Decreased susceptibility to penicillin G and Tet M plasmids in genital and anorectal isolates of Neisseria meningitidis

Evolution and exchange of plasmids in pathogenic Neisseria

IMPORTANCE

Horizontal gene transfer (HGT) is a major influence in driving the spread of antimicrobial resistance (AMR) in many bacteria. A conjugative plasmid which is widespread in Neisseria gonorrhoeae, pConj, prevented the use of tetracycline/doxycycline for treating gonococcal infection. Here, we show that pConj evolved in the related pathogen, Neisseria meningitidis, and has been acquired by the gonococcus from the meningococcus on multiple occasions. Following its initial acquisition, pConj spread to different gonococcal lineages; changes in the plasmid's conjugation machinery associated with another transfer event limit spread in the gonococcal populations. Our findings have important implications for the use of doxycycline to prevent bacterial sexually transmitted disease which is likely to exacerbate the spread of AMR through HGT in pathogenic bacteria.

Atypical, Yet Not Infrequent, Infections with Neisseria Species

Neisseria species are extremely well-adapted to their mammalian hosts and they display unique phenotypes that account for their ability to thrive within niche-specific conditions. The closely related species N. gonorrhoeae and N. meningitidis are the only two species of the genus recognized as strict human pathogens, causing the sexually transmitted disease gonorrhea and meningitis and sepsis, respectively. Gonococci colonize the mucosal epithelium of the male urethra and female endo/ectocervix, whereas meningococci colonize the mucosal epithelium of the human nasopharynx. The pathophysiological host responses to gonococcal and meningococcal infection are distinct. However, medical evidence dating back to the early 1900s demonstrates that these two species can cross-colonize anatomical niches, with patients often presenting with clinically-indistinguishable infections. The remaining Neisseria species are not commonly associated with disease and are considered as commensals within the normal microbiota of the human and animal nasopharynx. Nonetheless, clinical case reports suggest that they can behave as opportunistic pathogens. In this review, we describe the diversity of the genus Neisseria in the clinical context and raise the attention of microbiologists and clinicians for more cautious approaches in the diagnosis and treatment of the many pathologies these species may cause.

Genomic analysis of urogenital and rectal Neisseria meningitidis isolates reveals encapsulated hyperinvasive meningococci and coincident multidrug-resistant gonococci

Objective

Invasive meningococcal disease (IMD) outbreaks in men who have sex with men (MSM) have been associated with meningococcal colonisation of the urethra and rectum, but little is known about this colonisation or co-colonisation with the closely related gonococcus. Whole genome sequencing (WGS) was employed to explore these phenomena.

Methods

Meningococci isolated from the urogenital tract and rectum (n=23) and coincident gonococci (n=14) were analysed by WGS along with contemporary meningococci from IMD (n=11). All isolates were obtained from hospital admissions in Brighton, UK, 2011–2013. Assembled WGS were deposited in the PubMLST/neisseria database (http://pubmlst.org/neisseria) and compared at genomic loci common to gonococci or meningococci.

Results

As expected, most meningococci from IMD were encapsulated and belonged to hyperinvasive lineages. So too were meningococci found in the urogenital tract and rectum, contrasting to those asymptomatically carried in the nasopharynx where such meningococci are rare. Five hyperinvasive meningococcal lineages and four distinct gonococcal genotypes were recovered, including multiresistant ST-1901 (NG MAST-1407) gonococci.

Conclusions

These data were consistent with a predisposition for potentially virulent encapsulated hyperinvasive meningococci to colonise the urethra and rectum, which suggests their involvement in MSM IMD outbreaks. The coincidence of multiresistant gonococci raises wider public health concerns.

Tetracycline antibiotics: mode of action, applications, molecular biology, and epidemiology of bacterial resistance

Tetracyclines were discovered in the 1940s and exhibited activity against a wide range of microorganisms including gram-positive and gram-negative bacteria, chlamydiae, mycoplasmas, rickettsiae, and protozoan parasites. They are inexpensive antibiotics, which have been used extensively in the prophlylaxis and therapy of human and animal infections and also at subtherapeutic levels in animal feed as growth promoters. The first tetracycline-resistant bacterium, Shigella dysenteriae, was isolated in 1953. Tetracycline resistance now occurs in an increasing number of pathogenic, opportunistic, and commensal bacteria. The presence of tetracycline-resistant pathogens limits the use of these agents in treatment of disease. Tetracycline resistance is often due to the acquisition of new genes, which code for energy-dependent efflux of tetracyclines or for a protein that protects bacterial ribosomes from the action of tetracyclines. Many of these genes are associated with mobile plasmids or transposons and can be distinguished from each other using molecular methods including DNA-DNA hybridization with oligonucleotide probes and DNA sequencing. A limited number of bacteria acquire resistance by mutations, which alter the permeability of the outer membrane porins and/or lipopolysaccharides in the outer membrane, change the regulation of innate efflux systems, or alter the 16S rRNA. New tetracycline derivatives are being examined, although their role in treatment is not clear. Changing the use of tetracyclines in human and animal health as well as in food production is needed if we are to continue to use this class of broad-spectrum antimicrobials through the present century.

Tetracycline antibiotics: mode of action, applications, molecular biology, and epidemiology of bacterial resistance

Tetracyclines were discovered in the 1940s and exhibited activity against a wide range of microorganisms including gram-positive and gram-negative bacteria, chlamydiae, mycoplasmas, rickettsiae, and protozoan parasites. They are inexpensive antibiotics, which have been used extensively in the prophlylaxis and therapy of human and animal infections and also at subtherapeutic levels in animal feed as growth promoters. The first tetracycline-resistant bacterium, Shigella dysenteriae, was isolated in 1953. Tetracycline resistance now occurs in an increasing number of pathogenic, opportunistic, and commensal bacteria. The presence of tetracycline-resistant pathogens limits the use of these agents in treatment of disease. Tetracycline resistance is often due to the acquisition of new genes, which code for energy-dependent efflux of tetracyclines or for a protein that protects bacterial ribosomes from the action of tetracyclines. Many of these genes are associated with mobile plasmids or transposons and can be distinguished from each other using molecular methods including DNA-DNA hybridization with oligonucleotide probes and DNA sequencing. A limited number of bacteria acquire resistance by mutations, which alter the permeability of the outer membrane porins and/or lipopolysaccharides in the outer membrane, change the regulation of innate efflux systems, or alter the 16S rRNA. New tetracycline derivatives are being examined, although their role in treatment is not clear. Changing the use of tetracyclines in human and animal health as well as in food production is needed if we are to continue to use this class of broad-spectrum antimicrobials through the present century.

High-level chloramphenicol resistance in Neisseria meningitidis

BACKGROUND

Neisseria meningitidis is nearly always susceptible to the penicillins, the cephalosporins, and chloramphenicol. Between 1987 and 1996, however, chloramphenicol-resistant strains were isolated from 11 patients in Vietnam and 1 in France.

METHODS

The minimal inhibitory concentration of chloramphenicol was determined for the 12 isolates. The isolates were analyzed by monoclonal-antibody-based serotyping and subtyping, pulsed-field gel electrophoresis, and multilocus enzyme electrophoresis. Bacterial DNA was analyzed by hybridization, the polymerase chain reaction, and sequencing to identify the resistance gene and determine the origin of the resistance.

RESULTS

The isolates were resistant to chloramphenicol (minimal inhibitory concentration, > or =64 mg per liter) and produced an active chloramphenicol acetyltransferase. All 12 strains belonged to serogroup B but had a high degree of diversity, and 10 could not be typed with the use of monoclonal antibodies. The nucleotide sequence of the resistance gene and the flanking regions was identical to that of an internal portion of transposon Tn4451 that carries the catP gene in Clostridium perfringens. Moreover, this gene was located in the same genomic site in the chloramphenicol-resistant isolates.

CONCLUSIONS

The high-level chloramphenicol resistance that we describe in N. meningitidis isolates is of great concern, since in developing countries, chloramphenicol given intramuscularly is the standard therapy for meningococcal meningitis. The resistance to chloramphenicol is due to the presence of the catP gene on a truncated transposon that has lost mobility because of internal deletions, and the transformation of genetic material between strains of N. meningitidis probably played an important part in the dissemination of the gene.

Comparative evaluation of etest for susceptibility testing Neisseria meningitidis with eight antimicrobial agents. An investigation using U.S. Food and Drug Administration regulatory criteria

Invasive infections caused by Neisseria meningitidis continue to be a serious clinical problem for therapy, epidemiology, and potential prophylaxis. Multiple antimicrobial resistances have emerged among meningococcal strains including elevated MICs to penicillin, sulfonamides, tetracyclines, and rifampin. Thus, the need to perform accurate susceptibility testing of meningococci in clinical practice and for surveillance programs has renewed priority. In this study, for the first time Etest (AB Biodisk, Solna, Sweden) was compared to a reference agar dilution method using a large number (100) of clinical strains selected for a range of drug resistances. Etest quantitative accuracy (+/-one log2 dilution agreement) ranged from 94% (penicillin) to 100% (three drugs) for the eight clinically useful antimicrobial agents tested. Intermethod categorical accuracy for all drug ranged from 92% (penicillin, erythromycin) to 100% (five drugs), without false-susceptible or -resistant errors using Etest. Etest and reference methods were highly reproducible (99.6 to 100.0%, respectively). Quantitative discords between methods (> or = two log2 dilutions) were not reproducible and resolved following repeated testing. Etest method proved to be an accurate and reproducible quantitative method for testing N. meningitidis strains for the compared antimicrobial agents (eight) often utilized for therapy and prophylaxis of serious meningococcal disease.

Comparison of broth microdilution and E-test for susceptibility testing of Neisseria meningitidis

The susceptibilities of 54 clinical isolates of Neisseria meningitidis to penicillin, cefotaxime, ceftriaxone, cefepime, imipenem, ciprofloxacin, chloramphenicol, and rifampin were determined by the microdilution method in both cation-adjusted Mueller-Hinton broth (CAMHB) and Haemophilus test medium (HTM). Poor growth was observed in 16.6 and 9% of the strains in CAMHB and HTM, respectively. As a result, the growth of the 54 N. meningitidis strains was evaluated in three other commercially available batches of CAMHB and in one in-house batch of HTM. Poor growth was observed for 9.3 to 16.6% of the strains in all four batches. More important, three of the CAMHB batches failed to support growth for 3.7 to 33.3% of the strains; 3.7% of the strains did not grow in the in-house-prepared HTM. Ten (18.7%) strains were relatively resistant to penicillin (RRP; MIC, > 0.125 mu g/ml) in CAMHB and 13 (24%) strains were RRP in HTM. The percentages of agreement obtained by using CAMHB as the reference ranged from 78% for cefepime to 100% for ceftriaxone. Seven minor errors were observed for penicillin; five of them were for strains susceptible to penicillin in CAMHB and RRP in HTM. All strains were susceptible to the other antimicrobial agents evaluated. The growth of N. meningitidis was also evaluated in four batches of Mueller-Hinton agar (MHA). In two of them, 3.7 and 44.4% of the strains did not grow, and considering all four batches, 5.5 to 11.1% grew poorly. All strains grew adequately in MHA supplemented with blood (MHA-b). The activities of penicillin and cefotaxime were also evaluated by the E-test in MHA and MHA-b. The proportion of RRP strains were 24% in MHA and 59% in MHA-b. For penicillin, the percentages of agreement of the E-test with the microdilution method in CAMHB (reference) were 64.8 and 70.3% in MHA and MHA-b, respectively. For cefotaxime, the agreement was 98.1%. Minor errors for the penicillin MIC were detected for 38% of the strains tested. Further studies are needed to define adequate culture media for reference methods to evaluate the susceptibility of N. meningitidis to antimicrobial agents.

Rifampin resistance in Neisseria meningitidis due to alterations in membrane permeability

Rifampin-resistant (Rifr) Neisseria meningitidis strains are known to have single point mutations in the central conserved regions of the rpoB gene. We have demonstrated two distinct resistance phenotypes in strains with identical mutations in this region, an intermediate level of resistance in Rifr clinical isolates and a high level of resistance in mutants selected in vitro. The possible role of membrane permeability in the latter was investigated by measuring MICs in the presence of Tween 80; values for high-level-resistance mutants were reduced to intermediate levels, whereas those for intermediate-level-resistance strains were unaffected. The highly resistant mutants were also found to have increased resistance to Triton X-100 and gentian violet. Sequencing of the meningococcal mtrR gene and its promoter region (which determine resistance to hydrophobic agents in Neisseria gonorrhoeae) from susceptible or intermediate strains and highly resistant mutants generated from them showed no mutation within this region. Two-dimensional gel electrophoresis of two parent and Rif mutant strains showed identical shifts in the pI of one protein, indicating that differences between the parent and the highly Rifr mutant are not confined to the rpoB gene. These results indicate that both permeability and rpoB mutations play a role in determining the resistance of N. meningitidis to rifampin.

Detection of two groups of 25.2 MDa Tet M plasmids by polymerase chain reaction of the downstream region

Forty-four Neisseria gonorrhoeae, 12 N. meningitidis, four Kingella denitrificans and one Eikenella corrodens carrying 25.2 MDa Tet M plasmids were analysed using polymerase chain reaction (PCR) to the downstream region of the incomplete Tet M transposon. From each isolate, one of two different PCR fragments of approximately 700 or 1600 bp were obtained. The two different sized PCR fragments had > or = 90% DNA sequence identity with Ureaplasma urealyticum Tet M downstream sequences. The difference between the large PCR fragment and the smaller PCR fragment was a deletion of over 800 bp in the smaller fragment. Both PCR fragments were found in plasmids isolated from N. gonorrhoeae and K. denitrificans. The smaller PCR fragment was found in N. meningitidis plasmids and the larger PCR fragment was found in the E. corrodens plasmid.