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San Mauro AJS, Høiby N, Ciofu O. Increased susceptibility to azithromycin of Pseudomonas aeruginosa biofilms using RPMI 1640 testing media. APMIS 2024. [PMID: 38622982 DOI: 10.1111/apm.13413] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Accepted: 03/20/2024] [Indexed: 04/17/2024]
Abstract
Azithromycin (AZM) is efficient for treatment of chronic Pseudomonas aeruginosa biofilm lung infections, despite of resistance in conventional susceptibility testing. It has been shown that planktonic P. aeruginosa are more susceptible to AZM when tested in RPMI 1640 medium. The aim of the study was to test the susceptibility to AZM of P. aeruginosa biofilms in LB vs RPMI 1640 media. We investigated the effect of AZM on planktonic and biofilms of (WT) P. aeruginosa (PAO1), the hypermutable (ΔmutS) and the antibiotic-resistant phenotype(ΔnfxB) mutants. The effect of AZM on young and mature biofilms was investigated in the modified Calgary Biofilm Device by estimation of the minimal biofilm inhibitory concentration (MBIC). The AZM MBIC90 in LB/RPMI1640 on young biofilms treated for 24 h was 16/4 μg/mL for PAO1, 32/8 μg/mL for ΔmutS, and 256/16 μg/mL for ΔnfxB, while in mature biofilms was 256/2 μg/mL for PAO1 and ΔmutS and 16/1 μg/mL for ΔnfxB. The effect of AZM was improved when the treatment was prolonged to 72 h, supporting the intracellular accumulation of AZM. An increased susceptibility of P. aeruginosa biofilms to AZM was observed in RPMI 1640 than in LB medium. Our results might improve susceptibility testing and dosing of AZM for treatment of biofilm infections.
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Affiliation(s)
| | - Niels Høiby
- Institute of Immunology & Microbiology, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Oana Ciofu
- Institute of Immunology & Microbiology, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
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Høiby N, Moser C, Ciofu O. The microenvironment in antibiotic susceptibility testing. APMIS 2024. [PMID: 38565324 DOI: 10.1111/apm.13405] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 03/08/2024] [Indexed: 04/04/2024]
Abstract
Antibiotic susceptibility testing (AST) by agar diffusion has been repeatedly standardized and, in most cases, gives results which predict clinical success when antibiotic treatment is based on such results. The formation of the inhibition zone is due to a transition from planktonic to biofilm mode of growth. The kinetics of the interaction of antibiotics with bacteria is similar during AST by agar diffusion and during administration of antibiotics to the patients. However, the Mueller-Hinton agar (MHA) recommended for AST agar diffusion test is fundamentally different from the composition of the interstitial fluid in the human body where the infections take place and human cells do not thrive in MH media. Use of RPMI 1640 medium designed for growth of eucaryotic cells for AST of Pseudomonas aeruginosa against azithromycin results in lower minimal inhibitory concentration, compared to results obtained by MHA. The reason is that the RPMI 1640 medium increases uptake and reduces efflux of azithromycin compared to MHA. During treatment of cystic fibrosis patients with azithromycin, mutational resistance occur which is not detected by AST with MHA. Whether this is the case with other antibiotics and bacteria is not known but it is of clinical importance to be studied.
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Affiliation(s)
- Niels Høiby
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Institute of Immunology and Microbiology, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
- Institute of Immunology and Microbiology, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Oana Ciofu
- Institute of Immunology and Microbiology, Panum Institute, University of Copenhagen, Copenhagen, Denmark
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Higazy D, Pham AD, van Hasselt C, Høiby N, Jelsbak L, Moser C, Ciofu O. In vivo evolution of antimicrobial resistance in a biofilm model of Pseudomonas aeruginosa lung infection. ISME J 2024; 18:wrae036. [PMID: 38478426 PMCID: PMC10980832 DOI: 10.1093/ismejo/wrae036] [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] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 02/10/2024] [Accepted: 02/29/2024] [Indexed: 04/01/2024]
Abstract
The evolution of antimicrobial resistance (AMR) in biofilms has been repeatedly studied by experimental evolution in vitro, but rarely in vivo. The complex microenvironment at the infection site imposes selective pressures on the bacterial biofilms, potentially influencing the development of AMR. We report here the development of AMR in an in vivo mouse model of Pseudomonas aeruginosa biofilm lung infection. The P. aeruginosa embedded in seaweed alginate beads underwent four successive lung infection passages with or without ciprofloxacin (CIP) exposure. The development of CIP resistance was assessed at each passage by population analysis of the bacterial populations recovered from the lungs of CIP-treated and control mice, with subsequent whole-genome sequencing of selected isolates. As inflammation plays a crucial role in shaping the microenvironment at the infection site, its impact was explored through the measurement of cytokine levels in the lung homogenate. A rapid development of AMR was observed starting from the second passage in the CIP-treated mice. Genetic analysis revealed mutations in nfxB, efflux pumps (mexZ), and two-component systems (parS) contribution to CIP resistance. The control group isolates exhibited mutations in the dipA gene, likely associated with biofilm dispersion. In the initial two passages, the CIP-treated group exhibited an elevated inflammatory response compared to the control group. This increase may potentially contribute to the release of mutagenic reactive oxygen species and the development of AMR. In conclusion, this study illustrates the complex relationship between infection, antibiotic treatment, and immune response.
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Affiliation(s)
- Doaa Higazy
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, 2200 N Copenhagen, Denmark
- Department of Microbiology, Faculty of Agriculture, Cairo University, 12613 Giza, Egypt
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, 2100 Ø Copenhagen, Denmark
| | - Anh Duc Pham
- Division of Systems Pharmacology & Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2300 RA Leiden, The Netherlands
| | - Coen van Hasselt
- Division of Systems Pharmacology & Pharmacy, Leiden Academic Centre for Drug Research, Leiden University, 2300 RA Leiden, The Netherlands
| | - Niels Høiby
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, 2200 N Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, 2100 Ø Copenhagen, Denmark
| | - Lars Jelsbak
- Department of Biotechnology and Biomedicine, Technical University of Denmark, 2800 Kgs. Lyngby, Denmark
| | - Claus Moser
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, 2200 N Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, University of Copenhagen, 2100 Ø Copenhagen, Denmark
| | - Oana Ciofu
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, 2200 N Copenhagen, Denmark
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Armengol E, Kragh KN, Tolker-Nielsen T, Sierra JM, Higazy D, Ciofu O, Viñas M, Høiby N. Colistin Enhances Rifampicin's Antimicrobial Action in Colistin-Resistant Pseudomonas aeruginosa Biofilms. Antimicrob Agents Chemother 2023; 67:e0164122. [PMID: 36856424 PMCID: PMC10112245 DOI: 10.1128/aac.01641-22] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 12/07/2022] [Accepted: 01/30/2023] [Indexed: 03/02/2023] Open
Abstract
The emergence of multidrug-resistant Pseudomonas aeruginosa infections has urged the need to find new strategies, such as the use of combinations of antibiotics. Among these, the combination of colistin with other antibiotics has been studied. Here, the action of combinations of colistin and rifampicin on both planktonic and sessile cells of colistin-resistant P. aeruginosa was studied. Dynamic biofilms were formed and treated with such a combination, resulting in an active killing effect of both colistin-resistant and colistin-susceptible P. aeruginosa in biofilms. The results suggest that the action of colistin on the outer membrane facilitates rifampicin penetration, regardless of the colistin-resistant phenotype. Based on these in vitro data, we propose a colistin-rifampicin combination as a promising treatment for infections caused by colistin-resistant P. aeruginosa.
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Affiliation(s)
- Eva Armengol
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Laboratory of Molecular Microbiology & Antimicrobials, Department of Pathology & Experimental Therapeutics, Medical School and IDIBELL, University of Barcelona, Hospitalet de Llobregat, Spain
| | - Kasper Nørskov Kragh
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Tim Tolker-Nielsen
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Josep M. Sierra
- Laboratory of Molecular Microbiology & Antimicrobials, Department of Pathology & Experimental Therapeutics, Medical School and IDIBELL, University of Barcelona, Hospitalet de Llobregat, Spain
| | - Doaa Higazy
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Oana Ciofu
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Miguel Viñas
- Laboratory of Molecular Microbiology & Antimicrobials, Department of Pathology & Experimental Therapeutics, Medical School and IDIBELL, University of Barcelona, Hospitalet de Llobregat, Spain
| | - Niels Høiby
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
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Abstract
Chronic infections caused by microbial biofilms represent an important clinical challenge. The recalcitrance of microbial biofilms to antimicrobials and to the immune system is a major cause of persistence and clinical recurrence of these infections. In this Review, we present the extent of the clinical problem, and the mechanisms underlying the tolerance of biofilms to antibiotics and to host responses. We also explore the role of biofilms in the development of antimicrobial resistance mechanisms.
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Affiliation(s)
- Oana Ciofu
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Claus Moser
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Peter Østrup Jensen
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Niels Høiby
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
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Laulund AS, Schwartz F, Trøstrup H, Thomsen K, Christophersen L, Calum H, Ciofu O, Høiby N, Moser C. Adjunctive S100A8/A9 Immunomodulation Hinders Ciprofloxacin Resistance in Pseudomonas aeruginosa in a Murine Biofilm Wound Model. Front Cell Infect Microbiol 2021; 11:652012. [PMID: 33912476 PMCID: PMC8072475 DOI: 10.3389/fcimb.2021.652012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Accepted: 03/19/2021] [Indexed: 12/24/2022] Open
Abstract
Objective Pseudomonas aeruginosa is known to contribute to the pathogenesis of chronic wounds by biofilm-establishment with increased tolerance to host response and antibiotics. The neutrophil-factor S100A8/A9 has a promising adjuvant effect when combined with ciprofloxacin, measured by quantitative bacteriology, and increased anti- and lowered pro-inflammatory proteins. We speculated whether a S100A8/A9 supplement could prevent ciprofloxacin resistance in infected wounds. Method Full-thickness 2.9cm2-necrosis was inflicted on 32 mice. On day 4, P.aeruginosa in seaweed alginate was injected sub-eschar to mimic a mono-pathogenic biofilm. Mice were randomized to receive ciprofloxacin and S100A8/A9 (n=14), ciprofloxacin (n=12) or saline (n=6). Half of the mice in each group were euthanized day 6 and the remaining day 10 post-infection. Mice were treated until sacrifice. Primary endpoint was the appearance of ciprofloxacin resistant P.aeruginosa. The study was further evaluated by genetic characterization of resistance, means of quantitative bacteriology, wound-size and cytokine-production. Results Three mice receiving ciprofloxacin monotherapy developed resistance after 14 days. None of the mice receiving combination therapy changed resistance pattern. Sequencing of fluoroquinolone-resistance determining regions in the ciprofloxacin resistant isolates identified two high-resistant strains mutated in gyrA C248T (MIC>32µg/ml) and a gyr B mutation was found in the sample with low level resistance (MIC=3µg/ml). Bacterial densities in wounds were lower in the dual treated group compared to the placebo group on both termination days. Conclusion This study supports the ciprofloxacin augmenting effect and indicates a protective effect in terms of hindered ciprofloxacin resistance of adjuvant S100A8/A9 in P.aeruginosa biofilm infected chronic wounds.
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Affiliation(s)
- Anne S Laulund
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Franziska Schwartz
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hannah Trøstrup
- Department of Plastic Surgery, Zealand University Hospital, Copenhagen, Denmark
| | - Kim Thomsen
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Christophersen
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Henrik Calum
- Department of Clinical Microbiology, Hvidovre Hospital, Hvidovre, Denmark
| | - Oana Ciofu
- Department of Immunology and Microbiology (ISIM), University of Copenhagen, Copenhagen, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark.,Department of Immunology and Microbiology (ISIM), University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital, Copenhagen, Denmark
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Ahmed MN, Abdelsamad A, Wassermann T, Porse A, Becker J, Sommer MOA, Høiby N, Ciofu O. The evolutionary trajectories of P. aeruginosa in biofilm and planktonic growth modes exposed to ciprofloxacin: beyond selection of antibiotic resistance. NPJ Biofilms Microbiomes 2020; 6:28. [PMID: 32709907 PMCID: PMC7381665 DOI: 10.1038/s41522-020-00138-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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] [Received: 02/20/2020] [Accepted: 07/06/2020] [Indexed: 12/22/2022] Open
Abstract
Ciprofloxacin (CIP) is used to treat Pseudomonas aeruginosa biofilm infections. We showed that the pathways of CIP-resistance development during exposure of biofilms and planktonic P. aeruginosa populations to subinhibitory levels of CIP depend on the mode of growth. In the present study, we analyzed CIP-resistant isolates obtained from previous evolution experiments, and we report a variety of evolved phenotypic and genotypic changes that occurred in parallel with the evolution of CIP-resistance. Cross-resistance to beta-lactam antibiotics was associated with mutations in genes involved in cell-wall recycling (ftsZ, murG); and could also be explained by mutations in the TCA cycle (sdhA) genes and in genes involved in arginine catabolism. We found that CIP-exposed isolates that lacked mutations in quorum-sensing genes and acquired mutations in type IV pili genes maintained swarming motility and lost twitching motility, respectively. Evolved CIP-resistant isolates showed high fitness cost in planktonic competition experiments, yet persisted in the biofilm under control conditions, compared with ancestor isolates and had an advantage when exposed to CIP. Their persistence in biofilm competition experiments in spite of their fitness cost in planktonic growth could be explained by their prolonged lag-phase. Interestingly, the set of mutated genes that we identified in these in vitro-evolved CIP-resistant colonies, overlap with a large number of patho-adaptive genes previously reported in P. aeruginosa isolates from cystic fibrosis (CF) patients. This suggests that the antibiotic stress is contributing to the bacterial evolution in vivo, and that adaptive laboratory evolution can be used to predict the in vivo evolutionary trajectories.
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Affiliation(s)
- Marwa N Ahmed
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Microbiology, Faculty of Agriculture, Cairo University, Giza, Egypt
| | - Ahmed Abdelsamad
- Department of Genetics, Faculty of Agriculture, Cairo University, Giza, Egypt
| | - Tina Wassermann
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Andreas Porse
- Novo Nordisk Foundation Center for Sustainability, Technical University of Denmark, Lyngby, Denmark
| | - Janna Becker
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Morten O A Sommer
- Novo Nordisk Foundation Center for Sustainability, Technical University of Denmark, Lyngby, Denmark
| | - Niels Høiby
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Oana Ciofu
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark.
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Henriksen K, Rørbo N, Rybtke ML, Martinet MG, Tolker-Nielsen T, Høiby N, Middelboe M, Ciofu O. P. aeruginosa flow-cell biofilms are enhanced by repeated phage treatments but can be eradicated by phage-ciprofloxacin combination. Pathog Dis 2020; 77:5368070. [PMID: 30821815 DOI: 10.1093/femspd/ftz011] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2018] [Accepted: 02/28/2019] [Indexed: 02/06/2023] Open
Abstract
Phage therapy has shown promising results in the treatment of Pseudomonas aeruginosa biofilm infections in animal studies and case reports. The aim of this study was to quantify effects of phage treatments on P. aeruginosa biofilm production and structure. Confocal scanning microscopy was used to follow the interaction between a cocktail of three virulent phages and P. aeruginosa flow-cell biofilms. The role of (i) biofilm age, (ii) repeated phage treatments, (iii) alginate production and (iv) the combination with sub-MIC levels of ciprofloxacin was investigated. Single phage treatment in the early biofilm stages significantly reduced P. aeruginosa PAO1 biovolume (85%-98% reduction). Repeated phage treatments increased the biovolume from 18.25 (untreated biofilm) to 22.24 and 31.07 µm3/µm2 for biofilms treated with phages twice and thrice, respectively. Alginate protected against the phage treatment as the live biovolume remained unaffected by the phage treatment in the mucoid biofilm (20.11 µm3/µm2 in untreated and 21.74 µm3/µm2 in phage-treated biofilm) but decreased in the PAO1 biofilm from 27.35 to 0.89 µm3/µm2. We show that the combination of phages with antibiotics at sub-MIC levels caused a ∼6 log units reduction in the abundance of P. aeruginosa cells in biofilms and that phage treatment increased the size of microcolonies in flow-cell system.
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Affiliation(s)
- Karoline Henriksen
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200 N, Copenhagen, Denmark
| | - Nanna Rørbo
- Department of Biology, Marine Biological Section, University of Copenhagen, Strandpromenaden 5, 3000 Helsingør, Denmark
| | - Morten Levin Rybtke
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200 N, Copenhagen, Denmark
| | - Mark Grevsen Martinet
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200 N, Copenhagen, Denmark
| | - Tim Tolker-Nielsen
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200 N, Copenhagen, Denmark
| | - Niels Høiby
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200 N, Copenhagen, Denmark.,Department of Clinical Microbiology, University Hospital, Rigshospitalet, Henrik Harpestrengs Vej 4A, 2100 , Copenhagen, Denmark
| | - Mathias Middelboe
- Department of Biology, Marine Biological Section, University of Copenhagen, Strandpromenaden 5, 3000 Helsingør, Denmark
| | - Oana Ciofu
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Blegdamsvej 3, 2200 N, Copenhagen, Denmark
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Ciofu O, Smith S, Lykkesfeldt J. A systematic Cochrane Review of antioxidant supplementation lung disease for cystic fibrosis. Paediatr Respir Rev 2020; 33:28-29. [PMID: 31956034 DOI: 10.1016/j.prrv.2019.12.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 12/03/2019] [Indexed: 10/25/2022]
Affiliation(s)
- Oana Ciofu
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark.
| | - Sherie Smith
- Faculty of Medicine & Health Sciences, University of Nottingham, Nottingham, UK
| | - Jens Lykkesfeldt
- Department of Veterinary and Animal Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark
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Jensen P, Møller S, Lerche C, Moser C, Bjarnsholt T, Ciofu O, Faurholt-Jepsen D, Høiby N, Kolpen M. Improving antibiotic treatment of bacterial biofilm by hyperbaric oxygen therapy: Not just hot air. Biofilm 2019; 1:100008. [PMID: 33447795 PMCID: PMC7798444 DOI: 10.1016/j.bioflm.2019.100008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Revised: 10/22/2019] [Accepted: 10/23/2019] [Indexed: 10/26/2022] Open
Abstract
Bacteria and fungi show substantial increased recalcitrance when growing as infectious biofilms. Chronic infections caused by biofilm growing microorganisms is considered a major problem of modern medicine. New strategies are needed to improve antibiotic treatment of biofilms. We have improved antibiotic treatment of bacterial biofilms by reviving the dormant bacteria and thereby make them susceptible to antibiotics by means of reoxygenation. Here we review the rationale for associating lack of oxygen with low susceptibility in infectious biofilm, and how hyperbaric oxygen therapy may result in reoxygenation leading to enhanced bactericidal activity of antibiotics. We address issues of feasibility and potential adverse effects regarding patient safety and development of resistance. Finally, we propose means for supplying reoxygenation to antibiotic treatment of infectious biofilm with the potential to benefit large groups of patients.
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Affiliation(s)
- P.Ø. Jensen
- Department of Clinical Microbiology, Rigshospitalet, 2100, Copenhagen, Denmark
- Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health Sciences University of Copenhagen, 2200, Copenhagen, Denmark
| | - S.A. Møller
- Department of Clinical Microbiology, Rigshospitalet, 2100, Copenhagen, Denmark
| | - C.J. Lerche
- Department of Clinical Microbiology, Rigshospitalet, 2100, Copenhagen, Denmark
| | - C. Moser
- Department of Clinical Microbiology, Rigshospitalet, 2100, Copenhagen, Denmark
| | - T. Bjarnsholt
- Department of Clinical Microbiology, Rigshospitalet, 2100, Copenhagen, Denmark
- Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health Sciences University of Copenhagen, 2200, Copenhagen, Denmark
| | - O. Ciofu
- Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health Sciences University of Copenhagen, 2200, Copenhagen, Denmark
| | - D. Faurholt-Jepsen
- Copenhagen Cystic Fibrosis Center, Department of Infectious Diseases, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, DK2100, Copenhagen, Denmark
| | - N. Høiby
- Department of Clinical Microbiology, Rigshospitalet, 2100, Copenhagen, Denmark
- Costerton Biofilm Center, Department of Immunology and Microbiology, Faculty of Health Sciences University of Copenhagen, 2200, Copenhagen, Denmark
| | - M. Kolpen
- Department of Clinical Microbiology, Rigshospitalet, 2100, Copenhagen, Denmark
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Abstract
BACKGROUND Airway infection leads to progressive damage of the lungs in cystic fibrosis (CF) and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, beta-carotene and selenium) or N-acetylcysteine (NAC) as a source of glutathione, may therefore potentially help maintain an oxidant-antioxidant balance. Glutathione or NAC can also be inhaled and if administered in this way can also have a mucolytic effect besides the antioxidant effect. Current literature suggests a relationship between oxidative status and lung function. This is an update of a previously published review. OBJECTIVES To synthesise existing knowledge on the effect of antioxidants such as vitamin C, vitamin E, beta-carotene, selenium and glutathione (or NAC as precursor of glutathione) on lung function through inflammatory and oxidative stress markers in people with CF. SEARCH METHODS The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies. We also searched online trials registries.Last search of Cystic Fibrosis Trials Register: 08 January 2019. SELECTION CRITERIA Randomised and quasi-randomised controlled studies comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care in people with CF. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted study investigators to obtain missing information. If meta-analysed, studies were subgrouped according to supplement, method of administration and the duration of supplementation. We assessed the quality of the evidence using GRADE. MAIN RESULTS One quasi-randomised and 19 randomised controlled studies (924 children and adults) were included; 16 studies (n = 639) analysed oral antioxidant supplementation and four analysed inhaled supplements (n = 285). Only one of the 20 included studies was judged to be free of bias.Oral supplements versus controlThe change from baseline in forced expiratory volume in one second (FEV1) % predicted at three months and six months was only reported for the comparison of NAC to control. Four studies (125 participants) reported at three months; we are uncertain whether NAC improved FEV1 % predicted as the quality of the evidence was very low, mean difference (MD) 2.83% (95% confidence interval (CI) -2.16 to 7.83). However, at six months two studies (109 participants) showed that NAC probably increased FEV1 % predicted from baseline (moderate-quality evidence), MD 4.38% (95% CI 0.89 to 7.87). A study of a combined vitamin and selenium supplement (46 participants) reported a greater change from baseline in FEV1 % predicted in the control group at two months, MD -4.30% (95% CI -5.64 to -2.96). One study (61 participants) found that NAC probably makes little or no difference in the change from baseline in quality of life (QoL) at six months (moderate-quality evidence), standardised mean difference (SMD) -0.03 (95% CI -0.53 to 0.47), but the two-month combined vitamin and selenium study reported a small difference in QoL in favour of the control group, SMD -0.66 (95% CI -1.26 to -0.07). The NAC study reported on the change from baseline in body mass index (BMI) (62 participants) and similarly found that NAC probably made no difference between groups (moderate-quality evidence). One study (69 participants) found that a mixed vitamin and mineral supplement may lead to a slightly lower risk of pulmonary exacerbation at six months than a multivitamin supplement (low-quality evidence). Nine studies (366 participants) provided information on adverse events, but did not find any clear and consistent evidence of differences between treatment or control groups with the quality of the evidence ranging from low to moderate. Studies of β-carotene and vitamin E consistently reported greater plasma levels of the respective antioxidants.Inhaled supplements versus controlTwo studies (258 participants) showed inhaled glutathione probably improves FEV1 % predicted at three months, MD 3.50% (95% CI 1.38 to 5.62), but not at six months compared to placebo, MD 2.30% (95% CI -0.12 to 4.71) (moderate-quality evidence). The same studies additionally reported an improvement in FEV1 L in the treated group compared to placebo at both three and six months. One study (153 participants) reported inhaled glutathione probably made little or no difference to the change in QoL from baseline, MD 0.80 (95% CI -1.63 to 3.23) (moderate-quality evidence). No study reported on the change from baseline in BMI at six months, but one study (16 participants) reported at two months and a further study (105 participants) at 12 months; neither study found any difference at either time point. One study (153 participants) reported no difference in the time to the first pulmonary exacerbation at six months. Two studies (223 participants) reported treatment may make little or no difference in adverse events (low-quality evidence), a further study (153 participants) reported that the number of serious adverse events were similar across groups. AUTHORS' CONCLUSIONS With regards to micronutrients, there does not appear to be a positive treatment effect of antioxidant micronutrients on clinical end-points; however, oral supplementation with glutathione showed some benefit to lung function and nutritional status. Based on the available evidence, inhaled and oral glutathione appear to improve lung function, while oral administration decreases oxidative stress; however, due to the very intensive antibiotic treatment and other concurrent treatments that people with CF take, the beneficial effect of antioxidants remains difficult to assess in those with chronic infection without a very large population sample and a long-term study period. Further studies, especially in very young children, using outcome measures such as lung clearance index and the bronchiectasis scores derived from chest scans, with improved focus on study design variables (such as dose levels and timing), and elucidating clear biological pathways by which oxidative stress is involved in CF, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn. The benefit of antioxidants in people with CF who receive CFTR modulators therapies should also be assessed in the future.
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Affiliation(s)
- Oana Ciofu
- University of CopenhagenDepartment of International Health, Immunology and MicrobiologyBlegdamsvej 3CopenhagenDenmark2200
| | - Sherie Smith
- University of NottinghamDivision of Child Health, Obstetrics & Gynaecology (COG), School of Medicine1701 E FloorEast Block Queens Medical CentreNottinghamNG7 2UHUK
| | - Jens Lykkesfeldt
- University of CopenhagenDepartment of Veterinary Disease Biology, Experimental Animal ModelsRidebanevej 9CopenhagenDenmark1870 Frb.
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12
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Ahmed M, Porse A, Abdelsamad A, Sommer M, Hoiby N, Ciofu O. P128 Lack of katA catalase in Pseudomonas aeruginosa accelerates evolution of antibiotic resistance in ciprofloxacin-treated biofilms. J Cyst Fibros 2019. [DOI: 10.1016/s1569-1993(19)30422-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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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13
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Hengzhuang W, Høiby N, Ciofu O. P124 Effect of ceftazidime-avibactam on biofilm of AmpC hyperproducers Pseudomonas aeruginosa. J Cyst Fibros 2019. [DOI: 10.1016/s1569-1993(19)30418-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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14
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Moser C, Lerche CJ, Thomsen K, Hartvig T, Schierbeck J, Jensen PØ, Ciofu O, Høiby N. Antibiotic therapy as personalized medicine - general considerations and complicating factors. APMIS 2019; 127:361-371. [PMID: 30983040 DOI: 10.1111/apm.12951] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Accepted: 04/07/2019] [Indexed: 12/16/2022]
Abstract
The discovery of antibiotic drugs is considered one of the previous century's most important medical discoveries (Medicine's 10 greatest discoveries. New Haven, CT: Yale University Press, 1998: 263). Appropriate use of antibiotics saves millions of lives each year and prevents infectious complications for numerous people. Still, infections kill unacceptable many people around the world, even in developed countries with easy access to most antibiotic drugs. Optimal use of antibiotics is dependent on the identification of primary and secondary focus, and knowledge on which pathogens to expect in a specific infectious syndrome and information on general patterns of regional antibiotic resistance. Furthermore, sampling for microbiological analysis, knowledge of patient immune status and organ functions, travel history, pharmacokinetics and -dynamics of the different antibiotics and possible biofilm formation are among several factors involved in antibiotic therapy of infectious diseases. The present review aims at describing important considerations when using antibacterial antibiotics and to describe how this is becoming substantially more personalized. The parameters relevant in considering the optimal use of antibiotics to treat infections are shown in Fig. 1 - leading to the most relevant antibiotic therapy for that specific patient. To illustrate this subject, the present review's focus will be on challenges with optimal dosing of antibiotics and risks of underdosing. Especially, in cases highly challenging for achieving the aimed antibiotic effect against bacterial infections - this includes augmented renal clearance (ARC) in sepsis, dosing challenges of antibiotics in pregnancy and against biofilm infections.
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Affiliation(s)
- Claus Moser
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Johann Lerche
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kim Thomsen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Tom Hartvig
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Jens Schierbeck
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Peter Østrup Jensen
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Oana Ciofu
- Costerton Biofilm Center, Institute of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Costerton Biofilm Center, Institute of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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15
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Ciofu O, Tolker-Nielsen T. Tolerance and Resistance of Pseudomonas aeruginosa Biofilms to Antimicrobial Agents-How P. aeruginosa Can Escape Antibiotics. Front Microbiol 2019; 10:913. [PMID: 31130925 PMCID: PMC6509751 DOI: 10.3389/fmicb.2019.00913] [Citation(s) in RCA: 351] [Impact Index Per Article: 70.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2019] [Accepted: 04/10/2019] [Indexed: 11/24/2022] Open
Abstract
Pseudomonas aeruginosa is one of the six bacterial pathogens, Enterococcus faecium, Staphylococcus aureus, Klebsiella pneumoniae, Acinetobacter baumannii, Pseudomonas aeruginosa, and Enterobacter spp., which are commonly associated with antimicrobial resistance, and denoted by their acronym ESKAPE. P. aeruginosa is also recognized as an important cause of chronic infections due to its ability to form biofilms, where the bacteria are present in aggregates encased in a self-produced extracellular matrix and are difficult or impossible to eradicate with antibiotic treatment. P. aeruginosa causes chronic infections in the lungs of patients with cystic fibrosis and chronic obstructive lung disease, as well as chronic urinary tract infections in patients with permanent bladder catheter, and ventilator-associated pneumonia in intubated patients, and is also an important pathogen in chronic wounds. Antibiotic treatment cannot eradicate these biofilm infections due to their intrinsic antibiotic tolerance and the development of mutational antibiotic resistance. The tolerance of biofilms to antibiotics is multifactorial involving physical, physiological, and genetic determinants, whereas the antibiotic resistance of bacteria in biofilms is caused by mutations and driven by the repeated exposure of the bacteria to high levels of antibiotics. In this review, both the antimicrobial tolerance and the development of resistance to antibiotics in P. aeruginosa biofilms are discussed. Possible therapeutic approaches based on the understanding of the mechanisms involved in the tolerance and resistances of biofilms to antibiotics are also addressed.
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Affiliation(s)
- Oana Ciofu
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
| | - Tim Tolker-Nielsen
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
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16
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Høiby N, Henneberg KÅ, Wang H, Stavnsbjerg C, Bjarnsholt T, Ciofu O, Johansen UR, Sams T. Formation of Pseudomonas aeruginosa inhibition zone during tobramycin disk diffusion is due to transition from planktonic to biofilm mode of growth. Int J Antimicrob Agents 2019; 53:564-573. [DOI: 10.1016/j.ijantimicag.2018.12.015] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Revised: 12/17/2018] [Accepted: 12/23/2018] [Indexed: 12/21/2022]
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17
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Candido Caçador N, Paulino da Costa Capizzani C, Gomes Monteiro Marin Torres LA, Galetti R, Ciofu O, da Costa Darini AL, Høiby N. Adaptation of Pseudomonas aeruginosa to the chronic phenotype by mutations in the algTmucABD operon in isolates from Brazilian cystic fibrosis patients. PLoS One 2018; 13:e0208013. [PMID: 30496246 PMCID: PMC6264809 DOI: 10.1371/journal.pone.0208013] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 11/09/2018] [Indexed: 01/15/2023] Open
Abstract
Chronic lung infection by Pseudomonas aeruginosa is the leading cause of morbidity and mortality in cystic fibrosis (CF) patients. This is associated with the conversion of the non-mucoid to the mucoid phenotype. However, there is little information about the occurrence of alginate-producing P. aeruginosa in CF patients outside Europe and North America. The aim of the present study was to investigate mutations in the algTmucABD operon in mucoid and non-mucoid isolates from Brazilian CF patients. Twenty-seven mucoid and 37 non-mucoid isolates from 40 CF patients chronically infected by P. aeruginosa attending a CF reference center in Brazil were evaluated by sequence analysis. Mutations in mucA were observed in 93% of the mucoid isolates and 54% of the non-mucoid isolates. Among these non-mucoid isolates, 55% were considered revertants, since they also had mutations in algT (algU). Most isolates associated with moderate alginate production presented point mutations in mucB and/or mucD. We identified 30 mutations not previously described in the operon. In conclusion, mutations in mucA were the main mechanism of conversion to mucoidy, and most of the non-mucoid isolates were revertants, but the mechanism of revertance is not fully explained by changes in algT.
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Affiliation(s)
- Natália Candido Caçador
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- * E-mail: (NCC); (ALCD)
| | | | | | - Renata Galetti
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Oana Ciofu
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Ana Lúcia da Costa Darini
- School of Pharmaceutical Sciences of Ribeirão Preto, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
- * E-mail: (NCC); (ALCD)
| | - Niels Høiby
- Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Microbiology, University Hospital, Rigshospitalet, Copenhagen, Denmark
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18
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Arge O, Høiby N, Hansen C, Johansen U, Pressler T, Skov M, Jelsbak L, Ciofu O. P044 Azithromycin resistance develops fast in P. aeruginosa but has no negative impact on lung function development in CF patients with chronic infection. J Cyst Fibros 2018. [DOI: 10.1016/s1569-1993(18)30341-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Møller S, Ciofu O, Jensen P, Høiby N, Kolpen M. WS11.2 Hyperbaric oxygen treatment enhances the effect of tobramycin against biofilm-growing Pseudomonas aeruginosa. J Cyst Fibros 2018. [DOI: 10.1016/s1569-1993(18)30179-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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20
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Mauch RM, Nørregaard LL, Ciofu O, Levy CE, Høiby N. IgG avidity to Pseudomonas aeruginosa over the course of chronic lung biofilm infection in cystic fibrosis. J Cyst Fibros 2017; 17:356-359. [PMID: 29032178 DOI: 10.1016/j.jcf.2017.09.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2017] [Revised: 09/20/2017] [Accepted: 09/20/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVES The mechanisms leading to low effectiveness of the humoral immune response against P. aeruginosa in cystic fibrosis (CF) are poorly understood. The aim of the present study was to assess the avidity maturation of specific antipseudomonal IgG before and during the development of chronic lung infection in a cohort of Danish CF patients. METHODS Avidity maturation was assessed against a pooled P. aeruginosa antigen (St-Ag) and against P. aeruginosa alginate in 10 CF patients who developed chronic lung infection and 10 patients who developed intermittent lung colonization, using an ELISA technique with the thiocyanate elution method. Avidity was quantitatively determined by calculating the avidity Constant (Kav). RESULTS IgG avidity to St-Ag significantly increased at the onset (Median Kav=2.47) and one year after the onset of chronic infection (Median Kav=3.27), but did not significantly changed in patients who developed intermittent colonization. IgG avidity against alginate did not significantly change over the years neither in patients who developed chronic lung infection (Median Kav=3.84 at the onset of chronic infection), nor in patients who developed intermittent colonization. CONCLUSION IgG avidity to P. aeruginosa alginate does not significantly enhance as chronic lung infection progresses. This probably plays a role in the difficulty to mount an effective opsonophagocytic killing to clear mucoid P. aeruginosa infection in CF.
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Affiliation(s)
- Renan Marrichi Mauch
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, Brazil
| | - Lena Lingren Nørregaard
- Department of Clinical Microbiology, Rigshospitalet (Copenhagen University Hospital), University of Copenhagen, Denmark
| | - Oana Ciofu
- Department of International Health, Immunology and Microbiology, Faculty of Health and Medical Sciences, Panum Institute, University of Copenhagen, Denmark
| | - Carlos Emilio Levy
- Department of Clinical Pathology, School of Medical Sciences, University of Campinas, Brazil; Laboratory of Microbiology, Division of Clinical Pathology, Hospital de Clínicas (Campinas University Hospital), Brazil
| | - Niels Høiby
- Department of Clinical Microbiology, Rigshospitalet (Copenhagen University Hospital), University of Copenhagen, Denmark; Department of International Health, Immunology and Microbiology, Faculty of Health and Medical Sciences, Panum Institute, University of Copenhagen, Denmark.
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21
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Abstract
Bacterial biofilms are associated with a wide range of infections, from those related to exogenous devices, such as catheters or prosthetic joints, to chronic tissue infections such as those occurring in the lungs of cystic fibrosis patients. Biofilms are recalcitrant to antibiotic treatment due to multiple tolerance mechanisms (phenotypic resistance). This causes persistence of biofilm infections in spite of antibiotic exposure which predisposes to antibiotic resistance development (genetic resistance). Understanding the interplay between phenotypic and genetic resistance mechanisms acting on biofilms, as well as appreciating the diversity of environmental conditions of biofilm infections which influence the effect of antibiotics are required in order to optimize the antibiotic treatment of biofilm infections. Here, we review the current knowledge on phenotypic and genetic resistance in biofilms and describe the potential strategies for the antibiotic treatment of biofilm infections. Of note is the optimization of PK/PD parameters in biofilms, high-dose topical treatments, combined and sequential/alternate therapies or the use antibiotic adjuvants.
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Affiliation(s)
- Oana Ciofu
- Department of Immunology and Microbiology, Faculty of Health and Medical Sciences, Costerton Biofilm Center, University of Copenhagen, Copenhagen, Denmark
| | - Estrella Rojo-Molinero
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
| | - María D Macià
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
| | - Antonio Oliver
- Servicio de Microbiología, Hospital Son Espases, Instituto de Investigación Sanitaria de Palma (IdISPa), Palma de Mallorca, Spain
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22
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Høiby N, Bjarnsholt T, Moser C, Jensen PØ, Kolpen M, Qvist T, Aanaes K, Pressler T, Skov M, Ciofu O. Diagnosis of biofilm infections in cystic fibrosis patients. APMIS 2017; 125:339-343. [PMID: 28407432 DOI: 10.1111/apm.12689] [Citation(s) in RCA: 52] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Accepted: 02/03/2017] [Indexed: 12/22/2022]
Abstract
Chronic Pseudomonas aeruginosa biofilm lung infection in cystic fibrosis patients is the best described biofilm infection in medicine. The initial focus can be the paranasal sinuses and then follows repeated colonization and infection of the lungs by aspiration. The matrix of the biofilms is dominated by alginate and the pathogenesis of tissue damage is immune complex-mediated chronic inflammation dominated by polymorphonuclear leukocytes and their products (DNA, oxygen radicals and proteases). The P. aeruginosa biofilm infection can be diagnosed by microscopy of lung tissue, sputum and mucus from the paranasal sinuses, where aggregates of the bacteria are found surrounded by the abundant alginate matrix. Specific PNA-FISH probes can be used to identify P. aeruginosa and other pathogens in situ in the biofilms. Growth of mucoid colonies from the locations mentioned above is also diagnostic for biofilm infection. Rise of specific anti-P. aeruginosa antibodies is likewise diagnostic, IgG in serum in case of lung infection, sIgA in saliva or nasal secretions in case of paranasal sinus infection. Similar approaches have been developed to diagnose chronic biofilm infections in cystic fibrosis caused by other pathogens e.g., Stenotrophomonas, Burkholderia multivorans, Achromobacter xylosoxidans and Mycobacterium abscessus complex.
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Affiliation(s)
- Niels Høiby
- Department of Clinical Microbiology, University of Copenhagen, Copenhagen, Denmark.,Costerton Biofilm Center, Institute for Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology, University of Copenhagen, Copenhagen, Denmark.,Costerton Biofilm Center, Institute for Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Peter Østrup Jensen
- Department of Clinical Microbiology, University of Copenhagen, Copenhagen, Denmark.,Costerton Biofilm Center, Institute for Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Mette Kolpen
- Department of Clinical Microbiology, University of Copenhagen, Copenhagen, Denmark.,Costerton Biofilm Center, Institute for Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Tavs Qvist
- Copenhagen Cystic Fibrosis Centre, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Aanaes
- Department of Otorhinology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Tanja Pressler
- Copenhagen Cystic Fibrosis Centre, University of Copenhagen, Copenhagen, Denmark
| | - Marianne Skov
- Copenhagen Cystic Fibrosis Centre, University of Copenhagen, Copenhagen, Denmark
| | - Oana Ciofu
- Costerton Biofilm Center, Institute for Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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23
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Zaborskyte G, Andersen JB, Kragh KN, Ciofu O. Real-Time Monitoring of nfxB Mutant Occurrence and Dynamics in Pseudomonas aeruginosa Biofilm Exposed to Subinhibitory Concentrations of Ciprofloxacin. Antimicrob Agents Chemother 2017; 61:e02292-16. [PMID: 27993856 PMCID: PMC5328521 DOI: 10.1128/aac.02292-16] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2016] [Accepted: 12/11/2016] [Indexed: 12/14/2022] Open
Abstract
Biofilm infections caused by Pseudomonas aeruginosa are frequently treated with ciprofloxacin (CIP); however, resistance rapidly develops. One of the primary resistance mechanisms is the overexpression of the MexCD-OprJ pump due to a mutation in nfxB, encoding the transcriptional repressor of this pump. The aim of this study was to investigate the effect of subinhibitory concentrations of CIP on the occurrence of nfxB mutants in the wild-type PAO1 flow cell biofilm model. For this purpose, we constructed fluorescent reporter strains (PAO1 background) with an mCherry tag for constitutive red fluorescence and chromosomal transcriptional fusion between the P mexCD promoter and gfp leading to green fluorescence upon mutation of nfxB We observed a rapid development of nfxB mutants by live confocal laser scanning microscopy (CLSM) imaging of the flow cell biofilm (reaching 80 to 90% of the whole population) when treated with 1/10 minimal biofilm inhibitory concentration of CIP for 24 h and 96 h. Based on the observed developmental stages, we propose that nfxB mutants emerged de novo in the biofilm during CIP treatment from filamentous cells, which might have arisen due to the stress responses induced by CIP. Identical nfxB mutations were found in fluorescent colonies from the same flow cell biofilm, especially in 24-h biofilms, suggesting selection and clonal expansion of the mutants during biofilm growth. Our findings point at the significant role of high-enough antibiotic dosages or appropriate combination therapy to avoid the emergence of resistant mutants in biofilms.
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Affiliation(s)
- Greta Zaborskyte
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Jens Bo Andersen
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Kasper Nørskov Kragh
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Oana Ciofu
- Costerton Biofilm Center, Department of Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
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24
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Fernández-Barat L, Ciofu O, Kragh KN, Pressler T, Johansen U, Motos A, Torres A, Hoiby N. Phenotypic shift in Pseudomonas aeruginosa populations from cystic fibrosis lungs after 2-week antipseudomonal treatment. J Cyst Fibros 2016; 16:222-229. [PMID: 27651273 DOI: 10.1016/j.jcf.2016.08.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2016] [Revised: 08/25/2016] [Accepted: 08/25/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND The influence of suppressive therapy on the different P. aeruginosa phenotypes harbored in the lungs of cystic fibrosis (CF) patients remains unclear. Our aim was to investigate the phenotypic changes (mucoidy, hypermutability, antibiotic resistance, transcriptomic profiles and biofilm) in P. aeruginosa populations before and after a 2-week course of suppressive antimicrobial therapy in chronically infected CF patients in Denmark. MATERIAL AND METHODS Prospective observational clinical study. Sputum samples were assessed before and after treatment for P. aeruginosa, with regard to: a) colony-forming units (CFU/mL), b) frequency of mucoids and non-mucoids, c) resistance pattern to anti-pseudomonal drugs, d) hypermutability, e) transcriptomic profiles, and f) presence of biofilms. RESULTS We collected 23 sputum samples (12 before antibiotic treatment and 11 after) and 77 P. aeruginosa from different CF patients. After treatment, the P. aeruginosa burden diminished but antimicrobial resistance to aztreonam, tobramycin and ceftazidime rose; non-mucoid phenotypes presented increased resistance to colistin, tobramycin, meropenem, and ciprofloxacin, and hypermutable phenotypes to ciprofloxacin. In spite of biofilm persistence, a down-regulation of genes involved in denitrification was detected. CONCLUSION A 2-week course of suppressive therapy reduces P. aeruginosa lung colonization and influences nitrogen metabolism genes, but also promotes antimicrobial resistance while P. aeruginosa persists in biofilms.
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Affiliation(s)
- Laia Fernández-Barat
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CELLEX Laboratories, School of Medicine, University of Barcelona, Spain.
| | - Oana Ciofu
- Department of Immunology and Microbiology, Costerton Biofilm Center, Copenhagen, Denmark; Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Kasper N Kragh
- Department of Immunology and Microbiology, Costerton Biofilm Center, Copenhagen, Denmark; Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Tania Pressler
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark; CF Center, Rigshospitalet, Denmark
| | - Ulla Johansen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Anna Motos
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CELLEX Laboratories, School of Medicine, University of Barcelona, Spain
| | - Antoni Torres
- Centro de Investigación Biomedica En Red-Enfermedades Respiratorias (CibeRes, CB06/06/0028), Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), CELLEX Laboratories, School of Medicine, University of Barcelona, Spain; Pneumology Service, Clinical Thorax Institute, Hospital Clinic, Barcelona, Spain
| | - Niels Hoiby
- Department of Immunology and Microbiology, Costerton Biofilm Center, Copenhagen, Denmark; Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
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25
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Wane H, Li F, Ciofu O, Høiby N. ePS06.7 Antibiotic treatment strategy with fusidic acid on colistin resistant Pseudomonas aeruginosa in cystic fibrosis. J Cyst Fibros 2016. [DOI: 10.1016/s1569-1993(16)30237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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26
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Wassermann T, Meinike Jørgensen K, Ivanyshyn K, Bjarnsholt T, Khademi SMH, Jelsbak L, Høiby N, Ciofu O. The phenotypic evolution of Pseudomonas aeruginosa populations changes in the presence of subinhibitory concentrations of ciprofloxacin. Microbiology (Reading) 2016; 162:865-875. [PMID: 26953154 DOI: 10.1099/mic.0.000273] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Ciprofloxacin is a widely used antibiotic, in the class of quinolones, for treatment of Pseudomonas aeruginosa infections. The immediate response of P. aeruginosa to subinhibitory concentrations of ciprofloxacin has been investigated previously. However, the long-term phenotypic adaptation, which identifies the fitted phenotypes that have been selected during evolution with subinhibitory concentrations of ciprofloxacin, has not been studied. We chose an experimental evolution approach to investigate how exposure to subinhibitory concentrations of ciprofloxacin changes the evolution of P. aeruginosa populations compared to unexposed populations. Three replicate populations of P. aeruginosa PAO1 and its hypermutable mutant ΔmutS were cultured aerobically for approximately 940 generations by daily passages in LB medium with and without subinhibitory concentration of ciprofloxacin and aliquots of the bacterial populations were regularly sampled and kept at - 80 °C for further investigations. We investigate here phenotypic changes between the ancestor (50 colonies) and evolved populations (120 colonies/strain). Decreased protease activity and swimming motility, higher levels of quorum-sensing signal molecules and occurrence of mutator subpopulations were observed in the ciprofloxacin-exposed populations compared to the ancestor and control populations. Transcriptomic analysis showed downregulation of the type III secretion system in evolved populations compared to the ancestor population and upregulation of denitrification genes in ciprofloxacin-evolved populations. In conclusion, the presence of antibiotics at subinhibitory concentration in the environment affects bacterial evolution and further studies are needed to obtain insight into the dynamics of the phenotypes and the mechanisms involved.
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Affiliation(s)
- Tina Wassermann
- Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Karin Meinike Jørgensen
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Karolina Ivanyshyn
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - S M Hossein Khademi
- Department of System Biology, Technical University of Denmark, Lyngby, Denmark
| | - Lars Jelsbak
- Department of System Biology, Technical University of Denmark, Lyngby, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, University Hospital Rigshospitalet, Copenhagen, Denmark.,Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Oana Ciofu
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Kolpen M, Mousavi N, Sams T, Bjarnsholt T, Ciofu O, Moser C, Kühl M, Høiby N, Jensen PØ. Reinforcement of the bactericidal effect of ciprofloxacin on Pseudomonas aeruginosa biofilm by hyperbaric oxygen treatment. Int J Antimicrob Agents 2016; 47:163-7. [DOI: 10.1016/j.ijantimicag.2015.12.005] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2015] [Revised: 12/03/2015] [Accepted: 12/09/2015] [Indexed: 02/07/2023]
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Marvig RL, Dolce D, Sommer LM, Petersen B, Ciofu O, Campana S, Molin S, Taccetti G, Johansen HK. Within-host microevolution of Pseudomonas aeruginosa in Italian cystic fibrosis patients. BMC Microbiol 2015; 15:218. [PMID: 26482905 PMCID: PMC4612410 DOI: 10.1186/s12866-015-0563-9] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [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] [Received: 04/08/2015] [Accepted: 10/12/2015] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Chronic infection with Pseudomonas aeruginosa is a major cause of morbidity and mortality in cystic fibrosis (CF) patients, and a more complete understanding of P. aeruginosa within-host genomic evolution, transmission, and population genomics may provide a basis for improving intervention strategies. Here, we report the first genomic analysis of P. aeruginosa isolates sampled from Italian CF patients. RESULTS By genome sequencing of 26 isolates sampled over 19 years from four patients, we elucidated the within-host evolution of clonal lineages in each individual patient. Many of the identified mutations were located in pathoadaptive genes previously associated with host adaptation, and we correlated mutations with changes in CF-relevant phenotypes such as antibiotic resistance. In addition, the genomic analysis revealed that three patients shared the same clone. Furthermore, we compared the genomes of the Italian CF isolates to a panel of genome sequenced strains of P. aeruginosa from other countries. Isolates from two of the Italian lineages belonged to clonal complexes of P. aeruginosa that have previously been identified in Danish CF patients, and our genomic comparison showed that clonal isolates from the same country may be more distantly related than clonal isolates from different countries. CONCLUSIONS This is the first whole-genome analysis of P. aeruginosa isolated from Italian CF patients, and together with both phenotypic and clinical information this dataset facilitates a more detailed understanding of P. aeruginosa within-host genomic evolution, transmission, and population genomics. We conclude that the evolution of the Italian lineages resembles what has been found in other countries.
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Affiliation(s)
- Rasmus Lykke Marvig
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. .,Center for Genomic Medicine, Rigshospitalet, Copenhagen, Denmark.
| | - Daniela Dolce
- Department of Paediatric Medicine, Cystic Fibrosis Centre, Anna Meyer Children's University Hospital, Florence, Italy.
| | - Lea M Sommer
- Department of Systems Biology, Technical University of Denmark, Lyngby, Denmark. .,The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Lyngby, Denmark.
| | - Bent Petersen
- Center for Biological Sequence Analysis, Technical University of Denmark, Lyngby, Denmark.
| | - Oana Ciofu
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark.
| | - Silvia Campana
- Department of Paediatric Medicine, Cystic Fibrosis Centre, Anna Meyer Children's University Hospital, Florence, Italy.
| | - Søren Molin
- Department of Systems Biology, Technical University of Denmark, Lyngby, Denmark. .,The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Lyngby, Denmark.
| | - Giovanni Taccetti
- Department of Paediatric Medicine, Cystic Fibrosis Centre, Anna Meyer Children's University Hospital, Florence, Italy.
| | - Helle Krogh Johansen
- Department of Immunology and Microbiology, Costerton Biofilm Center, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark. .,The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Lyngby, Denmark.
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Kolpen M, Appeldorff CF, Brandt S, Mousavi N, Kragh KN, Aydogan S, Uppal HA, Bjarnsholt T, Ciofu O, Høiby N, Jensen PØ. Increased bactericidal activity of colistin on Pseudomonas aeruginosa biofilms in anaerobic conditions. Pathog Dis 2015; 74:ftv086. [PMID: 26458402 PMCID: PMC4655427 DOI: 10.1093/femspd/ftv086] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2015] [Indexed: 12/19/2022] Open
Abstract
Tolerance towards antibiotics of Pseudomonas aeruginosa biofilms is recognized as a major cause of therapeutic failure of chronic lung infection in cystic fibrosis (CF) patients. This lung infection is characterized by antibiotic-tolerant biofilms in mucus with zones of O2 depletion mainly due to polymorphonuclear leukocytic activity. In contrast to the main types of bactericidal antibiotics, it has not been possible to establish an association between the bactericidal effects of colistin and the production of detectable levels of OH ˙ on several strains of planktonic P. aeruginosa. Therefore, we propose that production of OH ˙ may not contribute significantly to the bactericidal activity of colistin on P. aeruginosa biofilm. Thus, we investigated the effect of colistin treatment on biofilm of wild-type PAO1, a catalase-deficient mutant (ΔkatA) and a colistin-resistant CF isolate cultured in microtiter plates in normoxic- or anoxic atmosphere with 1 mM nitrate. The killing of bacteria during colistin treatment was measured by CFU counts, and the OH⋅ formation was measured by 3(')-(p-hydroxylphenyl fluorescein) fluorescein (HPF) fluorescence. Validation of the assay was done by hydrogen peroxide treatment. OH⋅ formation was undetectable in aerobic PAO1 biofilms during 3 h of colistin treatment. Interestingly, we demonstrate increased susceptibility of P. aeruginosa biofilms towards colistin during anaerobic conditions. In fact, the maximum enhancement of killing by anaerobic conditions exceeded 2 logs using 4 mg L(-1) of colistin compared to killing at aerobic conditions.
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Affiliation(s)
- Mette Kolpen
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark Department of Immunology and Microbiology, UC-CARE, Faculty of Health Sciences University of Copenhagen, 2200 Copenhagen, Denmark
| | | | - Sarah Brandt
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Nabi Mousavi
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Kasper N Kragh
- Department of Immunology and Microbiology, UC-CARE, Faculty of Health Sciences University of Copenhagen, 2200 Copenhagen, Denmark
| | - Sevtap Aydogan
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Haleema A Uppal
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark Department of Immunology and Microbiology, UC-CARE, Faculty of Health Sciences University of Copenhagen, 2200 Copenhagen, Denmark
| | - Oana Ciofu
- Department of Immunology and Microbiology, UC-CARE, Faculty of Health Sciences University of Copenhagen, 2200 Copenhagen, Denmark
| | - Niels Høiby
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark Department of Immunology and Microbiology, UC-CARE, Faculty of Health Sciences University of Copenhagen, 2200 Copenhagen, Denmark
| | - Peter Ø Jensen
- Department of Clinical Microbiology, Rigshospitalet, 2100 Copenhagen, Denmark
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Caçador N, Darini A, Torres L, Ciofu O, Høiby N. WS19.5 Alginate phenotypes of Pseudomonas aeruginosa from a Brazilian CF center compared to Scandinavian CF centers. J Cyst Fibros 2015. [DOI: 10.1016/s1569-1993(15)30112-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Kolpen M, Appeldorff C, Brandt S, Mousavi N, Kragh K, Bjarnsholt T, Ciofu O, Høiby N, Jensen P. WS02.6 Increased bactericidal activity of colistin on Pseudomonas aeruginosa biofilms in anaerobic conditions. J Cyst Fibros 2015. [DOI: 10.1016/s1569-1993(15)30012-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ciofu O, Tolker-Nielsen T, Jensen PØ, Wang H, Høiby N. Antimicrobial resistance, respiratory tract infections and role of biofilms in lung infections in cystic fibrosis patients. Adv Drug Deliv Rev 2015; 85:7-23. [PMID: 25477303 DOI: 10.1016/j.addr.2014.11.017] [Citation(s) in RCA: 206] [Impact Index Per Article: 22.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2014] [Revised: 11/11/2014] [Accepted: 11/23/2014] [Indexed: 02/08/2023]
Abstract
Lung infection is the main cause of morbidity and mortality in patients with cystic fibrosis and is mainly dominated by Pseudomonas aeruginosa. The biofilm mode of growth makes eradication of the infection impossible, and it causes a chronic inflammation in the airways. The general mechanisms of biofilm formation and antimicrobial tolerance and resistance are reviewed. Potential anti-biofilm therapeutic targets such as weakening of biofilms by quorum-sensing inhibitors or antibiotic killing guided by pharmacokinetics and pharmacodynamics of antibiotics are presented. The vicious circle of adaptive evolution of the persisting bacteria imposes important therapeutic challenges and requires development of new drug delivery systems able to reach the different niches occupied by the bacteria in the lung of cystic fibrosis patients.
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Jørgensen KM, Wassermann T, Johansen HK, Christiansen LE, Molin S, Høiby N, Ciofu O. Diversity of metabolic profiles of cystic fibrosis Pseudomonas aeruginosa during the early stages of lung infection. Microbiology (Reading) 2015; 161:1447-62. [PMID: 25873584 DOI: 10.1099/mic.0.000093] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Pseudomonas aeruginosa is the dominant pathogen infecting the airways of cystic fibrosis (CF) patients. During the intermittent colonization phase, P. aeruginosa resembles environmental strains but later evolves to the chronic adapted phenotype characterized by resistance to antibiotics and mutations in the global regulator genes mucA, lasR and rpoN. Our aim was to understand the metabolic changes occurring over time and between niches of the CF airways. By applying Phenotype MicroArrays, we investigated changes in the carbon and nitrogen catabolism of subsequently clonally related mucoid and non-mucoid (NM) lung and sinus P. aeruginosa isolates from 10 CF patients (five intermittently colonized/five chronically infected). We found the most pronounced catabolic changes for the early/late NM isolate comparisons, with respiratory reduction seen for all chronically infecting isolates and two intermittently colonizing isolates. Fewer differences were observed between sinus and lung isolates, showing a higher degree of isolate similarity between these two niches. Modest respiratory changes were seen for the early isolate/PAO1 comparisons, indicating colonization with environmental isolates. Assignment of metabolic pathways via the KEGG database showed a prevalence of substrates involved in the metabolism of Ala, Asp and Glu, d-Ala, and Arg and Pro. In conclusion, extensive heterogeneity in the metabolic profiles of the P. aeruginosa isolates was observed from the initial stages of the infection, showing a rapid diversification of the bacteria in the heterogeneous environment of the lung. Metabolic reduction seems to be a common trait and therefore an adaptive phenotype, though it can be reached via multiple metabolic pathways.
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Affiliation(s)
- Karin Meinike Jørgensen
- 1 Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen, Denmark
| | - Tina Wassermann
- 2 Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Helle Krogh Johansen
- 2 Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark 3 The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Hørsholm, Denmark
| | - Lasse Engbo Christiansen
- 4 Department of Informatics and Mathematical Modelling, Technical University of Denmark, Denmark
| | - Søren Molin
- 3 The Novo Nordisk Foundation Center for Biosustainability, Technical University of Denmark, Hørsholm, Denmark 5 Center for Systems Biology, Technical University of Denmark, Denmark
| | - Niels Høiby
- 1 Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen, Denmark 2 Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
| | - Oana Ciofu
- 1 Department of Immunology and Microbiology, Costerton Biofilm Center, University of Copenhagen, Denmark
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Line L, Alhede M, Kolpen M, Kühl M, Ciofu O, Bjarnsholt T, Moser C, Toyofuku M, Nomura N, Høiby N, Jensen PØ. Physiological levels of nitrate support anoxic growth by denitrification of Pseudomonas aeruginosa at growth rates reported in cystic fibrosis lungs and sputum. Front Microbiol 2014; 5:554. [PMID: 25386171 PMCID: PMC4208399 DOI: 10.3389/fmicb.2014.00554] [Citation(s) in RCA: 59] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2014] [Accepted: 10/03/2014] [Indexed: 12/13/2022] Open
Abstract
Chronic Pseudomonas aeruginosa lung infection is the most severe complication in patients with cystic fibrosis (CF). The infection is characterized by the formation of biofilm surrounded by numerous polymorphonuclear leukocytes (PMNs) and strong O2 depletion in the endobronchial mucus. We have reported that O2 is mainly consumed by the activated PMNs, while O2 consumption by aerobic respiration is diminutive and nitrous oxide (N2O) is produced in infected CF sputum. This suggests that the reported growth rates of P. aeruginosa in lungs and sputum may result from anaerobic respiration using denitrification. The growth rate of P. aeruginosa achieved by denitrification at physiological levels (~400 μM) of nitrate (NO(-) 3) is however, not known. Therefore, we have measured growth rates of anoxic cultures of PAO1 and clinical isolates (n = 12) in LB media supplemented with NO(-) 3 and found a significant increase of growth when supplementing PAO1 and clinical isolates with ≥150 μM NO(-) 3 and 100 μM NO(-) 3, respectively. An essential contribution to growth by denitrification was demonstrated by the inability to establish a significantly increased growth rate by a denitrification deficient ΔnirS-N mutant at <1 mM of NO(-) 3. Activation of denitrification could be achieved by supplementation with as little as 62.5 μM of NO(-) 3 according to the significant production of N2O by the nitrous oxide reductase deficient ΔnosZ mutant. Studies of the promoter activity, gene transcripts, and enzyme activity of the four N-oxide reductases in PAO1 (Nar, Nir, Nor, Nos) further verified the engagement of denitrification, showing a transient increase in activation and expression and rapid consumption of NO(-) 3 followed by a transient increase of NO(-) 2. Growth rates obtained by denitrification in this study were comparable to our reported growth rates in the majority of P. aeruginosa cells in CF lungs and sputum. Thus, we have demonstrated that denitrification is required for P. aeruginosa growth in infected endobronchial CF mucus.
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Affiliation(s)
- Laura Line
- Department of Clinical Microbiology Rigshospitalet, Copenhagen, Denmark ; Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen Copenhagen, Denmark
| | - Morten Alhede
- Department of Clinical Microbiology Rigshospitalet, Copenhagen, Denmark ; Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen Copenhagen, Denmark
| | - Mette Kolpen
- Department of Clinical Microbiology Rigshospitalet, Copenhagen, Denmark ; Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen Copenhagen, Denmark
| | - Michael Kühl
- Marine Biological Section, Department of Biology, University of Copenhagen Copenhagen, Denmark ; Plant Functional Biology and Climate Change Cluster, University of Technology Sydney Sydney, NSW, Australia ; Singapore Centre on Environmental Life Sciences Engineering, Nanyang Technological University Singapore, Singapore
| | - Oana Ciofu
- Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen Copenhagen, Denmark
| | - Thomas Bjarnsholt
- Department of Clinical Microbiology Rigshospitalet, Copenhagen, Denmark ; Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen Copenhagen, Denmark
| | - Claus Moser
- Department of Clinical Microbiology Rigshospitalet, Copenhagen, Denmark
| | - Masanori Toyofuku
- Graduate School of Life and Environmental Sciences, University of Tsukuba Tsukuba, Japan
| | - Nobuhiko Nomura
- Graduate School of Life and Environmental Sciences, University of Tsukuba Tsukuba, Japan
| | - Niels Høiby
- Department of Clinical Microbiology Rigshospitalet, Copenhagen, Denmark ; Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, University of Copenhagen Copenhagen, Denmark
| | - Peter Ø Jensen
- Department of Clinical Microbiology Rigshospitalet, Copenhagen, Denmark
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Abstract
BACKGROUND Airway infection leads to progressive damage of the lungs in cystic fibrosis and oxidative stress has been implicated in the etiology. Supplementation of antioxidant micronutrients (vitamin E, vitamin C, ß-carotene and selenium) or glutathione may therefore potentially help maintain an oxidant-antioxidant balance. Current literature suggests a relationship between oxidative status and lung function. OBJECTIVES To synthesize existing knowledge of the effect of antioxidants such as vitamin C, vitamin E, ß-carotene, selenium and glutathione in cystic fibrosis lung disease. SEARCH METHODS The Cochrane Cystic Fibrosis and Genetic Disorders Group's Cystic Fibrosis Trials Register and PubMed were searched using detailed search strategies. We contacted authors of included studies and checked reference lists of these studies for additional, potentially relevant studies.Last search of Cystic Fibrosis Trials Register: 29 August 2013. SELECTION CRITERIA Randomized controlled studies and quasi-randomized controlled studies of people with cystic fibrosis comparing antioxidants as listed above (individually or in combination) in more than a single administration to placebo or standard care. DATA COLLECTION AND ANALYSIS Two authors independently selected studies, extracted data and assessed the risk of bias in the included studies. We contacted trial investigators to obtain missing information. Primary outcomes are lung function and quality of life; secondary outcomes are oxidative stress, inflammation, nutritional status, days on antibiotics and adverse events during supplementation. If meta-analysed, studies were subgrouped according to method of administration and the duration of supplementation. MAIN RESULTS One quasi-randomized and nine randomized controlled studies were included, with a total of 436 participants. Eight studies analyzed oral supplementation with antioxidants and two inhaled supplements.One study (n = 46) of an oral combined supplement demonstrated a significant difference in forced expiratory volume at one second expressed as per cent predicted after two weeks in favour of the control group, mean difference -4.30 (95% confidence interval -5.64 to -2.96); however a further study (n = 41) of oral supplementation with glutathione showed a significant improvement in this outcome and in forced vital capacity after six months from the treatment start, mean difference 17.40 (95% confidence interval 13.69 to 21.11) and 14.80 (95% confidence interval 9.66 to 19.94) respectively. The combined supplement study also indicated a significant improvement in quality of life favouring control, mean difference -0.06 points on the quality of well-being scale (95% confidence interval -0.12 to -0.01). Based on one study (n = 41) of oral glutathione supplementation in children, the supplements had a positive effect on the nutritional status (body mass index %) of the patients, mean difference 17.20 (95% confidence interval 12.17 to 22.23). In two studies (n = 83) that supplemented vitamin E, there was an improvement after two months in the blood levels of vitamin E, mean difference 11.78 μM/L (95% confidence interval 10.14 to 13.42).Based on one of the two studies of inhaled glutathione supplementation, there was an improvement in the forced expiratory volume at one second expressed as per cent predicted after three and six months (n = 153), mean difference 2.57 (95% confidence interval 2.24 to 2.90) and 0.97 (95% confidence interval 0.65 to 1.29) respectively. Only one of the studies reported quality of life data that could be analysed, but data showed no significant differences between treatment and control.None of the 10 included studies was judged to be free of bias. AUTHORS' CONCLUSIONS There appears to be conflicting evidence regarding the clinical effectiveness of antioxidant supplementation in cystic fibrosis. Based on the available evidence, glutathione (administered either orally or by inhalation) appears to improve lung function in some cases and decrease oxidative stress; however, due to the very intensive antibiotic treatment and other treatments that cystic fibrosis patients receive, the beneficial effect of antioxidants is very difficult to assess in patients with chronic infection without a very large population sample and a long-term (at least six months) study period. Further studies, especially in very young patients, examining clinically relevant outcomes, dose levels, timing and the elucidation of clear biological pathways by which oxidative stress is involved in cystic fibrosis, are necessary before a firm conclusion regarding effects of antioxidants supplementation can be drawn.
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Affiliation(s)
- Oana Ciofu
- Department of International Health, Immunology and Microbiology, University of Copenhagen, Blegdamsvej 3, Copenhagen, Denmark, 2200
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Sjölander I, Hansen F, Elmanama A, Khayyat R, Abu-Zant A, Hussein A, Taha AA, Hammerum AM, Ciofu O. Detection of NDM-2-producing Acinetobacter baumannii and VIM-producing Pseudomonas aeruginosa in Palestine. J Glob Antimicrob Resist 2014; 2:93-97. [DOI: 10.1016/j.jgar.2013.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2013] [Revised: 11/08/2013] [Accepted: 11/09/2013] [Indexed: 11/16/2022] Open
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Jensen PØ, Briales A, Brochmann RP, Wang H, Kragh KN, Kolpen M, Hempel C, Bjarnsholt T, Høiby N, Ciofu O. Formation of hydroxyl radicals contributes to the bactericidal activity of ciprofloxacin against Pseudomonas aeruginosa biofilms. Pathog Dis 2014; 70:440-3. [PMID: 24376174 DOI: 10.1111/2049-632x.12120] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 12/12/2013] [Accepted: 12/12/2013] [Indexed: 01/15/2023] Open
Abstract
Antibiotic-tolerant, biofilm-forming Pseudomonas aeruginosa has long been recognized as a major cause of chronic lung infections of cystic fibrosis patients. The mechanisms involved in the activity of antibiotics on biofilm are not completely clear. We have investigated whether the proposed induction of cytotoxic hydroxyl radicals (OH˙) during antibiotic treatment of planktonically grown cells may contribute to action of the commonly used antibiotic ciprofloxacin on P. aeruginosa biofilms. For this purpose, WT PAO1, a catalase deficient ΔkatA and a ciprofloxacin resistant mutant of PAO1 (gyrA), were grown as biofilms in microtiter plates and treated with ciprofloxacin. Formation of OH˙ and total amount of reactive oxygen species (ROS) was measured and viability was estimated. Formation of OH˙ and total ROS in PAO1 biofilms treated with ciprofloxacin was shown but higher levels were measured in ΔkatA biofilms, and no ROS production was seen in the gyrA biofilms. Treatment with ciprofloxacin decreased the viability of PAO1 and ΔkatA biofilms but not of gyrA biofilms. Addition of thiourea, a OH˙ scavenger, decreased the OH˙ levels and killing of PAO1 biofilm. Our study shows that OH˙ is produced by P. aeruginosa biofilms treated with ciprofloxacin, which may contribute to the killing of biofilm subpopulations.
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Affiliation(s)
- Peter Ø Jensen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
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Hengzhuang W, Høiby N, Ciofu O. Pharmacokinetics and pharmacodynamics of antibiotics in biofilm infections of Pseudomonas aeruginosa in vitro and in vivo. Methods Mol Biol 2014; 1147:239-254. [PMID: 24664838 DOI: 10.1007/978-1-4939-0467-9_17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [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: 06/03/2023]
Abstract
Although progress on biofilm research has been obtained during the past decades, the treatment of biofilm infections with antibiotics remains a riddle. The pharmacokinetic (PK) and pharmacodynamic (PD) profiles of an antimicrobial agent provide important information helping to establish an efficient dosing regimen and to minimize the development of antimicrobial tolerance and resistance in biofilm infections. Unfortunately, most previous PK/PD studies of antibiotics have been done on planktonic cells, and extrapolation of the results on biofilms is problematic as bacterial biofilms differ from planktonic grown cells in the growth rate, gene expression, and metabolism. Here, we set up several protocols for the studies of PK/PD of antibiotics in biofilm infections of P. aeruginosa in vitro and in vivo. It should be underlined that none of the protocols in biofilms have yet been certificated for clinical use or proved useful for guidance of antibiotic therapy.
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Affiliation(s)
- Wang Hengzhuang
- Department of Clinical Microbiology, Rigshospitalet, University Hospital of Copenhagen, Juliane Maries Vej 22, 2100, Copenhagen, Denmark,
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van de Weert – van Leeuwen PB, de Vrankrijker AMM, Fentz J, Ciofu O, Wojtaszewski JFP, Arets HGM, Hulzebos HJ, van der Ent CK, Beekman JM, Johansen HK. Effect of long-term voluntary exercise wheel running on susceptibility to bacterial pulmonary infections in a mouse model. PLoS One 2013; 8:e82869. [PMID: 24376599 PMCID: PMC3871638 DOI: 10.1371/journal.pone.0082869] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2013] [Accepted: 11/06/2013] [Indexed: 12/29/2022] Open
Abstract
Regular moderate exercise has been suggested to exert anti-inflammatory effects and improve immune effector functions, resulting in reduced disease incidence and viral infection susceptibility. Whether regular exercise also affects bacterial infection susceptibility is unknown. The aim of this study was to investigate whether regular voluntary exercise wheel running prior to a pulmonary infection with bacteria (P. aeruginosa) affects lung bacteriology, sickness severity and phagocyte immune function in mice. Balb/c mice were randomly placed in a cage with or without a running wheel. After 28 days, mice were intranasally infected with P. aeruginosa. Our study showed that regular exercise resulted in a higher sickness severity score and bacterial (P. aeruginosa) loads in the lungs. The phagocytic capacity of monocytes and neutrophils from spleen and lungs was not affected. Although regular moderate exercise has many health benefits, healthy mice showed increased bacterial (P. aeruginosa) load and symptoms, after regular voluntary exercise, with perseverance of the phagocytic capacity of monocytes and neutrophils. Whether patients, suffering from bacterial infectious diseases, should be encouraged to engage in exercise and physical activities with caution requires further research.
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Affiliation(s)
- Pauline B. van de Weert – van Leeuwen
- Department of Pediatric Pulmonology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Centre for Molecular and Cellular Intervention, University Medical Centre Utrecht, Utrecht, The Netherlands
- * E-mail:
| | | | - Joachim Fentz
- Department of Nutrition, Exercise and Sports, Section of Molecular Physiology, University of Copenhagen, Copenhagen, Denmark
| | - Oana Ciofu
- Department of International Health, Immunology and Microbiology, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Jørgen F. P. Wojtaszewski
- Department of Nutrition, Exercise and Sports, Section of Molecular Physiology, University of Copenhagen, Copenhagen, Denmark
| | - Hubertus G. M. Arets
- Department of Pediatric Pulmonology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Hendrikus J. Hulzebos
- Child Development & Exercise Centre, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Cornelis K. van der Ent
- Department of Pediatric Pulmonology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jeffrey M. Beekman
- Department of Pediatric Pulmonology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Department of Translational Immunology, University Medical Centre Utrecht, Utrecht, The Netherlands
- Centre for Molecular and Cellular Intervention, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Helle K. Johansen
- Department of Clinical Microbiology, Rigshospitalet, Copenhagen, Denmark
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Ciofu O, Johansen HK, Aanaes K, Wassermann T, Alhede M, von Buchwald C, Høiby N. P. aeruginosa in the paranasal sinuses and transplanted lungs have similar adaptive mutations as isolates from chronically infected CF lungs. J Cyst Fibros 2013; 12:729-36. [PMID: 23478131 DOI: 10.1016/j.jcf.2013.02.004] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2012] [Revised: 02/06/2013] [Accepted: 02/11/2013] [Indexed: 01/02/2023]
Abstract
BACKGROUND Pseudomonas aeruginosa cells are present as biofilms in the paranasal sinuses and the lungs of chronically infected cystic fibrosis (CF) patients. Since different inflammatory responses and selective antibiotic pressures are acting in the sinuses compared with the lungs, we compared the adaptive profiles of mucoid and non-mucoid isolates from the two locations. METHODS We studied the genetic basis of phenotypic diversification and gene expression profiles in sequential lung and sinus P. aeruginosa isolates from four chronically infected CF patients, including pre- and post-lung transplantation isolates. RESULTS The same phenotypes caused by similar mutations and similar gene expression profiles were found in mucoid and non-mucoid isolates from the paranasal sinuses and from the lungs before and after transplantation. CONCLUSION Bilateral exchange of P. aeruginosa isolates between the paranasal sinuses and the lungs occurs in chronically infected patients and extensive sinus surgery before the lung transplantation might prevent infection of the new lung.
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Affiliation(s)
- Oana Ciofu
- Department of International Health, Immunology and Microbiology, Unit of Bacteriology, Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark.
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Hengzhuang W, Ciofu O, Yang L, Wu H, Song Z, Oliver A, Høiby N. High β-lactamase levels change the pharmacodynamics of β-lactam antibiotics in Pseudomonas aeruginosa biofilms. Antimicrob Agents Chemother 2013; 57:196-204. [PMID: 23089750 PMCID: PMC3535908 DOI: 10.1128/aac.01393-12] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2012] [Accepted: 10/14/2012] [Indexed: 01/15/2023] Open
Abstract
Resistance to β-lactam antibiotics is a frequent problem in Pseudomonas aeruginosa lung infection of cystic fibrosis (CF) patients. This resistance is mainly due to the hyperproduction of chromosomally encoded β-lactamase and biofilm formation. The purpose of this study was to investigate the role of β-lactamase in the pharmacokinetics (PK) and pharmacodynamics (PD) of ceftazidime and imipenem on P. aeruginosa biofilms. P. aeruginosa PAO1 and its corresponding β-lactamase-overproducing mutant, PAΔDDh2Dh3, were used in this study. Biofilms of these two strains in flow chambers, microtiter plates, and on alginate beads were treated with different concentrations of ceftazidime and imipenem. The kinetics of antibiotics on the biofilms was investigated in vitro by time-kill methods. Time-dependent killing of ceftazidime was observed in PAO1 biofilms, but concentration-dependent killing activity of ceftazidime was observed for β-lactamase-overproducing biofilms of P. aeruginosa in all three models. Ceftazidime showed time-dependent killing on planktonic PAO1 and PAΔDDh2Dh3. This difference is probably due to the special distribution and accumulation in the biofilm matrix of β-lactamase, which can hydrolyze the β-lactam antibiotics. The PK/PD indices of the AUC/MBIC and C(max)/MBIC (AUC is the area under concentration-time curve, MBIC is the minimal biofilm-inhibitory concentration, and C(max) is the maximum concentration of drug in serum) are probably the best parameters to describe the effect of ceftazidime in β-lactamase-overproducing P. aeruginosa biofilms. Meanwhile, imipenem showed time-dependent killing on both PAO1 and PAΔDDh2Dh3 biofilms. An inoculum effect of β-lactams was found for both planktonic and biofilm P. aeruginosa cells. The inoculum effect of ceftazidime for the β-lactamase-overproducing mutant PAΔDDh2Dh3 biofilms was more obvious than for PAO1 biofilms, with a requirement of higher antibiotic concentration and a longer period of treatment.
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Affiliation(s)
- Wang Hengzhuang
- Department of Clinical Microbiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Oana Ciofu
- Institute for International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
| | - Liang Yang
- Department of Systems Biology, Center for Systems Microbiology, Technical University of Denmark, Lyngby, Denmark
- The Singapore Centre on Environmental Life Sciences Engineering, Nanyang Technological University, Singapore
| | - Hong Wu
- Department of Clinical Microbiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Institute for International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- The Singapore Centre on Environmental Life Sciences Engineering, Nanyang Technological University, Singapore
| | - Zhijun Song
- Department of Clinical Microbiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
| | - Antonio Oliver
- Servicio de Microbiología, Hospital Universitario Son Espases, Palma de Mallorca, Spain
| | - Niels Høiby
- Department of Clinical Microbiology, Rigshospitalet, University Hospital of Copenhagen, Copenhagen, Denmark
- Institute for International Health, Immunology and Microbiology, University of Copenhagen, Copenhagen, Denmark
- European Study Group for Biofilms, European Society of Clinical Microbiology and Infectious Diseases, Basel, Switzerland
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Cramer N, Wiehlmann L, Ciofu O, Tamm S, Høiby N, Tümmler B. Molecular epidemiology of chronic Pseudomonas aeruginosa airway infections in cystic fibrosis. PLoS One 2012; 7:e50731. [PMID: 23209821 PMCID: PMC3508996 DOI: 10.1371/journal.pone.0050731] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2012] [Accepted: 10/24/2012] [Indexed: 12/20/2022] Open
Abstract
Background/Methods The molecular epidemiology of the chronic airway infections with Pseudomonas aeruginosa in individuals with cystic fibrosis (CF) was investigated by cross-sectional analysis of bacterial isolates from 51 CF centers and by longitudinal analysis of serial isolates which had been collected at the CF centers Hanover and Copenhagen since the onset of airway colonization over 30 years. Results Genotyping revealed that the P. aeruginosa population in CF is dominated by a few ubiquitous clones. The five most common clones retrieved from the CF host also belonged to the twenty most frequent clones in the environment and in other human disease habitats. Turnover of clones in CF airways was rare. At the Hanover clinic more than half of the patient cohort was still harbouring the initially acquired clone after twenty years of airway colonization. At the Copenhagen clinic, however, two rare clones replaced the initially acquired individual clones in all but one patient. Conclusion The divergent epidemiology at the two sites is explained by their differential management of hygiene and antipseudomonal chemotherapy. Hygienic measures to prohibit patient-to-patient transmission and the modalities of antipseudomonal chemotherapy modify the epidemiology of the chronic P. aeruginosa infections in CF.
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Affiliation(s)
- Nina Cramer
- Clinical Research Group, Clinic for Pediatric Pneumology, Allergology and Neonatology, Hanover Medical School, Hanover, Germany
| | - Lutz Wiehlmann
- Clinical Research Group, Clinic for Pediatric Pneumology, Allergology and Neonatology, Hanover Medical School, Hanover, Germany
| | - Oana Ciofu
- Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, and Department of Clinical Microbiology, University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Stephanie Tamm
- Clinical Research Group, Clinic for Pediatric Pneumology, Allergology and Neonatology, Hanover Medical School, Hanover, Germany
| | - Niels Høiby
- Department of International Health, Immunology and Microbiology, Faculty of Health Sciences, and Department of Clinical Microbiology, University Hospital, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Burkhard Tümmler
- Clinical Research Group, Clinic for Pediatric Pneumology, Allergology and Neonatology, Hanover Medical School, Hanover, Germany
- Biomedical Research in Endstage and Obstructive Lung Disease Hannover (BREATH), Member of the German Center for Lung Research, Hanover, Germany
- * E-mail:
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Folkesson A, Jelsbak L, Yang L, Johansen HK, Ciofu O, Høiby N, Molin S. Adaptation of Pseudomonas aeruginosa to the cystic fibrosis airway: an evolutionary perspective. Nat Rev Microbiol 2012; 10:841-51. [DOI: 10.1038/nrmicro2907] [Citation(s) in RCA: 513] [Impact Index Per Article: 42.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Ciofu O, Mandsberg LF, Wang H, Høiby N. Phenotypes selected during chronic lung infection in cystic fibrosis patients: implications for the treatment ofPseudomonas aeruginosabiofilm infections. ACTA ACUST UNITED AC 2012; 65:215-25. [DOI: 10.1111/j.1574-695x.2012.00983.x] [Citation(s) in RCA: 67] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Revised: 04/23/2012] [Accepted: 04/24/2012] [Indexed: 12/18/2022]
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Wang H, Ciofu O, Yang L, Wu H, Song Z, Oliver A, Høiby N. 60 Ceftazidime shows concentration-dependent killing on ß-lactamase-overproducing biofilm of Pseudomonas aeruginosa. J Cyst Fibros 2012. [DOI: 10.1016/s1569-1993(12)60230-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
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Tramper-Stranders G, van der Ent C, Molin S, Yang L, Hansen S, Rau M, Ciofu O, Johansen H, Wolfs T. Initial Pseudomonas aeruginosa infection in patients with cystic fibrosis: characteristics of eradicated and persistent isolates. Clin Microbiol Infect 2012; 18:567-74. [DOI: 10.1111/j.1469-0691.2011.03627.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Jensen PØ, Lykkesfeldt J, Bjarnsholt T, Hougen HP, Høiby N, Ciofu O. Poor antioxidant status exacerbates oxidative stress and inflammatory response to Pseudomonas aeruginosa lung infection in guinea pigs. Basic Clin Pharmacol Toxicol 2011; 110:353-8. [PMID: 22008605 DOI: 10.1111/j.1742-7843.2011.00822.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Considerable evidence supports the presence of oxidative stress in cystic fibrosis (CF). The disease has long been associated with both increased production of reactive oxygen species and impaired antioxidant status, in particular during the chronic pulmonary infection with Pseudomonas aeruginosa, which is the main cause of morbidity and mortality in CF. Guinea pigs are unable to synthesize ascorbate (ASC) or vitamin C, a major antioxidant of the lung, and thus like human beings rely on its presence in the diet. On this basis, guinea pigs receiving ASC-deficient diet have been used as a model of oxidative stress. The aim of our study was to investigate the consequences of a 7-day biofilm-grown P. aeruginosa lung infection in 3-month-old guinea pigs receiving either ASC-sufficient or ASC-deficient diet for at least 2 months. The animals receiving ASC-deficient diet showed significantly higher mortality during infection and increased respiratory burst of peripheral polymorphonuclear neutrophils (PMNs) compared with the animals receiving ASC sufficient diet. The inflammatory response at the site of lung infection consisted of PMNs and mononuclear leucocytes (MN), and higher PMN/MN ratios were present in animals on ASC-deficient diet compared with animals on ASC sufficient diet. Measurements of the ASC levels in the lung were significantly decreased in infected compared with non-infected animals. Interestingly, the infection by itself decreased the antioxidant capacity of the plasma (measured as plasma oxidizability) more than the ASC-deficient diet, suggesting a high consumption of the antioxidants during infection. Our data show that poor antioxidant status exacerbates the outcome of biofilm-related infections.
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Affiliation(s)
- Peter Ø Jensen
- Department of Clinical Microbiology, University Hospital, Copenhagen, Denmark
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48
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Sautter R, Ramos D, Schneper L, Ciofu O, Wassermann T, Koh CL, Heydorn A, Hentzer M, Høiby N, Kharazmi A, Molin S, Devries CA, Ohman DE, Mathee K. A complex multilevel attack on Pseudomonas aeruginosa algT/U expression and algT/U activity results in the loss of alginate production. Gene 2011; 498:242-53. [PMID: 22088575 DOI: 10.1016/j.gene.2011.11.005] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [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] [Received: 05/08/2011] [Revised: 09/27/2011] [Accepted: 11/01/2011] [Indexed: 11/18/2022]
Abstract
Infection by the opportunistic pathogen Pseudomonas aeruginosa is a leading cause of morbidity and mortality seen in cystic fibrosis (CF) patients. This is mainly due to the genotypic and phenotypic changes of the bacteria that cause conversion from a typical nonmucoid to a mucoid form in the CF lung. Mucoid conversion is indicative of overproduction of a capsule-like polysaccharide called alginate. The alginate-overproducing (Alg(+)) mucoid phenotype seen in the CF isolates is extremely unstable. Low oxygen tension growth of mucoid variants readily selects for nonmucoid variants. The switching off mechanism has been mapped to the algT/U locus, and the molecular basis for this conversion was partially attributed to mutations in the algT/U gene itself. To further characterize molecular changes resulting in the unstable phenotype, an isogenic PAO1 derivative that is constitutively Alg(+) due to the replacement of the mucA with mucA22 (PDO300) was used. The mucA22 allele is common in mucoid CF isolates. Thirty-four spontaneous nonmucoid variants, or sap (suppressor of alginate production) mutants, of PDO300 were isolated under low oxygen tension. About 40% of the sap mutants were rescued by a plasmid carrying algT/U (Group A). The remaining sap mutants were not (Group B). The members of Group B fall into two subsets: one similar to PAO1, and another comparable to PDO300. Sequence analysis of the algT/U and mucA genes in Group A shows that mucA22 is intact, whereas algT/U contains mutations. Genetic complementation and sequencing of one Group B sap mutant, sap22, revealed that the nonmucoid phenotype was due to the presence of a mutation in PA3257. PA3257 encodes a putative periplasmic protease. Mutation of PA3257 resulted in decreased algT/U expression. Thus, inhibition of algT/U is a primary mechanism for alginate synthesis suppression.
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Affiliation(s)
- Robert Sautter
- Department of Biological Sciences, College of Arts and Sciences, Florida International University, Miami, FL 33199, USA
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Mandsberg LF, Maciá MD, Bergmann KR, Christiansen LE, Alhede M, Kirkby N, Høiby N, Oliver A, Ciofu O. Development of antibiotic resistance and up-regulation of the antimutator gene pfpI in mutator Pseudomonas aeruginosa due to inactivation of two DNA oxidative repair genes (mutY, mutM). FEMS Microbiol Lett 2011; 324:28-37. [DOI: 10.1111/j.1574-6968.2011.02383.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)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2011] [Revised: 08/08/2011] [Accepted: 08/08/2011] [Indexed: 11/26/2022] Open
Affiliation(s)
- Lotte Frigaard Mandsberg
- Department of International Health; Immunology and Microbiology; University of Copenhagen; Copenhagen; Denmark
| | - Maria D. Maciá
- Servicio de Microbiología; Hospital Universitario Son Espases; Palma de Mallorca; Spain
| | - Kirsten R. Bergmann
- Informatics and Mathematical Modelling; Technical University of Denmark; Lyngby; Denmark
| | - Lasse E. Christiansen
- Informatics and Mathematical Modelling; Technical University of Denmark; Lyngby; Denmark
| | - Morten Alhede
- Department of International Health; Immunology and Microbiology; University of Copenhagen; Copenhagen; Denmark
| | - Nikolai Kirkby
- Department of Clinical Microbiology; Copenhagen University Hospital; Copenhagen; Denmark
| | | | - Antonio Oliver
- Servicio de Microbiología; Hospital Universitario Son Espases; Palma de Mallorca; Spain
| | - Oana Ciofu
- Department of International Health; Immunology and Microbiology; University of Copenhagen; Copenhagen; Denmark
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Hansen SK, Rau MH, Johansen HK, Ciofu O, Jelsbak L, Yang L, Folkesson A, Jarmer HØ, Aanæs K, von Buchwald C, Høiby N, Molin S. Evolution and diversification of Pseudomonas aeruginosa in the paranasal sinuses of cystic fibrosis children have implications for chronic lung infection. ISME J 2011; 6:31-45. [PMID: 21716309 DOI: 10.1038/ismej.2011.83] [Citation(s) in RCA: 162] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
The opportunistic pathogen Pseudomonas aeruginosa is a frequent colonizer of the airways of patients suffering from cystic fibrosis (CF). Depending on early treatment regimens, the colonization will, with high probability, develop into chronic infections sooner or later, and it is important to establish under which conditions the switch to chronic infection takes place. In association with a recently established sinus surgery treatment program for CF patients at the Copenhagen CF Center, colonization of the paranasal sinuses with P. aeruginosa has been investigated, paralleled by sampling of sputum from the same patients. On the basis of genotyping and phenotypic characterization including transcription profiling, the diversity of the P. aeruginosa populations in the sinuses and the lower airways was investigated and compared. The observations made from several children show that the paranasal sinuses constitute an important niche for the colonizing bacteria in many patients. The paranasal sinuses often harbor distinct bacterial subpopulations, and in the early colonization phases there seems to be a migration from the sinuses to the lower airways, suggesting that independent adaptation and evolution take place in the sinuses. Importantly, before the onset of chronic lung infection, lineages with mutations conferring a large fitness benefit in CF airways such as mucA and lasR as well as small colony variants and antibiotic-resistant clones are part of the sinus populations. Thus, the paranasal sinuses potentially constitute a protected niche of adapted clones of P. aeruginosa, which can intermittently seed the lungs and pave the way for subsequent chronic lung infections.
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