin activity. Vancomycin tolerance in S. aureus and S. pneumoniae also appears to be somehow related with the two-component regulatory systems linked to cell envelope stress, although the precise molecular regulatory pathways remain poorly defined.

Pharmacokinetic-pharmacodynamic model for gentamicin and its adaptive resistance with predictions of dosing schedules in newborn infants

Gentamicin is commonly used in the management of neonatal infections. Development of adaptive resistance is typical for aminoglycosides and reduces the antibacterial effect. There is, however, a lack of understanding of how this phenomenon influences the effect of different dosing schedules. The aim was to develop a pharmacokinetic-pharmacodynamic (PKPD) model that describes the time course of the bactericidal activity of gentamicin and its adaptive resistance and to investigate different dosing schedules in preterm and term newborn infants based on the developed model. In vitro time-kill curve experiments were conducted on a strain of Escherichia coli (MIC of 2 mg/liter). The gentamicin exposure was either constant (0.125 to 16 mg/liter) or dynamic (simulated concentration-time profiles in a kinetic system with peak concentrations of 2.0, 3.9, 7.8, and 16 mg/liter given as single doses or as repeated doses every 6, 12, or 24 h). Semimechanistic PKPD models were fitted to the bacterial counts in the NONMEM (nonlinear mixed effects modeling) program. A model with compartments for growing and resting bacteria, with a function allowing the maximal bacterial killing of gentamicin to reduce with exposure, characterized both the fast bactericidal effect and the adaptive resistance. Despite a lower peak concentration, preterm neonates were predicted to have a higher bacterial killing effect than term neonates for the same per-kg dose because of gentamicin's longer half-life. The model supported an extended dosing interval of gentamicin in preterm neonates, and for all neonates, dosing intervals of 36 to 48 h were as effective as a 24-h dosing interval for the same total dose.

Age of inoculum strongly influences persister frequency and can mask effects of mutations implicated in altered persistence

The majority of cells transferred from stationary-phase culture into fresh medium resume growth quickly, while a few remain in a nongrowing state for longer. These temporarily nonproliferating bacteria are tolerant of several bactericidal antibiotics and constitute a main source of persisters. Several genes have been shown to influence the frequency of persisters in Escherichia coli, although the exact mechanism underlying persister formation is unknown. This study demonstrates that the frequency of persisters is highly dependent on the age of the inoculum and the medium in which it has been grown. The hipA7 mutant had 1,000 times more persisters than the wild type when inocula were sampled from younger stationary-phase cultures. When started after a long stationary phase, the two displayed equal and elevated persister frequencies. The lower persister frequencies of glpD, dnaJ, and surA knockout strains were increased to the level of the wild type when inocula aged. The mqsR and phoU deletions showed decreased persister levels only when the inocula were from aged cultures, while sucB and ygfA deletions had decreased persister levels irrespective of the age of the inocula. A dependency on culture conditions underlines the notion that during screening for mutants with altered persister frequencies, the exact experimental details are of great importance. Unlike ampicillin and norfloxacin, which always leave a fraction of bacteria alive, amikacin killed all cells in the growth resumption experiment. It was concluded that the frequency of persisters depends on the conditions of inoculum cultivation, particularly its age, and the choice of antibiotic.

Evidence for persisters in Staphylococcus epidermidis RP62a planktonic cultures and biofilms

The pathogenesis of Staphylococcus epidermidis in foreign device-related infections is attributed primarily to its ability to form biofilms on a polymer surface. One mechanism proposed for the survival of organisms in a biofilm is the presence of persister cells. Persister cells survive antibiotic treatment without acquiring heritable antibiotic resistance. This study was conducted to determine if S. epidermidis RP62a growing in planktonic cultures and biofilms could survive as persister cells following treatment with levofloxacin and vancomycin. S. epidermidis RP62a produced a small percentage of persisters (levofloxacin, 3.09×10⁻⁷%; vancomycin, 8.21×10⁻⁵ %) when grown to exponential phase, whereas biofilms contained 28 and 94 % persisters, following exposure to levofloxacin and vancomycin, respectively. The highest percentages of persisters were obtained during stationary phase in planktonic cultures and the lowest percentages of persisters were obtained during mid-exponential phase. An increase in persister number was not due to activation of quorum-sensing regulons. Confocal laser scanning microscopy images of biofilms exposed to levofloxacin demonstrated that the antibiotic was able to kill bacteria throughout the biofilm. Our results suggest that antibiotic tolerance in biofilms and in planktonic cultures of S. epidermidis RP62a is due in part to the presence of persister cells.