Title:
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Response of clinically-relevant enterococcal isolates to antibiotic challenge
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Enterococci are a leading cause of infective endocarditis, bacteraemia and urinary
tract infections. Unfortunately, an increasing proportion of these organisms display
resistance to front-line antimicrobial agents. The aim of the work described in this
thesis was to assess the efficacy of antibiotics against clinical strains of enterococci
and evaluate their ability to trigger adaptive mechanisms (stringent response)
associated with drug tolerance and virulence.
Enterococcus faecalis and Enterococcus faecium isolates grown in planktonic and
biofilm states were assessed for susceptibility to vancomycin, rifampicin, linezolid
and tigecycline. As a potential avenue to overcome resistance and preserve
antibiotic activity, combinations of drugs were evaluated for synergy against
sensitive and drug-resistant strains of enterococci using in vitro and in vivo models.
Transcriptome analysis of parental E. faecalis OG1RF and mutants defective or void
of stringent response activity were examined to determine if this response was
induced by exposure to antibiotics and if virulence gene expression was modulated.
The majority of enterococci tested planktonically were susceptible to all four
antibiotics, while biofilm-associated cells were refractory to killing. Rifampicin in
combination with vancomycin, linezolid and tigecycline demonstrated enhanced
killing properties against enterococci in planktonic and biofilm growth states
compared to killing by individual agents. When tested in vivo, synergistic
combinations improved Galleria mellonella survival compared to monotherapy.
Exposure of parental E. faeca/is OG1RF to vancomycin and linezolid triggered upregulation
of stringent response genes (re/A and re/Q). In contrast, tigecycline did
not induce modulation of these genes, which suggests that the stringent response
was not activated. Virulence genes associated with biofilm formation were upregulated
by all antibiotics during exposure, independent of stringent response
induction, while increased modulation of an endocarditis-associated adhesin and
proteases were only apparent in linezolid exposed cells. Comparison of stringent
response deletion mutants of E. faecalis OG1RF revealed that expression of re/A
was necessary for an antibiotic induced stringent response, while re/A and re/Q
worked synergistically to enhance virulence gene modulation.
Combination therapy is widely used when difficult-to-treat infections are identified,
though the clinical outcome is not always predictable. Additionally, antibiotics have
properties other than those related to their therapeutic use. Specifically, they act
as signalling molecules that provoke adaptive responses in bacteria, including
modulation of gene expression. The findings of this thesis suggest that tigecyclinebased
combinations may prove useful in therapy against enterococci when
antibiotic resistance is detected. Additionally, tigecycline did not appear to trigger a
stringent response thorough modulation of associated genes, while vancomycin
and linezolid induced expression of stringent response and virulence factor
associated genes. The clinical relevance of an active stringent response in E. faecalis
has not been fully elucidated, though it may underlie patient treatment failure.
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