Antibiotic susceptibilities of two Coxiella burnetii isolates implicated in distinct clinical syndromes

Neurotransmitter System-Targeting Drugs Antagonize Growth of the Q Fever Agent, Coxiella burnetii, in Human Cells

Coxiella burnetii is a highly infectious, intracellular, Gram-negative bacterial pathogen that causes human Q fever, an acute flu-like illness that can progress to chronic endocarditis. C. burnetii is transmitted to humans via aerosols and has long been considered a potential biological warfare agent. Although antibiotics, such as doxycycline, effectively treat acute Q fever, a recently identified antibiotic-resistant strain demonstrates the ability of C. burnetii to resist traditional antimicrobials, and chronic disease is extremely difficult to treat with current options. These findings highlight the need for new Q fever therapeutics, and repurposed drugs that target eukaryotic functions to prevent bacterial replication are of increasing interest in infectious disease. To identify this class of anti-C. burnetii therapeutics, we screened a library of 727 FDA-approved or late-stage clinical trial compounds using a human macrophage-like cell model of infection. Eighty-eight compounds inhibited bacterial replication, including known antibiotics, antipsychotic or antidepressant treatments, antihistamines, and several additional compounds used to treat a variety of conditions. The majority of identified anti-C. burnetii compounds target host neurotransmitter system components. Serotoninergic, dopaminergic, and adrenergic components are among the most highly represented targets and potentially regulate macrophage activation, cytokine production, and autophagy. Overall, our screen identified multiple host-directed compounds that can be pursued for potential use as anti-C. burnetii drugs.

IMPORTANCECoxiella burnetii causes the debilitating disease Q fever in humans. This infection is difficult to treat with current antibiotics and can progress to long-term, potentially fatal infection in immunocompromised individuals or when treatment is delayed. Here, we identified many new potential treatment options in the form of drugs that are either FDA approved or have been used in late-stage clinical trials and target human neurotransmitter systems. These compounds are poised for future characterization as nontraditional anti-C. burnetii therapies.

Q fever in Quebec (1989-93): Report of 14 cases

Q fever, a zoonosis acquired by inhalation of the rickettsia Coxiella burnetii, is rarely diagnosed in Canada. The world incidence has been increasing since 1960, because of progressive dissemination of this microorganism in animal populations, particularly domestic ruminants. Some recent outbreaks were caused by cats. Of 14 cases reported in Quebec between 1989 and the beginning of 1993, nine occurred successively in an 18-month period in the rural region surrounding Trois-Rivières, after contact with livestock or cats. These cases are reported here, with the results of serological screening of the workers of an abattoir where one of the cases worked. Five additional cases reported in Quebec during the same period are briefly reviewed.

Acute Q fever with Hemophagocytic Syndrome: Case Report and Literature Review

Hemophagocytic syndrome is a rare complication of acute Q fever. We reported the case of 26-year-old man with fever, chills, severe headache, non-productive cough and progressive thrombocytopenia. Bone marrow aspirate revealed hemophagocytosis. We discussed the differences among the three previous reported cases and the possible mechanisms of hemophagocytic syndrome.

Antibiotic selection and resistance issues with fluoroquinolones and doxycycline against bioterrorism agents

Bacillus anthracis (anthrax), Yersinia pestis (plague), Francisella tularensis (tularemia), Coxiella burnetti (Q fever), and Brucella sp (brucellosis) are all potential bioterrorism agents. Their known virulence, potential lethality, and ability to develop resistance to known antibiotic treatments make these pathogens particularly dangerous. We reviewed the scientific literature by searching MEDLINE databases and published abstracts from the Interscience Conference on Antimicrobial Agents and Chemotherapy and the Infectious Diseases Society of America from 1989-2005 for studies of each of these biologic agents with the specific aim of examining whether doxycycline or a fluoroquinolone should be stockpiled for mass-scale postexposure prophylaxis. An evidence-based approach was used to determine whether doxycycline or fluoroquinolones were efficacious (both in vitro and in vivo) against these biologic agents and to examine these drugs' respective susceptibility patterns and differences in cost, based on available data. Little published data are available on these pathogens, and much of the data are from studies that used older strains obtained from patient or animal sources in outbreaks decades ago. Doxycycline appears to show comparable minimum inhibitory concentrations to those of the fluoroquinolone class in most clinical and in vitro studies, perhaps with the exception of inhalation plague. Studies also suggest that development of antibiotic resistance is less likely to occur with doxycycline. Doxycycline is several-fold less expensive than most fluoroquinolones and appears to have similar efficacy in most scenarios based on clinical case studies and established Clinical and Laboratory Standards Institute (formerly known as the National Committee for Clinical Laboratory Standards) breakpoints for staphylococci. Therefore, doxycycline should be considered as a first-line antibiotic in the management of bioterrorism agents.

Evaluation of Coxiella burnetii antibiotic susceptibilities by real-time PCR assay

Coxiella burnetii is an obligate intracellular bacterium. The inability to cultivate this organism on axenic medium has made calculation of infectious units challenging and prevents the use of conventional antibiotic susceptibility assays. A rapid and reliable real-time PCR assay was developed to quantify C. burnetii cells from J774.16 mouse macrophage cells and was applied to antibiotic susceptibility testing of C. burnetii Nine Mile, phase I. For calculation of bacterial replication, real-time PCR performed equally as well as immunofluorescent-antibody (IFA) assay when J774.16 cells were infected with 10-fold serial dilutions of C. burnetii and was significantly (P < 0.05) more repeatable than IFA when 2-fold dilutions were used. Newly infected murine macrophage-like J774.16 cells were treated with 8 microg of chloramphenicol per ml, 4 microg of tetracycline per ml, 4 microg of rifampin per ml, 4 microg of ampicillin per ml, or 1 microg of ciprofloxacin per ml. After 6 days of treatment, tetracycline, rifampin, and ampicillin significantly (P < 0.01) inhibited the replication of C. burnetii, while chloramphenicol and ciprofloxacin did not. In general, these results are consistent with those from prior reports on the efficacy of these antibiotics against C. burnetii Nine Mile, phase I, and indicate that a real-time PCR-based assay is an appropriate alternative to the present methodology for evaluation of the antibiotic susceptibilities of C. burnetii.

Q fever

Q fever is a zoonosis with a worldwide distribution with the exception of New Zealand. The disease is caused by Coxiella burnetii, a strictly intracellular, gram-negative bacterium. Many species of mammals, birds, and ticks are reservoirs of C. burnetii in nature. C. burnetii infection is most often latent in animals, with persistent shedding of bacteria into the environment. However, in females intermittent high-level shedding occurs at the time of parturition, with millions of bacteria being released per gram of placenta. Humans are usually infected by contaminated aerosols from domestic animals, particularly after contact with parturient females and their birth products. Although often asymptomatic, Q fever may manifest in humans as an acute disease (mainly as a self-limited febrile illness, pneumonia, or hepatitis) or as a chronic disease (mainly endocarditis), especially in patients with previous valvulopathy and to a lesser extent in immunocompromised hosts and in pregnant women. Specific diagnosis of Q fever remains based upon serology. Immunoglobulin M (IgM) and IgG antiphase II antibodies are detected 2 to 3 weeks after infection with C. burnetii, whereas the presence of IgG antiphase I C. burnetii antibodies at titers of >/=1:800 by microimmunofluorescence is indicative of chronic Q fever. The tetracyclines are still considered the mainstay of antibiotic therapy of acute Q fever, whereas antibiotic combinations administered over prolonged periods are necessary to prevent relapses in Q fever endocarditis patients. Although the protective role of Q fever vaccination with whole-cell extracts has been established, the population which should be primarily vaccinated remains to be clearly identified. Vaccination should probably be considered in the population at high risk for Q fever endocarditis.

Determination of Coxiella burnetii rpoB sequence and its use for phylogenetic analysis

The nucleotide sequence of the rpoB, encoding the beta-subunit of RNA polymerase of the obligate intracellular bacterium Coxiella burnetii, was determined using a polymerase chain reaction amplification and direct sequencing methodology. Comparison between C. burnetii and other eubacterial rpoB sequences indicated sequence similarity ranging from 53.6% to 67.6%. Coxiella burnetii rpoB consists of 4128 base pairs with a 45.3% GC content encoding 1375 amino acids with a calculated molecular mass of 153.67 kDa. Comparison of 512 bases of the rpoB variable region I, from eight C. burnetii strains isolated from various sources, revealed fewer than four base differences, although the distribution of these did not correlate with previously determined genotypic groupings with the species. Phylogenetic analysis of C. burnetii based on comparison of its rpoB sequence with sequences available for other bacteria is consistent with those previously derived from 16S rRNA gene sequence, and indicate that C. burnetii belongs to the gamma-group of Proteobacteria. Furthermore, phylogeny inferred from comparison of RpoB, or homologous sequences including Archae, Bacteria and Eukarya, concurred with these results.

Acid phosphatase activity in Coxiella burnetii: a possible virulence factor

High-speed supernatant fluids derived from sonicated Coxiella burnetii contained considerable acid phosphatase activity when assayed by using 4-methylumbelliferylphosphate; they also contained a factor that blocked superoxide anion production by human neutrophils stimulated with formyl-Met-Leu-Phe. The pH optimum of the enzyme was approximately 5.0. The level of phosphatase activity detected in several isolates of C. burnetii implicated in acute (Nine Mile) and chronic (S Q217, PRS Q177, K Q154) Q fever was 25 to 60 times greater than that reported in other microorganisms, including Leishmania and Legionella spp. The enzyme was found in rickettsiae grown in different hosts (L929 cells and embryonated eggs) and, in the case of L929 cells, for both short periods (less than a month) and the long term (years). Cytochemical techniques coupled with electron microscopy localized the phosphatase activity to the periplasmic gap in the parasite. Ion-exchange chromatography revealed a major species of the enzyme and showed that the enzyme of the parasite was distinct from that of the host cell (L929 fibroblasts); its apparent molecular weight was 74,000. Phosphatase inhibitors (i.e., molybdate heteropolyanions) had differential effects on the phosphatases of the parasite and host cell. C. burnetii supernatant fluid inhibited superoxide anion production by formyl-Met-Leu-Phe-stimulated human neutrophils; molybdate inhibitors reversed the inhibition. Treatment of C. burnetii-infected L929 cells with one of the molybdate compounds (complex B') significantly reduced the level of infection and did not affect the viability or growth of the host cell. These data suggest that the acid phosphatase of the parasite may be a major virulence determinant, allowing the agent to avoid being killed during uptake by phagocytes and subsequently in the phagolysosome.

In vitro activities of ceftriaxone and fusidic acid against 13 isolates of Coxiella burnetii, determined using the shell vial assay

The susceptibilities of 13 isolates of Coxiella burnetii to fusidic acid and ceftriaxone were determined by use of the recently described shell vial assay (D. Raoult, H. Torres, and M. Drancourt, Antimicrob. Agents Chemother, 35:2070-2077, 1991). At a concentration of 4 micrograms/ml, ceftriaxone was bacteriostatic for four isolates and slowed the multiplication of the other nine. Fusidic acid at a concentration of 2 micrograms/ml was bacteriostatic for six isolates and slowed the multiplication of three others. These results show that these compounds could be effective in the phagolysosome of C. burnetii-infected cells.

Phagolysosomes of Coxiella burnetii-infected cell lines maintain an acidic pH during persistent infection

Coxiella burnetii, the agent of Q fever, is an obligate intracellular bacterium that multiples within vacuoles of phagolysosomal origin. Persistently infected cell lines were maintained in continuous culture for months. We studied the pH of the phagolysosomes by using two murine cell lines during early propagation of the bacteria and after establishment of persistent infection. Three strains of C. burnetii were studied because of the purported propensity of each strain to cause acute or chronic disease and to be resistant or susceptible to antibiotics. The pHs were calculated from fluorescence experiments with fluoresceinated dextran as a lysosomal probe. Phagolysosomal vacuoles maintained an acidic pH during a 36-day infection. Minimal variation of the pH occurred over the duration of the experiment with strains that caused either acute or chronic disease. Phagolysosomal pH remained stable for as long as 153 days with the Nine Mile phase II isolate. Thus, neither the course of C. burnetti infection nor the diversity of antibiotic susceptibility of the strains is related to variations in the phagolysosomal pH.

Susceptibility of Rickettsia conorii, R. rickettsii, and Coxiella burnetii to PD 127,391, PD 131,628, pefloxacin, ofloxacin, and ciprofloxacin

Plaque formation and dye uptake assays were used to measure the MICs of PD 127,391 and PD 131,628 against Rickettsia species. The MICs of PD 127,391 were 0.25 microgram/ml for Rickettsia rickettsii and 0.125 to 0.25 microgram/ml for Rickettsia conorii. The MICs of PD 131,628 were 0.25 to 0.5 microgram/ml for R. rickettsii and 0.5 microgram/ml for R. conorii. As determined by the shell vial technique, 15 strains of Coxiella burnetii were susceptible to PD 127,391 and PD 131,628 (MIC, < or = 1 microgram/ml), while one strain of C. burnetii (MP10) was of intermediate susceptibility.

A plasmid-encoded surface protein found in chronic-disease isolates of Coxiella burnetti

The cbbE' gene codes for the E' protein of Coxiella burnetii and was detected in genomic DNA from all known human isolates of the biotzere strain but not in DNA from the other five strains of C. burnetti. The biotzere strain is strictly associated with chronic disease in humans. Extrinsic iodination of biotzere strain cells radiolabeled a 55-kDa protein which comigrated on sodium dodecyl sulfate-polyacrylamide gel electrophoresis with the E' protein synthesized in vitro from recombinants containing the cbbE' gene. The 125I-labeled 55-kDa protein was immunoprecipitated with polyclonal anti-E' antiserum, confirming its identity as E'. Predicted secondary structure of the E' polypeptide shows six regions of beta-sheet structure and an alpha-helix near the C terminus with adequate lengths to span a membrane. The predicted hydropathy profile of E' is similar to profiles of known outer membrane proteins and corroborates the biochemical data, indicating that the protein is located in the outer membrane of C. burnetii.

Shell-vial assay: evaluation of a new technique for determining antibiotic susceptibility, tested in 13 isolates of Coxiella burnetii

Coxiella burnetii is a strictly intracellular bacterium. Bacteriostatic effects have been described previously on a few isolates in embryonated eggs (A. J. Spicer, M. G. Peacock, and J. C. Williams, p. 375-383, in W. Burgdorfer and R. L. Anacker, ed., Rickettsiae and rickettsial diseases, 1981). We used the shell-vial technique (D. Raoult, G. Vestris, and M. Enea, J. Clin. Microbiol. 28:2482-2484, 1990) to determine the susceptibility of C. burnetii to amoxicillin, amikacin, erythromycin, co-trimoxazole, pefloxacin, ofloxacin, ciprofloxacin, chloramphenicol, tetracycline, doxycycline, minocycline, and rifampin antibiotics at a single dilution. Human embryonic lung fibroblast monolayers in shell vials were seeded with 13 different C. burnetii isolates, including 3 reference strains (Nine Mile, Q212, and Priscilla) and 10 new isolates, in order to obtain 30% infected cells 6 days later. After inoculation, antibiotics were added, shell vials were incubated for 7 days, and immunofluorescence was revealed and compared with that of the positive controls. Strain Nine Mile was more susceptible than strains Q212 and Priscilla were. The heterogeneity of susceptibility to fluoroquinolones, chloramphenicol, and erythromycin was noted among the strains; all were resistant to amoxicillin and amikacin, and all were susceptible to rifampin, co-trimoxazole, tetracycline, and tetracycline analogs.

Quinolones in the treatment of lower respiratory tract infections caused by intracellular pathogens

Intracellular pathogens are inhibited to varying degrees, depending upon the strain of the organism and the quinolone tested. Quinolones achieve levels in the lower respiratory tract that equal or exceed serum concentrations, and they also achieve good intracellular concentrations. Experimental models of intracellular infection have demonstrated the efficacy of ciprofloxacin, difloxacin, fleroxacin, ofloxacin and pefloxacin. Animal models of experimental legionellosis have confirmed in vivo their efficacy in this field. Thus, quinolones appear to be a safe and efficacious alternative treatment in lower respiratory tract infection (LRTI) due to intracellular pathogens. Considering the in vitro and experimental studies, quinolones should play an important role in the treatment of LRTI caused by intracellular pathogens, and prospective controlled studies are strongly recommended.

Antibiotic treatment of rickettsiosis, recent advances and current concepts

The author reviews the recent advances in the treatment of Mediterranean Spotted Fever and Q fever. In mediterranean spotted fever (M.S.F.), in vitro and preliminary in vivo data support the place of quinolones and josamycin in the treatment of M.S.F. In children josamycin could become the first choice drug as well as in pregnant woman. In Q fever chronic disease should be treated using a combination of antibiotic (doxycycline + quinolones) for a minimum of 3 years.

Mechanisms that may account for differential antibiotic susceptibilities among Coxiella burnetii isolates

The Nine Mile, S Q217, and Priscilla isolates, representative of the three major genetic groups of Coxiella burnetii, are known to differ in their susceptibilities to antibiotics. Mechanisms potentially responsible for these differences were investigated. Accumulation of antibiotics by infected L929 cells and purified isolates was measured. In addition, C. burnetii plasmid-transformed Escherichia coli HB101 cells were used to study the possibility that different C. burnetii plasmids are responsible for disparate antibiotic susceptibilities of the isolates. L929 cells recently or persistently infected with the Priscilla isolate exhibited a significantly reduced accumulation of [3H]tetracycline as compared with that in L929 cells infected with either the Nine Mile or S Q217 isolates; accumulation of this drug was greater in cells recently infected each isolate. In contrast, L929 cells recently or persistently infected with the different isolates accumulated [3H]norfloxacin to an equivalent extent. [3H]tetracycline accumulation was approximately the same among the purified isolates. However, as measured by both scintillation and spectrofluorometry, norfloxacin accumulation was significantly diminished in the purified Priscilla isolate. pH had no apparent effect upon isolate permeabilities. The presence of C. burnetii QpH1 or QpRS plasmids did not alter the antibiotic susceptibility of E. coli. Collectively, these results indicate that differential susceptibilities to tetracyclines or fluoroquinolones in C. burnetii isolates may be the result of distinct mechanisms involving altered host-cell (tetracyclines) or isolate-specific (fluoroquinolones) permeabilities.

Comparison of different antibiotic regimens for therapy of 32 cases of Q fever endocarditis

We studied 32 cases of Q fever endocarditis diagnosed in France between January 1985 and December 1989 to evaluate the efficacies of the different regimens of antibiotics used for treatment. Each patient was monitored during the treatment (range, 12 to 60 months), and clinical and biological information was computerized. Various treatments were prescribed, including doxycycline alone (9 cases) or in association with rifampin (4 cases), quinolones (16 cases), or sulfamethoxazole-trimethoprim (1 case). Two patients died before the beginning of the treatment. Nineteen patients had hemodynamic failure and subsequently underwent valve replacement. Nine valve tissue cultures were positive despite previous antibiotic treatment. In terms of their effects on mortality, the difference between doxycycline alone and doxycycline plus quinolones is statistically significant. We conclude that the addition of quinolones to doxycycline is beneficial. On the basis of clinical, serological, and valve tissue culture results, no treatment was able to cure Q fever endocarditis within 2 years, even with a combination of antibiotics. We advise a minimum duration of treatment of 3 years with therapy combining quinolones and doxycycline.

In vitro susceptibilities of Coxiella burnetii, Rickettsia rickettsii, and Rickettsia conorii to the fluoroquinolone sparfloxacin

In vitro susceptibilities of Rickettsia rickettsii, Rickettsia conorii, and Coxiella burnetii to the new fluoroquinolone sparfloxacin (AT-4140; RP 64206) were determined. Plaque and dye uptake assays were used to measure the MICs against R. rickettsii and R. conorii. The susceptibilities of C. burnetii Nine Mile and Q 212 were determined in two acute-infection models and in two chronic-infection models. The MICs were 0.125 to 0.25 microgram/ml for R. rickettsii and 0.25 to 0.5 microgram/ml for R. conorii. Sparfloxacin (1 microgram/ml) cured cells recently infected with C. burnetii Nine Mile and Q 212 within 4 to 9 days and cured multiplying, persistently infected cells within 10 days. As previously described with other fluoroquinolones (D. Raoult, M. Drancourt, and G. Vestris, Antimicrob. Agents Chemother. 34:1512-1514, 1990), sparfloxacin failed to cure cells persistently infected with C. burnetii and blocked from dividing with cycloheximide. As determined by the dye uptake assay, no cellular toxicity was noted with sparfloxacin at up to 128 micrograms/ml. These results are consistent with those previously obtained with fluoroquinolones (D. Raoult, M. Yeaman, and O. Baca, Rev. Infect. Dis. 11[Suppl. 5]:S986, 1989), although sparfloxacin may be slightly more active.

Bactericidal effect of doxycycline associated with lysosomotropic agents on Coxiella burnetii in P388D1 cells

There is no consistently reliable treatment for endocarditis resulting from chronic Coxiella burnetii infection, the causative agent of Q fever. Although certain antibiotics are recommended on the basis of their in vitro bactericidal activities, results of therapy with these antibiotics are often disappointing. To evaluate whether the currently recommended antibiotic susceptibility tests for C. burnetii give misleading results because of continued division of uninfected cells, thereby resulting in the dilution of infected cells and, hence, a false picture of antibiotic efficacy, we blocked cell division during antibiotic susceptibility testing with cycloheximide. Using this new method, we found that the currently recommended antibiotics for the treatment of Q fever, doxycycline, pefloxacin, and rifampin, did not reduce the ratio of infected to noninfected cells (either L929 or P388D1) by 9 days postinfection. To test the hypothesis that this lack of antibacterial activity is due to antibiotic inactivation by the low pH of the phagolysosomes in which C. burnetii is found, we used alkalinizing lysosomotropic agents (chloroquine or amantadine) concurrently with doxycycline. This resulted in the sterilization of C. burnetii infection in P388D1 cells. This finding seems to confirm our suspicion that the acidic conditions of the phagolysosomes in which C. burnetii is located inhibit antibiotic activity. This inhibition can be reversed in vitro when lysosomotropic alkalinizing agents are used.

Unexpected antibiotic susceptibility of a chronic isolate of Coxiella burnetii

Evidence is mounting in support of the idea that different isolates of Coxiella burnetii, the etiologic agent of Q fever, are responsible for the distinct disease syndromes observed clinically. Recent studies have shown distinct antibiotic susceptibilities of different isolates of C. burnetii implicated in distinct clinical Q fever syndromes. With this in mind, we performed antibiotic susceptibility testing of the "S" isolate, a chronic-type isolate retrieved from a human patient with chronic disease. Antibiotics with differing efficacies upon the Nine Mile and Priscilla isolates were tested for their abilities to control acute and persistent "S" isolate infection of L-929 cells in vitro. The efficacies of doxycycline, rifampin, and three fluoroquinolone drugs--ciprofloxacin, ofloxacin, and norfloxacin--were tested. Compared to the chronic Q fever-implicated Priscilla isolate, which has been shown to exhibit a significant resistance to these antibiotics, the "S" isolate was much more susceptible. In persistently infected cells (greater than 300 d), the "S" isolate proved to be significantly more resistant to doxycycline, slightly more resistant to ciprofloxacin, slightly more susceptible to rifampin, and equally sensitive to ofloxacin and norfloxacin compared to the acute Q fever-implicated Nine Mile isolate. As with both the Nine Mile and Priscilla isolates, the "S" isolate was more susceptible to doxycycline, rifampin, and ofloxacin in recently infected cells (22 d) compared to cells having been persistently infected. With respect to the resistant nature of the chronic Q fever-implicated Priscilla isolate, as well as the lack of success in treating the "S" isolate in vivo, these results were unexpected. Such data supports an evolving hypothesis that the distinct C. burnetii isolates which may be responsible for the clearly different Q fever syndromes exhibit a spectrum of antibiotic susceptibility ranging from very susceptible (acute-implicate), Nine Mile isolate), to moderately susceptible (chronic-implicated "S" isolate), to moderately resistant (chronic-implicated Priscilla isolate).