Detection of mixed infection from bacterial whole genome sequence data allows assessment of its role in Clostridium difficile transmission

Bacterial whole genome sequencing offers the prospect of rapid and high precision investigation of infectious disease outbreaks. Close genetic relationships between microorganisms isolated from different infected cases suggest transmission is a strong possibility, whereas transmission between cases with genetically distinct bacterial isolates can be excluded. However, undetected mixed infections-infection with ≥2 unrelated strains of the same species where only one is sequenced-potentially impairs exclusion of transmission with certainty, and may therefore limit the utility of this technique. We investigated the problem by developing a computationally efficient method for detecting mixed infection without the need for resource-intensive independent sequencing of multiple bacterial colonies. Given the relatively low density of single nucleotide polymorphisms within bacterial sequence data, direct reconstruction of mixed infection haplotypes from current short-read sequence data is not consistently possible. We therefore use a two-step maximum likelihood-based approach, assuming each sample contains up to two infecting strains. We jointly estimate the proportion of the infection arising from the dominant and minor strains, and the sequence divergence between these strains. In cases where mixed infection is confirmed, the dominant and minor haplotypes are then matched to a database of previously sequenced local isolates. We demonstrate the performance of our algorithm with in silico and in vitro mixed infection experiments, and apply it to transmission of an important healthcare-associated pathogen, Clostridium difficile. Using hospital ward movement data in a previously described stochastic transmission model, 15 pairs of cases enriched for likely transmission events associated with mixed infection were selected. Our method identified four previously undetected mixed infections, and a previously undetected transmission event, but no direct transmission between the pairs of cases under investigation. These results demonstrate that mixed infections can be detected without additional sequencing effort, and this will be important in assessing the extent of cryptic transmission in our hospitals

Inactivation of pathogens on food and contact surfaces using ozone as a biocidal agent

This study focuses on the inactivation of a range of food borne pathogens using ozone as a biocidal agent. Experiments were carried out using Campylobacter jejuni, E. coli and Salmonella enteritidis in which population size effects and different treatment temperatures were investigate

Culture-Independent Metagenomics Characterisation of Infection

Next-generation sequencing (NGS) technologies are revolutionising our ability to study and characterise microorganisms and investigate infectious diseases. The potential of metagenomics sequencing for use as a single, all-inclusive diagnostic test for comprehensive detection of pathogens, resistance genes and virulence markers directly from clinical samples has been discussed at length in the literature in recent years. However, implementation has been slow as there are several challenges associated with applying metagenomics sequencing to clinical microbiology. These include the large number of human cells, the often low proportion of pathogen cells/DNA and, in some cases, the high background of normal microbiological flora present in clinical samples. Here we report rapid, culture-independent metagenomics workflows that overcome these challenges. Metagenomics pipelines were developed and evaluated in three model samples: i) blood, for the diagnosis of sepsis, ii) urine, for the diagnosis of urinary tract infections, and iii) stool, for the diagnosis of Clostridioides difficile infection. Developed workflows comprised of rapid depletion of unwanted cells/DNA (human and normal flora (in stool)), genomic DNA extraction from remaining microorganisms, whole genome amplification (in blood), rapid nanopore library preparation and real-time metagenomics analysis. These pipelines enabled comprehensive detection of pathogens and resistance genes in clinical blood samples within eight hours and in clinical urine samples within four hours. The C. difficile pipeline could enrich for and sequence the pathogen directly from stool within 24 hours. However, further optimisation of this pipeline is required to increase genome coverage before it can be utilised for typing C. difficile directly from stool. The rapid host depletion and metagenomics sequencing pipelines developed here demonstrate that this technology can provide clinicians with the necessary information to tailor antibiotic therapy for the specific infecting pathogen before second dose of empiric therapy is administered (usually eight-hour intervals), thereby improving patient outcomes and antibiotic stewardship

Development of a phage-based diagnostic test for the identification of Clostridium difficile

Clostridium difficile is the most common bacterial cause of infectious diarrhoea in healthcare environments and in 2014 was responsible for 13,785 infections in the UK. C. difficile infection (CDI) is spread via the faecal-oral route and by contact with contaminated surfaces. However, despite the healthcare concerns no tests are available to validate if sufficient cleaning has been conducted. In addition, Polymerase Chain Reaction (PCR) and Enzyme Immunoassays (EIAs)-based tests used to diagnose CDI lack sensitivity and specificity and hence false negative results are commonly obtained. To overcome these concerns the aim of the PhD research has been to develop the first diagnostic test that exploits the specific interactions of C. difficile bacteriophages (phages), viruses that specifically infect and kill C. difficile. In order to develop a C. difficile phage-based test, first suitable phages that can be used for the test were identified and this was conducted by screening 35 different C. difficile phages against 160 clinically relevant C. difficile isolates. Five phages were found to infect the most number of isolates and were investigated further to identify whether a phage-based diagnostic could be developed based on phages binding (adsorption) to different C. difficile subgroups. However, for all five phages, adsorption rates were not consistently high for C. difficile subgroups in comparison to other common bacteria found in similar locations to C. difficile. Therefore, to increase specificity of the phage-based diagnostic test a new approach was taken by tagging two phages with luminescence luxAB genes (reporter phages), which would be expressed once C. difficile cells were infected with the phages. To design the C. difficile reporter phages, non-essential phage genes were replaced with the luxAB genes, but this study revealed mutagenesis of C. difficile was troublesome and extensive optimisation was required. In addition, once the reporter phages had successfully been constructed the luxAB genes were unstable within the phage genome and were lost during phage replication. Despite extensive optimisation and due to time constrains the luxAB genes were not stabilised within the phages but future work will focus on stabilising the genes

Proteomics as a tool for the characterisation of nosocomial pathogens

The aim of the present investigation was to develop and assess the potential of various proteomic approaches for the characterisation of two major nosocomial pathogens, S. aureus and C. difficile and to further investigate the intraspecies diversity of C. difficile using a genotypic approach. The surface-associated proteins of S. aureus and intracellular stable ribosomal proteins of C. difficile were analysed by MALDI-TOF-MS and the resulting spectra interrogated using two databases viz. MMU (Waters®) and SARAMIS™ (AnagnosTec) respectively. A total of 134 clinical S. aureus isolates were tested using the MMU database and the MicrobeLynx™ software. All were successfully identified with minor contamination errors that corroborated with 16S rRNA sequencing. By contrast, C. difficile isolates were only partially identified (to the genus level) using the MMU database and protocol. Changes in the matrix solution and use of the new database (SARAMIS™) resulted in the correct identification of all C. difficile isolates and, detailed ultra-structural studies indicated that intracellular proteins were the new diagnostic biomarkers

Assessment of the Transmission Dynamics of Clostridioides difficile in a Farm Environment Reveals the Presence of a New Toxigenic Strain Connected to Swine Production

The recent increase in community-acquired Clostridioides difficile infections discloses the shift in this bacterium epidemiology. This study aimed at establishing a transmission network involving One Health components, as well as assessing the zoonotic potential and genomic features of dominant clones. Samples were collected from different compartments of animal, human and environmental origin, from an animal production unit. C. difficile isolates were characterized for toxigenic profile by multiplex-PCR, while genetic diversity was evaluated by PCR-ribotyping and whole genome-based analysis. The overall C. difficile prevalence was 37.2% (70/188), and included samples from environmental (58.3%, 35/60) and animal (31.5%, 35/111) compartments; human samples (n = 17) taken from healthy workers were negative. A predominant clone from RT033 was found in almost 90% of the positive samples, including samples from all compartments connected to the pig production unit, with core-genome single nucleotide variant (SNV)-based Analysis supporting a clonal transmission between them (mean distance of 0.1 ± 0.1 core-SNVs). The isolates from this clone (herein designated PT RT033) were positive for all C. difficile toxin genes (tcdA, tcdB, cdtA/cdtB). The phyloGenetic positioning of this clone was clearly distinct from the classical RT033 cluster, suggesting a different evolutionary route. This new clone shares genomic features with several RTs from the clade 5 Sequence Type (ST) 11, including a complete pathogenicity locus (PaLoc) that is more similar to the one found in toxigenic strains and contrasting to the less virulent classical RT033 (tcdA-, tcdB-, cdtA + /cdtB +). The presence of a tcdA gene truncated into two ORFs, not previously described, requires further evaluation concerning toxin functionality. We hypothesize that the unique combination of genetic elements found in the PT RT033 clone may contribute to host tropism and environmental dissemination and maintenance. This study constitutes the first report of a toxigenic RT033 clone and adds to the overall knowledge on Clade 5 sequence type 11, considered the C. difficile evolutionary lineage with the highest zoonotic potential. The presence of this clone in all compartments associated with the pig production unit suggests a transmission chain involving these animals and contributes to unveil the role played by animal and environmental reservoirs in this pathogen epidemiology.This work was supported by funding from the European Union’s Horizon 2020 Research and Innovation programme under grant agreement No. 773830: One Health European Joint Programme. FA and RC were recipients of fellowships from the same programme.info:eu-repo/semantics/publishedVersio

Strain-resolved analysis of the human intestinal microbiota

The gut microbiota is ascribed a crucial role in human health, particularly in regulating immune and inflammatory responses, which is why it is being associated with a wide range of diseases, including obesity, diabetes, and cancer. Nonetheless, fundamental ecological questions of microbiome establishment, stability and resilience, as well as its transmission across hosts and generations remain incompletely understood, partly due to the lack of methods for high-resolution microbiome profiling. New insights in this field can therefore directly contribute to the development of bacterial and microbiota-based therapies. This work introduces SameStr, a novel bioinformatic program for strain-resolved metagenomics that allows for the specific tracking of microbes across samples, enabling the detection and quantification of microbial transmission and persistence, as well as the observation of direct strain competition. Deployed across cohorts to process over 4200 metagenomes, SameStr enabled analysis of the microbiome with unprecedented phylogenetic resolution. The data included both publicly available metagenomes and sequence data generated in collaboration with our research partners, and was examined using multivariate statistics and machine learning frameworks. First, the establishment and development of the neonatal microbiota was studied, revealing a birth mode-dependent vertical transmission of the maternal microbiota. The microbiota of neonates born by cesarean section was characterized by increased relative abundance of oxygen-tolerant and atypical organisms and showed signs of a delayed establishment of a strictly anaerobic gut environment in these children. Such birth mode-dependent differences diminished over time, yet were measurable within the first two years of life. Furthermore, strain analysis verified the transmission and colonization of parental microbes, which indicated a possible lifelong colonization by microbes from selected species. The temporal persistence of microbes was also characterized in healthy adults, revealing similar taxonomy-dependent patterns of stability. For some species, persistence has been demonstrated both in children and in adults over a period of at least two years. These species are known for their capability to metabolize host-derived glycans found both in breastmilk and intestinal mucus, pointing to a potential strategy for effective cross-generational microbiota transmission, and warranting additional research to assess the implications of their disturbed transfer for long-term health. Since their specificity allows assignment to individual hosts, fingerprints of individual microbial strains offer the potential to be used in forensics and data quality control applications. Finally, to gain new insights into the microbiota dynamics during Fecal Microbiota Transplantation (FMT), microbial strain transmission was analyzed in the context of a diverse set of patient, microbiome, and clinical conditions. In the analyzed studies, FMT was used for the experimental treatment of a variety of diseases, including colonization with drug-resistant and pathogenic microbes, metabolic and inflammatory bowel diseases, and as an adjunct to the immunotherapeutic treatment of cancer. Analyses uncovered what appear to be the universal drivers of post-FMT microbiota assembly, including clinical and ecological factors that are important for successful transplantation of donor strains. In particular, the relevance of the microbiota dysbiosis of the recipient was emphasized, which was inducible by pre-treating the patient with antibiotics or laxatives. Presumably, this can open up ecological niches in the patients intestines, which favors colonization with donor strains. Colonization rates did not play a role for the treatment success of recurrent C. difficile infections and inflammatory bowel disease, but indicated a trend associated with an improved immune response in cancer patients. Concerningly, the transfer of an atypical and potentially pro-inflammatory microbial community from one donor was also observed, calling for further investigations into the immediate and long-term clinical consequences of FMT. These analyses demonstrate the advantages of a strain-based microbiome analysis. Due to the achieved methodological accuracy, strain-resolved microbial dynamics could be precisely disentangled when comparing longitudinal samples from healthy adults as well as parent-child and patient-donor pairs. This revealed taxonomic, clinical, and ecological factors that are critical to microbiome assembly, including microbial transmission, persistence, and competition. Together, these findings lay the groundwork for future developments of precision personalized microbiota modulation therapies.Der Darmmikrobiota wird eine entscheidende Rolle für die menschliche Gesundheit zugeschrieben, was insbesondere die Regulation von Immun- und Entzündungsreaktionen betrifft, weshalb sie mit einer Vielzahl von Krankheiten wie etwa Fettleibigkeit, Diabetes oder Krebs in Verbindung gebracht wird. Nichtsdestotrotz sind grundlegende ökologische Fragen der Etablierung, Stabilität und Resilienz von Mikrobiomen sowie ihrer Übertragung über Wirte und Generationen hinweg noch immer unvollständig untersucht, was teilweise auf das Fehlen von Methoden zur hochauflösenden Mikrobiom-Profilierung zurückzuführen ist. Neue Erkenntnisse auf diesem Gebiet können daher unmittelbar zur Entwicklung von Bakterien- und Mikrobiota-basierten Therapien beitragen. Diese Arbeit stellt SameStr vor, ein neues bioinformatisches Programm für stammaufgelöste Metagenomik, das die spezifische probenübergreifende Untersuchung von Mikroorganismen ermöglicht. Hiermit können der Nachweis und die Quantifizierung der Übertragung und Persistenz, sowie die Beobachtung der direkten Konkurrenz mikrobieller Stämme erfolgen. SameStr wurde kohortenübergreifend für die Analyse von über 4200 Metagenomen eingesetzt und ermöglichte die Profilierung des Mikrobioms mit einer beispiellosen phylogenetischen Auflösung. Die Metagenome, welche sowohl öffentlich verfügbare als auch in Zusammenarbeit mit unseren Forschungspartnern generierte Daten beinhalteten, konnten mittels multivariater Statistik und maschinellen Lernens beleuchtet werden. Zunächst wurde die Etablierung und Entwicklung der neonatalen Mikrobiota analysiert, was eine vom Geburtsmodus abhängige vertikale Übertragung der mütterlichen Mikrobiota aufzeigte. Die Mikrobiota von Neugeborenen die durch einen Kaiserschnitt zur Welt gekommen waren, war vermehrt von Sauerstoff-toleranten und Darm-untypischen Organismen besiedelt und deutete darauf hin, dass sich ein strikt anaerobes Darmmilieu bei diesen Kindern mit einer gewissen Verzögerung einstellte. Derartige geburtsabhängige Veränderungen schwächten sich mit der Zeit ab, waren jedoch bis zum zweiten Lebensjahr messbar. Weiterhin konnte die Übertragung und Kolonisierung elterlicher Organismen mittels Stamm-Analyse nachgewiesen werden, was außerdem auf eine mögliche lebenslange Besiedlung durch Mikroben ausgewählter Spezies hindeutete. Die zeitliche Persistenz von Mikroorganismen wurde darüber hinaus auch bei gesunden Erwachsenen charakterisiert, was ebenfalls Taxonomie-abhängige Stabilitätsmuster zum Vorschein brachte. Bei einigen Spezies, die bekannt dafür sind vom menschlichen Wirt stammende Glykane zu metabolisieren, wurde die Persistenz sowohl bei Kindern als auch bei Erwachsenen über einen Zeitraum von mindestens zwei Jahren nachgewiesen. Diese Glykane kommen sowohl in der Muttermilch als auch im Darmschleim vor, was auf eine potenzielle Strategie für eine effektive generationsübergreifende Übertragung der Mikrobiota hinweist. Um die langfristigen Auswirkungen einer gestörten Mikrobiota-Übertragung auf die Gesundheit bewerten zu können, wird jedoch weitere Forschung benötigt. Da ihre Spezifität die Zuordnung zu individuellen Wirten ermöglicht, bieten mikrobielle Stämme zudem das Potenzial in der Forensik und bei Datenqualitätstests Anwendung zu finden. Um schließlich neue Erkenntnisse zur Mikrobiota-Dynamik während der fäkalen Mikrobiota-Transplantation (FMT) zu gewinnen, wurde die Stammübertragung im Kontext einer Vielzahl von Patienten-, Mikrobiom- und klinischen Parametern analysiert. FMT wurde in den vorliegenden Studien zur experimentellen Behandlung verschiedenster Erkrankungen eingesetzt, darunter Kolonisierung mit resistenten und pathogenen Keimen, metabolische Erkrankungen, entzündliche Erkrankungen des Darms, sowie begleitend zur immuntherapeutischen Behandlung von Krebs. Die Analysen zeigten scheinbar universelle klinische und ökologische Faktoren auf, welche für eine erfolgreiche Integration von Spenderstämmen von Bedeutung sind. Insbesondere wurde die Relevanz der Mikrobiota-Dysbiose des Empfängers hervorgehoben, welche zudem durch Vorbehandlung der Patienten mittels Gabe von Antibiotika oder Laxativa induziert werden kann. Vermutlich können hierdurch ökologische Nischen im Darm der Patienten eröffnet werden, was eine Kolonisierung mit Spenderstämmen begünstigt. Kolonisierungsraten spielten für den Behandlungserfolg wiederkehrender Clostridien-Infektionen und entzündlicher Darmerkrankungen keine Rolle, deuteten jedoch auf einen Trend hin, der mit einer verbesserten Immunantwort bei Krebspatienten einhergeht. Beunruhigenderweise wurde auch die Übertragung einer atypischen und potenziell entzündungsfördernden Mikrobiota eines Donoren beobachtet, was weitere Untersuchungen zu unmittelbaren und langfristigen klinischen Folgen der FMT erforderlich macht. Die Ergebnisse dieser Arbeit zeigen die Vorteile einer Stamm-basierten Mikrobiom-Analyse auf. Durch die erreichte methodische Genauigkeit konnten bei Vergleichen von Zeitverlaufsproben gesunder Erwachsener sowie Eltern-Kind- und Patienten-Spender-Paaren, die Dynamiken mikrobieller Stämme präzise entschlüsselt werden. Dabei kamen taxonomische, klinische und ökologische Faktoren zum Vorschein, welche für die Zusammensetzung der Mikrobiota, einschließlich der mikrobiellen Übertragung, Persistenz und Kompetition, maßgebend sind. Diese neuen Erkenntnisse bilden die Grundlage für künftige Entwicklungen von Therapien zur präzisen, personalisierten Modulation der Mikrobiota

Genomic analysis of clostridioides difficile recovered from horses in Western Australia

Clostridioides difficile poses an ongoing threat as a cause of gastrointestinal disease in humans and animals. Traditionally considered a human healthcare-related disease, increases in community-associated C. difficile infection (CDI) and growing evidence of inter-species transmission suggest a wider perspective is required for CDI control. In horses, C. difficile is a major cause of diarrhoea and life-threatening colitis. This study aimed to better understand the epidemiology of CDI in Australian horses and provide insights into the relationships between horse, human and environmental strains. A total of 752 faecal samples from 387 Western Australian horses were collected. C. difficile was isolated from 104 (30.9%) horses without gastrointestinal signs and 19 (37.8%) with gastrointestinal signs. Of these, 68 (55.3%) harboured one or more toxigenic strains, including C. difficile PCR ribotypes (RTs) 012 (n = 14), 014/020 (n = 10) and 087 (n = 7), all prominent in human infection. Whole-genome analysis of 45 strains identified a phylogenetic cluster of 10 closely related C. difficile RT 012 strains of equine, human and environmental origin (0–62 SNP differences; average 23), indicating recent shared ancestry. Evidence of possible clonal inter-species transmission or common-source exposure was identified for a subgroup of three horse and one human isolates, highlighting the need for a One Health approach to C. difficile surveillance

Introduction of NGS in Environmental Surveillance for Healthcare-Associated Infection Control

The hospital environment significantly contributes to the onset of healthcare associated infections (HAIs), representing the most frequent and severe complications related to health care. The monitoring of hospital surfaces is generally addressed by microbial cultural isolation, with some performance limitations. Hence there is need to implement environmental surveillance systems using more effective methods. This study aimed to evaluate next-generation sequencing (NGS) technologies for hospital environment microbiome characterization, in comparison with conventional and molecular methods, in an Italian pediatric hospital. Environmental samples included critical surfaces of randomized rooms, surgical rooms, intensive care units and delivery rooms. The resistome of the contaminating population was also evaluated. NGS, compared to other methods, detected with higher sensitivity the environmental bacteria, and was the only method able to detect even unsearched bacteria. By contrast, however, it did not detect mycetes, nor it could distinguish viable from dead bacteria. Microbiological and PCR methods could identify and quantify mycetes, in addition to bacteria, and PCR could define the population resistome. These data suggest that NGS could be an effective method for hospital environment monitoring, especially if flanked by PCR for species identification and resistome characterization, providing a potential tool for the control of HAI transmission

Investigation into the mobile genetic elements of Clostridium difficile

Clostridium difficile is a pathogenic bacterium that can colonise both humans and various animals. Toxin production leads to clinical symptoms ranging from mild to severe diarrhoea and can result in potentially fatal pseudomembranous colitis. These symptoms are caused by the disruption of the cytoskeleton and tight junctions of gut epithelial cells by the toxins. Genomic sequencing of C. difficile has indicated the chromosome carries a number of mobile genetic elements including conjugative transposons, which can encode antibiotic resistance genes. Analysing the sequence of a number of C. difficile strains indicated that each genome carries at least one and often multiple conjugative transposons. For many of the genes on these elements, functions were predicted using various bioinformatic tools. The study of conjugative transposons in C. difficile has been limited by the lack of resistance genes encoded by the elements. Therefore, an antibiotic resistance gene was inserted into six of the elements in strains 630 and R20291 and filter-matings performed. Conjugative transfer was shown for all elements from strain 630 but not for Tn6103 from R20291. The study of transconjugants of these matings showed the pathogenicity locus, encoding the two major toxins of C. difficile, to transfer at a low frequency into a non-toxigenic recipient strain. Whole genome sequencing of transconjugants determined that the transfer is not limited to the pathogenicity locus but includes varying sizes of chromosomal DNA flanking the pathogenicity locus. RNA-seq was used for the comparison of mutants for transcriptional regulators of conjugative transposons CTn2 and CTn4, however no significant differential expression was detected. Furthermore, strain 630Δerm, a commonly used laboratory strain for the generation of knockout mutants, was compared to the wildtype strain 630. A predicted oxidative stress operon was upregulated in 630Δerm which raises the question of the biological impact of these results on the knockout model