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Löckener I, Behrmann LV, Reuter J, Schiefer A, Klöckner A, Krannich S, Otten C, Mölleken K, Ichikawa S, Hoerauf A, Schneider T, Pfarr KM, Henrichfreise B. The MraY Inhibitor Muraymycin D2 and Its Derivatives Induce Enlarged Cells in Obligate Intracellular Chlamydia and Wolbachia and Break the Persistence Phenotype in Chlamydia. Antibiotics (Basel) 2024; 13:421. [PMID: 38786149 PMCID: PMC11117252 DOI: 10.3390/antibiotics13050421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/26/2024] [Accepted: 04/28/2024] [Indexed: 05/25/2024] Open
Abstract
Chlamydial infections and diseases caused by filarial nematodes are global health concerns. However, treatment presents challenges due to treatment failures potentially caused by persisting Chlamydia and long regimens against filarial infections accompanied by low compliance. A new treatment strategy could be the targeting of the reduced peptidoglycan structures involved in cell division in the obligate intracellular bacteria Chlamydia and Wolbachia, the latter being obligate endosymbionts supporting filarial development, growth, and survival. Here, cell culture experiments with C. trachomatis and Wolbachia showed that the nucleoside antibiotics muraymycin and carbacaprazamycin interfere with bacterial cell division and induce enlarged, aberrant cells resembling the penicillin-induced persistence phenotype in Chlamydia. Enzymatic inhibition experiments with purified C. pneumoniae MraY revealed that muraymycin derivatives abolish the synthesis of the peptidoglycan precursor lipid I. Comparative in silico analyses of chlamydial and wolbachial MraY with the corresponding well-characterized enzyme in Aquifex aeolicus revealed a high degree of conservation, providing evidence for a similar mode of inhibition. Muraymycin D2 treatment eradicated persisting non-dividing C. trachomatis cells from an established penicillin-induced persistent infection. This finding indicates that nucleoside antibiotics may have additional properties that can break bacterial persistence.
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Affiliation(s)
- Iris Löckener
- Institute for Pharmaceutical Microbiology (IPM), University of Bonn, University Hospital Bonn, Meckenheimer Allee 168, 53115 Bonn, Germany (C.O.); (B.H.)
| | - Lara Vanessa Behrmann
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (L.V.B.)
| | - Jula Reuter
- Institute for Pharmaceutical Microbiology (IPM), University of Bonn, University Hospital Bonn, Meckenheimer Allee 168, 53115 Bonn, Germany (C.O.); (B.H.)
| | - Andrea Schiefer
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (L.V.B.)
| | - Anna Klöckner
- Institute for Pharmaceutical Microbiology (IPM), University of Bonn, University Hospital Bonn, Meckenheimer Allee 168, 53115 Bonn, Germany (C.O.); (B.H.)
| | - Sebastian Krannich
- Institute for Pharmaceutical Microbiology (IPM), University of Bonn, University Hospital Bonn, Meckenheimer Allee 168, 53115 Bonn, Germany (C.O.); (B.H.)
| | - Christian Otten
- Institute for Pharmaceutical Microbiology (IPM), University of Bonn, University Hospital Bonn, Meckenheimer Allee 168, 53115 Bonn, Germany (C.O.); (B.H.)
| | - Katja Mölleken
- Institute for Functional Microbial Genomics, Heinrich Heine University Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany;
| | - Satoshi Ichikawa
- Faculty of Pharmaceutical Sciences, Hokkaido University, Kita-12, Nishi-6, Kita-ku, Sapporo 060-0812, Japan
| | - Achim Hoerauf
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (L.V.B.)
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, 53127 Bonn, Germany
| | - Tanja Schneider
- Institute for Pharmaceutical Microbiology (IPM), University of Bonn, University Hospital Bonn, Meckenheimer Allee 168, 53115 Bonn, Germany (C.O.); (B.H.)
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, 53127 Bonn, Germany
| | - Kenneth M. Pfarr
- Institute for Medical Microbiology, Immunology and Parasitology (IMMIP), University Hospital Bonn, Venusberg-Campus 1, 53127 Bonn, Germany; (L.V.B.)
- German Center for Infection Research (DZIF), Partner Site Bonn-Cologne, 53127 Bonn, Germany
| | - Beate Henrichfreise
- Institute for Pharmaceutical Microbiology (IPM), University of Bonn, University Hospital Bonn, Meckenheimer Allee 168, 53115 Bonn, Germany (C.O.); (B.H.)
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Reuter J, Otten C, Jacquier N, Lee J, Mengin-Lecreulx D, Löckener I, Kluj R, Mayer C, Corona F, Dannenberg J, Aeby S, Bühl H, Greub G, Vollmer W, Ouellette SP, Schneider T, Henrichfreise B. An NlpC/P60 protein catalyzes a key step in peptidoglycan recycling at the intersection of energy recovery, cell division and immune evasion in the intracellular pathogen Chlamydia trachomatis. PLoS Pathog 2023; 19:e1011047. [PMID: 36730465 PMCID: PMC9928106 DOI: 10.1371/journal.ppat.1011047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/14/2023] [Accepted: 12/06/2022] [Indexed: 02/04/2023] Open
Abstract
The obligate intracellular Chlamydiaceae do not need to resist osmotic challenges and thus lost their cell wall in the course of evolution. Nevertheless, these pathogens maintain a rudimentary peptidoglycan machinery for cell division. They build a transient peptidoglycan ring, which is remodeled during the process of cell division and degraded afterwards. Uncontrolled degradation of peptidoglycan poses risks to the chlamydial cell, as essential building blocks might get lost or trigger host immune response upon release into the host cell. Here, we provide evidence that a primordial enzyme class prevents energy intensive de novo synthesis and uncontrolled release of immunogenic peptidoglycan subunits in Chlamydia trachomatis. Our data indicate that the homolog of a Bacillus NlpC/P60 protein is widely conserved among Chlamydiales. We show that the enzyme is tailored to hydrolyze peptidoglycan-derived peptides, does not interfere with peptidoglycan precursor biosynthesis, and is targeted by cysteine protease inhibitors in vitro and in cell culture. The peptidase plays a key role in the underexplored process of chlamydial peptidoglycan recycling. Our study suggests that chlamydiae orchestrate a closed-loop system of peptidoglycan ring biosynthesis, remodeling, and recycling to support cell division and maintain long-term residence inside the host. Operating at the intersection of energy recovery, cell division and immune evasion, the peptidoglycan recycling NlpC/P60 peptidase could be a promising target for the development of drugs that combine features of classical antibiotics and anti-virulence drugs.
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Affiliation(s)
- Jula Reuter
- Institute for Pharmaceutical Microbiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Christian Otten
- Institute for Pharmaceutical Microbiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Nicolas Jacquier
- Institute of Microbiology, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Junghoon Lee
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Dominique Mengin-Lecreulx
- Université Paris-Saclay, CEA, CNRS, Institute for Integrative Biology of the Cell (I2BC), Gif-sur-Yvette, France
| | - Iris Löckener
- Institute for Pharmaceutical Microbiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Robert Kluj
- Interfaculty Institute of Microbiology and Infection Medicine, Organismic Interactions/Glycobiology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Christoph Mayer
- Interfaculty Institute of Microbiology and Infection Medicine, Organismic Interactions/Glycobiology, Eberhard Karls Universität Tübingen, Tübingen, Germany
| | - Federico Corona
- Centre for Bacterial Cell Biology, Biosciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Julia Dannenberg
- Institute for Pharmaceutical Microbiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Sébastien Aeby
- Institute of Microbiology, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Henrike Bühl
- Institute for Pharmaceutical Microbiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Gilbert Greub
- Institute of Microbiology, University Hospital Center and University of Lausanne, Lausanne, Switzerland
| | - Waldemar Vollmer
- Centre for Bacterial Cell Biology, Biosciences Institute, Newcastle University, Newcastle Upon Tyne, United Kingdom
| | - Scot P. Ouellette
- Department of Pathology and Microbiology, College of Medicine, University of Nebraska Medical Center, Omaha, Nebraska, United States of America
| | - Tanja Schneider
- Institute for Pharmaceutical Microbiology, University Hospital Bonn, University of Bonn, Bonn, Germany
| | - Beate Henrichfreise
- Institute for Pharmaceutical Microbiology, University Hospital Bonn, University of Bonn, Bonn, Germany
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Melzer ES, Kado T, García-Heredia A, Gupta KR, Meniche X, Morita YS, Sassetti CM, Rego EH, Siegrist MS. Cell Wall Damage Reveals Spatial Flexibility in Peptidoglycan Synthesis and a Nonredundant Role for RodA in Mycobacteria. J Bacteriol 2022; 204:e0054021. [PMID: 35543537 PMCID: PMC9210966 DOI: 10.1128/jb.00540-21] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Accepted: 03/06/2022] [Indexed: 12/28/2022] Open
Abstract
Cell wall peptidoglycan is a heteropolymeric mesh that protects the bacterium from internal turgor and external insults. In many rod-shaped bacteria, peptidoglycan synthesis for normal growth is achieved by two distinct pathways: the Rod complex, comprised of MreB, RodA, and a cognate class B penicillin-binding protein (PBP), and the class A PBPs (aPBPs). In contrast to laterally growing bacteria, pole-growing mycobacteria do not encode an MreB homolog and do not require SEDS protein RodA for in vitro growth. However, RodA contributes to the survival of Mycobacterium tuberculosis in some infection models, suggesting that the protein could have a stress-dependent role in maintaining cell wall integrity. Under basal conditions, we find here that the subcellular distribution of RodA largely overlaps that of the aPBP PonA1 and that both RodA and the aPBPs promote polar peptidoglycan assembly. Upon cell wall damage, RodA fortifies Mycobacterium smegmatis against lysis and, unlike aPBPs, contributes to a shift in peptidoglycan assembly from the poles to the sidewall. Neither RodA nor PonA1 relocalize; instead, the redistribution of nascent cell wall parallels that of peptidoglycan precursor synthase MurG. Our results support a model in which mycobacteria balance polar growth and cell-wide repair via spatial flexibility in precursor synthesis and extracellular insertion. IMPORTANCE Peptidoglycan synthesis is a highly successful target for antibiotics. The pathway has been extensively studied in model organisms under laboratory-optimized conditions. In natural environments, bacteria are frequently under attack. Moreover, the vast majority of bacterial species are unlikely to fit a single paradigm of cell wall assembly because of differences in growth mode and/or envelope structure. Studying cell wall synthesis under nonoptimal conditions and in nonstandard species may improve our understanding of pathway function and suggest new inhibition strategies. Mycobacterium smegmatis, a relative of several notorious human and animal pathogens, has an unusual polar growth mode and multilayered envelope. In this work, we challenged M. smegmatis with cell wall-damaging enzymes to characterize the roles of cell wall-building enzymes when the bacterium is under attack.
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Affiliation(s)
- Emily S. Melzer
- Department of Microbiology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Takehiro Kado
- Department of Microbiology, University of Massachusetts, Amherst, Massachusetts, USA
| | - Alam García-Heredia
- Molecular and Cellular Biology Graduate Program, University of Massachusetts, Amherst, Massachusetts, USA
- Department of Biology, Massachusetts Institute of Technology, Cambridge, Massachusetts, USA
| | | | - Xavier Meniche
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Yasu S. Morita
- Department of Microbiology, University of Massachusetts, Amherst, Massachusetts, USA
- Molecular and Cellular Biology Graduate Program, University of Massachusetts, Amherst, Massachusetts, USA
| | - Christopher M. Sassetti
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - E. Hesper Rego
- Department of Microbial Pathogenesis, Yale University School of Medicine, New Haven, Connecticut, USA
| | - M. Sloan Siegrist
- Department of Microbiology, University of Massachusetts, Amherst, Massachusetts, USA
- Molecular and Cellular Biology Graduate Program, University of Massachusetts, Amherst, Massachusetts, USA
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Wamp S, Rothe P, Stern D, Holland G, Döhling J, Halbedel S. MurA escape mutations uncouple peptidoglycan biosynthesis from PrkA signaling. PLoS Pathog 2022; 18:e1010406. [PMID: 35294506 PMCID: PMC8959180 DOI: 10.1371/journal.ppat.1010406] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 03/28/2022] [Accepted: 02/28/2022] [Indexed: 01/23/2023] Open
Abstract
Gram-positive bacteria are protected by a thick mesh of peptidoglycan (PG) completely engulfing their cells. This PG network is the main component of the bacterial cell wall, it provides rigidity and acts as foundation for the attachment of other surface molecules. Biosynthesis of PG consumes a high amount of cellular resources and therefore requires careful adjustments to environmental conditions. An important switch in the control of PG biosynthesis of Listeria monocytogenes, a Gram-positive pathogen with a high infection fatality rate, is the serine/threonine protein kinase PrkA. A key substrate of this kinase is the small cytosolic protein ReoM. We have shown previously that ReoM phosphorylation regulates PG formation through control of MurA stability. MurA catalyzes the first step in PG biosynthesis and the current model suggests that phosphorylated ReoM prevents MurA degradation by the ClpCP protease. In contrast, conditions leading to ReoM dephosphorylation stimulate MurA degradation. How ReoM controls degradation of MurA and potential other substrates is not understood. Also, the individual contribution of the ~20 other known PrkA targets to PG biosynthesis regulation is unknown. We here present murA mutants which escape proteolytic degradation. The release of MurA from ClpCP-dependent proteolysis was able to activate PG biosynthesis and further enhanced the intrinsic cephalosporin resistance of L. monocytogenes. This latter effect required the RodA3/PBP B3 transglycosylase/transpeptidase pair. One murA escape mutation not only fully rescued an otherwise non-viable prkA mutant during growth in batch culture and inside macrophages but also overcompensated cephalosporin hypersensitivity. Our data collectively indicate that the main purpose of PrkA-mediated signaling in L. monocytogenes is control of MurA stability during standard laboratory growth conditions and intracellular growth in macrophages. These findings have important implications for the understanding of PG biosynthesis regulation and β-lactam resistance of L. monocytogenes and related Gram-positive bacteria. Peptidoglycan (PG) is the main component of the bacterial cell wall and many of the PG synthesizing enzymes are antibiotic targets. We previously have discovered a new signaling route controlling PG production in the human pathogen Listeria monocytogenes. This route also determines the intrinsic resistance of L. monocytogenes against cephalosporins, a group of β-lactam antibiotics. Signaling involves PrkA, a membrane-embedded protein kinase, that is activated during cell wall stress to phosphorylate its target ReoM. Depending on its phosphorylation, ReoM activates or inactivates PG production by controlling the proteolytic stability of MurA, which catalyzes the first step in PG biosynthesis. MurA degradation depends on the ClpCP protease and we here have isolated murA mutations that escape this degradation. Using these mutants, we could show that regulation of PG biosynthesis through control of MurA stability is an important purpose of PrkA-mediated signaling in L. monocytogenes. Further experiments identified the transglycosylase RodA and the transpeptidase PBP B3 as additional downstream factors. Our results suggest that both proteins act together to translate the signals received by PrkA into adjustment of PG biosynthesis. These findings shed new light on the regulation of PG biosynthesis in Gram-positive bacteria with intrinsic β-lactam resistance.
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Affiliation(s)
- Sabrina Wamp
- FG11 - Division of Enteropathogenic bacteria and Legionella, Robert Koch Institute, Wernigerode, Germany
| | - Patricia Rothe
- FG11 - Division of Enteropathogenic bacteria and Legionella, Robert Koch Institute, Wernigerode, Germany
| | - Daniel Stern
- ZBS3 - Biological Toxins, Robert Koch Institute, Berlin, Germany
| | - Gudrun Holland
- ZBS4 - Advanced Light and Electron Microscopy, Robert Koch Institute, Berlin, Germany
| | - Janina Döhling
- FG11 - Division of Enteropathogenic bacteria and Legionella, Robert Koch Institute, Wernigerode, Germany
| | - Sven Halbedel
- FG11 - Division of Enteropathogenic bacteria and Legionella, Robert Koch Institute, Wernigerode, Germany
- * E-mail:
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Discovery of a Diverse Set of Bacteria That Build Their Cell Walls without the Canonical Peptidoglycan Polymerase aPBP. mBio 2021; 12:e0134221. [PMID: 34311584 PMCID: PMC8406291 DOI: 10.1128/mbio.01342-21] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023] Open
Abstract
Peptidoglycan (PG) is a highly cross-linked peptide-glycan mesh that confers structural rigidity and shape to most bacterial cells. Polymerization of new PG is usually achieved by the concerted activity of two membrane-bound machineries, class-A penicillin binding proteins (aPBPs) and class-B penicillin binding proteins (bPBPs) in complex with shape, elongation, division, and sporulation (SEDS) proteins. Here, we have identified four phylogenetically distinct groups of bacteria that lack any identifiable aPBPs. We performed experiments on a panel of species within one of these groups, the Rickettsiales, and found that bacteria lacking aPBPs build a PG-like cell wall with minimal abundance and rigidity relative to cell walls of aPBP-containing bacteria. This reduced cell wall may have evolved to minimize the activation of host responses to pathogens and endosymbionts while retaining the minimal PG-biosynthesis machinery required for cell elongation and division. We term these “peptidoglycan-intermediate” bacteria, a cohort of host-associated species that includes some human pathogens.
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Caccamo PD, Brun YV. The Molecular Basis of Noncanonical Bacterial Morphology. Trends Microbiol 2017; 26:191-208. [PMID: 29056293 DOI: 10.1016/j.tim.2017.09.012] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 09/08/2017] [Accepted: 09/28/2017] [Indexed: 01/04/2023]
Abstract
Bacteria come in a wide variety of shapes and sizes. The true picture of bacterial morphological diversity is likely skewed due to an experimental focus on pathogens and industrially relevant organisms. Indeed, most of the work elucidating the genes and molecular processes involved in maintaining bacterial morphology has been limited to rod- or coccal-shaped model systems. The mechanisms of shape evolution, the molecular processes underlying diverse shapes and growth modes, and how individual cells can dynamically modulate their shape are just beginning to be revealed. Here we discuss recent work aimed at advancing our knowledge of shape diversity and uncovering the molecular basis for shape generation in noncanonical and morphologically complex bacteria.
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Affiliation(s)
- Paul D Caccamo
- Department of Biology, Indiana University, 1001 E. 3rd St, Bloomington, IN 47405, USA
| | - Yves V Brun
- Department of Biology, Indiana University, 1001 E. 3rd St, Bloomington, IN 47405, USA.
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Wilmes M, Meier K, Schiefer A, Josten M, Otten CF, Klöckner A, Henrichfreise B, Vollmer W, Hoerauf A, Pfarr K. AmiD Is a Novel Peptidoglycan Amidase in Wolbachia Endosymbionts of Drosophila melanogaster. Front Cell Infect Microbiol 2017; 7:353. [PMID: 28824885 PMCID: PMC5543032 DOI: 10.3389/fcimb.2017.00353] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2017] [Accepted: 07/21/2017] [Indexed: 11/13/2022] Open
Abstract
Wolbachia endobacteria are obligate intracellular bacteria with a highly reduced genome infecting many arthropod and filarial species, in which they manipulate arthropod reproduction to increase their transmission and are essential for nematode development and survival. The Wolbachia genome encodes all enzymes required for the synthesis of the cell wall building block lipid II, although a peptidoglycan-like structure has not been detected. Despite the ability to synthesize lipid II, Wolbachia from arthropods and nematodes have only a subset of genes encoding enzymes involved in the periplasmic processing of lipid II and peptidoglycan recycling, with arthropods having two more than nematodes. We functionally analyzed the activity of the putative cell wall hydrolase AmiD from the Wolbachia endosymbiont of Drosophila melanogaster, an enzyme not encoded by the nematode endobacteria. Wolbachia AmiD has Zn2+-dependent amidase activity and cleaves intact peptidoglycan, monomeric lipid II and anhydromuropeptides, substrates that are generated during bacterial growth. AmiD may have been maintained in arthropod Wolbachia to avoid host immune recognition by degrading cell wall fragments in the periplasm. This is the first description of a wolbachial lipid II processing enzyme putatively expressed in the periplasm.
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Affiliation(s)
- Miriam Wilmes
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital BonnBonn, Germany
| | - Kirstin Meier
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital BonnBonn, Germany
| | - Andrea Schiefer
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital BonnBonn, Germany
| | - Michaele Josten
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital BonnBonn, Germany
| | - Christian F Otten
- Institute for Cell and Molecular Bioscience, Newcastle UniversityNewcastle upon Tyne, United Kingdom
| | - Anna Klöckner
- Institute for Pharmaceutical Microbiology, University of BonnBonn, Germany
| | | | - Waldemar Vollmer
- Institute for Cell and Molecular Bioscience, Newcastle UniversityNewcastle upon Tyne, United Kingdom
| | - Achim Hoerauf
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital BonnBonn, Germany.,German Center for Infection Research (DZIF), Partner Site Bonn-CologneBonn, Germany
| | - Kenneth Pfarr
- Institute of Medical Microbiology, Immunology and Parasitology, University Hospital BonnBonn, Germany
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