Role of hemolysin BL in the pathogenesis of extraintestinal Bacillus cereus infection assessed in an endophthalmitis model.

Bacillus cereus is a rare cause of serious human infection but, paradoxically, causes one of the most severe posttraumatic or endogenous infections of the eye, endophthalmitis, which frequently results in blindness. The virulence of B. cereus endophthalmitis historically has been attributed to toxin production. We therefore sought to examine the contribution of the dermonecrotic toxin, hemolysin BL, to the pathogenesis of B. cereus infection in an endophthalmitis system that is highly amenable to study. The pathogenesis of infection resulting from intravitreal injection of 10(2) CFU of either a clinical ocular isolate of B. cereus producing hemolysin BL (HBL+) or an isogenic mutant in this trait (HBL-) was assessed bacteriologically and by slit lamp biomicroscopy, electroretinography, histology, and inflammatory cell enumeration. Both HBL+ and HBL- strains evoked severe intraocular inflammatory responses as early as 12 h postinfection, with complete loss of retinal responsiveness by 12 h. The infections caused by both strains spread of the infection to adjacent tissues by 18 h. No significant differences in intraocular bacterial growth (P >/= 0.21) or inflammatory changes (P >/= 0.21) were observed in eyes infected with either HBL+ or HBL- strains during the course of infection. The level of retinal responsiveness was greater in HBL- infected eyes than in HBL+-infected eyes at 6 h only (P = 0.01). These results indicate that hemolysin BL makes no essential contribution to the severe and rapid course of infection in the endophthalmitis model.

Pathogenesis of gram-positive bacterial endophthalmitis.

The severity of endophthalmitis has been associated generally with the virulence of the offending pathogen. However, precisely what constitutes the virulence in intraocular infections remains ill defined. We therefore sought to identify the basis for virulence for three common ocular pathogens (Bacillus cereus, Enterococcus faecalis, and Staphylococcus aureus) in terms of intraocular growth rates, bacterial localization patterns, and the contribution of cell walls and secreted products to the pathogenesis of endophthalmitis. Rabbit eyes were injected intravitreally with (i) viable B. cereus, E. faecalis, or S. aureus, (ii) metabolically inactive B. cereus, E. faecalis, or S. aureus, (iii) sacculus preparations from each strain, or (iv) culture fluid containing products secreted by each strain. Eyes were assessed at various times following injection by slit lamp biomicroscopy, electroretinography (ERG), bacterial and inflammatory cell enumeration, and histology. B. cereus endophthalmitis followed a more rapid and virulent course than E. faecalis or S. aureus endophthalmitis, eliminating retinal responsiveness, as measured by ERG, by 12 h. Analysis of bacterial localization revealed that B. cereus uniquely migrated rapidly from posterior to anterior segment during infection. Although injection of neither metabolically inactive bacteria nor cell wall sacculi greatly affected ERG, significant intraocular inflammation was observed. Injection of B. cereus or S. aureus culture fluids caused both significant reductions in retinal responsiveness and significant intraocular inflammation, paralleling that seen in natural infections. The results demonstrate that toxins, intraocular localization, and, to a lesser extent, the intraocular host response to cell walls all contribute to the pathogenesis of B. cereus, S. aureus, and E. faecalis endophthalmitis in a pathogen-specific manner. The key pathophysiologic differences in these intraocular diseases highlight opportunities for optimizing conventional therapies and deriving new ones.

Ceftazidime-resistant Klebsiella pneumoniae and Escherichia coli isolates producing TEM-10 and TEM-43 beta-lactamases from St. Louis, Missouri.

Ceftazidime-resistant Escherichia coli and Klebsiella pneumoniae (49 and 102 isolates, respectively) were collected from Barnes-Jewish Hospital, St. Louis, Mo., from 1992 to 1996. They were uniformly resistant to ceftazidime, generally resistant to aztreonam, and variably susceptible to cefotaxime. Four representative E. coli strains and 15 Klebsiella strains were examined. From one to four beta-lactamases were produced per strain, with three possible enzymes related to ceftazidime resistance: enzymes with pI values of 5.6, 6.1, or 7.6. By pulsed-field gel electrophoresis there were at least 13 different Klebsiella strain types and 3 different E. coli strain types, indicating that the outbreak was not clonal. After cloning and sequencing of the beta-lactamase-encoding genes, the enzyme with a pI of 5.6 was identified as TEM-10. The enzyme with a pI of 6.1 was a novel TEM variant (TEM-43) with Lys at 104, His at 164, and Thr at 182. TEM-43 showed broad-spectrum hydrolytic activity against all penicillins, with the highest hydrolysis rate for ceftazidime compared to those for the other expanded-spectrum cephalosporins. Aztreonam was also a good substrate for TEM-43, with hydrolytic activity similar to that of ceftazidime and affinity higher than that of ceftazidime. The TEM-43 beta-lactamase was well inhibited by clavulanic acid and tazobactam at concentrations of < 10 nM. Sulbactam was less effective than the other inhibitors. The Thr182 mutation previously reported in an inhibitor-resistant beta-lactamase did not cause the TEM-43 enzyme to become resistant to any of the inhibitors.

Enterococcus faecalis localization in experimental endophthalmitis: role of plasmid-encoded aggregation substance.

Enterococci have emerged as leading agents of nosocomial infection, yet relatively little is known about the pathogenesis of enterococcal disease. In previous studies, we developed an Enterococcus faecalis endophthalmitis infection model which provides unique opportunities to study the evolution of enterococcal disease by direct observation, as well as through sensitive electrophysiologic measures of organ function. The present study was designed to determine whether E. faecalis possesses traits that permit its attachment to mammalian tissues during infection. It was also of interest to determine whether a plasmid-encoded adhesin, aggregation substance, contributes to enterococcal localization or otherwise mediates adherence to alternate sites. These studies found that, in this model, enterococci attach to membranous structures occurring within the vitreous but that this attachment or the course or severity of disease is unaffected by the aggregation substance phenotype.

Molecular epidemiology of Staphylococcus aureus and Enterococcus faecalis in endophthalmitis.

Genomic DNA fingerprint analysis was performed on 39 Staphylococcus aureus and 28 Enterococcus faecalis endophthalmitis isolates collected from multiple clinical centers. Among 21 S. aureus genomic DNA fingerprint patterns identified, five clonotypes were recovered from multiple unrelated patients and accounted for 58.9% (23 of 39) of the isolates analyzed. Compared with strains having unique genomic DNA fingerprint patterns, the S. aureus clonotypes occurring more than once were more likely to result in visual acuities of 20/200 or worse (P = 0.036 [chi2 test]). In contrast to the S. aureus isolates, the E. faecalis endophthalmitis isolates were a clonally diverse population, enriched for the expression of a known toxin, cytolysin, which is plasmid encoded.

Staphylococcal accessory regulator (sar) in conjunction with agr contributes to Staphylococcus aureus virulence in endophthalmitis.

Previous studies showed that an agr mutant strain of Staphylococcus aureus was partially attenuated in virulence compared to a parental strain in experimental endophthalmitis. The purpose of this study was to determine whether the sar locus, either alone or through interactions with agr, contributes to the regulation of virulence in S. aureus endophthalmitis. Experimental endophthalmitis was established by the midvitreous injection of approximately 30 CFU of S. aureus RN6390 or the isogenic attenuated strains RN6911 (agr mutant), ALC136 (sar mutant), and ALC135 (agr sar double mutant). Unexpectedly, the rate of reduction in electroretinographic B-wave amplitude in eyes infected with strain ALC136 (sar mutant) was not significantly different from the parental strain on postinfection day (PID) 5 (10% retention). In contrast, ALC135 (agr sar double mutant)-infected eyes retained 73% of preoperative B-wave amplitude on PID 5. Therefore, unlike agr, a mutation in the sar locus alone does not alter the overall virulence of wild-type S. aureus in experimental endophthalmitis. However, the combined effect of insertional mutations in both the sar and agr global regulators leads to near-complete attenuation of virulence.

Host/parasite interactions in bacterial endophthalmitis.

Bacterial infections within the eye arise as complications of intraocular surgery, penetrating injury, or hematogenous spread from distant anatomical sites. Because: 1) the interior surfaces of the eye are lined with sensitive, nonregenerating tissues, 2) the inner chambers of the eye are relatively sequestered from circulating immunological components, 3) the integrity of blood-ocular barriers provides poor penetration of systemically administered antibiotics, and 4) aqueous and vitreous humor represent rich, relatively acellular culture media; endophthalmitis often progresses rapidly and total loss of vision frequently results. Years of clinical experience have shown that current therapies for endophthalmitis, including antimicrobials, antiinflammatory agents, and vitrectomy, are frequently unsuccessful in ameliorating destruction of intraocular tissues. While bacterial and host factors were thought to play key roles in the course and severity of endophthalmitis, it is only recently that their contributions have been experimentally defined. Molecular-based techniques are gaining increased use in the study of infectious eye diseases. Current findings regarding the host/parasite interactions within the eye are reviewed, and a resulting integrative model of the natural course of endophthalmitis proposed. A molecular-level understanding of the roles of both bacterial and host factors during endophthalmitis will likely reveal potential targets for therapeutic intervention aimed at salvaging vision.

In vitro activities of various beta-lactam antimicrobial agents against clinical isolates of Escherichia coli and Klebsiella spp. resistant to oxyimino cephalosporins.

Broth microdilution testing was used to study the activity of several beta-lactam antimicrobial agents, including piperacillin-tazobactam and cefepime, against 108 clinically derived Escherichia coli and Klebsiella sp. strains resistant to oxyimino cephalosporins (i.e., putative extended-spectrum beta-lactamase producers). On the basis of the percentage of susceptible strains, imipenem (100%), cefotetan (> or = 92%), and piperacillin-tazobactam (> or = 86%) were the most active agents. Cefepime activity (52 to 64% susceptible) was comparable to that of cefotaxime (40 to 63% susceptible) and aztreonam (20 to 63% susceptible). Among all beta-lactams tested, imipenem and cefotetan demonstrated the highest and most consistent level of activity and were the least affected by challenges with increased sizes of inocula of these resistant organisms.

Evaluation of therapeutic measures for treating endophthalmitis caused by isogenic toxin-producing and toxin-nonproducing Enterococcus faecalis strains.

PURPOSE: Management of endophthalmitis typically includes antibiotic combinations to arrest bacterial growth and antiinflammatory agents to limit inflammatory damage to sensitive tissues. Little research has been reported that systematically evaluates the contribution of each therapeutic component for treating infections caused by organisms of varying virulence. The authors determined the relative value of the antinflammatory corticosteroid, dexamethasone, as an intravitreal therapeutic adjunct for the treatment of infection caused by either Enterococcus faecalis expressing a cytolytic toxin previously shown to contribute to the course and severity of infection, or an otherwise identical strain of E. faecalis specifically attenuated in expression of the cytolytic toxin. METHODS: Endophthalmitis in rabbits was monitored using electroretinography (ERG). Eyes were infected with 100 colony forming units of either the cytolytic or the noncytolytic E. faecalis strain. Intravitreal ampicillin and gentamicin were administered at postinfection day 1, and intravitreal dexamethasone was either omitted or administered at day -1, 1, or 1.5. RESULTS: ERG B-wave amplitude declined precipitously throughout the course of infection with cytolytic toxin-producing E. faecalis, despite the administration of antibiotics and regardless of the time of dexamethasone administration. In fact, the ultimate course of infection caused by cytolytic E. faecalis did not differ from the course in untreated controls. In contrast, infections caused by specifically attenuated, noncytolytic strains of E. faecalis responded well to antibiotics augmented by antiinflammatory therapy when the latter was administered either 1 or 1.5 days after the initiation of infection. In these cases, no loss in ERG B-wave response was observed. CONCLUSIONS: These results underscore the importance of bacterial toxins in infectious diseases of the eye and their contribution to treatment failures. These results further suggest that in cases of endophthalmitis caused by toxin producing bacteria, significant improvement in clinical outcome will require specific therapeutic targeting of the toxins involved.

Virulence of enterococci.

Enterococci are commensal organisms well suited to survival in intestinal and vaginal tracts and the oral cavity. However, as for most bacteria described as causing human disease, enterococci also possess properties that can be ascribed roles in pathogenesis. The natural ability of enterococci to readily acquire, accumulate, and share extrachromosomal elements encoding virulence traits or antibiotic resistance genes lends advantages to their survival under unusual environmental stresses and in part explains their increasing importance as nosocomial pathogens. This review discusses the current understanding of enterococcal virulence relating to (i) adherence to host tissues, (ii) invasion and abscess formation, (iii) factors potentially relevant to modulation of host inflammatory responses, and (iv) potentially toxic secreted products. Aggregation substance, surface carbohydrates, or fibronectin-binding moieties may facilitate adherence to host tissues. Enterococcus faecalis appears to have the capacity to translocate across intact intestinal mucosa in models of antibiotic-induced superinfection. Extracellular toxins such as cytolysin can induce tissue damage as shown in an endophthalmitis model, increase mortality in combination with aggregation substance in an endocarditis model, and cause systemic toxicity in a murine peritonitis model. Finally, lipoteichoic acid, superoxide production, or pheromones and corresponding peptide inhibitors each may modulate local inflammatory reactions.

Transfer of pheromone-inducible plasmids between Enterococcus faecalis in the Syrian hamster gastrointestinal tract.

Pheromone-responsive plasmids are common to Enterococcus faecalis, transfer at high frequency in vitro, and carry cytolysin and other gene products implicated in the pathogenesis of enterococcal infection. A Syrian hamster model of enterococcal intestinal overgrowth was used to test for transfer of three isogenic plasmids differing in conjugative and cytolytic phenotypes. Transconjugants were found in 8 (44%) of 18 and 6 (35%) of 17 hamsters given donor strains containing cytolytic (pAM714) and noncytolytic (pAM771) pheromone-responsive plasmids. Of the 14 hamsters from which transconjugants were isolated from stool, 9 (64%) had transconjugants 1 day after donor strain inoculation. The frequency of transfer (mean +/- SD) for pAM714 and pAM771 was 1.4 +/- 2.2 x 10(-1) and 2.9 +/- 4.2 x 10(-2) transconjugants/donor, respectively (P > .20). Transconjugants were not recovered from hamsters receiving a cytolytic, nonconjugative plasmid (pAM930; transfer frequency < 2 x 10(-5) transconjugants/donor). Pheromone-responsive plasmid transfer between E. faecalis strains occurs at high frequency in the gastrointestinal tract of hamsters and may be one means by which enterococcal resistance and virulence factors disseminate.

Contribution of the pAD1-encoded cytolysin to the severity of experimental Enterococcus faecalis endophthalmitis.

The contribution of the pAD1-encoded cytolysin to Enterococcus faecalis virulence in an experimental endophthalmitis model was studied by using isogenic strains differing only in the location of transposon Tn917. The course of experimental endophthalmitis in New Zealand White rabbits was evaluated by postoperative reduction in retinal neuroresponsiveness, thin-section histopathology, and transmission electron microscopy. Infections caused by cytolytic E. faecalis resulted in 99% loss of retinal function at postoperative day 3, while isogenic, noncytolytic strains produced reductions of only 74.2%. Light microscopy revealed near-total destruction of retinal architecture at 24 h postinfection with cytolytic E. faecalis, while noncytolytic strains produced few or no destructive changes. Transmission electron microscopy revealed tissue destruction in retinal layers as early as 6 h postinfection with cytolytic E. faecalis. In vivo and in vitro growth rates of cytolytic and noncytolytic E. faecalis showed similar kinetics. These data demonstrate the contribution of the pAD1-encoded cytolysin to both the course and the severity of experimental E. faecalis endophthalmitis.

A hemolysin-encoding plasmid contributes to bacterial virulence in experimental Enterococcus faecalis endophthalmitis.

Beta-hemolysin production is a variable trait of the Lancefield group D streptococcus, Enterococcus faecalis. The E. faecalis hemolysin is encoded by large transmissible plasmids. The variable nature of this putative virulence factor provided an ideal system for testing its contribution in experimental endophthalmitis. In this study, isogenic E. faecalis strains were compared to determine whether the presence of the hemolysin-encoding plasmid affected the severity of disease in a rabbit endophthalmitis model. Experimental infections (n = 6) with 10(1)-10(4) E. faecalis organisms harboring the hemolysin-encoding plasmid resulted in a 98% loss of retinal function (by electroretinography [ERG]) and white reflex by postoperative day 3. By contrast, infections of similar numbers of plasmid-free E. faecalis organisms (n = 5) resulted in retention of some retinal function (23% per ERG) with a red reflex demonstrated on postoperative day 3. Results of light microscopy, slit-lamp examination, ERG, and indirect ophthalmoscopy indicated that infections with hemolysin-encoding plasmid-containing E. faecalis resulted in a more aggressive endophthalmitis compared with the endophthalmitis caused by plasmid-free E. faecalis. This is the first endophthalmitis model to the authors' knowledge that specifically evaluates bacterial virulence using isogenic strains.

The growth-inhibitory effect of the Enterococcus faecalis bacteriocin encoded by pAD1 extends to the oral streptococci.

Many strains of Enterococcus faecalis, a normal inhabitant of the oral cavity, elaborate a plasmid-encoded bacteriocin. The growth-inhibitory effect of this bacteriocin was observed to extend to a variety of pathogenic oral streptococci, including those that play a major role in tooth surface colonization and caries formation. These results suggest that transient colonization by bacteriocin-producing E. faecalis may effect shifts in oral colonization by susceptible organisms and that bacteriocin-producing E. faecalis may be a candidate for application in strain replacement therapy.