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Patil SB, Tamirat M, Khazhidinov K, Ardizzoni E, Atger M, Austin A, Baudin E, Bekhit M, Bektasov S, Berikova E, Bonnet M, Caboclo R, Chaudhry M, Chavan V, Cloez S, Coit J, Coutisson S, Dakenova Z, De Jong BC, Delifer C, Demaisons S, Do JM, Dos Santos Tozzi D, Ducher V, Ferlazzo G, Gouillou M, Khan U, Kunda M, Lachenal N, LaHood AN, Lecca L, Mazmanian M, McIlleron H, Moreau M, Moschioni M, Nahid P, Osso E, Oyewusi L, Panda S, Pâquet A, Thuong Huu P, Pichon L, Rich ML, Rupasinghe P, Salahuddin N, Sanchez Garavito E, Seung KJ, Velásquez GE, Vallet M, Varaine F, Yuya-Septoh FJ, Mitnick CD, Guglielmetti L. Evaluating newly approved drugs in combination regimens for multidrug-resistant tuberculosis with fluoroquinolone resistance (endTB-Q): study protocol for a multi-country randomized controlled trial. Trials 2023; 24:773. [PMID: 38037119 PMCID: PMC10688049 DOI: 10.1186/s13063-023-07701-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Accepted: 10/04/2023] [Indexed: 12/02/2023] Open
Abstract
BACKGROUND Treatment for fluoroquinolone-resistant multidrug-resistant/rifampicin-resistant tuberculosis (pre-XDR TB) often lasts longer than treatment for less resistant strains, yields worse efficacy results, and causes substantial toxicity. The newer anti-tuberculosis drugs, bedaquiline and delamanid, and repurposed drugs clofazimine and linezolid, show great promise for combination in shorter, less-toxic, and effective regimens. To date, there has been no randomized, internally and concurrently controlled trial of a shorter, all-oral regimen comprising these newer and repurposed drugs sufficiently powered to produce results for pre-XDR TB patients. METHODS endTB-Q is a phase III, multi-country, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of a treatment strategy for patients with pre-XDR TB. Study participants are randomized 2:1 to experimental or control arms, respectively. The experimental arm contains bedaquiline, linezolid, clofazimine, and delamanid. The control comprises the contemporaneous WHO standard of care for pre-XDR TB. Experimental arm duration is determined by a composite of smear microscopy and chest radiographic imaging at baseline and re-evaluated at 6 months using sputum culture results: participants with less extensive disease receive 6 months and participants with more extensive disease receive 9 months of treatment. Randomization is stratified by country and by participant extent-of-TB-disease phenotype defined according to screening/baseline characteristics. Study participation lasts up to 104 weeks post randomization. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 324 participants across 2 arms affords at least 80% power to show the non-inferiority, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per-protocol populations. DISCUSSION This internally controlled study of shortened treatment for pre-XDR TB will provide urgently needed data and evidence for clinical and policy decision-making around the treatment of pre-XDR TB with a four-drug, all-oral, shortened regimen. TRIAL REGISTRATION ClinicalTrials.Gov NCT03896685. Registered on 1 April 2018; the record was last updated for study protocol version 4.3 on 17 March 2023.
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Affiliation(s)
- S B Patil
- Indian Council of Medical Research (ICMR) - National AIDS Research Institute, Pune, India
| | | | | | - E Ardizzoni
- Institute of Tropical Medicine (ITM), Antwerp, Belgium
| | - M Atger
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - A Austin
- UCSF Center for Tuberculosis, University of California, , San Francisco, San Francisco, CA, USA
| | | | - M Bekhit
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | | | - E Berikova
- Partners In Health, Astana, Kazakhstan
- National Scientific Center of Phthisiopulmonology, Almaty, Kazakhstan
| | - M Bonnet
- Université de Montpellier, IRD, INSERM, Montpellier, TransVIHMI, France
| | - R Caboclo
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - M Chaudhry
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - V Chavan
- Médecins Sans Frontières, Mumbai, India
| | - S Cloez
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - J Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - S Coutisson
- Médecins Sans Frontières, Geneva, Switzerland
| | - Z Dakenova
- City Center of Phthisiopulmonology, Astana, Kazakhstan
| | - B C De Jong
- Institute of Tropical Medicine (ITM), Antwerp, Belgium
| | - C Delifer
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - S Demaisons
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - J M Do
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - V Ducher
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - G Ferlazzo
- Médecins Sans Frontières, Geneva, Switzerland
| | | | - U Khan
- Interactive Research and Development (IRD) Global, Singapore, Singapore
| | - M Kunda
- Partners In Health, Maseru, Lesotho
| | - N Lachenal
- Médecins Sans Frontières, Geneva, Switzerland
| | - A N LaHood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | - L Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Socios En Salud-Sucursal Peru, Lima, Peru
| | - M Mazmanian
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
- Assistance Publique Hôpitaux de Paris (APHP), Unité de Recherche Clinique, Hôpital Pitié-Salpêtrière, Paris, France
- Santé Arménie French-Armenian Research Center, Yerevan, Armenia
| | - H McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | - M Moreau
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | | | - P Nahid
- UCSF Center for Tuberculosis, University of California, , San Francisco, San Francisco, CA, USA
| | - E Osso
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
| | | | - S Panda
- Indian Council of Medical Research Headquarters, New Delhi, India
- Indian Journal of Medical Research, New Delhi, India
| | - A Pâquet
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | | | - L Pichon
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - M L Rich
- Partners In Health, Boston, MA, USA
- Division of Global Health Equity, Brigham and Women's Hospital, Boston, MA, USA
| | - P Rupasinghe
- Institute of Tropical Medicine (ITM), Antwerp, Belgium
| | - N Salahuddin
- Indus Hospital & Health Network, Karachi, Pakistan
| | | | | | - G E Velásquez
- UCSF Center for Tuberculosis, University of California, , San Francisco, San Francisco, CA, USA
- Division of HIV, Infectious Diseases, and Global Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - M Vallet
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | - F Varaine
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France
| | | | - C D Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA, USA
- Partners In Health, Boston, MA, USA
- Brigham and Women's Hospital, Boston, MA, USA
| | - L Guglielmetti
- Medical Department, Médecins Sans Frontières, 14-34 Avenue Jean Jaurès, 75019, Paris, France.
- Sorbonne Université, INSERM, U1135, Centre d'Immunologie Et Des Maladies Infectieuses, Paris, France.
- Assistance Publique Hôpitaux de Paris (APHP), Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié Salpêtrière, Centre National De Référence Des Mycobactéries Et De La Résistance Des Mycobactéries Aux Antituberculeux, Paris, France.
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Guglielmetti L, Ardizzoni E, Atger M, Baudin E, Berikova E, Bonnet M, Chang E, Cloez S, Coit JM, Cox V, de Jong BC, Delifer C, Do JM, Tozzi DDS, Ducher V, Ferlazzo G, Gouillou M, Khan A, Khan U, Lachenal N, LaHood AN, Lecca L, Mazmanian M, McIlleron H, Moschioni M, O’Brien K, Okunbor O, Oyewusi L, Panda S, Patil SB, Phillips PPJ, Pichon L, Rupasinghe P, Rich ML, Saluhuddin N, Seung KJ, Tamirat M, Trippa L, Cellamare M, Velásquez GE, Wasserman S, Zimetbaum PJ, Varaine F, Mitnick CD. Evaluating newly approved drugs for multidrug-resistant tuberculosis (endTB): study protocol for an adaptive, multi-country randomized controlled trial. Trials 2021; 22:651. [PMID: 34563240 PMCID: PMC8465691 DOI: 10.1186/s13063-021-05491-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Accepted: 07/27/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Treatment of multidrug- and rifampin-resistant tuberculosis (MDR/RR-TB) is expensive, labour-intensive, and associated with substantial adverse events and poor outcomes. While most MDR/RR-TB patients do not receive treatment, many who do are treated for 18 months or more. A shorter all-oral regimen is currently recommended for only a sub-set of MDR/RR-TB. Its use is only conditionally recommended because of very low-quality evidence underpinning the recommendation. Novel combinations of newer and repurposed drugs bring hope in the fight against MDR/RR-TB, but their use has not been optimized in all-oral, shorter regimens. This has greatly limited their impact on the burden of disease. There is, therefore, dire need for high-quality evidence on the performance of new, shortened, injectable-sparing regimens for MDR-TB which can be adapted to individual patients and different settings. METHODS endTB is a phase III, pragmatic, multi-country, adaptive, randomized, controlled, parallel, open-label clinical trial evaluating the efficacy and safety of shorter treatment regimens containing new drugs for patients with fluoroquinolone-susceptible, rifampin-resistant tuberculosis. Study participants are randomized to either the control arm, based on the current standard of care for MDR/RR-TB, or to one of five 39-week multi-drug regimens containing newly approved and repurposed drugs. Study participation in all arms lasts at least 73 and up to 104 weeks post-randomization. Randomization is response-adapted using interim Bayesian analysis of efficacy endpoints. The primary objective is to assess whether the efficacy of experimental regimens at 73 weeks is non-inferior to that of the control. A sample size of 750 patients across 6 arms affords at least 80% power to detect the non-inferiority of at least 1 (and up to 3) experimental regimens, with a one-sided alpha of 0.025 and a non-inferiority margin of 12%, against the control in both modified intention-to-treat and per protocol populations. DISCUSSION The lack of a safe and effective regimen that can be used in all patients is a major obstacle to delivering appropriate treatment to all patients with active MDR/RR-TB. Identifying multiple shorter, safe, and effective regimens has the potential to greatly reduce the burden of this deadly disease worldwide. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02754765. Registered on 28 April 2016; the record was last updated for study protocol version 3.3, on 27 August 2019.
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Affiliation(s)
- L. Guglielmetti
- Médecins Sans Frontières, Paris, France
- Sorbonne Université, INSERM, U1135, Centre d’Immunologie Et Des Maladies Infectieuses, Paris, France
- Assistance Publique Hôpitaux de Paris, Groupe Hospitalier Universitaire Sorbonne Université, Hôpital Pitié-Salpêtrière, Centre National De Référence Des Mycobactéries Et De La Résistance Des Mycobactéries Aux Antituberculeux, Paris, France
| | - E. Ardizzoni
- Institute of Tropical Medicine, Antwerp, Belgium
| | - M. Atger
- Médecins Sans Frontières, Paris, France
| | | | - E. Berikova
- Partners In Health, Astana, Kazakhstan
- National Scientific Center of Phthisiopulmonology, Almaty, Kazakhstan
| | - M. Bonnet
- Médecins Sans Frontières, Paris, France
- Institut de Recherche pour le Développement/INSERM U1175/UMI233/ Université de Montpellier, Montpellier, France
| | - E. Chang
- Médecins Sans Frontières, Toronto, Ontario Canada
| | - S. Cloez
- Médecins Sans Frontières, Paris, France
| | - J. M. Coit
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - V. Cox
- Centre for Infectious Disease Epidemiology and Research, School of Public Health and Medicine, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | | | | | - J. M. Do
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | | | - V. Ducher
- Médecins Sans Frontières, Paris, France
| | - G. Ferlazzo
- Southern Africa Medical Unit, Médecins Sans Frontières, Cape Town, South Africa
| | | | - A. Khan
- Interactive Research and Development, Karachi, Pakistan
| | - U. Khan
- Interactive Research and Development, Karachi, Pakistan
| | | | - A. N. LaHood
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
| | - L. Lecca
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Socios En Salud-Sucursal Peru, Lima, Peru
| | - M. Mazmanian
- Médecins Sans Frontières, Paris, France
- Assistance Publique Hôpitaux de Paris, Unité de Recherche Clinique, Hôpital Pitié-Salpêtrière, Paris, France
| | - H. McIlleron
- Division of Clinical Pharmacology, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Wellcome Centre for Infectious Diseases Research in Africa, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, Cape Town, South Africa
| | | | | | - O. Okunbor
- Social & Scientific Systems-DLH, Silver Spring, MD USA
| | | | - S. Panda
- Epidemiology and Communicable Diseases Division, Indian Council of Medical Research, Pune, India
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - S. B. Patil
- Indian Council of Medical Research – National AIDS Research Institute, Pune, India
| | - P. P. J. Phillips
- University of San Francisco Center for Tuberculosis, San Francisco, CA USA
| | - L. Pichon
- Médecins Sans Frontières, Paris, France
| | | | - M. L. Rich
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | - N. Saluhuddin
- Department of Infectious Diseases, Indus Hospital, Karachi, Pakistan
| | - K. J. Seung
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
| | | | - L. Trippa
- Dana-Farber Cancer Institute, Boston, MA USA
- Harvard T.H. Chan School of Public Health, Boston, MA USA
| | | | - G. E. Velásquez
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
- Division of Infectious Diseases, Brigham and Women’s Hospital, Boston, MA USA
| | - S. Wasserman
- Wellcome Centre for Infectious Diseases Research in Africa, Department of Medicine, University of Cape Town, Cape Town, South Africa
- Division of Infectious Diseases and HIV Medicine, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - P. J. Zimetbaum
- Harvard Medical School, Boston, MA USA
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | | | - C. D. Mitnick
- Department of Global Health and Social Medicine, Harvard Medical School, Boston, MA USA
- Partners In Health, Boston, MA USA
- Division of Global Health Equity, Brigham and Women’s Hospital, Boston, MA USA
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Turner P, Melchiorre S, Moschioni M, Barocchi MA, Turner C, Watthanaworawit W, Kaewcharernnet N, Nosten F, Goldblatt D. Assessment of Streptococcus pneumoniae pilus islet-1 prevalence in carried and transmitted isolates from mother-infant pairs on the Thailand-Burma border. Clin Microbiol Infect 2011; 18:970-5. [PMID: 22092910 PMCID: PMC3469734 DOI: 10.1111/j.1469-0691.2011.03711.x] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Streptococcus pneumoniae pilus islet-1 (PI-1)-encoded pilus enhances in vitro adhesion to the respiratory epithelium and may contribute to pneumococcal nasopharyngeal colonization and transmission. The pilus subunits are regarded as potential protein vaccine candidates. In this study, we sought to determine PI-1 prevalence in carried pneumococcal isolates and explore its relationship with transmissibility or carriage duration. We studied 896 pneumococcal isolates collected during a longitudinal carriage study that included monthly nasopharyngeal swabbing of 234 infants and their mothers between the ages of 1 and 24 months. These were cultured according to the WHO pneumococcal carriage detection protocol. PI-1 PCR and genotyping by multilocus sequence typing were performed on isolates chosen according to specific carriage and transmission definitions. Overall, 35.2% of the isolates were PI-1-positive, but PI-1 presence was restricted to ten of the 34 serotypes studied and was most frequently associated with serotypes 19F and 23F; 47.5% of transmitted and 43.3% of non-transmitted isolates were PI-1-positive (OR 1.2; 95% CI 0.8–1.7; p 0.4). The duration of first-ever infant pneumococcal carriage was significantly longer with PI-1-positive organisms, but this difference was not significant at the individual serotype level. In conclusion, PI-1 is commonly found in pneumococcal carriage isolates, but does not appear to be associated with pneumococcal transmissibility or carriage duration.
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Affiliation(s)
- P Turner
- Shoklo Malaria Research Unit, Mae Sot, Thailand.
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Moschioni M, De Angelis G, Melchiorre S, Masignani V, Leibovitz E, Barocchi MA, Dagan R. Prevalence of pilus-encoding islets among acute otitis media Streptococcus pneumoniae isolates from Israel. Clin Microbiol Infect 2011; 16:1501-4. [PMID: 19886901 DOI: 10.1111/j.1469-0691.2009.03105.x] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
We evaluated the distribution of the two known Streptococcus pneumoniae pilus encoding islets (PI-1 and PI-2) among a panel of 113 acute otitis media clinical isolates from Israel. PI-1 was present in 30.1% (n = 34) of the isolates tested, and PI-2 was present in 7% (n = 8). In addition, we found that: (i) the PI positive isolates, 50% of which belong to the international clones Spain(9V)-3 (ST156) and Taiwan(19F)-14 (ST236), correlate with the genotype (as determined by multilocus sequence typing) but not with the serotype; (ii) PI-2 was not present in the absence of Pl-1; and (iii) the frequency of PI-1 was higher among antibiotic-resistant isolates.
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Affiliation(s)
- M Moschioni
- Novartis Vaccines and Diagnostics srl, Research Center, Siena, Italy
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Moschioni M, De Angelis G, Melchiorre S, Masignani V, Leibovitz E, Barocchi M, Dagan R. Prevalence of pilus-encoding islets among acute otitis media Streptococcus pneumoniae isolates from Israel. Clin Microbiol Infect 2010. [DOI: 10.1111/j.1469-0691.2010.03105.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Sjöström K, Blomberg C, Fernebro J, Dagerhamn J, Morfeldt E, Barocchi MA, Browall S, Moschioni M, Andersson M, Henriques F, Albiger B, Rappuoli R, Normark S, Henriques-Normark B. Clonal success of piliated penicillin nonsusceptible pneumococci. Proc Natl Acad Sci U S A 2007; 104:12907-12. [PMID: 17644611 PMCID: PMC1929012 DOI: 10.1073/pnas.0705589104] [Citation(s) in RCA: 70] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Antibiotic resistance in pneumococci is due to the spread of strains belonging to a limited number of clones. The Spain(9V)-3 clone of sequence type (ST)156 is one of the most successful clones with reduced susceptibility to penicillin [pneumococci nonsusceptible to penicillin (PNSP)]. In Sweden during 2000-2003, a dramatic increase in the number of PNSP isolates was observed. Molecular characterization of these isolates showed that a single clone of sequence type ST156 increased from 40% to 80% of all serotype 14, thus causing the serotype expansion. Additionally, during the same time period, we examined the clonal composition of two serotypes 9V and 19F: all 9V and 20% of 19F isolates belonged to the clonal cluster of ST156, and overall approximately 50% of all PNSP belonged to the ST156 clonal cluster. Moreover, microarray and PCR analysis showed that all ST156 isolates, irrespective of capsular type, carried the rlrA pilus islet. This islet was also found to be present in the penicillin-sensitive ST162 clone, which is believed to be the drug-susceptible ancestor of ST156. Competitive experiments between related ST156 serotype 19F strains confirmed that those containing the rlrA pilus islet were more successful in an animal model of carriage. We conclude that the pilus island is an important biological factor common to ST156 isolates and other successful PNSP clones. In Sweden, a country where the low antibiotic usage does not explain the spread of resistant strains, at least 70% of all PNSP isolates collected during year 2003 carried the pilus islet.
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Affiliation(s)
- K. Sjöström
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Department of Microbiology, Tumor Biology, and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - C. Blomberg
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Department of Microbiology, Tumor Biology, and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - J. Fernebro
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Department of Microbiology, Tumor Biology, and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - J. Dagerhamn
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Department of Microbiology, Tumor Biology, and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - E. Morfeldt
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | | | - S. Browall
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | | | - M. Andersson
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | - F. Henriques
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | - B. Albiger
- Department of Microbiology, Tumor Biology, and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
- Department of Clinical Microbiology, Lund University, SE-221 00 Malmö, Sweden
| | - Rino Rappuoli
- Novartis Vaccines, 53100 Siena, Italy; and
- To whom correspondence may be addressed. E-mail: or
| | - S. Normark
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Department of Microbiology, Tumor Biology, and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
| | - B. Henriques-Normark
- *Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Department of Microbiology, Tumor Biology, and Cell Biology, Karolinska Institutet, SE-171 77 Stockholm, Sweden
- To whom correspondence may be addressed. E-mail: or
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Barocchi MA, Ries J, Zogaj X, Hemsley C, Albiger B, Kanth A, Dahlberg S, Fernebro J, Moschioni M, Masignani V, Hultenby K, Taddei AR, Beiter K, Wartha F, von Euler A, Covacci A, Holden DW, Normark S, Rappuoli R, Henriques-Normark B. A pneumococcal pilus influences virulence and host inflammatory responses. Proc Natl Acad Sci U S A 2006; 103:2857-62. [PMID: 16481624 PMCID: PMC1368962 DOI: 10.1073/pnas.0511017103] [Citation(s) in RCA: 325] [Impact Index Per Article: 18.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Streptococcus pneumoniae (pneumococcus) is a major cause of morbidity and mortality world-wide. The initial event in invasive pneumococcal disease is the attachment of encapsulated pneumococci to epithelial cells in the upper respiratory tract. This work provides evidence that initial bacterial adhesion and subsequent ability to cause invasive disease is enhanced by pili, long organelles able to extend beyond the polysaccharide capsule, previously unknown to exist in pneumococci. These adhesive pili-like appendages are encoded by the pneumococcal rlrA islet, present in some, but not all, clinical isolates. Introduction of the rlrA islet into an encapsulated rlrA-negative isolate allowed pilus expression, enhanced adherence to lung epithelial cells, and provided a competitive advantage upon mixed intranasal challenge of mice. Furthermore, a pilus-expressing rlrA islet-positive clinical isolate was more virulent than a nonpiliated deletion mutant, and it out-competed the mutant in murine models of colonization, pneumonia, and bacteremia. Additionally, piliated pneumococci evoked a higher TNF response during systemic infection, compared with nonpiliated derivatives, suggesting that pneumococcal pili not only contribute to adherence and virulence but also stimulate the host inflammatory response.
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Affiliation(s)
| | - J. Ries
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Microbiology and Tumorbiology Center, Karolinska Institutet, SE-17182 Stockholm, Sweden
| | - X. Zogaj
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | - C. Hemsley
- Centre for Molecular Microbiology and Infection, Imperial College, London SW7 2AZ, United Kingdom
| | - B. Albiger
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | - A. Kanth
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | - S. Dahlberg
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Microbiology and Tumorbiology Center, Karolinska Institutet, SE-17182 Stockholm, Sweden
| | - J. Fernebro
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
| | | | | | - K. Hultenby
- Clinical Research Center, Department of Laboratory Medicine, Karolinska Institutet, 141 86 Huddinge, Sweden; and
| | - A. R. Taddei
- **Centro Interdipartimentale di Microscopia Elettronica, University of Tuscia, 01100 Viterbo, Italy
| | - K. Beiter
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Microbiology and Tumorbiology Center, Karolinska Institutet, SE-17182 Stockholm, Sweden
| | - F. Wartha
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Microbiology and Tumorbiology Center, Karolinska Institutet, SE-17182 Stockholm, Sweden
| | - A. von Euler
- Microbiology and Tumorbiology Center, Karolinska Institutet, SE-17182 Stockholm, Sweden
| | | | - D. W. Holden
- Centre for Molecular Microbiology and Infection, Imperial College, London SW7 2AZ, United Kingdom
| | - S. Normark
- Microbiology and Tumorbiology Center, Karolinska Institutet, SE-17182 Stockholm, Sweden
| | - R. Rappuoli
- *Chiron Vaccines, 53100 Siena, Italy
- To whom correspondence may be addressed at:
Chiron Corporation, Via Florentina 1l, Siena, Tuscany 53100, Italy. E-mail:
| | - B. Henriques-Normark
- Department of Bacteriology, Swedish Institute for Infectious Disease Control, SE-171 82 Solna, Sweden
- Microbiology and Tumorbiology Center, Karolinska Institutet, SE-17182 Stockholm, Sweden
- To whom correspondence may be addressed at:
Swedish Institute for Infectious Disease Control/MTC Karolinska Institutet, Nobels väg 18, SE-171 82 Solna, Sweden. E-mail:
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8
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Romanello V, Marcacci M, Dal Molin F, Moschioni M, Censini S, Covacci A, Baritussio AG, Montecucco C, Tonello F. Cloning, expression, purification, and characterization of Streptococcus pneumoniae IgA1 protease. Protein Expr Purif 2005; 45:142-9. [PMID: 16146695 DOI: 10.1016/j.pep.2005.07.015] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2005] [Revised: 07/14/2005] [Accepted: 07/19/2005] [Indexed: 11/30/2022]
Abstract
The IgA1 protease of Streptococcus pneumoniae is a Zn-metalloproteinase of 1964 amino acids that specifically cleaves the hinge region of IgA1, the predominant class of immunoglobulin present on mucosal membranes. This protease is associated to the bacterial cell surface via an N-terminal membrane anchor. Following proteolysis it is released in several forms of different molecular weight. Here, we describe the cloning, expression, and characterization of the enzymatic activity and immunogenicity of three fragments of IgA1 protease, including a large one lacking only the 103 N-terminal amino acids that constitute a typical prokaryotic signal sequence. Further, a proteolytically inactive mutant was generated by replacement of the glutamate residue with an alanine residue in the active site motif HExxH (1605-1609). This is the first report of recombinant active forms of S. pneumoniae IgA1 protease, which open the possibility of identifying specific inhibitors that could interfere with the mucosal colonization by pneumococcus. Moreover the inactive mutant could be considered as a candidate vaccine component.
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Affiliation(s)
- V Romanello
- Dipartimento di Scienze Biomediche, Università di Padova, Viale G. Colombo 3, 35121 Padova, Italy
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9
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de Bernard M, Moschioni M, Habermann A, Griffiths G, Montecucco C. Cell vacuolization induced by Helicobacter pylori VacA cytotoxin does not depend on late endosomal SNAREs. Cell Microbiol 2002; 4:11-8. [PMID: 11856169 DOI: 10.1046/j.1462-5822.2002.00163.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Cellular vacuoles induced by the Helicobacter pylori vacuolating cytotoxin VacA originate from late endosomal compartments. Their biogenesis requires the activity of both rab7 GTPase and the ATPase proton pump. The toxin has been suggested to cause an increased luminal osmotic pressure via its anion-specific channel activity localized on late endosomal compartments after endocytosis. Here, we show that the extensive membrane fusion that takes place in the transition from the small late endosomal compartments to the large vacuoles does not depend on soluble N-ethylmaleimide-sensitive factor (NSF) attachment protein receptor (SNARE) proteins. The process of vacuolization leads to disappearance of the large array of internal membranes of late endosomes. We suggest that most of the vacuole-limiting membrane derives from internal membranes.
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Affiliation(s)
- M de Bernard
- Centro CNR Biomembrane and Dipartimento di Scienze Biomediche Sperimentali, Università di Padova, Via G. Colombo 3, 35121, Padova, Italy.
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10
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de Bernard M, Moschioni M, Napolitani G, Rappuoli R, Montecucco C. The VacA toxin of Helicobacter pylori identifies a new intermediate filament-interacting protein. EMBO J 2000; 19:48-56. [PMID: 10619843 PMCID: PMC1171776 DOI: 10.1093/emboj/19.1.48] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The VacA toxin produced by Helicobacter pylori acts inside cells and induces the formation of vacuoles arising from late endosomal/lysosomal compartments. Using VacA as bait in a yeast two-hybrid screening of a HeLa cell library, we have identified a novel protein of 54 kDa (VIP54), which interacts specifically with VacA, as indicated by co-immunoprecipitation and binding experiments. VIP54 is expressed in cultured cells and many tissues, with higher expression in the brain, muscle, kidney and liver. Confocal immunofluorescence microscopy with anti-VIP54 affinity- purified antibodies shows a fibrous pattern typical of intermediate filaments. Double label immunofluorescence performed on various cell lines with antibodies specific to different intermediate filament proteins revealed that VIP54 largely co-distributes with vimentin. In contrast to known intermediate filament proteins, VIP54 is predicted to contain approximately 50% of helical segments, but no extended coiled-coil regions. The possible involvement of this novel protein in interactions between intermediate filaments and late endosomal compartments is discussed.
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Affiliation(s)
- M de Bernard
- Centro CNR Biomembrane and Dipartimento di Scienze Biomediche, Università di Padova, Via G.Colombo 3, 35121 Padova, Italy.
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11
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Szabò I, Brutsche S, Tombola F, Moschioni M, Satin B, Telford JL, Rappuoli R, Montecucco C, Papini E, Zoratti M. Formation of anion-selective channels in the cell plasma membrane by the toxin VacA of Helicobacter pylori is required for its biological activity. EMBO J 1999; 18:5517-27. [PMID: 10523296 PMCID: PMC1171620 DOI: 10.1093/emboj/18.20.5517] [Citation(s) in RCA: 203] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
The vacuolating toxin VacA, a major determinant of Helicobacter pylori-associated gastric diseases, forms anion-selective channels in artificial planar lipid bilayers. Here we show that VacA increases the anion permeability of the HeLa cell plasma membrane and determines membrane depolarization. Electrophysiological and pharmacological approaches indicated that this effect is due to the formation of low-conductance VacA pores in the cell plasma membrane and not to the opening of Ca(2+)- or volume-activated chloride channels. VacA-dependent increase of current conduction both in artificial planar lipid bilayers and in the cellular system was effectively inhibited by the chloride channel blocker 5-nitro-2-(3-phenylpropylamino) benzoic acid (NPPB), while2-[(2-cyclopentenyl-6,7dichloro-2, 3-dihydro-2-methyl-1-oxo-1H-inden-5-yl)oxy]acetic acid (IAA-94) was less effective. NPPB inhibited and partially reversed the vacuolation of HeLa cells and the increase of ion conductivity of polarized Madine Darby canine kidney cell monolayers induced by VacA, while IAA-94 had a weaker effect. We conclude that pore formation by VacA accounts for plasma membrane permeabilization and is required for both cell vacuolation and increase of trans-epithelial conductivity.
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Affiliation(s)
- I Szabò
- Centro CNR Biomembrane e Dipartimento di Scienze Biomediche, Università di Padova, Via G. Colombo 3, 35121 Padova, Italy
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12
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de Bernard M, Moschioni M, Papini E, Telford J, Rappuoli R, Montecucco C. Cell vacuolization induced by Helicobacter pylori VacA toxin: cell line sensitivity and quantitative estimation. Toxicol Lett 1998; 99:109-15. [PMID: 9817082 DOI: 10.1016/s0378-4274(98)00140-4] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/09/2023]
Abstract
A major virulence factor released by Helicobacter pylori is a protein toxin, termed VacA, which induces the formation of large intracellular vacuoles characterised by a lumenal acidic pH. Consequently they accumulate membrane permeable weak bases. The increase in neutral red uptake by intoxicated cells is the only known in vitro procedure to estimate quantitatively the activity of VacA. With the goal to standardize this assay, several parameters were evaluated: cell type, serum concentration, cell density and toxin concentration. Among the different cell types tested, HeLa cells were found to be the most sensitive to VacA. Results show that several factors contribute to VacA activity and that optimal vacuolation is achieved at non-confluent cell density, in the presence of low serum concentrations.
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Affiliation(s)
- M de Bernard
- Centro CNR Biomembrane and Dipartimento di Scienze Biomediche, Università di Padova, Italy
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13
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de Bernard M, Moschioni M, Papini E, Telford JL, Rappuoli R, Montecucco C. TPA and butyrate increase cell sensitivity to the vacuolating toxin of Helicobacter pylori. FEBS Lett 1998; 436:218-22. [PMID: 9781682 DOI: 10.1016/s0014-5793(98)01132-6] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
The Helicobacter pylori toxin VacA induces large membrane-bound vacuolar compartments of late endosomal/lysosomal origin. Pre-treatment of cells with TPA and butyrate enhances the toxin induced vacuolisation up to 20 times, depending on the cell line, whereas other differentiating factors such as DMSO, EGF, valeric and retinoic acid have no effect. The higher toxin sensitivity induced by TPA does not result from an increased surface binding or endocytosis. The effect of TPA is apparent after several hours from addition and is inhibited by a PKC specific inhibitor. These data suggest that expression of cellular proteins, other than the toxin receptor(s), influences the vacuolating activity of VacA and may contribute to the sensitivity of different cell lines. The present findings define the most sensitive in vitro assay of the activity of VacA.
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Affiliation(s)
- M de Bernard
- Centro CNR Biomembrane and Dipartimento di Scienze Biomediche dell'Università di Padova, Padua, Italy
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