Uptake of metronidazole and its effect on viability in trichomonads and Entamoeba invadens under anaerobic and aerobic conditions

Gut microbiota interspecies interactions shape the response of Clostridioides difficile to clinically relevant antibiotics

In the human gut, the growth of the pathogen Clostridioides difficile is impacted by a complex web of interspecies interactions with members of human gut microbiota. We investigate the contribution of interspecies interactions on the antibiotic response of C. difficile to clinically relevant antibiotics using bottom-up assembly of human gut communities. We identify 2 classes of microbial interactions that alter C. difficile's antibiotic susceptibility: interactions resulting in increased ability of C. difficile to grow at high antibiotic concentrations (rare) and interactions resulting in C. difficile growth enhancement at low antibiotic concentrations (common). Based on genome-wide transcriptional profiling data, we demonstrate that metal sequestration due to hydrogen sulfide production by the prevalent gut species Desulfovibrio piger increases the minimum inhibitory concentration (MIC) of metronidazole for C. difficile. Competition with species that display higher sensitivity to the antibiotic than C. difficile leads to enhanced growth of C. difficile at low antibiotic concentrations due to competitive release. A dynamic computational model identifies the ecological principles driving this effect. Our results provide a deeper understanding of ecological and molecular principles shaping C. difficile's response to antibiotics, which could inform therapeutic interventions.

Unusual Cell Structures and Organelles in Giardia intestinalis and Trichomonas vaginalis Are Potential Drug Targets

This review presents the main cell organelles and structures of two important protist parasites, Giardia intestinalis, and Trichomonas vaginalis; many are unusual and are not found in other eukaryotic cells, thus could be good candidates for new drug targets aimed at improvement of the chemotherapy of diseases caused by these eukaryotic protists. For example, in Giardia, the ventral disc is a specific structure to this parasite and is fundamental for the adhesion and pathogenicity to the host. In Trichomonas, the hydrogenosome, a double membrane-bounded organelle that produces ATP, also can be a good target. Other structures include mitosomes, ribosomes, and proteasomes. Metronidazole is the most frequent compound used to kill many anaerobic organisms, including Giardia and Trichomonas. It enters the cell by passive diffusion and needs to find a highly reductive environment to be reduced to the nitro radicals to be active. However, it provokes several side effects, and some strains present metronidazole resistance. Therefore, to improve the quality of the chemotherapy against parasitic protozoa is important to invest in the development of highly specific compounds that interfere with key steps of essential metabolic pathways or in the functional macromolecular complexes which are most often associated with cell structures and organelles.

A reassessment of the role of oxygen scavenging enzymes in the emergence of metronidazole resistance in trichomonads

Trichomonads are an order of parasitic protists which infect a wide range of hosts. The human parasite Trichomonas vaginalis and the bovine parasite Tritrichomonas foetus which also infects cats and swine are of considerable medical and veterinary importance, respectively. Since trichomonads are microaerophiles/anaerobes they are susceptible to 5-nitroimidazoles such as metronidazole. 5-nitroimidazoles are exclusively toxic to microaerophilic/anaerobic organisms because reduction, i.e. activation, of the drug can only occur in a highly reductive environment. 5-nitroimidazoles have remained a reliable treatment option throughout the last decades but drug resistance can be a problem. Clinical resistance to 5-nitroimidazoles has been studied in more detail in T. vaginalis and has been ascribed to defective oxygen scavenging mechanisms which lead to higher intracellular oxygen concentrations and, consequently, to less drug being reduced. Two enzymes, flavin reductase (FR) and NADH oxidase have been suggested to be the major oxygen scavenging enzymes in T. vaginalis. The loss, or at least an impairment of FR which reduces oxygen to hydrogen peroxide, has been proposed as the central mechanism that enables the emergence of 5-nitroimidazole resistance. In this study we explored if T. foetus also encodes a homolog of FR and if it is, likewise, involved in resistance. T. foetus was indeed found to express a FR but it was only weakly active as compared to the T. vaginalis homolog. Further, activity of FR in T. foetus was unchanged in metronidazole-resistant cell lines, ruling out that it has a role in metronidazole resistance. Finally, we measured oxygen scavenging rates in metronidazole-sensitive and -resistant cell lines and found that NADH oxidase and FR are not the major oxygen scavenging enzymes in trichomonads and that oxygen scavenging is possibly a consequence, rather than a cause of metronidazole resistance.

Flow cytometry evaluation of in vitro susceptibility of bovine isolates of Tritrichomonas foetus to metronidazole

Bovine Trichomonosis, an endemic sexually transmitted disease in countries with extensive livestock and natural service, represents one of the most common causes of reproductive failure. 5-nitroimidazoles and their derivatives are used for its treatment, mainly metronidazole (Mz). The emergence of resistance mechanisms adopted by the parasites against the drug and failure of the treatments suggest the need to investigate susceptibility and obtain current values. The available information of in vitro susceptibility of these drugs comes from the use of a diversity of methodologies and criteria, especially observation of the mobility of the parasite under the optical microscope to evaluate its viability. These techniques are arduous and time consuming and lead to a subjective assessment dependent on the operator, the methodology used, and the morphology adopted by the protozoan. In this sense, flow cytometry has proven to be a fast and efficient method to evaluate viability in other protozoa. The aim of this study was to evaluate the in vitro susceptibility of six bovine isolates of Tritrichomonas foetus to Mz in aerobic (AC) and anaerobic (ANC) conditions by means of the calculation of the 50% inhibitory concentration (IC₅₀), by flow cytometry, and also to analyze minimum lethal concentration (MLC) by means of recovery tests post-treatment in vitro. IC₅₀ values ranged from 1.06 to 1.25 μM in ANC and from 1.44 to 3.03 μM in AC, these being the only ones reported at 48 h for these protozoa. With respect to MLC at 48 h, the results were from 3.67 to 7.35 μM in ANC, and from 7.35 to 14.7 μM for AC, where two isolates (Tf0 and Tf2) for AC and one (Tf2) for ANC showed higher values than those described in the literature. Flow cytometry has proven to be an effective, rapid and objective methodology and very useful in susceptibility tests. The data obtained through these tests allow us to describe the susceptibility exhibited by these protozoa, this being valuable information when establishing dosages in Mz treatments.

Metronidazole: an update on metabolism, structure-cytotoxicity and resistance mechanisms

Metronidazole, a nitroimidazole, remains a front-line choice for treatment of infections related to inflammatory disorders of the gastrointestinal tract including colitis linked to Clostridium difficile. Despite >60 years of research, the metabolism of metronidazole and associated cytotoxicity is not definitively characterized. Nitroimidazoles are prodrugs that are reductively activated (the nitro group is reduced) under low oxygen tension, leading to imidazole fragmentation and cytotoxicity. It remains unclear if nitroimidazole reduction (activation) contributes to the cytotoxicity profile, or whether subsequent fragmentation of the imidazole ring and formed metabolites alone mediate cytotoxicity. A molecular mechanism underpinning high level (>256 mg/L) bacterial resistance to metronidazole also remains elusive. Considering the widespread use of metronidazole and other nitroimidazoles, this review was undertaken to emphasize the structure-cytotoxicity profile of the numerous metabolites of metronidazole in human and murine models and to examine conflicting reports regarding metabolite-DNA interactions. An alternative hypothesis, that DNA synthesis and repair of existing DNA is indirectly inhibited by metronidazole is proposed. Prokaryotic metabolism of metronidazole is detailed to discuss new resistance mechanisms. Additionally, the review contextualizes the history and current use of metronidazole, rates of metronidazole resistance including metronidazole MDR as well as the biosynthesis of azomycin, the natural precursor of metronidazole. Changes in the gastrointestinal microbiome and the host after metronidazole administration are also reviewed. Finally, novel nitroimidazoles and new antibiotic strategies are discussed.

The effect of iron on metronidazole activity against Trichomonas vaginalis in vitro

Metronidazole is administered in an inactive form then activated to its cytotoxic form within the hydrogenosome of trichomonads. Two hydrogenosomal proteins, pyruvate ferredoxin oxidoreductase (PFOR) and ferredoxin, play a critical role in the reductive activation of metronidazole. The expression of these proteins and other hydrogenosomal proteins are likewise positively regulated by iron. In the present study, the effect of iron on minimal lethal concentration (MLC) of metronidazole on in vitro cultured Trichomonas vaginalis(T. vaginalis) isolates was investigated. Interestingly, Addition of Ferrous ammonium sulphate (FAS) to T. vaginalis culture led to decrease in the MLC of metronidazole. On using aerobic assay, MLC of metronidazole on untreated T. vaginalis of both isolates was 12.5 μg/ml that decreased to 0.38 μg/ml on FAS treated trichomonads. Also anaerobic assay revealed that MLC on untreated parasites was 3.12 μg/ml that decreased to 0.097 μg/ml and 0.19 μg/ml for isolate 1 and isolate 2 respectively after iron addition. It was concluded that, addition of iron to in vitro cultured T. vaginalis decreases metronidazole MLC that was detected by both aerobic and anaerobic assays.

A Comprehensive Review of Topical Odor-Controlling Treatment Options for Chronic Wounds

The process of wound healing is often accompanied by bacterial infection or critical colonization, resulting in protracted inflammation, delayed reepithelization, and production of pungent odors. The malodor produced by these wounds may lower health-related quality of life and produce psychological discomfort and social isolation. Current management focuses on reducing bacterial activity within the wound site and absorbing malodorous gases. For example, charcoal-based materials have been incorporated into dressing for direct adsorption of the responsible gases. In addition, multiple topical agents, including silver, iodine, honey, sugar, and essential oils, have been suggested for incorporation into dressings in an attempt to control the underlying bacterial infection. This review describes options for controlling malodor in chronic wounds, the benefits and drawbacks of each topical agent, and their mode of action. We also discuss the use of subjective odor evaluation techniques to assess the efficacy of odor-controlling therapies. The perspectives of employing novel biomaterials and technologies for wound odor management are also presented.

Recent advances in Entamoeba biology: RNA interference, drug discovery, and gut microbiome

In recent years, substantial progress has been made in understanding the molecular and cell biology of the human parasite Entamoeba histolytica, an important pathogen with significant global impact. This review outlines some recent advances in the Entamoeba field in the last five years, focusing on areas that have not recently been discussed in detail: (i) molecular mechanisms regulating parasite gene expression, (ii) new efforts at drug discovery using high-throughput drug screens, and (iii) the effect of gut microbiota on amoebiasis.

A novel galacto-glycerolipid from Oxalis corniculata kills Entamoeba histolytica and Giardia lamblia

Oxalis corniculata is a naturally occurring weed that has been used in traditional medicine for the cure of dysentery and diarrhea in India. One of the common causes of dysentery is due to infection by the protist pathogen Entamoeba histolytica. Bioactivity profiling of extracts from O. corniculata identified several compounds that showed antiamoebic activity in axenic cultures of E. histolytica. These were characterized by nuclear magnetic resonance, infrared, and mass spectrometry as (i) Oc-1, a mixture of saturated fatty acids C₂₄ to C₂₈; (ii) Oc-2, a mixture of long-chain alcohols C₁₈ to C₂₈; and (iii) Oc-3, a single compound that was a galacto-glycerolipid (GGL). Of the different compounds that were obtained, the strongest antiamoebic activity was found in GGL. The addition of GGL to E. histolytica xenic cultures containing other microbial flora from the large intestine did not affect its antiamoebic activity. Amoebicidal concentrations of GGL had no effect on intestinal microbial flora or on the mammalian cell line HEK-293. GGL was also found to be equally effective in killing another protist pathogen, Giardia lamblia, that causes diarrhea in humans. The importance of this study is based on the identification of novel natural products and the possibility of developing these compounds as active agents to treat at least two pathogenic parasitic intestinal infections endemic to tropical regions.

Predicting antitrichomonal activity: A computational screening using atom-based bilinear indices and experimental proofs

Existing Trichomonas vaginalis therapies are out of reach for most trichomoniasis people in developing countries and, where available, they are limited by their toxicity (mainly in pregnant women) and their cost. New antitrichomonal agents are needed to combat emerging metronidazole-resistant trichomoniasis and reduce the side effects associated with currently available drugs. Toward this end, atom-based bilinear indices, a new TOMOCOMD-CARDD molecular descriptor, and linear discriminant analysis (LDA) were used to discover novel, potent, and non-toxic lead trichomonacidal chemicals. Two discriminant functions were obtained with the use of non-stochastic and stochastic atom-type bilinear indices for heteroatoms and H-bonding of heteroatoms. These atomic-level molecular descriptors were calculated using a weighting scheme that includes four atomic labels, namely atomic masses, van der Waals volumes, atomic polarizabilities, and atomic electronegativities in Pauling scale. The obtained LDA-based QSAR models, using non-stochastic and stochastic indices, were able to classify correctly 94.51% (90.63%) and 93.41% (93.75%) of the chemicals in training (test) sets, respectively. They showed large Matthews' correlation coefficients (C); 0.89 (0.79) and 0.87 (0.85), for the training (test) sets, correspondingly. The result of predictions on the 15% full-out cross-validation test also evidenced the robustness and predictive power of the obtained models. In addition, canonical regression analyses corroborated the statistical quality of these models (R(can) of 0.749 and of 0.845, correspondingly); they were also used to compute biological activity canonical scores for each compound. On the other hand, a close inspection of the molecular descriptors included in both equations showed that several of these molecular fingerprints are strongly interrelated with each other. Therefore, these models were orthogonalized using the Randić orthogonalization procedure. These classification functions were then applied to find new lead antitrichomonal agents and six compounds were selected as possible active compounds by computational screening. The designed compounds were synthesized and tested for in vitro activity against T. vaginalis. Out of the six compounds that were designed, and synthesized, three molecules (chemicals VA5-5a, VA5-5c, and VA5-12b) showed high to moderate cytocidal activity at the concentration of 10 microg/ml, other two compounds (VA5-8pre and VA5-8) showed high cytocidal and cytostatic activity at the concentration of 100 microg/ml and 10 microg/ml, correspondingly, and the remaining chemical (compound VA5-5e) was inactive at these assayed concentrations. Nonetheless, these compounds possess structural features not seen in known trichomonacidal compounds and thus can serve as excellent leads for further optimization of antitrichomonal activity. The LDA-based QSAR models presented here can be considered as a computer-assisted system that could potentially significantly reduce the number of synthesized and tested compounds and increase the chance of finding new chemical entities with antitrichomonal activity.

Metronidazole and drug resistance

In recent years, the basis of metronidozole resistance has been examined in anaerobic protozoa, such as Trichomonas and Giardia, as well as anaerobic bacteria, such as Bacteroides and Clostridium. In this review, Patricia Johnson looks at a variety of mechanisms that lead to reduced susceptibility of these pathogens to the drug. The frequent correlation between metronidozole resistance and inefficient drug activation suggests that this is the level at which drug resistance operates.

The crystal structure of Trichomonas vaginalis ferredoxin provides insight into metronidazole activation

Crystallographic studies revealing the three-dimensional structure of the oxidized form of the [2Fe-2S] ferredoxin from Trichomonas vaginalis (TvFd) are presented. TvFd, a member of the hydrogenosomal class of ferredoxins, possesses a unique combination of redox and spectroscopic properties, and is believed to be the biological molecule that activates the drug metronidazole reductively in the treatment of trichomoniasis. It is the first hydrogenosomal ferredoxin to have its structure determined. The structure of TvFd reveals a monomeric, 93 residue protein with a fold similar to that of other known [2Fe-2S] ferredoxins. It contains nine hydrogen bonds to the sulfur atoms of the cluster, which is more than the number predicted on the basis of the spectroscopic data. The TvFd structure contains a large dipole moment like adrenodoxin, and appears to have a similar interaction domain. Our analysis demonstrates that TvFd has a unique cavity near the iron-sulfur cluster that exposes one of the inorganic sulfur atoms of the cluster to solvent. This cavity is not seen in any other [2Fe-2S] ferredoxin with known structure, and is hypothesized to be responsible for the high rate of metronidazole reduction by TvFd.

Mechanism and clinical significance of metronidazole resistance in Helicobacter pylori

Metronidazole was introduced in 1959 for the treatment of Trichomonas vaginalis, but was subsequently shown to be active against anaerobic and some micro-aerophilic bacteria as well. In anaerobic microorganisms with their low redox potential, metronidazole is reduced to its active metabolite by a one-electron transfer step. Metronidazole is often used in treatment regimens for Helicobacter pylori, a microaerophilic bacterium, but resistance to this drug is frequently encountered. The metabolism of metronidazole in H. pylori must differ from that in anaerobic bacteria as metabolites formed by a one-electron transfer are readily re-oxidized in the micro-aerophilic environment of H. pylori. This process is called 'futile cycling' and is accompanied by the formation of toxic oxygen radicals that are neutralized by an active scavenger system. Recently, it has been shown that in H. pylori, in contrast to the situation in anaerobes, an oxygen-insensitive nitroreductase. encoded by the rdxA gene, is responsible for the activation of metronidazole. Activation by this enzyme is by a two-electron transfer step, preventing futile cycling' and thereby enabling the activation of metronidazole in a micro-aerophilic environment. Metronidazole resistance has been shown to be associated with null mutations in the rdxA gene in most clinical isolates. However, there may be some 'background metronidazole susceptibility' in metronidazole-resistant strains caused by other (oxygen-sensitive) nitroreductases. Recently, three meta-analyses of the impact of metronidazole resistance on treatment efficacy have all shown a significant reduction in efficacy of metronidazole containing regimens in patients infected with a resistant strain. The impact of resistance proved to be dependent on the other components of the regimen and on treatment duration.

Potential involvement of several nitroreductases in metronidazole resistance in Helicobacter pylori

Susceptibility of Helicobacter pylori to the antibiotic metronidazole has been attributed to the activity of an oxygen-insensitive NADPH-dependent nitroreductase (RdxA), with resistance to this antimicrobial arising from null mutations in rdxA. To obtain a better understanding of the factors involved in resistance, nitroreductase and metronidazole reduction activities were investigated in matched pairs of clinical and laboratory-derived sensitive and resistant H. pylori strains. Significant differences in enzyme activities were observed between sensitive and resistant strains, suggesting that metronidazole susceptibility in H. pylori was associated with more than one enzyme activity. To establish the mutations occurring in rdxA, the genes from seventeen bacterial strains, including matched pairs were sequenced. To assess whether metronidazole was responsible for inducing random mutations in this gene, the complete nucleotide sequence of gene hp0630, encoding an NAD(P)H-quinone reductase which also has NADPH-dependent nitroreductase activity, was determined in the same strains. All resistant strains showed nonsense, missense, or frameshift mutations randomly throughout rdxA. In contrast, no mutations were observed in hp0630. The results confirmed the presence of rdxA null mutations in resistant strains and suggested that other factors involved in the metabolism of metronidazole contributed to the resistant phenotype.

Oxidases and reductases are involved in metronidazole sensitivity in Helicobacter pylori

Helicobacter pylori is a contributing factor to the development of gastric and duodenal ulcers and some gastric cancers. Some therapeutic regimes comprise of a number of components, one of which is the antimicrobial metronidazole. A problem with these therapies is the increasing prevalence of metronidazole-resistant (MtrR) H. pylori strains. Several resistance mechanisms have been proposed, and this study addresses the 'scavenging of oxygen' hypothesis. Spectrophotometric assays of cytosolic fractions indicated that metronidazole-sensitive (MtrS) H. pylori isolates had 2.6-fold greater nicotinamide adenine dinucleotide (NADH) oxidase activity, 34-fold greater NADH nitroreductase activity, and eightfold greater nicotinamide adenine dinucleotide phosphate (NADPH) nitroreductase activity than cytosolic fractions from matched MtrR strains. Electrophoresis of cytosolic fractions in non-denaturing gels showed up to 10 protein bands when stained with Coomassie blue. Activity staining of non-denaturing, non-reducing polyacrylamide gels detected NAD(P)H oxidase, disulphide reductase, tetrazolium reductase and nitroreductase activities in the protein bands. Oxidase and reductase activities observed in a band from MtrS strains were absent in the corresponding band from MtrR strains. This band comprised at least 13 proteins, and the major constituent was identified as an alkyl hydroperoxide reductase AhpC subunit. The absence of oxidase and reductase activities in the band from MtrR strains indicated a correlation between the activity of the proteins in this band and the metronidazole-sensitive phenotype.

Loss of multiple hydrogenosomal proteins associated with organelle metabolism and high-level drug resistance in trichomonads

Land, K. M., Clemens, D. L., and Johnson, P. J. 2001. Loss of multiple hydrogenosomal proteins associated with organelle metabolism and high-level drug resistance in trichomonads. Experimental Parasitology 97, 102-110. In trichomonads, metronidazole is activated to its cytotoxic form in a specialized energy-producing organelle called the hydrogenosome. Electron transport components in the organelle, pyruvate:ferredoxin oxidoreductase and ferredoxin, donate a single electron to the drug, converting it to a cytotoxic free radical. Previous biochemical analyses of enzyme activities of highly resistant strains of both Trichomonas vaginalis and Tritrichomonas foetus reveal undetectable activity for pyruvate:ferredoxin oxidoreductase and another hydrogenosomal enzyme, hydrogenase. We have chosen to analyze a highly drug-resistant strain of T. foetus and its parental drug-sensitive strain from which it was derived to study the molecular basis for these enzyme defects. Quantitation of pyruvate:ferredoxin oxidoreductase and ferredoxin levels in sensitive and resistant cells shows a marked reduction of these proteins in the resistant strain. RNA analysis reveals an approximately 60% reduction in pyruvate:ferredoxin oxidoreductase mRNA and 90-98% reduction in mRNA levels encoding hydrogenosomal proteins hydrogenase, ferredoxin, and malic enzyme. We have measured the levels of transcription of these genes and observed 60% reduction of pyruvate:ferredoxin oxidoreductase gene transcription and 85% reduction in malic enzyme gene transcription in the resistant strain. The reduction or absence of these organellar proteins is likely to reduce or eliminate the ability of the cell to activate the drug, giving rise to the highly resistant phenotype. Ultrastructural analysis of thin sections revealed that resistant cells are 20% smaller in size and hydrogenosomes in resistant cells are approximately one-third the size of those in the drug-sensitive parental strain. These data suggest that altered gene expression of multiple hydrogenosomal proteins results in the modification of the organelle and leads to drug resistance.

Molecular basis of metronidazole resistance in pathogenic bacteria and protozoa

The molecular basis of metronidazole resistance has been examined in anaerobic bacteria, such as Bacteroides, Clostridium, and Helicobacter, and anaerobic parasitic protists such as Giardia, Entamoeba, and trichomonads. A variety of enzymatic and cellular alterations have been shown to correlate with metronidazole susceptibility in these pathogens; however, a common theme has been revealed. Resistant cells are typically deficient in drug activation. The frequent correlation between metronidazole resistance and ineffective drug activation suggests that drug resistance is the result of modification of proteins involved in drug activation. Copyright 1999 Harcourt Publishers Ltd.

Trichomonads, hydrogenosomes and drug resistance

Trichomonas vaginalis and Tritrichomonas foetus are sexually transmitted pathogens of the genito-urinary tract of humans and cattle, respectively. These organisms are amitochondrial anaerobes possessing hydrogenosomes, double membrane-bound organelles involved in catabolic processes extending glycolysis. The oxidative decarboxylation of pyruvate in hydrogenosomes is coupled to ATP synthesis and linked to ferredoxin-mediated electron transport. This pathway is responsible for metabolic activation of 5-nitroimidazole drugs, such as metronidazole, used in chemotherapy of trichomoniasis. Prolonged cultivation of trichomonads under sublethal pressure of metronidazole results in development of drug resistance. In both pathogenic species the resistance develops in a multistep process involving a sequence of stages that differ in drug susceptibility and metabolic activities. Aerobic resistance, similar to that occurring in clinical isolates of T. vaginalis from treatment-refractory patients, appears as the earliest stage. The terminal stage is characterised by stable anaerobic resistance at which the parasites show very high levels of minimal lethal concentration for metronidazole under anaerobic conditions (approximately 1000 microg ml(-1)). The key event in the development of resistance is progressive decrease and eventual loss of the pyruvate:ferredoxin oxidoreductase so that the drug-activating process is averted. In T. vaginalis at least, the development of resistance is also accompanied by decreased expression of ferredoxin. The pyruvate:ferredoxin oxidoreductase deficiency completely precludes metronidazole activation in T. foetus, while T. vaginalis possesses an additional drug-activating system which must be eliminated before the full resistance is acquired. This alternative pathway involves the hydrogenosomal malic enzyme and NAD:ferredoxin oxidoreductase. Metronidazole-resistant trichomonads compensate for the hydrogenosomal deficiency by an increased rate of glycolysis and by changes in their cytosolic pathways. Trichomonas vaginalis enhances lactate fermentation while T. foetus activates pyruvate conversion to ethanol. Drug-resistant T. foetus also increases activity of the cytosolic NADP-dependent malic enzyme, to enhance the pyruvate producing bypass and provide NADPH required by alcohol dehydrogenase. Production of succinate by this species is abolished. Metabolic changes accompanying in-vitro development of metronidazole resistance demonstrate the versatility of trichomonad metabolism and provide an interesting example of how unicellular eukaryotes can adjust their metabolism in response to the pressure of an unfavorable environment.

Clinical and microbiological aspects of Trichomonas vaginalis

Trichomonas vaginalis, a parasitic protozoan, is the etiologic agent of trichomoniasis, a sexually transmitted disease (STD) of worldwide importance. Trichomoniasis is the most common nonviral STD, and it is associated with many perinatal complications, male and female genitourinary tract infections, and an increased incidence of HIV transmission. Diagnosis is difficult, since the symptoms of trichomoniasis mimic those of other STDs and detection methods lack precision. Although current treatment protocols involving nitroimidazoles are curative, metronidazole resistance is on the rise, outlining the need for research into alternative antibiotics. Vaccine development has been limited by a lack of understanding of the role of the host immune response to T. vaginalis infection. The lack of a good animal model has made it difficult to conduct standardized studies in drug and vaccine development and pathogenesis. Current work on pathogenesis has focused on the host-parasite relationship, in particular the initial events required to establish infection. These studies have illustrated that the pathogenesis of T. vaginalis is indeed very complex and involves adhesion, hemolysis, and soluble factors such as cysteine proteinases and cell-detaching factor. T. vaginalis interaction with the members of the resident vaginal flora, an advanced immune evasion strategy, and certain stress responses enable the organism to survive in its changing environment. Clearly, further research and collaboration will help elucidate these pathogenic mechanisms, and with better knowledge will come improved disease control.

In vitro induced anaerobic resistance to metronidazole in Trichomonas vaginalis

Resistance to metronidazole detectable under anaerobic conditions was induced in two Trichomonas vaginalis strains (TV 10-02 and MRP-2) by cultivation at gradually increasing pressure of the drug (1-100 micrograms/ml) for 12 to 21 months. The resistant derivatives reproduced in anaerobic trypticase-yeast-extract-maltose medium at 100 micrograms/ml metronidazole and showed very high values of minimal lethal concentration for metronidazole in anaerobic in vitro assays (556-1,600 micrograms/ml at 48-h exposure to the drug). Stepwise selection was necessary to develop the resistance in either strain. Attempts to induce resistance by prolonged maintenance of trichomonads with constant, low or moderate drug concentrations (3-10 micrograms/ml) were unsuccessful. Freshly developed resistance to high concentrations of metronidazole was unstable in absence of drug pressure as well as after cryopreservation. Development of stable resistance required further cultivation at 100 micrograms/ml metronidazole. Unstable substrains did not revert to original susceptibility. They retained a moderate level of resistance, being able to grow at 10 micrograms/ml metronidazole. The strains with fully developed resistance had no activity of the hydrogenosomal enzymes pyruvate: ferredoxin oxidoreductase and hydrogenase and ceased uptake of [14C]-metronidazole. These findings indicate that the pyruvate oxidizing pathway responsible for metronidazole activation was inactivated and metabolism of the drug stopped.

In vitro nitroimidazole resistance of Trichomonas gallinae and successful therapy with an increased dosage of ronidazole in racing pigeons (Columba livia domestica)

Six out of eight different Trichomonas gallinae strains isolated from racing pigeons proved to be resistant to the nitroimidazole drugs ronidazole, carnidazole and metronidazole. The minimal cytocidal concentration of ronidazole was determined in in vitro experiments. Moreover, a therapeutic dose for ronidazole was determined for the control of trichomoniasis in pigeons from which the resistant T. gallinae strains were isolated. It was a 5-fold increase of the recommended ronidazole dosage which eliminated the infection in affected pigeons.

Reduced transcription of the ferredoxin gene in metronidazole-resistant Trichomonas vaginalis

Metronidazole [1-(2-hydroxyethyl)-2-methyl-5-nitroimidazole] is used to treat infections caused by Trichomonas vaginalis, a sexually transmitted human parasite. This drug is administered in an inactive form and is reduced to its cytotoxic form within the hydrogenosome, an unusual organelle found in trichomonads. Metronidazole reduction occurs via ferredoxin-mediated electron transport. We have investigated the role of ferredoxin in metronidazole resistance. Immunoblot analysis of drug-resistant and -sensitive T. vaginalis strains shows that intracellular levels of ferredoxin are invariably reduced in the resistant strains relative to a sensitive strain. Similarly, Northern blot analysis shows that ferredoxin mRNA levels are reduced 50-65% in resistant strains. Using nuclear run-on assays, we show that ferredoxin gene transcription is reduced 40-65% in resistant strains. Sequence comparison of the region 5' of the ferredoxin gene among drug-sensitive and -resistant strains reveals two point mutations, at -178 and -239 nucleotides relative to the start of transcription, in a resistant strain. Interestingly, a protein of approximately 23 kDa binds to a 28-base-pair region that encompasses the mutation at -239 nucleotides. The binding affinity of this protein appears to be reduced in the mutant. These data strongly correlate drug resistance with altered regulation of ferredoxin gene transcription. A reduction in gene transcription results in decreased intracellular levels of ferredoxin. This, in turn, may play a role in metronidazole resistance by decreasing the ability of the cell to activate the drug.

The effects of subgingival irrigation with low dosage metronidazole on periodontal inflammation

The effects on chronic periodontitis of a simplified oral hygiene regimen combined with subgingival irrigation with 0.5% metronidazole were investigated. 19 patients, with 548 pockets greater than or equal to 4 mm, completed a 3-month randomised double-blind placebo-controlled trial. At day 0, prior to treatment, and at days 7, 28, 56 and 84, plaque index, sulcus bleeding index and probable pocket depth were recorded. The simplified oral hygiene regimen consisted of (1) one episode of root debridement, removal of subgingival approximal overhangs on restorations and subcontact area debridement with abrasive strips and polishing, and (2) instruction in Bass brushing (twice daily) with no stress on interdental cleaning. After baseline debridement, patients were allocated 0.5% metronidazole or a placebo. They were instructed to irrigate subgingivally once daily for 28 days. Treatment resulted in marked improvement in both groups and proportionately more sites improved in the metronidazole group at 28, 56 and 84 days. There were no significant differences between the procedures at any time. It was concluded that a simplified oral hygiene regimen combined with daily subgingival irrigation with 0.5% metronidazole or a placebo was effective in reducing periodontitis for at least a further 8 weeks, and that proportionately more sites improved in the metronidazole group.

The interactions between drugs and the parasite surface

The interrelationships between drugs and parasite surfaces are considered under the headings of (a) effects on membrane transport, (b) drug uptake mechanisms and (c) effects on surface morphology and function: praziquantel is discussed under a separate heading. The range of chemotherapeutic compounds that cause permeability changes and concomitant morphological disruption is discussed in terms of mode of drug action. Interpretation of the available data renders it difficult to identify the primary mode of action in the drugs considered. Drug uptake mechanisms are known for relatively few compounds; drug resistance as a function of drug acquisition is discussed. The role of the parasite surface as a specific drug target is argued.

Mechanism of toxicity of nitro compounds used in the chemotherapy of trichomoniasis

The mechanism of the trichomonicidal activity of metronidazole and other 5-nitroimidazoles appears to depend on the ferredoxin-mediated reduction of their nitro group, with generation of a reactive metabolite or metabolites which interact with DNA leading to a subsequent inhibition of nucleic acid and protein synthesis. Redox cycling of these compounds under aerobic conditions appears to be a detoxification reaction by inhibiting net reduction of the drugs, thereby inhibiting their uptake. On the other hand, redox cycling of nitrofurans or other compounds with more positive reduction potential results in formation of high steady-state concentrations of oxygen-derived metabolites that might be of toxicological significance. It seems likely that reduced metabolites of nitroimidazoles (perhaps through covalent binding to tissue macromolecules and/or thiols depletion) are also involved in the nitroimidazoles' toxic effects to animal tissues and in their mutagenic and carcinogenic action.

The modes of action of some anti-protozoal drugs

In spite of the continuing need for new and improved anti-protozoal drugs for use in man, a considerable contraction of industrially based research on anti-protozoal drugs has occurred in recent years. Newton (1983) reviewed the reasons for this decline and presented a compelling argument that fundamental research on the biology of the parasites is essential for the discovery of leads for the development of a new generation of drugs – a rational chemotherapy. The rapid advance in knowledge of the biochemistry of parasitic protozoa which has occurred in recent years has provided a number of potential leads to new drug development and has permitted a greater understanding of the mode of action of many current drugs. The account of these advances which follows is necessarily selective and relates to protozoan parasites of man.

Ferredoxin-linked reduction of metronidazole in Clostridium pasteurianum

Clostridium pasteurianum cell-free extracts enzymatically reduced metronidazole when coupled by hydrogenase via reduced ferredoxin. A 5 mM concentration of methyl viologen, flavin adenine dinucleotide, or flavin mononucleotide could completely replace ferredoxin (0.05 mM) in the in vitro reduction assay system, whereas 5 mM benzyl viologen was less effective. However, when these electron carriers were used at a concentration of 0.05 mM, there was a drastic loss in their abilities to couple the metronidazole reduction system compared with the comparable concentration of ferredoxin. It is not understood why these flavin coenzymes participate in this enzymatic reaction. NAD and NADP had no activity when substituted for ferredoxin in the enzyme system. Two reduced ferredoxin-linked pathways, "metronidazole reductase" and the inducible dissimilatory sulfite reductase system, when combined in a single in vitro competition experiment demonstrated a preferential flow of electrons to metronidazole away from sulfite. A proposed bactericidal mechanism for metronidazole against C. pasteurianum incorporating the above findings is discussed.

Metabolic differences between metronidazole resistant and susceptible strains of Tritrichomonas foetus

Tritrichomonas foetus mutants resistant to metronidazole lack the hydrogenosomal enzymes pyruvate: ferredoxin oxidoreductase and hydrogenase. Hydrogenosomes of these organisms did not oxidize pyruvate or produce ATP in its presence. Elimination of hydrogenosomal metabolism of pyruvate was compensated by an increased rate of glycolysis. The resistant mutants excreted no organic acids and H2 as metabolic end products. Glycolysis of the resistant T. foetus KV1-1MR-100 can be summarized as 1 mol glucose----2 mol ethanol + 2 mol CO2. The parent strain KV1, excreting H2, CO2 and acidic end products, converted about 10% of glucose to ethanol. Both strains produced ethanol from pyruvate through the action of two cytoplasmic enzymes: pyruvate decarboxylase and alcohol dehydrogenase. The specific activity of the former enzyme, catalyzing nonoxidative decarboxylation of pyruvate to acetaldehyde, was nearly seven times higher in the resistant than in the parent strain. Alcohol dehydrogenase reducing acetaldehyde to ethanol was specific to NADPH; it catalyzed the reverse reaction only slowly, and displayed similar activities in both resistant and sensitive trichomonads. Development of anaerobic metronidazole resistance in T. foetus depended on the loss of pyruvate:ferredoxin oxidoreductase as well as on the ability to increase alcoholic fermentation.

Inhibition of growth of Giardia lamblia by difluoromethylornithine, a specific inhibitor of polyamine biosynthesis

Difluoromethylornithine (DFMO) is a specific and irreversible inhibitor of ornithine decarboxylase, an enzyme which catalyzes the first step in the biosynthetic pathway of the polyamines. We tested the effect of DFMO on the growth of Giardia lamblia, Entamoeba histolytica, and Trichomonas vaginalis. Growth of G. lamblia was inhibited by DFMO at concentrations of greater than or equal to 1.25 mM. Culture doubling time increased with increasing DFMO concentration. Growth inhibition was reversed if spermidine was added within 53 h of addition of DFMO; no growth was observed if spermidine was added later, indicating eventual parasite death. The growth of E. histolytica and T. vaginalis, two unrelated mucosal-dwelling parasites of humans, was not inhibited by 20 mM DFMO. These studies indicate that polyamine biosynthesis from ornithine is required for growth of G. lamblia.

1-Thiocarbamoyl-2-imidazolidinone, a metabolite of niridazole in Schistosoma mansoni

Niridazole, a nitro heterocyclic antischistosomal drug, is extensively metabolized to unknown metabolites by Schistosoma mansoni. We report that 1-thiocarbamoyl-2-imidazolidinone was isolated by high pressure liquid chromatography and identified by high resolution electron impact mass spectroscopy as a niridazole metabolite in schistosomes. After a 20-h in vitro incubation in 30 ml of medium containing 10 micrograms ml-1 [14C]niridazole (5.2 Ci mol-1), 100 S. mansoni worm pairs contained approximately 275 ng of 1-thiocarbamoyl-2-imidazolidinone. This amount represented 4% of the total metabolized fraction of niridazole in the parasite. Incubation of schistosomes with 1-thiocarbamoyl-2-[2 14C]imidazolidinone (2.7 Ci mol-1) indicated that this metabolite was not taken up. However, schistosomes released an average of 44 ng ml-1 or 1% of the total 1-thiocarbamoyl-2-imidazolidinone found in the worm back into 1 ml of medium during incubation. No host oxidative metabolites of niridazole were found in the parasites.

Role of sulfhydryl compounds in the bactericidal effect of metronidazole

The bactericidal effect of metronidazole on Escherichia coli and Bacteroides fragilis can be partially reversed by cysteamine under conditions that lead to the formation of an adduct, the thioether, 4-(2-aminoethyl)thio-2-methylimidazole-1-ethanol (4-ATME). This adduct, which is not mutagenic for the Ames histidine auxotrophs of Salmonella typhimurium, forms at a rate that is independent of live bacterial cells and, therefore, can not be shown to relate to the biological effect of cysteamine. When treated with Raney nickel, this adduct yields 2-methylimidazole-1-ethanol. To determine whether a structurally related adduct forms with bacterial protein, a culture of B. fragilis was incubated with radiolabelled metronidazole and then treated with 5% trichloroacetic acid. That the radiolabel in the precipitate did not yield 2-methylimidazole-1-ethanol when treated with Raney nickel suggests that binding of metronidazole to cellular macromolecules does not involve thioether formation.

Metabolism and metronidazole uptake in Trichomonas vaginalis isolates with different metronidazole susceptibilities

Three Trichomonas vaginalis isolates with low in vivo susceptibilities to metronidazole (95% curative dose, greater than 3 X 100 mg kg-1 in subcutaneous infections in mice) were compared with strain ATCC 30001 and with four isolates exhibiting high in vivo susceptibilities (95% curative dose, less than 3 X 15 mg kg-1). Activity of pyruvate:ferredoxin oxidoreductase, anaerobic fermentation, and anaerobic intracellular accumulation of [14C]metronidazole label showed no significant isolate-dependent differences which could be correlated with drug susceptibility. The results suggest that processes providing electrons for metronidazole activation are not defective in the resistant strains. Aerobiosis, known to inhibit the antimicrobial action of metronidazole, inhibited accumulation of label more strongly in resistant isolates than in susceptible ones. No differences were detected, however, between resistant and susceptible isolates in respiration, aerobic fermentation, and the specific activity of NADH and NADPH oxidases, the main terminal oxidases of T. vaginalis. These findings suggest that the production of electrons is not diminished under aerobic conditions. The inhibitory effect of aerobic conditions on metronidazole activation, possibly due to competition for the electrons, is markedly enhanced in the resistant isolates compared to the susceptible ones. The mechanism of this effect, however, remains unknown.

Experimental amoebiasis and the development of anti-amoebic compounds

In the ideal situation, the development of new amoebicides, or more accurately anti-amoebic compounds which are compounds with activity against Entamoeba histolytica, should initially proceed with the study of parasite-specific metabolic pathways and their inhibition, followed by whole parasite in vitro studies, experimental in vivo models and finally clinical trial. However, there are considerable gaps in our knowledge which will be discussed below, and consequently many investigators consider that empirically selected compounds should be tested experimentally in addition to specifically designed compounds. Before clinical trials can begin, extensive examination of the candidate amoebicide in experimental animals is required in order to investigate possible toxicological hazards.

In addition to inhibiting the amoebic parasite, the drug has to reach the parasite in several different sites in the body, thus there is also a problem of pharmacokinetics and distribution. Prior to the discovery of the nitroimidazole class of amoebicides, the multi-site attack was solved by the use of several drugs, sometimes in sequence during the treatment of an individual case (Powell, 1972). The discovery of the nitroimidazole class of compound changed the situation dramatically and these have shown a clinical and parasitological effect against extra-intestinal and intestinal wall infections. The effect on intralumenal infection (that is mildly symptomatic or asymptomatic infections) of the large intestine is, however, less certain (Finegold, 1977; Spillman, Ayala & Sanchez, 1976).

Although the treatment of amoebiasis appears to be satisfactory at the present time, it is difficult to predict problems which might arise in the future, and therefore it is valuable to continue the pre-clinical development, especially the investigation of parasite metabolism, in order to define parasite-specific points of chemotherapeutic attack.

The chemotherapy of amoebiasis was reviewed comprehensively by Woolf (1963, 1965). The present account of the development of amoebicides therefore starts from the Woolfe reviews.

Metronidazole resistance of Trichomonas vaginalis as a cause of treatment failure in trichomoniasis--A case report

Six isolates of a strain (MRP-MT) of Trichomonas vaginalis obtained from a woman before and after unsuccessful treatment with metronidazole had an appreciably lower susceptibility to metronidazole both in vitro in the aerobic tube assay and in vivo in the mouse assay than did control strains from patients cured with standard doses of the drug. Our results support recent evidence that metronidazole-resistant strains of T vaginalis do cause treatment failure. Resistance of these strains could be detected in vitro under only aerobic but not anaerobic conditions. The prevalence of metronidazole-resistant strains of T vaginalis should be kept under surveillance in order to estimate their clinical importance. The patient harbouring the resistant strain MRP-MT was finally cured with increased doses of ornidazole.

Effects of niridazole and 5-nitroimidazoles on heart mitochondrial respiration

2.3 micromoles/mg protein of MFNI induced a 60% decrease in the heart mitochondrial ADP-stimulated oxygen uptake using glutamate-malate as substrate. The same amount of niridazole, ipronidazole, DA 3851 and ornidazole led to falls of less than 20% in the oxygen uptake, whilst metronidazole was ineffective. State 3 and state 3 mu (uncoupled) respiration were affected to the same extent. Oxygen-uptake using succinate as substrate was not inhibited indicating that the action was exerted at the NADH oxidation level. The relationship between electroreduction potentials of the test compounds and inhibition of respiration has been studied.

Effects of oxygen tension and reducing agents on sensitivity of Giardia lamblia to metronidazole in vitro

The effects of oxygen tension and reducing agents upon the sensitivity of Giardia lamblia to metronidazole in vitro were determined using two different assays. First, the parasites were exposed to drug under high or low oxygen tension in liquid medium with or without fresh cysteine and ascorbic acid. Survival was determined by colony assay. Second, the effect of thiol reducing agents was measured directly by colony assay in semi-solid media (low pO2 conditions). Trophozoites were strikingly (greater than 100-fold) less sensitive to metronidazole under the aerobic condition of the first assay. In contrast, the reducing agents had much lesser effects (2- to 5-fold) depending upon the assay. Finally, G. lamblia isolated from a patient treated with metronidazole unsuccessfully four times showed similar metronidazole sensitivity to a standard strain under both aerobic and reduced O2 tension conditions.

Respiration of the rumen ciliate Dasytricha ruminantium Schuberg

The endogenous respiration of the rumen ciliate Dasytricha ruminantium maintained under an O2 tension of 2kPa (approximately 0.02 atm) was partially inhibited by KCN (40% inhibition) and NaN3 (58% inhibition). The organisms lack cytochromes, and sensitivity of respiration to KCN, NaN3, chloroquine and quercetin suggest that the operation of flavoprotein-iron-sulphur-mediated electron transport. As in Tritrichomonas foetus, hydrogenosomal respiration can be stimulated by the addition of CoA in the presence of 0.025% Triton X-100; stimulation by ADP was not detected. Stimulation of pyruvate-supported O2 uptake by Pi suggests that acetate is produced via acetyl phosphate.

Medicated tampons: intravaginal sustained administration of metronidazole and in vitro-in vivo relationships

The technical feasibility of utilizing tampons as a drug delivery system for prolonged intravaginal drug administrations was studied. Several commercially available brands of tampons were examined. The methodology for the incorporation of various doses of metronidazole, an antitrichomonas agent, in tampons was described. The sustained-release profile of metronidazole from these medicated tampons was characterized. Intravaginal administration of metronidazole via the medicated tampons was investigated in rhesus monkeys and human volunteers, and in vitro-in vivo correlations were established. The biopharmaceutics of intravaginal absorption of metronidazole via medicated tampons was analyzed in comparison with a vaginal solution formulation.

Evidence suggesting that the mechanism for aerobic and hypoxic cytotoxicity of nitroheterocycles is the same

The fluorescence of three nitroheterocycles (AF-2, trans-5-amino-3-(2-(5-nitro-2furyl) vinyl)-1,2,4-oxadiazole and 4-NQO) was used to quantitate cellular uptake and binding using a fluorescence-activated cell sorter. Mean cellular fluorescence, proportional to the amount of bound drug, allowed accurate prediction of the amount of cell killing. At equitoxic concentrations, the same amount of drug was bound under either aerobic or hypoxic conditions. In addition, 5 mM glutathione was equally effective at inhibiting aerobic and hypoxic cell killing by AF-2. These results suggest that the mechanism for cell killing may be similar under aerobic and hypoxic conditions, and the presence of oxygen may influence the rate of drug uptake rather than the nature of the toxic species. The nitro anion radical, formed in the presence and absence of oxygen, seems a likely candidate for the "toxic species."