Characterization of Anti-Salmonella enterica Serotype Typhi Antibody Responses in Bacteremic Bangladeshi Patients by an Immunoaffinity Proteomics-Based Technology

Salmonella enterica serotype Typhi is the cause of typhoid fever and a human-restricted pathogen. Currently available typhoid vaccines provide 50 to 90% protection for 2 to 5 years, and available practical diagnostic assays to identify individuals with typhoid fever lack sensitivity and/or specificity. Identifying immunogenic S. Typhi antigens expressed during human infection could lead to improved diagnostic assays and vaccines. Here we describe a platform immunoaffinity proteomics-based technology (IPT) that involves the use of columns charged with IgG, IgM, or IgA antibody fractions recovered from humans bacteremic with S. Typhi to capture S. Typhi proteins that were subsequently identified by mass spectrometry. This screening tool identifies immunogenic proteins recognized by antibodies from infected hosts. Using this technology and the plasma of patients with S. Typhi bacteremia in Bangladesh, we identified 57 proteins of S. Typhi, including proteins known to be immunogenic (PagC, HlyE, OmpA, and GroEL) and a number of proteins present in the human-restricted serotypes S. Typhi and S. Paratyphi A but rarely found in broader-host-range Salmonella spp. (HlyE, CdtB, PltA, and STY1364). We categorized identified proteins into a number of major groupings, including those involved in energy metabolism, protein synthesis, iron homeostasis, and biosynthetic and metabolic functions and those predicted to localize to the outer membrane. We assessed systemic and mucosal anti-HlyE responses in S. Typhi-infected patients and detected anti-HlyE responses at the time of clinical presentation in patients but not in controls. These findings could assist in the development of improved diagnostic assays.Salmonella enterica serotype Typhi is a human-restricted pathogen that is the primary cause of enteric fever. It is estimated that S. Typhi infects over 20 million individuals and kills approximately 200,000 people globally each year (4). Currently, commercially available typhoid vaccines provide approximately 50 to 75% protection for 2 to 5 years (21), although an anti-typhoid Vi conjugate vaccine demonstrated 90% protection in 2- to 5-year-old children in a large field trial (23). Available and practical diagnostic tests for typhoid fever lack sensitivity and/or specificity (28). Identifying immunogenic S. Typhi antigens expressed during human infection could lead to improved diagnostic assays and vaccines.Infection with S. Typhi begins with the ingestion of contaminated water or food. The bacteria invade the gastrointestinal mucosa, translocate to the lymphoid follicles, where they survive and replicate within macrophages, and then disseminate via the bloodstream to the liver, spleen, and intestinal lymph nodes (14). The incubation period is typically 8 to 14 days (22), and symptoms include fever, abdominal pain, anorexia, weakness, potential complications of intestinal perforation, encephalopathy, and gastrointestinal bleeding (14, 34). Clinical studies demonstrate that S. Typhi infection stimulates both an intestinal mucosal and systemic humoral and cellular immune response (14, 34). S. Typhi is a facultative intracellular pathogen of macrophages, and both cellular and antibody-mediated immune responses are known to play roles in controlling and clearing S. Typhi infection (37). Despite this, there are limited data on antigen-specific cellular responses during wild-type S. Typhi infection in humans. Analyses of cellular immune responses during S. Typhi infection have largely used whole-cell preparations or flagellar antigens and have focused predominately on measuring immune responses in recipients of oral live attenuated typhoid vaccines, not in individuals with wild-type disease (24, 25, 40-42, 49).Antibody responses during wild-type infection have been better studied but have focused largely on a relatively small number of antigens, including O antigen (lipopolysaccharide [LPS]), H antigen (flagellar component), polysaccharide capsular antigen (Vi antigen), heat shock proteins such as GroEL, and outer membrane proteins such as OmpC and -F (13, 34). In addition, gut-derived IgA antibody-secreting cells that recognize LPS, a membrane preparation, or whole-killed S. Typhi organisms can be detected in the peripheral blood following natural S. Typhi infection or oral typhoid vaccination (16, 43, 50, 54). These cells eventually return home to the gastrointestinal mucosa, where they secrete secretory IgA antibody (36, 43).A number of immunoaffinity-based techniques that screen protein libraries of pathogens to identify immunogenic antigens have been developed (12, 17, 38), and we have previously reported using one such approach, in vivo-induced-antigen technology (IVIAT), to identify immunogenic S. Typhi antigens expressed during human infection (12). Another previously described technique, proteomics-based expression library screening (PELS), involves using antibody-charged columns to capture antigens produced by an Escherichia coli-based expression system containing an inducible library of a pathogen of interest, with subsequent elution and identification of bound proteins using mass spectrometric analysis (17). Here we describe using a modification of this approach that we have termed immunoaffinity proteomics-based technology (IPT). IPT involves directly screening the pathogen of interest using columns charged with IgG, IgM, or IgA antibody fractions recovered from the blood of infected humans. We applied IPT to S. Typhi to gain further insights into immunogenic antigens expressed in patients bacteremic with S. Typhi in Bangladesh.     

Salmonella enterica Serovar Typhi-Specific Immunoglobulin A Antibody Responses in Plasma and Antibody in Lymphocyte Supernatant Specimens in Bangladeshi Patients with Suspected Typhoid Fever

Many currently available diagnostic tests for typhoid fever lack sensitivity and/or specificity, especially in areas of the world where the disease is endemic. In order to identify a diagnostic test that better correlates with typhoid fever, we evaluated immune responses to Salmonella enterica serovar Typhi (serovar Typhi) in individuals with suspected typhoid fever in Dhaka, Bangladesh. We enrolled 112 individuals with suspected typhoid fever, cultured day 0 blood for serovar Typhi organisms, and performed Widal assays on days 0, 5, and 20. We harvested peripheral blood lymphocytes and analyzed antibody levels in supernatants collected on days 0, 5, and 20 (using an antibody-in-lymphocyte-supernatant [ALS] assay), as well as in plasma on these days. We measured ALS reactivity to a serovar Typhi membrane preparation (MP), a formalin-inactivated whole-cell preparation, and serovar Typhi lipopolysaccharide. We measured responses in healthy Bangladeshi, as well as in Bangladeshi febrile patients with confirmed dengue fever or leptospirosis. We categorized suspected typhoid fever individuals into different groups (groups I to V) based on blood culture results, Widal titer, and clinical features. Responses to MP antigen in the immunoglobulin A isotype were detectable at the time of presentation in the plasma of 81% of patients. The ALS assay, however, tested positive in all patients with documented or highly suspicious typhoid, suggesting that such a response could be the basis of improved diagnostic point-of-care-assay for serovar Typhi infection. It can be important for use in epidemiological studies, as well as in difficult cases involving fevers of unknown origin.Salmonella enterica serovar Typhi (serovar Typhi) is the cause of typhoid fever, an illness that affects over 20,000,000 individuals worldwide each year, killing over 200,000 (5, 8, 16). The largest burden of typhoid fever is borne by impoverished individuals in resource-poor areas of the world. Serovar Typhi is a human-restricted invasive enteric pathogen which, after ingestion, crosses the intestinal mucosa, is taken up by gut-associated lymphoreticular tissues, and enters the systemic circulation. Both mucosal and systemic host immune responses are stimulated after infection. Serovar Typhi is an intracellular pathogen, and antibody and cell-mediated immune responses occur after infection or immunization with live oral attenuated typhoid vaccines (10, 25, 34).Diagnostic tests for typhoid fever often lack sensitivity and/or specificity, especially in areas of the world that are endemic for typhoid fever, where clinically distinguishing typhoid fever from other febrile illnesses is difficult (5, 17, 39). Microbiologic culturing of blood is approximately 30 to 70% sensitive, with the highest sensitivity being associated with an absence of prior use of antibiotics and the culturing of larger volumes of blood, features that complicate this mode of diagnosis in young children (5, 6, 8, 36). Microbiologic culturing of bone marrow aspirates is more sensitive than blood but often clinically impractical (1, 11, 12). Serum Widal assay titers are often nonspecific in endemic settings and are of limited value unless titers are markedly elevated or are analyzed for changes from acute to convalescent phases of illness (18, 33, 38). Molecular diagnostic assays including PCR are promising, but issues of practicality, contamination, and quality control have limited their use in many resource-poor areas of the world (14).Since serovar Typhi interacts with both the mucosal and the systemic immune systems, we were interested to determine whether analyses of mucosal immune responses would give improved insight into this human-restricted infection. Activated mucosal lymphocytes migrate from intestinal tissue and circulate within peripheral blood before rehoming to mucosal tissues (20, 31). This migration peaks 1 to 2 weeks after intestinal infection and may be measured by using peripheral blood mononuclear cells (PBMC) in an antibody-secreting cell (ASC) assay (19, 26) or in supernatants recovered from harvested PBMC (the “antibody in lymphocyte supernatant” [ALS] assay) (7, 31). Although ALS and ASC responses have previously been measured after immunization with oral live attenuated typhoid vaccines, detailed analyses of ALS or ASC responses in individuals with wild-type typhoid fever are lacking (21, 24). In order to gain further insight into mucosal immune responses during wild-type serovar Typhi infection, we undertook a study to characterize the serum and ALS responses to serovar Typhi among individuals with suspected typhoid fever in Bangladesh.     

Multiple-Locus Variable-Number Tandem-Repeat Analysis of Salmonella enterica Serovar Typhi

Multilocus variable-number tandem repeats (VNTRs) are widely used as molecular markers to differentiate isolates of homogenous pathogenic clones. We explored the genomes of Salmonella enterica serovar Typhi strains CT18 and Ty2 for potential VNTRs. Among the 43 potential VNTRs screened, 2 were found to be polymorphic. Together with seven polymorphic VNTRs from previous studies, they were used to type 73 global serovar Typhi isolates. A total of 70 multilocus VNTR analysis (MLVA) profiles were found, distinguishing all except three pairs of isolates into individual profiles. The discriminatory power was 0.999. Phylogenetic analysis showed that the MLVA profiles can be divided into seven clusters. However, except for the closely related isolates, the relationships derived were in conflict with those inferred from single nucleotide polymorphism (SNP) typing using 38 SNPs done previously. We concluded that MLVA can resolve the relationships only among closely related isolates. A combination of SNP typing and MLVA typing offers the best approach for local and global epidemiology and the evolutionary analysis of serovar Typhi. We suggest that seven of the nine most polymorphic VNTRs be used as a standardized typing scheme for epidemiological typing.Typhoid fever remains a devastating disease in developing countries and is prevalent in areas with inadequate sanitation and poor hygiene. It is a serious systemic disease, spread via the fecal-oral route. Annually, there are more than 16 million cases of typhoid fever with 600,000 deaths reported worldwide (www.who.int). The etiological agent of typhoid fever is Salmonella enterica serovar Typhi, which is highly homogenous (13, 33). The genetic homogeneity of serovar Typhi has significantly impeded the development of suitable typing methods to differentiate serovar Typhi isolates for both phylogenetic and epidemiological purposes.Single nucleotide polymorphisms (SNPs) have recently been shown to be useful markers for typing serovar Typhi isolates (23, 29). SNP typing can resolve the relationships among global serovar Typhi isolates and be more discriminating than widely accepted population genetic methods, including multilocus enzyme electrophoresis (28) and multilocus sequence typing (13). However, some haplotypes or SNP profiles contained many isolates which could not be further differentiated (23, 29). In the study of Roumagnac et al. (29), 88 SNPs differentiated 481 global serovar Typhi isolates into 85 haplotypes. The majority of the isolates belonged to H58 (35%), H50 (12%), and H52 (11%). In the study by Octavia and Lan (23), 38 SNPs distinguished 73 global serovar Typhi isolates into 23 SNP profiles, and the majority of these isolates had SNP profile 10 (32%) and SNP profile 2 (16%). Clearly, SNP typing still has limited discriminatory power.Variable-number tandem repeats (VNTRs) have the potential to be more discriminating than SNPs and also to be used to establish the evolutionary relationships of the isolates. VNTRs are short sequence repeats, which are unique DNA elements repeated in tandem. The polymorphisms in VNTRs are believed to be a result of slippage strand misalignment (17). Therefore, isolates may contain different copy numbers for a repeat locus, allowing differentiation between isolates. Multilocus VNTR analysis (MLVA) involves determination of the number of repeats at multiple VNTR loci, and the number of loci required varies depending on the diversity of the organism studied. MLVA has been particularly effective in typing homogenous clones including Yersinia pestis (1, 14, 21, 25), Bacillus anthracis (8, 11, 12, 34), and Mycobacterium tuberculosis (7, 16, 32, 35, 36). In S. enterica, a few serovars, including serovars Enteritidis, Typhimurium, and Typhi have been studied by MLVA (3, 4, 18-20, 27).Two MLVA studies of serovar Typhi showed different levels of variation of VNTR loci analyzed (20, 27). Liu et al. (20) found five potential VNTR loci designated TR1 to TR5, with the first three showing variation among 59 serovar Typhi isolates from several Asian countries studied. Ramisse et al. (27) found five new polymorphic VNTRs (SAL02, SAL06, SAL10, SAL15, and SAL20). Together with two markers from previous serovar Typhi and Typhimurium studies, TR1 (20) and STTR5/Sal16 (18), a total of seven VNTRs distinguished 27 serovar Typhi isolates from France into 25 MLVA profiles (27). In these two studies, VNTR PCR products were resolved on standard agarose gels. However, the resolution of agarose gels is known to be low, which makes it especially difficult to resolve short repeat units, such as SAL10 with a 2-bp repeat unit. In this study we used seven published VNTRs, including SAL02, SAL06, SAL10, SAL16, SAL20, TR1, and TR2, and two new VNTRs uncovered in this study as markers to explore their potential in studying the molecular evolution of global serovar Typhi isolates. Our MLVA assay employed universal M13 tail primer tagged with a different fluorescent dye to resolve the tandem repeats by capillary electrophoresis. We combined the more rapidly evolving VNTR markers with the slower evolving SNPs to achieve an optimal resolution for typing global serovar Typhi isolates.     

Kinetics of the Natural,Humoral Immune Response to Salmonella enterica Serovar Typhi in Kathmandu,Nepal

Typhoid fever is a major public health problem in developing countries, conservatively estimated to occur in 17 million cases and be responsible for 200,000 deaths annually. We investigated the acquisition of natural immunity to Salmonella enterica serovar Typhi in a region where typhoid is endemic by testing sera from an age-stratified sample of 210 healthy participants in Kathmandu, Nepal, for bactericidal activity toward S. Typhi and for anti-Vi capsular polysaccharide antibodies. Bactericidal titers in children were significantly lower than those in newborns and adults (P < 0.0001). Anti-S. Typhi bactericidal geometric mean titers were age dependent, increasing 10-fold during childhood. Anti-Vi polysaccharide antibody geometric mean concentrations were also lower in children than in adults. Data presented here indicate the possibility of a relationship between low levels of bactericidal activity toward S. Typhi in serum and susceptibility to disease, as observed for other polysaccharide-encapsulated bacteria. Bactericidal antibody may be a marker of protective immunity against S. Typhi.Salmonella enterica subspecies enterica serotype Typhi is responsible for 17 million new cases of typhoid fever and 200,000 deaths annually (5). Since typhoid fever is a food- and waterborne disease transmitted by the fecal-oral route, it is endemic in regions where the quality of the drinking water supply is poor and sewage disposal facilities are inadequate, with annual incidence rates above 100 per 100,000 person years (2). Southern Asia carries a heavy burden of disease, with S. Typhi causing almost 40% of culture-positive bloodstream infections in Nepal (26). Although typhoid was thought to be a disease of school children and young adults, there is increasing evidence of a substantial disease burden in younger children in countries where typhoid is endemic (3, 24, 27).Three vaccines for the prevention of typhoid fever exist. The whole-cell inactivated vaccine is unpopular due to high rates of adverse reactions (19). A live attenuated oral vaccine (Ty21a) and a parenteral plain polysaccharide vaccine have comparable efficacies ranging between 50 and 70% and are suitable for community vaccination programs in areas of hyperendemicity (8, 9). A polysaccharide-protein conjugate vaccine has shown promising results in clinical trials and potentially could be used for children under 2 years of age, for whom the former two vaccines are either ineffective or unlicensed (17, 21). Similarly, a novel, drinkable, single-dose attenuated vaccine has demonstrated promising immunogenicity and tolerability in phase II trials in Vietnam (31). Despite the availability of two moderately efficacious vaccines and the possibility of another two, no country has implemented a systematic typhoid vaccination strategy. This is due partly to the limited data on disease burden and age-specific immunity, which are critical in determining the timing of and need for vaccination (6). Today, typhoid immunization is limited to travelers visiting regions of endemicity or laboratory workers potentially exposed to the pathogen.We investigated anti-S. Typhi bactericidal antibody titers and the concentrations of antibody against the S. Typhi Vi polysaccharide (ViPS) in a cross-sectional study of a population in Kathmandu, Nepal, in order to relate antibody levels to both age and reported disease rates.     

Reliable Means of Diagnosis and Serovar Determination of Blood-Borne Salmonella Strains: Quick PCR Amplification of Unique Genomic Loci by Novel Primer Sets

Typhoid fever is becoming an ever increasing threat in the developing countries. We have improved considerably upon the existing PCR-based diagnosis method by designing primers against a region that is unique to Salmonella enterica subsp. enterica serovar Typhi and Salmonella enterica subsp. enterica serovar Paratyphi A, corresponding to the STY0312 gene in S. Typhi and its homolog SPA2476 in S. Paratyphi A. An additional set of primers amplify another region in S. Typhi CT18 and S. Typhi Ty2 corresponding to the region between genes STY0313 to STY0316 but which is absent in S. Paratyphi A. The possibility of a false-negative result arising due to mutation in hypervariable genes has been reduced by targeting a gene unique to typhoidal Salmonella serovars as a diagnostic marker. The amplified region has been tested for genomic stability by amplifying the region from clinical isolates of patients from various geographical locations in India, thereby showing that this region is potentially stable. These set of primers can also differentiate between S. Typhi CT18, S. Typhi Ty2, and S. Paratyphi A, which have stable deletions in this specific locus. The PCR assay designed in this study has a sensitivity of 95% compared to the Widal test which has a sensitivity of only 63%. As observed, in certain cases, the PCR assay was more sensitive than the blood culture test was, as the PCR-based detection could also detect dead bacteria.Salmonella enterica is an important enteric pathogen and is involved in causing both systemic and intestinal diseases in humans and a wide range of other hosts (7, 21). Serotypes within subspecies I (Salmonella enterica subsp. enterica) are responsible for the vast majority of salmonellosis in warm-blooded animals. S. enterica subsp. enterica serovar Typhi and S. enterica subsp. enterica serovar Paratyphi A cause typhoid fever strictly in humans mostly in developing countries, with no age exemption, but it is less common in children younger than 2 years old. According to one estimate, the worldwide incidence of typhoid fever is 16 million cases annually and the mortality rate is 600,000 individuals per year (23). According to a press release from the Press Information Bureau, Government of India, dated 22 February 2006, the morbidity due to typhoid fever varies from 102 to 2,219 per 100,000 population in different parts of India, and in some areas, typhoid fever is responsible for 2 to 5% of all deaths. The problem of typhoid fever has been exacerbated by the appearance of multiple-drug-resistant strains (25), the treatment of which would depend on newer and advanced antibiotics and early and precise diagnosis.The existing modes of diagnosis are through the detection of antibodies against Salmonella bacteria by the Widal test and other serological tests like DOT enzyme immunoassay, dip stick assays, and semiquantitative tube agglutination test (22). Apart from this, the bacteremia observed in typhoid fever around day 6 to 9 enables it to be detected through the blood culture test (29) and PCR amplification of the bacterial DNA from blood. Of the commonly available diagnostic tests, Widal test and other serological diagnostic methods are limited because of the low specificity of the test. There are reports of a large number of false-positive cases especially in areas where typhoid fever is endemic and in patients exposed to typhoid fever earlier (6). The blood culture test has the major disadvantage of being a time-consuming test, which takes 2 to 3 days.PCR-based diagnoses are superior to the classical serological method, Widal test, and blood culture test in terms of their specificity and sensitivity. The modification by Sanchez-Jimenez and Cardona-Castro (26) where the initial DNA purification step is omitted and the whole blood is used directly as the template for PCR has been used in our assay system with minor modifications.The PCR-based systems currently use primers against flagellin genes (2, 4, 5, 12, 16, 17, 27), hilA (26), and invA and spvC genes (5). The different distributions of invA and spvC genes among Salmonella isolates from animals highlights the unsuitability of these two genes as PCR probes for Salmonella detection (20). Many genes carried on Salmonella pathogenicity islands have evolved differentially in typhoidal and nontyphoidal Salmonella serovars giving rise to different allelic variants of these genes (9). These genes are present in different Salmonella serovars, and their orthologs in other species of bacteria share various degrees of identity at the nucleotide levels (9). These differences, if minor, at certain PCR conditions can lead to promiscuous amplification, thereby leading to false-positive results. This problem can be overcome by choosing those regions that are unique to S. Typhi and S. Paratyphi A. Though certain pathogenicity islands are unique to S. Typhi and S. Paratyphi A, like Salmonella pathogenicity island 7 (SPI-7) and SPI-8, these islands are known to be unstable. These islands can be excised by the activation of certain recombinases as exemplified by isolation of the clinical variants lacking SPI-7 (19). Also, the presence of a gene encoding integrase on SPI-8 suggests that it is a mobile island (13). For the same reason, insertion sequences and bacteriophage genes are not good candidates for diagnostic purposes. However, a thorough examination of the whole-genome sequences of S. enterica serovar Typhi, S. Paratyphi A, and S. Typhimurium highlights the existence of genomic regions of unknown function with no homologous genes in related serovars and without the features of mobile DNA sequences. Using these criteria for the identification of a good diagnostic marker gene in S. Typhi CT18, we identified the genomic loci spanning the STY0312 gene, which is unique to S. Typhi CT18 and S. Paratyphi, the causative agents of typhoid fever. The adjoining locus spanning STY0313 to STY0316 was different in S. Typhi Ty2 and S. Paratyphi but otherwise conserved in most Salmonella strains. This region was found to be part of SPI-6, which is present in many Salmonella enterica subspecies I strains (10).We hypothesized that these novel primers could differentiate between typhoidal and nontyphoidal serovars of Salmonella enterica. Hence, the aim of the present work was to amplify the genomic region using the unique set of primers and demonstrate whether this method can be useful for the early diagnosis of typhoid fever.     

Physical and Chemical Characterization and Immunologic Properties of Salmonella enterica Serovar Typhi Capsular Polysaccharide-Diphtheria Toxoid Conjugates

Typhoid fever remains a serious public health problem in developing countries, especially among young children. Recent studies showed more than 50% of typhoid cases are in children under 5 years old. Licensed vaccines, such as Salmonella enterica serovar Typhi capsular Vi, did not confer protection against typhoid fever for this age group. Vi conjugate, prepared by binding Vi to Pseudomonas aeruginosa recombinant exoprotein A (rEPA), induces protective levels of antibody at as young as 2 years old. Because of the lack of regulatory precedent for rEPA in licensing vaccines, we employed diphtheria toxoid (DT) as the carrier protein to accommodate accessibility in developing countries. Five lots of Vi-DT conjugates were prepared using adipic acid dihydrazide (ADH) as the linker. All 5 lots showed consistency in their physical and chemical characteristics and final yields. These Vi-DT conjugates elicited levels of IgG anti-Vi in young mice significantly higher than those in mice injected with Vi alone and induced a booster response upon reinjection. This booster effect was absent if the Vi replaced one of the two conjugate injections. Vi-DT was stable under repeated freeze-thaw (20 cycles). We plan to perform clinical evaluation of the safety and immunogenicity of Vi-DT when added to the infant combination vaccines.Typhoid fever, a serious systemic infection caused by Salmonella enterica serovar Typhi, remains a major public health problem in Central Asia, Southeast Asia, Africa, and Latin America (11, 52, 53). It was estimated that more than 21 million cases of typhoid fever and >200,000 deaths occurred in 2000 (10). The treatment of patients and management of asymptomatic carriers are becoming more difficult due to the worldwide emergence of multidrug-resistant (MDR) strains (2, 15, 29, 42, 43). Vaccination is considered the most promising strategy for the control of typhoid fever in developing countries (11, 19, 52, 53).Typhoid fever in children younger than 5 years old has often been unrecognized due to atypical clinical symptoms, difficulties in the number and volume of blood drawings, and use of less than optimal culture media (35, 46). Several studies have shown that the incidence of typhoid fever among children less than 5 years old is similar to that in school age children and young adults (14, 27, 34, 50, 51).The 3 licensed typhoid vaccines have limited efficacy, and none are suitable for young children under 5 years old. The use of heat-inactivated whole-cell vaccine was suspended in many countries because of its reactogenicity. The parenteral Vi polysaccharide and the live attenuated oral Ty21a vaccine were introduced in the late 1980s; both vaccines are well accepted and confer moderate protection (50 to 70%) in older children and adults. However, neither vaccine is licensed for routine immunization of infants (52).The Vi capsular polysaccharide is both an essential virulence factor and a protective antigen for S. Typhi (36, 38, 39). The concentration of serum IgG anti-Vi is correlated with immunity to the pathogen (22, 25, 26, 28, 36, 38, 49). However, Vi is not suitable for routine immunization of infants and young children because of its age-related immunogenicity and T-cell independence. As was shown for other capsular polysaccharides, such as Haemophilus influenzae type b (8, 37); meningococcus groups A, C, and W135; and Streptococcus pneumoniae (12, 20), Vi covalently bound with protein conferred T-cell dependence and increased immunogenicity (48-50). To date, diphtheria toxoid (DT), tetanus toxoid (TT), cholera toxins (CT), the B subunit of the heat-labile toxin (LT-B) of Escherichia coli, recombinant outer membrane protein of Klebsiella pneumoniae (rP40), and iron-regulated outer-membrane proteins (IROMPs) of S. Typhi have served as carriers for Vi polysaccharide in laboratory studies (16, 17, 32, 48-50; personal communications). An improved method was developed (24), utilizing adipic acid dihydrazide (ADH) as the linker and Pseudomonas aeruginosa recombinant exoprotein A (rEPA) as the carrier. Clinical trials of Vi-rEPA conjugates conferred 89% protection in Vietnamese children 2 to 5 years old for 46 months (23, 26, 28). The level of serum IgG anti-Vi induced by Vi-rEPA conjugates was correlated with prevention of typhoid fever in these studies (7, 21-23, 26, 28).One limitation of using rEPA as the carrier protein is the lack of regulatory precedent in licensing vaccines. In this report, five lots of Vi conjugates using DT manufactured by pharmaceutical companies in China and India were prepared (24, 48, 49). Modifications of conjugation procedures were made for the purposes of easy adoption and scale up by manufacturers. The stability of Vi-DT was studied for the feasibility of stockpiling in disaster relief.Another important aspect of conjugate vaccine implementation is the optimum immunization formulation and schedule using alternating injections of polysaccharide and conjugate. Priming or boosting effects of polysaccharide on its conjugate vaccine have been observed in infants injected with pneumococcal and meningococcal vaccines (3, 4, 31, 40). There was no consistent conclusion about various types of polysaccharides studied (6, 9, 31, 40, 41). Here, we compared the immune response of Vi polysaccharide injected before or after the administration of Vi-DT with the responses of those receiving 2 injections of Vi-DT. We also investigated the dosage effect for the purpose of better formulation.     

Development of a Bead Immunoassay To Measure Vi Polysaccharide-Specific Serum IgG after Vaccination with the Salmonella enterica Serovar Typhi Vi Polysaccharide

Vi polysaccharide from Salmonella enterica serotype Typhi is used as one of the available vaccines to prevent typhoid fever. Measurement of Vi-specific serum antibodies after vaccination with Vi polysaccharide by enzyme-linked immunosorbent assay (ELISA) may be complicated due to poor binding of the Vi polysaccharide to ELISA plates resulting in poor reproducibility of measured antibody responses. We chemically conjugated Vi polysaccharide to fluorescent beads and performed studies to determine if a bead-based immunoassay provided a reproducible method to measure vaccine-induced anti-Vi serum IgG antibodies. Compared to ELISA, the Vi bead immunoassay had a lower background and therefore a greater signal-to-noise ratio. The Vi bead immunoassay was used to evaluate serum anti-Vi IgG in 996 subjects from the city of Kolkata, India, before and after vaccination. Due to the location being one where Salmonella serotype Typhi is endemic, approximately 45% of the subjects had protective levels of anti-Vi serum IgG (i.e., 1 μg/ml anti-Vi IgG) before vaccination, and nearly 98% of the subjects had protective levels of anti-Vi serum IgG after vaccination. Our results demonstrate that a bead-based immunoassay provides an effective, reproducible method to measure serum anti-Vi IgG responses before and after vaccination with the Vi polysaccharide vaccine.Typhoid fever is caused by Salmonella enterica serotype Typhi (32). Humans are the only natural host and reservoir of S. enterica serotype Typhi (32, 41). Typhoid fever represents a spectrum of diseases ranging from an acute uncomplicated disease—including fever, headache, malaise, and disturbances of bowel function (constipation in adults and diarrhea in children)—to a more severe, complicated form of disease in 10 to 20% of infected patients that includes bleeding in the gastrointestinal tract, intestinal perforation (in 1 to 3% of hospital typhoid fever cases) and an altered mental state (32, 41). The case fatality rate is highly variable, depending on the medical treatment available and geographic location. For example, the average fatality rate is less than 1% overall but may range between 2% fatality in hospitalized patients in Pakistan and Vietnam and 50% fatality in hospitalized patients in some parts of Indonesia and Papua New Guinea (32, 41). Worldwide, typhoid fever remains a significant public health problem, with an estimated 17,000,000 cases of typhoid fever each year and up to 600,000 deaths (2, 10, 32, 41).Typhoid vaccines currently available are composed of purified Vi polysaccharide or live attenuated S. enterica serotype Typhi (Ty21a) organisms (10, 39). The Vi polysaccharide vaccine induces protective serum antibody responses that reach a maximum at 28 days after a single intramuscular vaccination with 25 μg purified Vi polysaccharide (39), a capsular polysaccharide (Vi for virulence) that increases the virulence of S. enterica serotype Typhi (32). Protective antibody levels have been estimated to be 1 μg/ml anti-Vi IgG antibody in the serum (20). Protective efficacy of the Vi polysaccharide vaccine as determined by protection against disease is modest, with only 55 to 72% of subjects protected against disease through 3 years postvaccination (1, 20, 39). The live attenuated Ty21a vaccine is administered orally as three or four doses of enteric capsules (39). Due to its use as an oral, mucosally administered vaccine, the Ty21a vaccine induces protection against typhoid fever by induction of mucosal IgA and serum IgG antibodies specific for lipopolysaccharide antigens (39). The protective efficacy of the Ty21a vaccine at 3 years postvaccination was reported to range from 42 to 67% when using three doses of Ty21a enteric capsules (11, 39). Next-generation vaccines that utilize Vi conjugated to protein carriers that provide superior induction of anti-Vi antibodies are currently in development (14, 21, 25, 36).Despite its ability to induce protective immune responses when used alone or conjugated to protein carriers, the use of Vi polysaccharide as a coating antigen in enzyme-linked immunosorbent assay (ELISA) to measure vaccine-induced anti-Vi antibody responses has been reported to be problematic. The use of polysaccharides (lipopolysaccharide [LPS], Haemophilus influenzae type b capsular polysaccharide, Vi polysaccharide) as coating antigens for immunoassays is plagued by problems such as a poor binding of polysaccharides to ELISA plates and inconsistent results (3, 15, 16, 26, 33). To increase binding of Vi antigen to ELISA plates and produce more-robust assays, others have biotinylated Vi and then added it to streptavidin-coated plates (12) or conjugated Vi to tyramine (22, 26). However, some reports indicate that Vi was used without any additional treatment as an ELISA coating antigen (7, 19, 21) although a Vi ELISA performed on plates was less sensitive than a radioimmunoassay procedure (19).Immunoassays based on the use of fluorescent beads as the solid surface have recently been developed and compared to ELISA for the measurement of antigen-specific antibodies for polysaccharides from Streptococcus pneumoniae, Neisseria meningitidis, or Haemophilus influenzae type b (HiB) (5, 8, 23, 27, 34, 35). The fluorescent bead assays were comparable to ELISA and sometimes were noted as having enhanced dynamic ranges or increased sensitivity (5, 8, 27, 35). An additional benefit of fluorescent bead immunoassays is their ability to be multiplexed to permit the simultaneous measurement of antibodies specific for different antigens (8, 23, 27, 34, 35). This study was performed to evaluate a fluorescent bead immunoassay for its ability to measure vaccine-induced antibodies specific for Salmonella serotype Typhi Vi polysaccharide. The performance of the fluorescent bead assay was compared to that of ELISA.     

Single Nucleotide Polymorphism Typing of Global Salmonella enterica Serovar Typhi Isolates by Use of a Hairpin Primer Real-Time PCR Assay

Salmonella enterica serovar Typhi is highly homogeneous. Single nucleotide polymorphisms (SNPs) have been shown to be valuable markers for molecular typing of S. enterica serovar Typhi. Here, we used a hairpin primer real-time PCR assay for SNP typing of S. enterica serovar Typhi isolates. Forty-two SNPs were selected from a comparison of 19 published S. enterica serovar Typhi genomes and sequences from other studies. The SNPs were used to type 71 global S. enterica serovar Typhi isolates and differentiated these S. enterica serovar Typhi isolates and the 19 genome sequenced strains into 25 SNP profiles. Phylogenetic analysis revealed that these SNP profiles were grouped into six major clusters. These clusters can be identified by using five SNPs, while the full differentiation of the 25 SNP profiles requires a minimum of 24 SNPs. This real-time PCR-based SNP typing method will be useful for global epidemiological analysis.Salmonella enterica serovar Typhi is highly homogeneous (10, 17, 18). The lack of genetic diversity is a major challenge to the development of suitable typing methods to differentiate S. enterica serovar Typhi isolates for both phylogenetic and epidemiological purposes. Single nucleotide polymorphisms (SNPs) are considered the most valuable markers, particularly for studying the evolutionary relationships of isolates of homogeneous pathogenic clones, such as Bacillus anthracis (16), Mycobacterium tuberculosis (4), and Yersinia pestis (1).SNPs have been used as markers for molecular typing of S. enterica serovar Typhi in a large study by Roumagnac et al. (17). A total of 88 SNPs, found from analysis of 200 gene fragments from 105 diverse S. enterica serovar Typhi isolates, could differentiate 481 global S. enterica serovar Typhi isolates into 85 haplotypes (SNP profiles) and five major clusters (17). However, despite the large number of SNPs used, each of the five clusters was supported by only a single SNP and there was little resolution of the relationships of the haplotypes within a cluster. Eighty of the SNPs have also been used to differentiate 140 Indonesian S. enterica serovar Typhi isolates into nine haplotypes (2).We have also shown that genome-wide SNPs are useful for molecular typing and determining the relationships of global S. enterica serovar Typhi isolates (14). Thirty-seven SNPs selected from a comparison of the genomes of S. enterica serovar Typhi strains CT18 (15) and Ty2 (3) were typed using restriction enzyme digestion to differentiate 73 global S. enterica serovar Typhi isolates into 23 SNP profiles and four distinct genetic groups. As the SNPs were selected by comparison of only two S. enterica serovar Typhi genomes, this resulted in a phylogenetic bias which revealed the full path of the last common ancestors connecting strains CT18 and Ty2 but only the node locations for the other SNP profiles (14).Advances in technology, such as high-throughput sequencing, allow SNPs to be discovered to obtain a full resolution of the phylogenetic relationships of isolates. A recent study by Holt et al. (8) utilized 454 and/or Solexa technologies to sequence 19 S. enterica serovar Typhi isolates selected from the five major clusters found by Roumagnac et al. (17). There were more than 1,700 SNPs found, and these gave a fully resolved phylogenetic tree of these isolates. These SNPs are invaluable resources for investigation of the evolutionary history of global S. enterica serovar Typhi isolates. This study aimed to select a better set of SNPs on the basis of the genome tree and the previous SNP studies by Roumagnac et al. (17) to differentiate and establish the phylogenetic relationships of global S. enterica serovar Typhi isolates, using real-time (R-T) PCR assays based on hairpin (HP) primers (6).     

Variation in Susceptibility of Bloodstream Isolates of Candida glabrata to Fluconazole According to Patient Age and Geographic Location in the United States in 2001 to 2007

We examined the susceptibilities to fluconazole of 642 bloodstream infection (BSI) isolates of Candida glabrata and grouped the isolates by patient age and geographic location within the United States. Susceptibility of C. glabrata to fluconazole was lowest in the northeast region (46%) and was highest in the west (76%). The frequencies of isolation and of fluconazole resistance among C. glabrata BSI isolates were higher in the present study (years 2001 to 2007) than in a previous study conducted from 1992 to 2001. Whereas the frequency of C. glabrata increased with patient age, the rate of fluconazole resistance declined. The oldest age group (≥80 years) had the highest proportion of BSI isolates that were C. glabrata (32%) and the lowest rate of fluconazole resistance (5%).Candidemia is without question the most important of the invasive mycoses (6, 33, 35, 61, 65, 68, 78, 86, 88). Treatment of candidemia over the past 20 years has been enhanced considerably by the introduction of fluconazole in 1990 (7, 10, 15, 28, 29, 31, 40, 56-58, 61, 86, 90). Because of its widespread usage, concern about the development of fluconazole resistance among Candida spp. abounds (2, 6, 14, 32, 47, 53, 55, 56, 59, 60, 62, 80, 86). Despite these concerns, fluconazole resistance is relatively uncommon among most species of Candida causing bloodstream infections (BSI) (5, 6, 22, 24, 33, 42, 54, 56, 65, 68, 71, 86). The exception to this statement is Candida glabrata, of which more than 10% of BSI isolates may be highly resistant (MIC ≥ 64 μg/ml) to fluconazole (6, 9, 15, 23, 30, 32, 36, 63-65, 71, 87, 91). Suboptimal fluconazole dosing practices (low dose [<400 mg/day] and poor indications) may lead to an increased frequency of isolation of C. glabrata as an etiological agent of candidemia in hospitalized patients (6, 17, 29, 32, 35, 41, 47, 55, 60, 68, 85) and to increased fluconazole (and other azole) resistance secondary to induction of CDR efflux pumps (2, 11, 13, 16, 43, 47, 50, 55, 69, 77, 83, 84) and may adversely affect the survival of treated patients (7, 10, 29, 40, 59, 90). Among the various Candida species, C. glabrata alone has increased as a cause of BSI in U.S. intensive care units since 1993 (89). Within the United States, the proportion of fungemias due to C. glabrata has been shown to vary from 11% to 37% across the different regions (west, midwest, northeast, and south) of the country (63, 65) and from <10% to >30% within single institutions over the course of several years (9, 48). It has been shown that the prevalence of C. glabrata as a cause of BSI is potentially related to many disparate factors in addition to fluconazole exposure, including geographic characteristics (3, 6, 63-65, 71, 88), patient age (5, 6, 25, 35, 41, 42, 48, 63, 82, 92), and other characteristics of the patient population studied (1, 32, 35, 51). Because C. glabrata is relatively resistant to fluconazole, the frequency with which it causes BSI has important implications for therapy (21, 29, 32, 40, 41, 45, 56, 57, 59, 80, 81, 86, 90).Previously, we examined the susceptibilities to fluconazole of 559 BSI isolates of C. glabrata and grouped the isolates by patient age and geographic location within the United States over the time period from 1992 to 2001 (63). In the present study we build upon this experience and report the fluconazole susceptibilities of 642 BSI isolates of C. glabrata collected from sentinel surveillance sites throughout the United States for the time period from 2001 through 2007 and stratify the results by geographic region and patient age. The activities of voriconazole and the echinocandins against this contemporary collection of C. glabrata isolates are also reported.     

Ex Vivo Kinetics of Early and Long-Term Multifunctional Human Leukocyte Antigen E-Specific CD8+ Cells in Volunteers Immunized with the Ty21a Typhoid Vaccine

T cells are likely to play an important role in the host defense against Salmonella enterica serovar Typhi, the causative agent of typhoid fever. We have shown that HLA-E can function as a restriction element for S. Typhi-specific CD8⁺ T cells. Because of the potential importance of HLA-E-restricted CD8⁺ responses in resistance to Salmonella infection, we characterized these responses and investigated their kinetics of appearance and persistence in volunteers immunized orally with the licensed attenuated Ty21a strain typhoid vaccine. Cells were obtained from volunteers before and at days 2, 4, 7, 10, 14, 28, 42, 56, 120, 180, 360, and 720 after immunization. An ex vivo multicolor staining panel including antibodies to CD107a and -b, interleukin-2, gamma interferon (IFN-γ), and tumor necrosis factor alpha (TNF-α) was used to functionally assess memory T-cell subsets by flow cytometry. Increases in cytokine-secreting CD8⁺ cells were observed in the T effector/memory (T_EM) and CD45RA⁺ T_EM (T_EMRA) subsets as early as 4 days after immunization and persisted, particularly in the T_EMRA subset, up to 2 years after immunization. The majority of HLA-E-restricted CD8⁺ cells 28 to 56 days after immunization coexpressed CD107, IFN-γ, and TNF-α, showing characteristic features of multifunctional T cells. In summary, the multifunctionality and longevity of the HLA-E-restricted CD8 responses observed in this study highlight their significance in adaptive immunity to S. Typhi. Finally, this is the first demonstration, in either animals or humans, of the presence of long-term multifunctional HLA-E-restricted CD8⁺ cells after immunization.Salmonella enterica serovar Typhi, the causative agent of typhoid fever, is a facultative intracellular bacterial pathogen (5, 7, 37). In industrialized countries, Salmonella infection is rare, with most infections occurring in military personnel and in individuals traveling to areas where typhoid fever is endemic. However, it remains an important public health priority in undeveloped parts of the world. Overall, it is estimated that 16 million new cases and 600,000 deaths occur annually (5, 12, 18). Our laboratory has demonstrated that oral immunization of volunteers with attenuated typhoid vaccine strain Ty21a triggers the generation of CD8⁺ T cells that kill S. Typhi-infected cells displaying human leukocyte antigen E (HLA-E) on the cell surface (27). T cells are likely to play an important role in the host defense against S. Typhi. They might contribute to Salmonella control by secreting cytokines such as gamma interferon (IFN-γ), tumor necrosis factor alpha (TNF-α), and interleukin-2 (IL-2) and by directly killing bacterium-infected cells (27, 28, 30-32, 38-40).HLA-E is a protein that is part of a family of molecules known as class Ib or nonclassical HLA molecules (26). HLA-E is expressed ubiquitously on the peripheral blood mononuclear cell (PBMC; e.g., B cells, T cells, natural killer [NK] cells, and macrophages) surface at various levels, depending on the cell type (15, 34). Because HLA-E molecules are essentially monomorphic, they are likely to present a more conserved set of bacterial peptides that could be universally recognized by CD8⁺ T cells from most, if not all, individuals.Given the potential significance of HLA-E-restricted CD8⁺ responses in resistance to Salmonella infection, it is of great importance to study these responses in depth, including their kinetics of appearance and persistence, which currently remains largely unknown. These responses might provide key insights into the open question concerning the dual role of the HLA-E molecules in short-lived innate and long-lived adaptive immunity (35). In fact, HLA-E molecules were primarily described as ligands for CD94/NKG2A, -B, and -C receptors present on the innate NK cell surface (3). However, HLA-E-restricted T cells have recently been implicated in adaptive immunity not only to Salmonella but also to cytomegalovirus and Mycobacterium (10, 22).Oral immunization with the licensed Ty21a typhoid vaccine is a particularly relevant model of Salmonella infection, which is transmitted by the ingestion of virulent S. Typhi. In the present studies, volunteers were immunized with the standard regimen of four spaced doses of Ty21a given every other day (8, 28). This vaccination regimen results in levels of protection ranging from 60 to 80% (9). Using cells from Ty21a vaccinees, we investigated the kinetics of appearance and longevity of HLA-E-restricted CD8⁺ T-cell responses for up to 2 years after immunization with the Ty21a typhoid vaccine and defined in detail the various memory T-cell subsets and effector functions mediating these responses.     

Rapid Determination of Quinolone Resistance in Acinetobacter spp.

In the treatment of serious bacterial infections, the rapid institution of appropriate antimicrobial chemotherapy may be lifesaving. Choosing the correct antibiotic or combination of antibiotics is becoming very important, as multidrug resistance is found in many pathogens. Using a collection of 75 well-characterized multidrug-resistant (MDR) Acinetobacter sp. isolates, we show that PCR followed by electrospray ionization mass spectrometry (PCR/ESI-MS) and base composition analysis of PCR amplification products can quickly and accurately identify quinolone resistance mediated by mutations in the quinolone resistance-determining regions of gyrA and parC, two essential housekeeping genes. Single point mutations detected by PCR/ESI-MS in parC (found in 55/75 of the isolates) and in gyrA (found in 66/75 of the isolates) correlated with susceptibility testing and sequencing. By targeting resistance determinants that are encoded by genes with highly conserved DNA sequences (e.g., gyrA and parC), we demonstrate that PCR/ESI-MS can provide critical information for resistance determinant identification and can inform therapeutic decision making in the treatment of Acinetobacter sp. infections.Acinetobacter baumannii is a gram-negative, aerobic, non-lactose-fermenting bacterium of increasing clinical importance (10, 14, 19, 21, 23). Since the 1980s, the number of reports describing infections due to this organism has risen dramatically (5, 16, 20). Most A. baumannii infections occur within intensive care units in patients with serious underlying disease (2, 19). Sites of infection include lung, bloodstream, urinary tract, and skin (20). In addition, A. baumannii has emerged as an important pathogen in injured United States military personnel stationed in Afghanistan and Iraq as they return to major military medical treatment facilities (14, 24-26, 31).An unwelcome feature of A. baumannii is the frequency in which isolates manifest resistance to the most commonly used antibiotics (12, 14). When resistance to three or more classes of antibiotics is demonstrated, A. baumannii is referred to as multidrug resistant (MDR) (21). Among MDR A. baumannii isolates, resistance to quinolones (e.g., ciprofloxacin and levofloxacin), aminoglycosides (e.g., gentamicin and amikacin), ampicillin-sulbactam, extended-spectrum cephalosporins (e.g., ceftazidime), and carbapenems (e.g., imipenem, meropenem, and doripenem) is escalating (21, 23). Concern exists that, if the incorrect antimicrobial agents are chosen to treat MDR A. baumannii infection, the outcome of patients may be poor (9, 22). Thus, a rapid assessment of antimicrobial susceptibility could have a significant impact on patient care.In this report, we employ a rapid high-throughput method to identify unique DNA changes associated with quinolone resistance in a collection of MDR A. baumannii isolates. The method was originally developed to identify and genotype various species of bacteria from complex mixtures in respiratory samples (6). This process uses electrospray ionization mass spectrometry (ESI-MS) and base composition analysis of PCR amplification products derived from highly conserved genes (“housekeeping genes”). The primers that are designed for PCR/ESI-MS yield amplicons with unique mass signatures that can be measured by high-performance mass spectrometry and identified by base composition analysis (7, 13).The best-described mechanism of resistance to quinolones in Acinetobacter spp. is mutations in the genes encoding DNA gyrase A (i.e., gyrA) and subunit A of topoisomerase IV (i.e., parC). The most important mutations, resulting in changes at codon 83 for gyrA and at codon 80 for parC, have been mapped to a unique location in each of these genes, the quinolone resistance-determining region (QRDR) (27, 28). Additional mutations in the QRDR of gyrA thought to enhance quinolone resistance include mutations at codons for amino acids Gly81, Ala84, and Glu87 (1, 11, 17, 27, 28, 30). Another previously described mutation (at the Val101 codon) does not appear to have an effect on the susceptibility profiles (1). Ancillary mutations in parC, at codons for amino acids Gly78 and Glu84, when combined with the Ser83 and Ser80 codon mutations, also contribute to high-level quinolone resistance (11, 27, 30).Appreciating that mutations in the housekeeping genes gyrA and parC also define the quinolone resistance phenotype, we reasoned that PCR/ESI-MS and base composition analysis can be applied to determine the sequence variability of the QRDRs of Acinetobacter spp. and rapidly predict a quinolone-resistant phenotype. Therefore, we chose to study 73 well-characterized clinical isolates of A. baumannii, one Acinetobacter genome species strain 3 isolate, and one Acinetobacter johnsonii isolate. This paper describes the novel application of this highly sensitive and specific method to the analysis of resistance phenotypes in this clinically important pathogen.     

Borrelia burgdorferi BmpA Is a Laminin-Binding Protein

The Borrelia burgdorferi BmpA outer surface protein plays a significant role in mammalian infection by the Lyme disease spirochete and is an important antigen for the serodiagnosis of human infection. B. burgdorferi adheres to host extracellular matrix components, including laminin. The results of our studies indicate that BmpA and its three paralogous proteins, BmpB, BmpC, and BmpD, all bind to mammalian laminin. BmpA did not bind mammalian type I or type IV collagens or fibronectin. BmpA-directed antibodies significantly inhibited the adherence of live B. burgdorferi to laminin. The laminin-binding domain of BmpA was mapped to the carboxy-terminal 80 amino acids. Solubilized collagen inhibited BmpA-laminin binding, suggesting interactions through the collagen-binding domains of laminin. These results, together with previous data, indicate that BmpA and its paralogs are targets for the development of preventative and curative therapies for Lyme disease.Early during the course of Lyme disease, humans frequently produce antibodies directed against a Borrelia burgdorferi antigen originally described as “P39” (66). Antibodies recognizing P39 are considered to be specific and diagnostic for Lyme disease spirochete infection (5, 18, 30, 62, 64). The antigenic protein was subsequently identified as BmpA (Borrelia membrane protein A) (65). The bmpA gene is located on the main borrelial chromosome, adjacent to three paralogous genes named bmpB, bmpC, and bmpD, which together form a complex operon (3, 4, 28, 32, 55, 56, 65). These other Bmp proteins are also often antigenic in infected humans (14). In addition to the serological data described above, examination of B. burgdorferi within skin and joint tissues confirmed the production of BmpA protein during mammalian infection (21, 49). BmpA is located in the borrelial outer membrane (46), where it is exposed to the external environment and can be a target of bactericidal antibodies (49, 63; F. Cabello, personal communication). BmpA and its paralogs have been implicated as playing roles in some symptoms of Lyme disease (49, 72). B. burgdorferi mutants in which bmpA or bmpB is specifically deleted are unable to persist in mouse joint tissues (49), indicating an important role for these proteins in the maintenance of mammalian infection. Despite the extensive research conducted on these important antigens, functions for the Bmp proteins had not been determined previously.B. burgdorferi is an extracellular organism, frequently found associated with its hosts'' connective tissues (6-9, 16, 17, 24, 26, 31, 36, 39, 48). In the laboratory, B. burgdorferi shows affinity for various host extracellular matrix (ECM) components, such as type I collagen, fibronectin, and decorin (16, 33, 34, 50, 74). We recently determined that B. burgdorferi also adheres to mammalian laminin, an important component of many mammalian ECMs (13). Ligand affinity blot analyses of a B. burgdorferi cell fraction enriched for outer membrane components revealed that the type strain, B31, can produce several distinct laminin-binding proteins, one of which we previously identified as being the surface-exposed outer membrane lipoprotein ErpX (11, 13, 69). We now present data indicating that BmpA and its paralogs are also laminin-binding proteins.     

The Capsule-Encoding viaB Locus Reduces Intestinal Inflammation by a Salmonella Pathogenicity Island 1-Independent Mechanism

Salmonella enterica serotype Typhimurium elicits acute neutrophil influx in the human intestinal mucosa within 1 or 2 days after infection, resulting in inflammatory diarrhea. In contrast, no overt symptoms are observed within the first 1 or 2 weeks after infection with S. enterica serotype Typhi. Here we show that introduction of the capsule-encoding viaB locus of serotype Typhi reduced the ability of serotype Typhimurium to elicit acute intestinal inflammation in a streptomycin-pretreated mouse model. Serotype Typhimurium requires a functional invasion-associated type III secretion system (type III secretion system 1 [T3SS-1]) to elicit cecal inflammation within 48 h after infection of streptomycin-pretreated mice, and the presence of the viaB locus reduced its invasiveness for human intestinal epithelial cells in vitro. However, a reduced activity of T3SS-1 could not account for the ability of the viaB locus to attenuate cecal inflammation, because introduction of the viaB locus into an invasion-deficient serotype Typhimurium strain (invA mutant) resulted in a significant reduction of pathology and inflammatory cytokine expression in the cecum 5 days after infection of mice. We conclude that a T3SS-1-independent mechanism contributes to the ability of the viaB locus to reduce intestinal inflammation.Salmonella enterica serotype Typhimurium causes acute gastroenteritis, characterized by exudative inflammatory infiltrates in the intestine that are dominated by neutrophils (34). Exudative inflammation and diarrhea develop within 48 h after ingesting the organisms. The orchestration of these rapid intestinal inflammatory responses can be studied using the streptomycin-pretreated mouse model (11). In this model, motility and chemotaxis contribute to the induction of inflammatory responses in the cecum at early time points, between 10 and 24 h after infection, but become dispensable at later stages, between 48 and 120 h after infection (32). Mutants that lack a functional invasion-associated type III secretion system (type III secretion system 1 [T3SS-1]) are unable to elicit cecal inflammation within the first 48 h after infection, but marked inflammatory changes with neutrophil recruitment still develop in the cecal mucosa between 72 and 120 h after infection (5). These data suggest that flagella and T3SS-1 are important for eliciting early inflammatory changes in the ceca of mice. Induction of T3SS-1-independent inflammatory changes at later stages of infection (72 to 120 h after inoculation) require the presence of a functional myeloid differentiation primary response protein 88 (MyD88), an intracellular adaptor required for signaling through bacterium-specific Toll-like receptors (TLRs) (13).In contrast to serotype Typhimurium, S. enterica serotype Typhi does not elicit neutrophil recruitment in the intestinal mucosa but instead is associated with a systemic infection termed typhoid fever (34). This disease has an incubation period of approximately 2 weeks (24), which suggests that the pathogen initially prevents the generation of marked host responses. Severe interstitial inflammation in the intestine may develop late, 2 to 3 weeks after the onset of symptoms, and may result in hemorrhage, ulceration, and intestinal perforation at areas of Peyer''s patches (4). However, neutrophils remain scarce in intestinal infiltrates of typhoid fever patients (18, 22, 23, 31). The clinical presentation of typhoid fever suggests that serotype Typhi can prevent the rapid recruitment of neutrophils that characterizes the exudative inflammatory changes observed during serotype Typhimurium-induced gastroenteritis (27).Recently, the viaB locus has been implicated in reducing the amount of neutrophil chemoattractants (CXC chemokines) produced by cultured human epithelial cells, macrophages, or colonic tissue explants in response to serotype Typhi infection (26, 38, 39). Introduction of the cloned viaB locus into serotype Typhimurium reduces neutrophil recruitment and CXC chemokine expression in bovine ligated ileal loops (28). The viaB locus contains genes involved in the regulation (tviA), biosynthesis (tviBCDE), and export (vexABCDE) of the serotype Typhi Vi capsular polysaccharide (36). The TviA regulatory protein represses expression of flagella (39), and the presence of the viaB locus reduces T3SS-1-mediated invasion (1, 41), two factors important for inducing early intestinal inflammatory responses in the streptomycin-pretreated mouse model (10, 32) and in bovine ligated ileal loops (30, 40). Flagella contribute to inflammation in the ceca of streptomycin-pretreated mice largely by conferring motility and chemotaxis (32), which in turn promotes invasion of the intestinal epithelium by increasing bacterial contact with host cells (14, 15). Collectively, these observations raise the possibility that the viaB locus may reduce intestinal inflammation in vivo because the efficiency of T3SS-1-mediated invasion is reduced. However, this idea has not been tested experimentally, in part because no animal model is available for the strictly human-adapted serotype Typhi.Here we constructed a serotype Typhimurium strain stably expressing the Vi capsular antigen to test the role of the viaB locus in attenuating cecal inflammation in the streptomycin-pretreated mouse model. Our results suggest a mechanism for viaB-mediated attenuation of inflammatory responses in vivo that is independent of the serotype Typhimurium T3SS-1.     

Characteristics of Meropenem Heteroresistance in Klebsiella pneumoniae Carbapenemase (KPC)-Producing Clinical Isolates of K. pneumoniae

Meropenem heteroresistance was investigated in six apparently meropenem-susceptible, Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) clinical isolates, compared with that in carbapenemase-negative, meropenem-susceptible controls. In population analyses, the KPC-KP isolates grew at meropenem concentrations of 64 to 256 μg/ml. Heteroresistant colonies had significantly elevated expression of the bla_KPC gene compared with the native populations but did not retain heteroresistance when subcultured in drug-free media. Time-kill assays indicated that meropenem alone was not bactericidal against KPC-KP but efficiently killed the control strains.Since the beginning of the last decade, Klebsiella pneumoniae carbapenemase (KPC)-producing K. pneumoniae (KPC-KP) isolates have been increasingly detected in the United States and subsequently in several regions worldwide (3, 4, 13, 17, 21). KPC enzymes efficiently hydrolyze all β-lactam molecules (1, 22), conferring various levels of resistance to all β-lactam compounds, including carbapenems (13). However, KPC-producing K. pneumoniae may appear susceptible to carbapenems, mainly meropenem (2, 13), by reference CLSI agar dilution or broth microdilution methods as well as by automated systems (6, 15, 17). Characteristically, it has been reported that automated systems may identify as many as 87% of KPC-KP isolates to be susceptible to meropenem (13). The detection of the susceptibility level of KPC-KP isolates to carbapenems has been shown to be difficult due to the phenotypic heterogeneity that they commonly exhibit (3, 10, 13). For instance, in agar diffusion methods such as disk diffusion or Etest, the heterogeneous growth to carbapenems of KPC-KP results in the appearance of scattered colonies within the inhibition zones (9, 13).These issues raise the need for cautious evaluation of susceptibility testing in KPC-KP isolates that are recovered in clinical laboratories. In our clinical laboratories, several KPC-KP isolates that appear susceptible by automated susceptibility assays or reference dilution assays contain heterogeneous subpopulations (D. Sofianou and K. Themeli-Digalaki, personal communications). It has been also shown that among Greek KPC-KP isolates, meropenem tends to exhibit lower MICs than imipenem or ertapenem (17, 20). In that respect, the aim of the present study was to characterize the heterogeneous mode of growth of apparently meropenem-susceptible KPC-KP clinical isolates by population analyses and bactericidal assays.     

Glyceraldehyde-3-Phosphate Dehydrogenase Is a Surface-Associated,Fibronectin-Binding Protein of Trichomonas vaginalis

Trichomonas vaginalis colonizes the urogenital tract of humans and causes trichomonosis, the most prevalent nonviral sexually transmitted disease. We have shown an association of T. vaginalis with basement membrane extracellular matrix components, a property which we hypothesize is important for colonization and persistence. In this study, we identify a fibronectin (FN)-binding protein of T. vaginalis. A monoclonal antibody (MAb) from a library of hybridomas that inhibited the binding of T. vaginalis organisms to immobilized FN was identified. The MAb (called ws1) recognized a 39-kDa protein and was used to screen a cDNA expression library of T. vaginalis. A 1,086-bp reactive cDNA clone that encoded a protein of 362 amino acids with identity to glyceraldehyde-3-phosphate dehydrogenase (GAPDH) was obtained. The gapdh gene was cloned, and recombinant GAPDH (rGAPDH) was expressed in Escherichia coli cells. Natural GAPDH and rGAPDH bound to immobilized FN and to plasminogen and collagen but not to laminin. MAb ws1 inhibited binding to FN. GAPDH was detected on the surface of trichomonads and was upregulated in synthesis and surface expression by iron. Higher levels of binding to FN were seen for organisms grown in iron-replete medium than for organisms grown in iron-depleted medium. In addition, decreased synthesis of GAPDH by antisense transfection of T. vaginalis gave lower levels of organisms bound to FN and had no adverse effect on growth kinetics. Finally, GAPDH did not associate with immortalized vaginal epithelial cells (VECs), and neither GAPDH nor MAb ws1 inhibited the adherence of trichomonads to VECs. These results indicate that GAPDH is a surface-associated protein of T. vaginalis with alternative functions.Trichomonas vaginalis, an extracellular protozoan parasite, is the cause of trichomonosis, the most prevalent nonviral sexually transmitted disease (47). In women, vaginitis due to T. vaginalis clinically manifests with symptoms of vaginal itching, odor, and discharge. Adverse health outcomes for women with this sexually transmitted disease include cervical cancer (46) and preterm delivery and low-birth-weight infants (25). There is a relationship between seropositivity to T. vaginalis and prostate cancer (43). This disease is significant due to its association with human immunodeficiency virus (33, 45). More recently, persistent, undetected T. vaginalis infections associated with asymptomatic carriage were found among women (40).T. vaginalis penetration of the mucous layer (28), followed by adherence to vaginal epithelial cells (VECs), is preparatory for colonization (9, 10). VEC adherence by parasites is mediated by numerous distinct trichomonad surface adhesins (5, 10, 18). Brief contact of T. vaginalis with VECs and fibronectin (FN) elicited dramatic changes in parasite morphology, suggesting a host-specific signaling of parasites (8, 9). Importantly, iron and cell contact by parasites each upregulated the expression of adhesins in a coordinated fashion via distinct mechanisms (2, 4, 6, 21, 29). Genetic approaches using antisense (AS) inhibition of synthesis (36, 37) and heterologous expression in Tritrichomonas foetus (26, 36) have reaffirmed the role of these T. vaginalis proteins as adhesins. T. vaginalis organisms secrete or release numerous metabolic enzymes, including adhesin AP65 (decarboxylating malic enzyme), α-enolase, and glyceraldehyde-3-phosphate dehydrogenase (GAPDH) during growth and multiplication (27). AP65 and α-enolase were found to reassociate with the parasite surface for the expression of adhesin function (19) and binding to plasminogen (35), respectively.There is an increased awareness of the existence of metabolic enzymes on the surfaces of bacterial pathogens, yeast, and parasites (12, 24, 35). These surface-associated enzymes appear to be novel virulence factors (17, 22, 38, 39). The anchorless glycolytic enzymes GAPDH (13, 31, 38) and α-enolase (39) are present on the surface of group A streptococcus. The surface-associated GAPDH of Candida albicans binds with strong affinity to FN and laminin (22). In enterohemorrhagic Escherichia coli and enteropathogenic E. coli, GAPDH is an extracellular protein that binds human plasminogen and fibrinogen and also interacts with intestinal epithelial cells (17).We demonstrate that GAPDH is another enzyme on the surface of T. vaginalis. A monoclonal antibody (MAb) that inhibited parasite associations with FN was immunoreactive with GAPDH. Importantly, iron was found to regulate gene expression and synthesis and surface placement of GAPDH. Both low-iron-grown trichomonads and AS-transfected parasites with decreased amounts of GAPDH had smaller amounts of surface GAPDH and corresponding lower levels of binding to FN. GAPDH was not involved in adherence of trichomonads to immortalized VECs. Interestingly, as with other microbial pathogens, T. vaginalis GAPDH also bound plasminogen and collagen but not laminin (17, 22).     

Vancomycin MIC plus Heteroresistance and Outcome of Methicillin-Resistant Staphylococcus aureus Bacteremia: Trends over 11 Years

Vancomycin MICs (V-MIC) and the frequency of heteroresistant vancomycin-intermediate Staphylococcus aureus (hVISA) isolates are increasing among methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) isolates, but their relevance remains uncertain. We compared the V-MIC (Etest) and the frequency of hVISA (Etest macromethod) for all MRSA blood isolates saved over an 11-year span and correlated the results with the clinical outcome. We tested 489 isolates: 61, 55, 187, and 186 isolates recovered in 1996-1997, 2000, 2002-2003, and 2005-2006, respectively. The V-MICs were ≤1, 1.5, 2, and 3 μg/ml for 74 (15.1%), 355 (72.6%), 50 (10.2%), and 10 (2.1%) isolates, respectively. We detected hVISA in 0/74, 48/355 (13.5%), 15/50 (30.0%), and 8/10 (80.0%) isolates with V-MICs of ≤1, 1.5, 2, and 3 μg/ml, respectively (P < 0.001). The V-MIC distribution and the hVISA frequency were stable over the 11-year period. Most patients (89.0%) received vancomycin. The mortality rate (evaluated with 285 patients for whose isolates the trough V-MIC was ≥10 μg/ml) was comparable for patients whose isolates had V-MICs of ≤1 and 1.5 μg/ml (19.4% and 27.0%, respectively; P = 0.2) but higher for patients whose isolates had V-MICs of ≥2 μg/ml (47.6%; P = 0.03). However, the impact of V-MIC and hVISA status on mortality or persistent (≥7 days) bacteremia was not substantiated by multivariate analysis. Staphylococcal chromosome cassette mec (SCCmec) typing of 261 isolates (including all hVISA isolates) revealed that 93.0% of the hVISA isolates were SCCmec type II. These findings demonstrate that the V-MIC distribution and hVISA frequencies were stable over an 11-year span. A V-MIC of ≥2 μg/ml was associated with a higher rate of mortality by univariate analysis, but the relevance of the V-MIC and the presence of hVISA remain uncertain. A multicenter prospective randomized study by the use of standardized methods is needed to evaluate the relevance of hVISA and determine the optimal treatment of patients whose isolates have V-MICs of ≥2.0 μg/ml.The treatment of methicillin (meticillin)-resistant Staphylococcus aureus (MRSA) bacteremia with vancomycin is often associated with a poor clinical outcome (6, 15, 28, 40). Treatment failure was reported among patients infected with isolates whose vancomycin MICs were ≥4 μg/ml (6, 9, 12, 25, 28, 42). This prompted the Clinical and Laboratory Standards Institute to lower the cutoffs for S. aureus susceptibility to ≤2 μg/ml for susceptible, 4 to 8 μg/ml for intermediate (vancomycin-intermediate S. aureus [VISA]), and 16 μg/ml for resistance (39). Within the susceptibility range, the MIC is reported to increase over time (14, 25, 35-40). This is often referred to as MIC creep (38). Additionally, isolates with heteroresistance (heteroresistant vancomycin-intermediate S. aureus [hVISA]) are emerging, and this has uncertain implications for laboratory detection and clinical management (2, 5, 15, 24, 40-42). The first isolate of hVISA to be identified was reported from Japan in 1997 (11). Since then, it has been reported worldwide at frequencies of 0 to 50% (2, 4, 6, 9, 12, 19, 20, 21, 24, 26, 27, 31, 40, 42, 44). This disparity in frequency is probably a result of its variable incidence and the different testing methodologies used. Likewise, the frequency of isolates with MICs of 1.5 to <4 μg/ml varies according to the testing method used (3, 32). The relevance of an MIC on the higher side of the susceptibility range and the presence of hVISA isolates remains uncertain (8, 19, 21). Therapeutic failure was reported in patients infected with isolates with vancomycin MICs of 2 μg/ml (6, 12, 28) and 1.5 or 1 μg/ml (25, 34, 37). Most clinical microbiology laboratories use automated testing methods that are known to underestimate the vancomycin MIC (13, 24). Additionally, most previous studies addressing the relevance of such isolates were observational and usually involved only a few patients and poorly selected controls (1, 4, 7, 9, 12, 14, 25, 35, 38, 42). At our institution, we found the frequency of hVISA isolates among isolates from patients with persistent MRSA bacteremia to be 14%; however, heteroresistance did not correlate with the mortality rate (19). In the current study, we tested all blood MRSA isolates collected over 11 years to determine whether the vancomycin MIC and the prevalence of hVISA have changed over time and to evaluate the effects of increasing vancomycin MICs and the hVISA frequency on patient outcomes.     

Hag Mediates Adherence of Moraxella catarrhalis to Ciliated Human Airway Cells

Moraxella catarrhalis is a human pathogen causing otitis media in infants and respiratory infections in adults, particularly patients with chronic obstructive pulmonary disease. The surface protein Hag (also designated MID) has previously been shown to be a key adherence factor for several epithelial cell lines relevant to pathogenesis by M. catarrhalis, including NCIH292 lung cells, middle ear cells, and A549 type II pneumocytes. In this study, we demonstrate that Hag mediates adherence to air-liquid interface cultures of normal human bronchial epithelium (NHBE) exhibiting mucociliary activity. Immunofluorescent staining and laser scanning confocal microscopy experiments demonstrated that the M. catarrhalis wild-type isolates O35E, O12E, TTA37, V1171, and McGHS1 bind principally to ciliated NHBE cells and that their corresponding hag mutant strains no longer associate with cilia. The hag gene product of M. catarrhalis isolate O35E was expressed in the heterologous genetic background of a nonadherent Haemophilus influenzae strain, and quantitative assays revealed that the adherence of these recombinant bacteria to NHBE cultures was increased 27-fold. These experiments conclusively demonstrate that the hag gene product is responsible for the previously unidentified tropism of M. catarrhalis for ciliated NHBE cells.Moraxella catarrhalis is a gram-negative pathogen of the middle ear and lower respiratory tract (29, 40, 51, 52, 69, 78). The organism is responsible for ∼15% of bacterial otitis media cases in children and up to 10% of infectious exacerbations in patients with chronic obstructive pulmonary disease (COPD). The cost of treating these ailments places a large financial burden on the health care system, adding up to well over $10 billion per annum in the United States alone (29, 40, 52, 95, 97). In recent years, M. catarrhalis has also been increasingly associated with infections such as bronchitis, conjunctivitis, sinusitis, bacteremia, pneumonia, meningitis, pericarditis, and endocarditis (3, 12, 13, 17-19, 24, 25, 27, 51, 67, 70, 72, 92, 99, 102-104). Therefore, the organism is emerging as an important health problem.M. catarrhalis infections are a matter of concern due to high carriage rates in children, the lack of a preventative vaccine, and the rapid emergence of antibiotic resistance in clinical isolates. Virtually all M. catarrhalis strains are resistant to β-lactams (34, 47, 48, 50, 53, 65, 81, 84). The genes specifying this resistance appear to be gram positive in origin (14, 15), suggesting that the organism could acquire genes conferring resistance to other antibiotics via horizontal transfer. Carriage rates as high as 81.6% have been reported for children (39, 104). In one study, Faden and colleagues analyzed the nasopharynx of 120 children over a 2-year period and showed that 77.5% of these patients became colonized by M. catarrhalis (35). These investigators also observed a direct relationship between the development of otitis media and the frequency of colonization. This high carriage rate, coupled with the emergence of antibiotic resistance, suggests that M. catarrhalis infections may become more prevalent and difficult to treat. This emphasizes the need to study pathogenesis by this bacterium in order to identify vaccine candidates and new targets for therapeutic approaches.One key aspect of pathogenesis by most infectious agents is adherence to mucosal surfaces, because it leads to colonization of the host (11, 16, 83, 93). Crucial to this process are surface proteins termed adhesins, which mediate the binding of microorganisms to human cells and are potential targets for vaccine development. M. catarrhalis has been shown to express several adhesins, namely UspA1 (20, 21, 59, 60, 77, 98), UspA2H (59, 75), Hag (also designated MID) (22, 23, 37, 42, 66), OMPCD (4, 41), McaP (61, 100), and a type 4 pilus (63, 64), as well as the filamentous hemagglutinin-like proteins MhaB1, MhaB2, MchA1, and MchA2 (7, 79). Each of these adhesins was characterized by demonstrating a decrease in the adherence of mutant strains to a variety of human-derived epithelial cell lines, including A549 type II pneumocytes and Chang conjunctival, NCIH292 lung mucoepidermoid, HEp2 laryngeal, and 16HBE14o-polarized bronchial cells. Although all of these cell types are relevant to the diseases caused by M. catarrhalis, they lack important aspects of the pathogen-targeted mucosa, such as the features of cilia and mucociliary activity. The ciliated cells of the respiratory tract and other mucosal membranes keep secretions moving out of the body so as to assist in preventing colonization by invading microbial pathogens (10, 26, 71, 91). Given this critical role in host defense, it is interesting to note that a few bacterial pathogens target ciliated cells for adherence, including Actinobacillus pleuropneumoniae (32), Pseudomonas aeruginosa (38, 108), Mycoplasma pneumoniae (58), Mycoplasma hyopneumoniae (44, 45), and Bordetella species (5, 62, 85, 101).In the present study, M. catarrhalis is shown to specifically bind to ciliated cells of a normal human bronchial epithelium (NHBE) culture exhibiting mucociliary activity. This tropism was found to be conserved among isolates, and analysis of mutants revealed a direct role for the adhesin Hag in binding to ciliated airway cells.