Pathogenic synergy: mixed intra-abdominal infections

Bactericidal activity of ertapenem against major intra-abdominal pathogens

Treatment of intra-abdominal infections remains a challenge owing to their polymicrobial nature and associated mortality risk. Treatment regimens must provide broad-spectrum coverage, including Gram-positive and Gram-negative aerobic and anaerobic bacteria of gastrointestinal origin. Ertapenem is a long-acting 1-beta-methyl parenteral group 1 carbapenem antibiotic that has a broad antibacterial spectrum and once-daily dosing supported by clinical studies. It is active against Gram-positive and Gram-negative bacteria, including Enterobacteriaceae, Streptococcus pneumoniae and most species of anaerobic bacteria. The aim of this study was to measure the killing effects of ertapenem against a selected group of strains responsible for intra-abdominal infections. Gram-negative isolates comprised the following species: Escherichia coli, Klebsiella pneumoniae, Klebsiella oxytoca, Klebsiella ozaenae, Enterobacter cloacae and Proteus mirabilis (extended-spectrum beta-lactamase (ESBL) producers and non-producers). Gram-positive isolates comprised methicillin-susceptible Staphylococcus aureus (MSSA), Enterococcus faecalis and anaerobic Bacteroides fragilis. Ertapenem activity was tested by determination of minimal inhibitory concentrations (MICs) and minimal bactericidal concentrations (MBCs). Killing curves were performed in monocultures and co-cultures at selected antibiotic concentrations. Ertapenem showed a rapid and potent bactericidal activity in the first few hours of the kinetic curves against E. coli (6 log(10) colony-forming unit (CFU) reduction in the first 2h), B. fragilis (4 log(10) CFU reduction in 4h), MSSA (3 log(10) CFU reduction in 4-6h), K. ozaenae (ESBL+), K. pneumoniae (ESBL+ and -), E. cloacae (ESBL-) in 1h and P. mirabilis (ESBL+) in the first 2h. The potent bactericidal activity of ertapenem compared with ceftriaxone and piperacillin/tazobactam was well demonstrated in the co-cultures of E. coli-B. fragilis and E. coli-B. fragilis-E. faecalis, whilst ertapenem was shown to be bactericidal at 24h in the mixed culture of S. aureus-P. mirabilis. These results support the potent in vitro bactericidal activity of ertapenem against all multiresistant strains selected in this study and the use of this drug in the treatment of intra-abdominal infections.

Escherichia coli hemoglobin protease autotransporter contributes to synergistic abscess formation and heme-dependent growth of Bacteroides fragilis

Intra-abdominal infections (IAI) continue to be a serious clinical problem. Bacterial synergism is an important factor that influences the shift from contamination to IAI, leading to the development of lesions and abscess formation. Escherichia coli and Bacteroides fragilis are particularly abundant in IAI. The underlying molecular mechanisms of this pathogenic synergy are still unclear. The role of the hemoglobin protease (Hbp) autotransporter protein from E. coli in the synergy of IAI was investigated. Hbp is identical to Tsh, a temperature-sensitive hemagglutinin associated with avian pathogenic E. coli. Clinical isolates from miscellaneous extraintestinal infections were phenotypically and genotypically screened for Hbp. The presence of Hbp was significantly associated with E. coli isolated from IAI and other extraintestinal infections. In a murine infection model, Hbp was shown to contribute to the pathogenic synergy of abscess development. Mice immunized with Hbp were protected against mixed infections and did not develop abscess lesions. Furthermore, an E. coli wild-type strain that did not induce abscess formation in the synergy model was transformed with a plasmid encoding the hbp gene, and mixed infections with this strain lead to increased growth of B. fragilis and induction of abscess lesions. Growth-promoting studies showed that purified Hbp is able to deliver heme to B. fragilis strain BE1. In conclusion, results suggest the synergy of abscess formation by E. coli and B. fragilis can be partly explained by the capacity of B. fragilis to intercept Hbp and iron from heme to overcome the iron restrictions imposed by the host.

Characterization and detection of the 40 kDa fimbrial subunit of Bacteroides fragilis BE1

The amino acid composition and amino-terminal amino acid sequence of the 40 kDa fimbrial subunit of Bacteroides fragilis were determined. No similarity with other known fimbrial subunits or protein sequences was found. The isoelectric point of the fimbriae was determined to be 3.8. The acidic nature of these fimbriae is in agreement with the amino acid composition of the fimbrial subunit. An IgM monoclonal antibody, raised against the denaturated subunit of strain BE1 fimbriae, reacted with native BE1 fimbriae and appeared to be strain specific. Bacteroides fragilis strain BE38 expressed fimbriae which did not react with the polyclonal or monoclonal antibodies directed against strain BE1 fimbriae.

Outer membrane proteins of Bacteroides fragilis and Bacteroides vulgatus in relation to iron uptake and virulence

A virulent strain B. fragilis BE1 and an avirulent strain B. vulgatus BE20 were grown in a culture medium with and without the addition of a synthetic chelator (Bipyridyl) to induce iron limitation. Cells grew more slowly under iron stress, although the growth rate of the B. vulgatus strain was more affected under these conditions than the strain of B. fragilis. The outer membrane protein profile of these strains was studied in relation to the iron concentration in the growth medium by means of SDS-polyacrylamide gel electrophoresis. Four proteins, with the apparent molecular weights of 89, 49, 44 and 23.5 kDa, were consistently present in the outer membrane of B. fragilis BE1 grown under iron restricted conditions. In B. vulgatus BE20 cells a 44 and a 23.5 kDa protein were absent and only the expression of an 89 kDa protein was clearly seen under these conditions. The iron regulated proteins, particularly the 44 kDa protein, could be involved to an iron uptake mechanism in B. fragilis. So the presence of these proteins might play an important role in the virulence of this anaerobic bacterium.

Characterization of fimbriae from Bacteroides fragilis

Fimbriae derived from Bacteroides fragilis strain BE1 (BE1 fimbriae) appeared to be composed of subunits with a molecular weight of 40,000. Under the electron microscope the fimbriae could be visualized as straight filaments with a diameter of 4 nm. It appeared that production of the BE1 fimbriae is repressed under conditions of iron limitation, and at a growth temperature of 20 degrees C. Antibodies raised against the 40,000 dalton polypeptide, purified by means of preparative SDS-polyacrylamide gelelectrophoresis, recognized the native fimbriae, as was shown by immunogold labelling of intact bacterial cells, and by immunoprecipitation. Immunoblot experiments showed that other strains of B fragilis tested produced polypeptides, ranging in molecular weight from 40,000 to 42,000, that are antigenically related to the BE1 fimbrial subunit. No haemagglutination activity could be associated with the BE1 fimbriae.

Effect of Bacteroides fragilis grown in the presence of clindamycin, metronidazole and fusidic acid on opsonization and killing of Escherichia coli

Bactericidal action of human polymorphonuclear leucocytes on Escherichia coli in the presence of Bacteroides fragilis grown in subinhibitory concentrations of clindamycin, metronidazole and fusidic acid was studied. Bacteroides fragilis grown in the absence of drugs significantly inhibited the killing of Escherichia coli. Bacteroides fragilis grown in the presence of the drugs had a reduced inhibitory effect on the killing of Escherichia coli but this reduction was only significant for Bacteroides fragilis grown in 1/2 MIC of clindamycin. The phagocytosis of Bacteroides fragilis grown with and without clindamycin, as measured by killing, was the same. Complement consumption of Bacteroides fragilis grown with and without clindamycin did not differ. Clindamycin-treated Bacteroides fragilis fixed C3 to a significantly lower degree than did untreated bacteria. The chemiluminescence of Escherichia coli opsonized with serum preincubated with clindamycin-treated Bacteroides fragilis was significantly higher than with serum preincubated with untreated bacteria. These results suggested that in killing experiments of mixed Escherichia coli and Bacteroides fragilis, the mechanism underlying the reduced inhibitory capacity of clindamycin-exposed Bacteroides fragilis is related to greater availability of C3 in serum for opsonization of Escherichia coli.

Interactions between polymorphonuclear leucocytes, Bacteroides sp, and Escherichia coli: their role in the pathogenesis of mixed infection

Five Bacteroides fragilis strains and five Bacteroides vulgatus strains were compared with regard to their ability to consume complement and to fix C3, their killing by polymorphonuclear leucocytes, and their ability to inhibit the bactericidal effect of serum and polymorphs on Escherichia coli strains. Complement consumption was positively related to C3 fixation, but no relation was observed between these variables and the killing of the anaerobes. Greatest inhibition of the killing of E coli by serum and polymorphs was achieved with the bacteroides strains that fixed most complement. The greater virulence of B fragilis in mixed infections with E coli was not reflected either by a greater ability to inhibit the killing of E coli or a greater resistance of the anaerobes themselves to the bactericidal effect of serum and polymorphs.

Pathogenic synergy: mixed infections in the oral cavity

In almost all infections in the oral cavity, mixed populations of bacteria are present. However, recent evidence points to a certain specificity in these infections: Streptococcus mutans is related to caries and black-pigmented Bacteroides species are suspected pathogens in periodontal disease. Periodontal diseases, endodontic infections and submucous abscesses in the oral cavity are probably mixed infections in which anaerobic bacteria together with facultatives or other anaerobes are present. In experimental mixed anaerobic infections black-pigmented Bacteroides strains have been shown to play a key role. Little is known about the pathogenic synergy between the bacteria involved in mixed infections. Important mechanisms could be nutritional interrelationships and interactions with the host defense. Within the group of black-pigmented Bacteroides B. gingivalis seems to be the most virulent species. These bacteria possess a great number of virulence factors, which might be important in the pathogenesis of oral infections.