Antifungal therapy in patients with pulmonary Candida spp. colonization may have no beneficial effects.

BACKGROUND: In critically ill patients, Candida spp. can often be identified in pulmonary samples. The impact of prompt antifungal therapy in these patients is unknown. METHODS: In this retrospective study, 500 adult patients with pulmonary Candida spp. colonization admitted to the intensive care unit (ICU) between 2010 and 2012 were included. The patients were analyzed according to whether or not they received antifungal therapy, which was administered at the discretion of the attending physician. Logistic regression analysis was performed to investigate the impact of antifungal therapy on hospital mortality and new onset of ventilator-associated pneumonia. In a stepwise backward elimination, the impact of age, cancer as an underlying disease, Simplified Acute Physiology Score (SAPS) II, and Sequential Organ Failure Assessment (SOFA) score were considered. RESULTS: After excluding 178 patients with multifocal Candida spp., isolated pulmonary Candida spp. colonization was found in 322 patients (cohort 1). Pre-existing pneumonia was found in 147/322 patients. Out of the remaining 175 patients (cohort 2), 44 patients received any antifungal therapy, and 131 were defined as the control group. Patients who received antifungal therapy had higher hospital mortality (50 vs. 30 %, p = 0.02) and pneumonia rates (47.7 vs. 16.8 %; p < 0.001) than those who did not. In Cox regression analysis, antifungal therapy was not independently associated with favorable outcome (mortality: odds ratio 0.854 (95 % CI 0.467-1.561); new pneumonia: 1.048 (0.536-2.046)), but SAPS II and SOFA score were significantly (p < 0.05) independent covariates for worse outcome. CONCLUSIONS: In critically ill patients with pulmonary Candida spp. colonization, antifungal therapy may not have an impact on the incidence of new pneumonia or in-hospital mortality after adjustment for confounders.

The relapsing fever spirochete Borrelia miyamotoi resists complement-mediated killing by human serum.

Borrelia miyamotoi, a relapsing fever spirochete transmitted by ixodid ticks, is able to cause infections associated with systemic complaints, including malaise and fever, as well as meningoencephalitis in immunocompromised patients. In order to elucidate immune evasion of previously difficult to cultivate B. miyamotoi, we have examined the ability of this newly emerging human pathogen to escape the complement system. Growth inhibition assays revealed that B. miyamotoi is strongly resistant to complement-mediated bacteriolysis. Investigating complement activation, we found that B. miyamotoi showed reduced deposition of components C3, C5, C7, C8, C9 as well as the membrane attack complex (MAC) on the borrelial surface. In addition, no aberrations in cell morphology were observed after incubation of B. miyamotoi in active human serum, confirming the findings of the growth inhibition assay. The data presented here provide strong evidence that B. miyamotoi overcome human complement by affecting the central complement component C3, thereby inhibiting formation of the C3 convertase and downstream activation of the complement cascade.

Identification and characterization of the factor H and FHL-1 binding complement regulator-acquiring surface protein 1 of the Lyme disease spirochete Borrelia spielmanii sp. nov.

Borrelia spielmanii, one of the etiological agents of Lyme disease found in Europe, evades host complement-mediated killing by recruitment of the immune regulators factor H and FHL-1 from human serum. Serum-resistant and intermediate serum-resistant isolates express up to 3 distinct complement regulator-acquiring surface proteins (CRASPs) that bind factor H and/or FHL-1. The present study describes identification and functional characterization of BsCRASP-1 as the dominant factor H and FHL-1 binding protein of B. spielmanii. BsCRASP-1 is a 27.7kDa outer surface lipoprotein, which after processing has a predicted mass of 24.9kDa. BsCRASP-1 is encoded by a single copy gene, cspA, that maps to a linear plasmid of approximately 55kb. Ligand affinity blot techniques revealed that both native and recombinant BsCRASP-1 from different isolates can strongly bind FHL-1, but only weakly factor H. Deletion mutants of recombinant BsCRASP-1 were generated and a high-affinity binding site for factor H and FHL-1 was mapped to its carboxy-terminal 10-amino-acid residue domain. Similarly, the dominant binding site of factor H and FHL-1 was localized to short consensus repeats (SCRs) 5-7. Factor H and FHL-1 maintained cofactor activity for factor I-mediated C3b inactivation when bound to full-length BsCRASP-1 but not to a deletion mutant lacking the carboxy-terminal 10-amino-acid residue domain. In conclusion, BsCRASP-1 binds the host immune regulators factor H and FHL-1, and is suggested to represent a key molecule of B. spielmanii for complement resistance. Thus, BsCRASP-1 most likely contributes to persistence of B. spielmanii and to pathogenesis of Lyme disease.

Human pathogenic Borrelia spielmanii sp. nov. resists complement-mediated killing by direct binding of immune regulators factor H and factor H-like protein 1.

Borrelia spielmanii sp. nov. has recently been shown to be a novel human pathogenic genospecies that causes Lyme disease in Europe. In order to elucidate the immune evasion mechanisms of B. spielmanii, we compared the abilities of isolates obtained from Lyme disease patients and tick isolate PC-Eq17 to escape from complement-mediated bacteriolysis. Using a growth inhibition assay, we show that four B. spielmanii isolates, including PC-Eq17, are serum resistant, whereas a single isolate, PMew, was more sensitive to complement-mediated lysis. All isolates activated complement in vitro, as demonstrated by covalent attachment of C3 fragments; however, deposition of the later activation products C6 and C5b-9 was restricted to the moderately serum-resistant isolate PMew and the serum-sensitive B. garinii isolate G1. Furthermore, serum adsorption experiments revealed that all B. spielmanii isolates acquired the host alternative pathway regulators factor H and factor H-like protein (FHL-1) from human serum. Both complement regulators retained their factor I-mediated C3b inactivation activities when bound to spirochetes. In addition, two distinct factor H and FHL-1 binding proteins, BsCRASP-1 and BsCRASP-2, were identified, which we estimated to be approximately 23 to 25 kDa in mass. A further factor H binding protein, BsCRASP-3, was found exclusively in the tick isolate, PC-Eq17. This is the first report describing an immune evasion mechanism utilized by B. spielmanii sp. nov., and it demonstrates the capture of human immune regulators to resist complement-mediated killing.

Dual binding specificity of a Borrelia hermsii-associated complement regulator-acquiring surface protein for factor H and plasminogen discloses a putative virulence factor of relapsing fever spirochetes.

Tick-borne relapsing fever in North America is primarily caused by the spirochete Borrelia hermsii. The pathogen employs multiple strategies, including the acquisition of complement regulators and antigenic variation, to escape innate and humoral immunity. In this study we identified in B. hermsii a novel member of the complement regulator-acquiring surface protein (CRASP) family, designated BhCRASP-1, that binds the complement regulators factor H (FH) and FH-related protein 1 (FHR-1) but not FH-like protein 1 (FHL-1). BhCRASP-1 specifically interacts with the short consensus repeat 20 of FH, thereby maintaining FH-associated cofactor activity for factor I-mediated C3b inactivation. Furthermore, ectopic expression of BhCRASP- 1 converted the serum-sensitive Borrelia burgdorferi B313 strain into an intermediate complement-resistant strain. Finally, we report for the first time that BhCRASP-1 binds plasminogen/plasmin in addition to FH via, however, distinct nonoverlapping domains. The fact that surface-bound plasmin retains its proteolytic activity suggest that the dual binding specificity of BhCRASP-1 for FH and plasminogen/plasmin contributes to both the dissemination/invasion of B. hermsii and its resistance to innate immunity.