GABAA Immunomodulation & Infection

GABAergic drugs, such as benzodiazepines, are widely used in clinical practice yet their immune side effects are poorly understood. Preliminary studies have suggested that immune cells express GABAA receptors indicating that they may be controlled by GABA signaling. Herein parallel preclinical, translational and epidemiological approaches are described to help understand the importance of GABAA immunomodulation. The hypothesis is that GABA signaling acts to reduce responsiveness to a pathogen and thus that GABAergic drugs will increase susceptibility to infection. To inform on the clinical importance of this work, data from a subgroup analysis of the Maximizing Efficacy of Targeted Sedation and Reducing Neurological Dysfunction (MENDS) trial (where the relative effects of lorazepam, and dexmedetomidine were compared) are described in septic and non‐septic patients. Consistent with the hypothesis, avoidance of lorazepam sedation decreased mortality by 70% in septic patients but did not affect outcome in non‐septic patients. As preclinical data suggests that benzodiazepines increase mortality at subsedative doses we next conducted a population‐based cohort and nested case‐control design analysis of The Health Improvement Network (THIN), a comprehensive UK general practice database. Benzodiazepines exposure increased the incidence of community acquired pneumonia (CAP) and both 30‐day and long‐term mortality from CAP. Based on these significant accumulating data of the harm of exposure to benzodiazepines during an infection, animal studies were conducted to understand (i) the biological plausibility of our findings and (ii) the mechanism of the effect. In a series of mouse studies the prototypical benzodiazepine, diazepam, increased mortality from Streptococcus pneumoniae through potentiation of GABAA signaling. The increased mortality was associated with increased pathogen load and a delayed cytokine response to the infection. However cellular recruitment was not affected, indicating that local mechanisms were perturbed. Immune cell profiling revealed that alveolar macrophage and monocytes abundantly expressed subunits of the GABAA receptor, compatible with benzodiazepine sensitivity. Ex vivo studies showed that GABAA receptor activation decreased cytokine responses, phagocytosis and bacterial killing by alveolar macrophage likely via inducing an intracellular acidosis. Finally based on the immune cell profile of GABAA receptors we predicted that benzodiazepines that do not target the α1 GABAA subunit would lack the immune suppression observed by nonselective drugs. In accordance with this hypothesis we show that these selective benzodiazepines do not provoke intracellular acidosis, affect cytokine release or bacterial killing of macrophage ex vivo. In vivo the selective benzodiazepine did not increase mortality from infection or increase pathogen load

Isolation and characterisation of bacteria associated with flying insects in hospitals, with particular emphasis on Clostridium difficile

Clostridium difficile is a bacterial healthcare-associated infection, which houseflies Musca domestica may transfer due to their synanthropic nature. The aims of this thesis were to determine the ability of M. domestica to transfer C. difficile mechanically and to collect and identify flying insects in UK hospitals and classify any associated bacteria. M. domestica exposed to independent suspensions of vegetative cells and spores of C. difficile were able to mechanically transfer the bacteria on to agar for up to 4 hours following exposure. C. difficile could be recovered from fly excreta for 96hrs and was isolated from the M. domestica alimentary canal. Also confirmed was the carriage of C. difficile by M. domestica larvae, although it was not retained in the pupae or in the adults that subsequently developed. Flying insects were collected from ultra-violet light flytraps in hospitals. Flies (order Diptera) were the most commonly identified. Chironomidae were the most common flies, Calliphora vicina were the most common synanthropic fly and ‘drain flies’ were surprisingly numerous and represent an emerging problem in hospitals. External washings and macerates of flying insects were prepared and inoculated onto a variety of agars and following incubation bacterial colonies identified by biochemical tests. A variety of flying insects, including synanthropic flies (e.g. M. domestica and C. vicina) collected from UK hospitals harboured pathogenic bacteria of different species. Enterobacteriaceae were the group of bacteria most commonly isolated, followed by Bacillus spp, Staphylococci, Clostridia, Streptococci and Micrococcus spp. This study highlights the potential for M. domestica to contribute to environmental persistence and spread of C. difficile in hospitals. Also illustrated is the potential for flying insects to contribute to environmental persistence and spread of other pathogenic bacteria in hospitals and therefore the need to implement pest control as part of infection control strategies

Pneumonia in pre-school children : Terveysnetti

Pneumonia is an illness, usually caused by bacterial, viral or more rarely fungal organisms. Common symptoms in children and infants include difficult breathing, cough, and wheezing. Diagnosis involves confirmatory chest radiography and laboratory tests. Antibiotics are the preferred choice for treatment and management. Risks factors include low paternal education, low birth weight, lack of breastfeeding. Key strategies for the prevention of childhood pneumonia are community –based case management, adequate nutrition and zinc intake. Main aim is produce guidelines for these families by producing web pages to be published in Terveysnetti so that they can be able to understand and recognize the disease well. The purpose of my bachelor thesis is to provide information to families with pre-school children about pneumonia. Literature review was used in analysis of research articles which were obtained from electronic sources in our school library. Main search engine used to retrieve the articles was CINAHL. Searches were limited and compared against each other thus the relevant information was retrieved by selecting meaningful articles and abstracts. Results concluded that pneumonia kills more children than any other illness- more than AIDS, malaria and measles combined resulting to over two million deaths each year. In conclusion, increased understanding about etiology and pathophysiology of the disease should guide new approaches to tackle the immense global problem of child deaths from pneumonia, the most effective intervention to reduce pneumonia related deaths would be to improve access to early care where simple, appropriate interventions are provided, including referral where necessary

Characterization of neglected Streptococcus suis pathotypes: molecular epidemiology and IdeSsuis-based vaccination approaches

Einleitung Streptococcus (S.) suis verursacht bei Schweinen unter anderem Meningitis, Arthritis, Serositis und Endokarditis und ist eine der größten Herausforderungen für die Schweineindustrie. Von 29 beschriebenen Serotypen sind die Serotypen 2, 7 und 9 unter invasiven Isolaten weltweit besonders prävalent, vor allem in Europa. Bis heute gibt es keinen zugelassenen Impfstoff zur Prävention von S. suis-Erkrankungen in Europa, daher ist im Feld die Anwendung stallspezifischer Impfstoffe verbreitet. Diese bieten jedoch höchstens homologen Schutz und ihre Wirkung kann durch prädisponierende Faktoren wie eine Infektion mit dem porcine reproductive and respiratory syndrome Virus (PRRSV) beeinträchtigt werden. Daher hat sich die Forschung auf Antigene fokussiert, die potentiell heterologen Schutz vermitteln. Zielstellung Ziele der Studie waren die Charakterisierung vernachlässigter invasiver S. suis Pathotypen der wichtigen Serotypen 7 und 9 und die Etablierung neuer Infektionsmodelle im Schwein. Des Weiteren sollte die immunogene und protektive Wirkung des Immunoglobulin (Ig) M-degradierenden Enzyms von S. suis, IdeSsuis, im Serotyp 9 Infektionsversuch untersucht werden. Material und Methoden In dieser Arbeit wurden in vitro Versuche und experimentelle Infektionen im Schwein durchgeführt. Dazu gehörte die Geno- und Phänotypisierung von 22 S. suis Serotyp 7 Stämmen und vier Serotyp 9 Stämmen. Die Genotypisierung erfolgte mittels multiplex (MP) Polymerase-Kettenreaktion (PCR), einer PCR zur Differenzierung verschiedener Genvarianten des muramidase-release protein (MRP) sowie mittels multilocus sequence typing (MLST). Zur Phänotypisierung der S. suis Stämme wurden bactericidal assays eingesetzt, die als Bakteriämiemodell fungierten. Auf diese Weise konnten die Empfänglichkeit gegenüber S. suis Stämmen sowie deren Virulenz beurteilt werden. Durch Zugabe von rekombinantem (r) IdeSsuis wurde die Rolle adaptiven IgMs in der Begrenzung der Bakteriämie untersucht. Anhand von Western Blot Analysen erfolgte die Untersuchung der Expression und Funktionalität von IdeSsuis sowie die Expression von MRP in S. suis Serotyp 7 Stämmen. Enzyme-linked immunosorbent assays (ELISA) kamen zum Einsatz, um die Entwicklung von IgM und IgG Spiegeln in Ferkeln im zeitlichen Verlauf und die IgG Spiegel nach rIdeSsuis Immunisierung zu messen. Durch rIdeSsuis Immunisierung induzierte Antigen-spezifische T-Helferzellen (Th-Zellen) wurden mithilfe der Durchflusszytometrie untersucht. Schließlich erfolgte die Durchführung zweier S. suis Serotyp 7 Etablierungsversuche mit je 18 bzw. 5 Ferkeln sowie zwei S. suis Serotyp 9 Impf- und Infektionsversuche mit je 18 Ferkeln. Sektionsproben wurden histologisch untersucht. In einem Fall wurde eine Endokarditis mittels fluorescence in situ hybridization (FISH) charakterisiert. Ergebnisse Die meisten untersuchten Serotyp 7 Stämme gehörten dem Sequenztyp (ST) 29 an, einem emerging pathotype in Europa. Trotz der engen phylogenetischen Verwandtschaft, war mrp in den Stämmen sehr variabel. Phänotypisch bildeten alle Stämme gleichermaßen eine kleine MRP Variante, MRPs. Für vier ausgewählte Serotyp 7 Stämme wurde die Expression von IdeSsuis gezeigt, jedoch mit Unterschieden in Größe und Funktionalität. Bactericidal assays dieser vier Stämme zeigten starke Proliferation im Blut von Absatzferkeln, aber Abtöten im Blut von Läuferschweinen aus zwei Herden mit unterschiedlichem S. suis Status. Dieses Überlebensmuster unterschied sich deutlich von dem eines Serotyp 9 Stammes. Durch Zugabe von rIdeSsuis, konnte gezeigt werden, dass das Abtöten der Serotyp 7 Stämme im Blut von Läuferschweinen des infizierten Bestandes IgM-vermittelt war. Unabhängig von der Herkunft entwickelten sich die IgM Spiegel in den Ferkeln im zeitlichen Verlauf fast synchron. Schließlich konnte die Virulenz eines Serotyp 7 Stammes in einem intravenösen Infektionsversuch mit 5 Ferkeln gezeigt werden. Alle Tiere entwickelten schwere Symptome einer S. suis Erkrankung. In einem Impf- und Infektionsversuch mit einem hoch virulenten Serotyp 9 Stamm wurde die immunogene und protektive Wirkung einer rIdeSsuis Immunisierung untersucht. Neun Ferkel wurden mit rIdeSsuis oder einem Placebo prime-boost-boost immunisiert und zwei Wochen später infiziert. Neunzig Prozent der Placebotiere entwickelten schwere Symptome einer S. suis Erkrankung und starben oder mussten aus Tierschutzgründen euthanasiert werden. Alle geimpften Tiere überlebten den Versuch, fielen jedoch mit Fieber und Lahmheiten auf. Es konnte also gezeigt werden, dass eine rIdeSsuis Immunisierung vor Mortalität, nicht aber Morbidität durch den Infektionsstamm schützt. Alle immunisierten Ferkel serokonvertierten und Antigen-spezifische Th-Zellen wurden nachgewiesen. Weder die IgG Antwort noch die Th-Zell Antwort wurde jedoch durch die Infektion verstärkt. In einem weiteren Impf- und Infektionsversuch mit einem anderen Serotyp 9 Stamm fiel ein Tier am 11. Tag nach der Infektion mit Zeichen einer akuten Leptomeningitis auf, nachdem es zuvor klinisch völlig unauffällig war. In der Sektion des Tieres wurde eine Endokarditis der Mitralklappe diagnostiziert, die mit Biofilm-Bildung assoziiert war, was mithilfe von Histologie und FISH gezeigt werden konnte. Zusätzlich wurde eine fibrinopurulente Leptomeningitis diagnostiziert. Das Ferkel hatte Antikörper gegen rIdeSsuis und tötete den Infektionsstamm ex vivo im Blut ab. Schlussfolgerungen In dieser Arbeit habe ich zwei wichtige S. suis Pathotypen charakterisiert: S. suis Serotyp 7 Stämme des ST29 und einen hoch virulenten Serotyp 9 Stamm vom ST94. Die Serotyp 7 Stämme stellten einen besonderen Pathotypen dar, bei dessen Bekämpfung IgM eine wichtige Rolle spielt. Bei einer Serotyp 9 Infektion konnten trotz des Abtötens der Bakterien im Blut und opsonisierender Antikörper Biofilmbildung und eine folgende akute Leptomeningitis nicht verhindert werden. Letztlich wurde Schutz vor einem hoch virulenten Serotyp 9 Stamm durch rIdeSsuis Immunisierung und damit zum ersten Mal für ein Antigen Protektion vor den wichtigen Serotypen 2 und 9 aufgezeigt. Dies ist ein vielversprechendes Ergebnis hinsichtlich der Entwicklung eines Impfstoffes gegen S. suis.Introduction Streptococcus (S.) suis causes meningitis, arthritis, serositis and endocarditis and is one of the biggest challenges for the swine industry. Of 29 described serotypes, the serotypes 2, 7 and 9 are highly prevalent amongst invasive S. suis isolates worldwide, especially in European countries. To date, no commercially produced vaccine is available in Europe for prevention of S. suis disease, thus the use of autogenous vaccines in the field is common. However, bacterins may at most confer homologous protection and their efficacy may be influenced by predisposing factors such as an infection with the porcine reproductive and respiratory syndrome virus (PRRSV). Research has therefore focused on subunit vaccines with the potential to elicit cross-protection against various serotypes. Aim of the study The objective of this study was to characterize neglected invasive S. suis pathotypes of the important serotypes 7 and 9 and to establish infection models in the main host of S. suis, the pig. A further aim was to investigate immunogenicities and protective efficacies of the immunoglobulin (Ig) M-degrading enzyme of S. suis, IdeSsuis, in a serotype 9 challenge experiment. Materials and methods In vitro experiments and experimental challenges in swine were conducted as part of this thesis. This included the geno- and phenotyping of 22 S. suis serotype 7 strains and four serotype 9 strains. Genotyping was conducted using a multiplex (MP) polymerase chain reaction (PCR), a PCR for differentiation of variants of the muramidase-released protein (MRP) gene and multilocus sequence typing (MLST). For phenotyping of the S. suis strains, bactericidal assays were carried out which served as a model for bacteraemia. This way, susceptibility to S. suis strains and virulence of different strains was assessed. Further, through addition of recombinant (r) IdeSsuis, the role of adaptive IgM in limiting bacteraemia was elucidated. Western blot analyses were conducted to investigate expression and functionality of IdeSsuis as well as expression of MRP in S. suis serotype 7 strains. Enzyme-linked immunosorbent assays (ELISA) were used to determine the development of IgM and IgG levels in piglets over time and to assess IgG levels following rIdeSsuis immunization. Antigen-reactive T-helper (h) cells induced by rIdeSsuis immunization were investigated using flow cytometry. Finally, two experiments to establish a serotype 7 infection model with 18 and 5 piglets each and two vaccination and challenge experiments using different S. suis serotype 9 strains (n=18 piglets/ experiment) were conducted. Samples of dissected animals were examined histologically. In one case, an endocarditis was analysed using fluorescence in situ hybridization (FISH). Results Most of the investigated serotype 7 strains belonged to sequence type (ST) 29 which was thus shown to be an emerging pathotype in Europe. Despite the close phylogenetic relation of the strains, mrp was highly variable. Phenotypically, all strains expressed a small variant of MRP, MRPs. Four selected serotype 7 strains were shown to express IdeSsuis with differences in size and functionality. Bactericidal assays of these four strains revealed high proliferation in blood of weaning piglets but killing in blood of growing piglets of two herds which differed in their S. suis infection status. This survival pattern was distinct from a serotype 9 strain. Addition of rIdeSsuis revealed that killing of the serotype 7 strains in blood of growing piglets of the infected herd was IgM-mediated. Independent of the originating herd, IgM levels of the piglets rose almost synchronous over time. Finally, the virulence of a serotype 7 strain was proven in an intravenous challenge experiment with five pigs which all developed severe clinical signs of S. suis disease. In a vaccination and challenge experiment using a highly virulent serotype 9 strain, immunogenicities and protective efficacies of rIdeSsuis immunization were investigated. Nine piglets were prime-boost-boost vaccinated with rIdeSsuis or placebo-treated and challenged two weeks later. Ninety per cent of the placebo-treated piglets developed severe clinical signs of S. suis disease and died or had to be euthanized due to animal welfare reasons. All vaccinated piglets survived the experiment, however elevated body temperatures and lameness were also noted in this group. Accordingly, rIdeSsuis vaccination protected from mortality but not morbidity caused by the challenge strain. Seroconversion of the immunized piglets and antigen-reactive Th cells were detected. Neither the IgG response nor the Th cell response was boosted through the challenge. In a further vaccination and challenge experiment with a different serotype 9 strain, one animal was clinically unobtrusive following infection and then developed an acute leptomeningitis on the 11th day post infection and had to be euthanized. Dissection of the animal revealed an endocarditis on the mitral valve which was proven to be associated with biofilm formation by histology and FISH. In addition, a fibrinosuppurative leptomeningitis was diagnosed. The piglet had specific antibodies against rIdeSsuis and mediated killing of the challenge strain in a bactericidal assay. Conclusions In this thesis, I characterized two important pathotypes: S. suis serotype 7 strains of ST29 and a highly virulent serotype 9 strain of ST94. The serotype 7 strains represent a distinct pathotype and IgM plays a significant role in their control. Following a serotype 9 infection, biofilm formation and a subsequent acute leptomeningitis could not be prevented despite blood bactericidal activity and opsonizing antibodies. Finally, protection against challenge with a highly virulent serotype 9 strain through rIdeSsuis immunization was demonstrated. Thereby, for the first time an antigen was shown to confer cross-protection against the important serotypes 2 and 9, which is highly encouraging regarding the development of a vaccine against S. suis

Interaction of Streptococcus suis with blood immune cells: Influence of the complement system and modification of lipoteichoic acids

Einleitung Streptococcus (S.) suis ist weltweit in Schweinepopulationen verbreitet. S. suis verursacht hohe wirtschaftliche Verluste durch das Auftreten von Meningitis, Arthritis, Serositis und Endokarditis und stellt als Zoonoseerreger gleichzeitig ein Risiko für den Menschen dar. Im Zusammenhang mit Infektionen in europäischen Schweinebetrieben werden Serotyp 2, 7 und 9 am häufigsten nachgewiesen. Die Bakteriämie spielt eine Schlüsselrolle in der invasiven S. suis Erkrankung und die Interaktion der Streptokokken mit den Immunzellen des Wirts im Blut ist entscheidend für den Ausgang der Infektion. Ziele der Untersuchung Das Ziel der vorliegenden Arbeit, war die Untersuchung der Fähigkeit von porzinen Immunzellen S. suis durch Phagozytose und reaktive Sauerstoffspezies (ROS) zu töten. Dabei wurden vor allem die Bedeutung von IgM und des Komplementsystems beleuchtet. In diesem Sinne, wurde auch die Arbeitshypothese untersucht, dass eine Modifizierung der bakteriellen Zellwand durch D-Alanylierung von Lipoteichonsäuren (LTAs) S. suis hilft, angeborene Immunfunktionen zu umgehen, wie z. B. die Opsonisierung mit Komplementfaktoren, sowie dass diese Zellwandveränderung die Interaktion von S. suis mit Leukozyten beeinflusst. Material und Methoden Die Bestimmung von ROS und dem Überleben der Streptokokken wurde in vivo im Blut zweier mit S. suis-infizierter Ferkel und in vitro in einem rekonstituierten Blutmodel durchgeführt. Die ROS-Messung erfolgte unter Zugabe von Dihydrorhodamine 123 mittels Durchflusszytometrie in Granulozyten. Verschiedene Inhibitoren wurden dabei eingesetzt: Apocynin um die NADPH Oxidase und damit die ROS-Bildung zu hemmen, Vaccinia Virus Complement Control Protein (VCP) für die Inaktivierung der Komplementkaskade und IdeSsuis um porzines IgM zu spalten. Mithilfe eines thermosensitiven Vektors wurde eine isogene Deletionsmutante des dltA Gens erstellt, um den Einfluss der D-Alanylierung von LTAs zu untersuchen. Die Sequenzierung des entsprechenden Genabschnitts und ein Southern Blot dienten der genetischen Verifizierung der Mutante. Weiterhin wurden Wachstumsverhalten, Hydrophobie und Ladung der Oberfläche sowie minimale Hemmkonzentrationen einer Reihe antimikrobieller Peptide für die dltA Mutante untersucht. Die Assoziation von Blutleukozyten mit S. suis wurde mithilfe von Far Red markierten Bakterien in der Durchflusszytometrie bestimmt. Die Zytokin-Messung erfolgte mit kommerziell erhältlichen Enzyme-linked immunosorbent assays (ELISA)-Kits. Ergebnisse S. suis Stämme der Serotypen 2, 7 und 9 zeigten sich hochsensibel gegenüber Wasserstoffperoxid. Eine Hemmung der Bildung von ROS in rekonstituierten Blutproben führte selbst in Anwesenheit einer hohen Konzentration von S. suis-spezifischen Antikörpern zu einem signifikanten Anstieg des bakteriellen Überlebens. Die Induktion von ROS durch S. suis in Granulozyten wurde durch spezifische Antikörper verstärkt und hing partiell von der Anwesenheit funktionellen Komplements ab. In der Abwesenheit von IgG reduzierte die Spaltung von IgM oder die Inaktivierung von Komplement die ROS Produktion um mehr als das Dreifache, was in einem Anstieg des bakteriellen Überlebens resultierte. Der Mechanismus von S. suis D-Alanin in seine LTAs einzulagern, erhöhte die Hydrophobie der bakteriellen Oberfläche und reduzierte die Opsonisierung mit Komplementfaktor C3b, sowie die Phagozytose durch Granulozyten in Vollblut und die Assoziation von S. suis mit Monozyten and Lymphozyten. Trotzdem wurde das Überleben der Streptokokken in Blut, welches S. suis-spezifische Antikörper enthielt, nicht signifikant durch diese Zellwandmodifikation gesteigert. Allerdings war der durch die dltA Mutante induzierte Gehalt an IL-1β im Blut signifikant geringer als der durch den Wildtyp induzierte. Hohe Antikörperspiegel verursachten einen hochsignifikanten Anstieg der Interaktion von S. suis mit Monozyten, was bei diesen zum inflammatorischen Zelltod mit einer starken Sekretion von IL-1β und TNF-α führte. Schlussfolgerung Trotz einer Vielzahl an Abwehrmechanismen von S. suis gegen oxidativen Stress, stellen Phagozytose und ROS einen sehr effektiven Mechanismus des Immunsystems dar, um die eingedrungenen Streptokokken zu töten. Die Induktion von ROS durch S. suis hängt dabei stark von der Anwesenheit spezifischer Antikörper und teilweise von aktivem Komplement ab. Die Fähigkeit von S. suis D-Alanin in seine LTAs einzulagern, verändert Eigenschaften der bakteriellen Zellwand und vermittelt dabei Schutz vor angeborenen Immunmechanismen, wie antimikrobiellen Peptiden und dem Komplementsystem, aber sie sorgt nicht für ein besseres Überleben der Streptokokken, in der Anwesenheit von spezifischen Immunglobulinen. Sie reduziert die Assoziation von S. suis mit Monozyten, was etwas in Diskrepanz zu einer 2000 postulierten modifizierten „Trojanisches Pferd“-Theorie steht. Die durch LTA D-Alanylierung gesteigerte IL 1β Sekretion im Vollblut, führt zu der Schlussfolgerung, dass S. suis durch diese Zellwandmodifikation Entzündungsprozesse im Wirt beeinflusst.:Contents 1 Introduction 2 Literature 2.1 Streptococcus suis 2.1.1 Characteristics and classification 2.1.2 Epidemiology and Pathology 2.1.3 Pathogenesis of S. suis infection 2.1.4 Cell wall modifications of S. suis 2.2 Selected aspects of the porcine blood immune system 2.2.1 Characteristics and components of porcine blood 2.2.2 Innate immunity 2.2.2.1 Cellular innate immunity in blood 2.2.2.2 Humoral innate immunity in blood 2.2.3 Adaptive immunity 2.2.3.1 Cellular adaptive immunity in blood 2.2.3.2 Humoral adaptive immunity in blood 2.3 Interaction of S. suis with the blood immune system 2.3.1 Immune evasion strategies against blood leukocytes 2.3.2 Complement evasion and S. suis cell wall modifications 3 Publications 3.1 Survival of Streptococcus suis in Porcine Blood Is Limited by the Antibody- and Complement-Dependent Oxidative Burst Response of Granulocytes 3.2 D-Alanylation of Lipoteichoic Acids in Streptococcus suis Reduces Association with Leukocytes in Porcine Blood 4 Discussion 4.1 Phagocytosis and oxidative burst in porcine blood 4.2 Interaction of S. suis with blood monocytes and lymphocytes 4.3 Conclusion 5 Zusammenfassung 6 Summary 7 References 8 Appendix 8.1 Presentations given during the development of this thesisIntroduction Streptococcus (S.) suis is a widespread pathobiont in the porcine population. It is reason for high economic losses in the swine industry by causing meningitis, arthritis, serositis, and endocarditis, but also poses a threat to human health as a zoonotic pathogen. Serotype 2, 7 and 9 play an important role in European disease cases on pig farms. Bacteremia is a hallmark of invasive S. suis infections and the interaction of the streptococci with blood immune cells is crucial for the outcome of infection. Aim of the study The objective of this thesis was to investigate the ability of porcine blood immune cells to kill S. suis by phagocytosis and oxidative burst and the importance of IgM and the complement system in the killing process. In this context, I investigated the working hypothesis that modifying its cell wall by D-alanylation of lipoteichoic acids (LTAs) aids S. suis to evade certain functions of innate immunity, like opsonization with complement components, and influences the interaction of S. suis with blood leukocytes. Materials and Methods The investigation of reactive oxygen species (ROS) and colony forming units (CFU) was performed in vivo in the blood of two S. suis-infected piglets and in vitro in a reconstituted blood model. ROS were measured by addition of dihydrorhodamine 123 and flow cytometry analysis of granulocytes. To analyze the influence of immunological components, different inhibitors were used: apocynin inhibits the NADPH oxidase and therefore the ROS production, vaccinia virus complement control protein (VCP) inhibits the complement cascade and IdeSsuis cleaves porcine IgM. To investigate the role of D-alanylation of S. suis-LTA an isogenic in-frame deletion mutant of the dltA gene, ΔdltA, was generated by using a thermosensitive shuttle vector. It was genetically verified by sequencing of the respective gene sequence and southern blotting. Phenotypical characterization included growth behavior, evaluation of surface hydrophobicity and electric charge and minimal inhibitory concentrations of a number of antimicrobial peptides. The association of blood leukocytes with S. suis was investigated by flow cytometry, using Far Red-labeled S. suis stocks. Cytokines were detected by commercially available Enzyme-linked immunosorbent assays (ELISA). Results S. suis strains of serotype 2, 7 and 9 were shown to be highly susceptible to oxidative burst intermediate hydrogen peroxide and inhibition of oxidative burst in reconstituted blood samples led to a significant increase of bacterial survival, even in the presence of high S. suis-specific antibody levels. The induction of ROS in granulocytes in response to S. suis was enhanced by specific antibodies and partially depended on the presence of functional complement. In the absence of IgG, IgM cleavage or complement inactivation both reduced the ROS production more than 3-fold and resulted in increased bacterial survival in accordance with an IgM-complement-oxidative burst axis. The mechanism of S. suis to introduce D-alanine into its LTAs increased the hydrophobicity of its surface, reduced opsonization with complement factor C3b, reduced phagocytosis by granulocytes in whole blood and association with monocytes and lymphocytes in isolated peripheral blood mononuclear cells. Nevertheless, in whole blood containing S. suis-specific antibodies, survival of the streptococci was not significantly increased by this cell wall modification, but levels of IL-1β induced by ΔdltA were significantly lower than those induced by the wt. High antibody levels caused a highly significant increase in the interaction of S. suis with monocytes in isolated PBMCs leading to an inflammatory cell death associated with the secretion of high levels of IL-1β and TNF-α. Conclusion Despite numerous described defense mechanisms of S. suis against oxidative stress, phagocytosis and ROS represent a very effective way of the porcine immune system to kill the invading streptococci. The induction of ROS by S. suis is highly dependent on the presence of specific antibodies and partially depends on active complement. The ability of S. suis to D-alanylate its LTAs changes surface properties of S. suis and provides protection from innate host defenses like antimicrobial peptides and the complement system, but does not help the bacteria to survive in the presence of specific immunoglobulins. It reduces the association with monocytes, in contradiction to a proposed “modified trojan horse theory”. The increased IL-1β production in response to S. suis, due to LTA D-alanylation, leads to the suggestion that this surface modification influences inflammatory processes is the host.:Contents 1 Introduction 2 Literature 2.1 Streptococcus suis 2.1.1 Characteristics and classification 2.1.2 Epidemiology and Pathology 2.1.3 Pathogenesis of S. suis infection 2.1.4 Cell wall modifications of S. suis 2.2 Selected aspects of the porcine blood immune system 2.2.1 Characteristics and components of porcine blood 2.2.2 Innate immunity 2.2.2.1 Cellular innate immunity in blood 2.2.2.2 Humoral innate immunity in blood 2.2.3 Adaptive immunity 2.2.3.1 Cellular adaptive immunity in blood 2.2.3.2 Humoral adaptive immunity in blood 2.3 Interaction of S. suis with the blood immune system 2.3.1 Immune evasion strategies against blood leukocytes 2.3.2 Complement evasion and S. suis cell wall modifications 3 Publications 3.1 Survival of Streptococcus suis in Porcine Blood Is Limited by the Antibody- and Complement-Dependent Oxidative Burst Response of Granulocytes 3.2 D-Alanylation of Lipoteichoic Acids in Streptococcus suis Reduces Association with Leukocytes in Porcine Blood 4 Discussion 4.1 Phagocytosis and oxidative burst in porcine blood 4.2 Interaction of S. suis with blood monocytes and lymphocytes 4.3 Conclusion 5 Zusammenfassung 6 Summary 7 References 8 Appendix 8.1 Presentations given during the development of this thesi

Acute Mastoiditis in Children – A National Study in Sweden

One of the greatest threats to society today is the development of bacterial resistance to antibiotics. It is commonly accepted that this is mainly due to the use of antibiotics. Acute otitis media (AOM) is responsible for the highest number of antibiotic prescriptions to children although it is in most cases a self-limiting disease. Nevertheless, complications do occur in some case and the most common complication is acute mastoiditis (AM). Treatment guidelines advocating the restrictive use of antibiotics in uncomplicated AOM have been implemented hoping to slow down the development of resistance to antibiotics. This has led to concerns that an increase of complications will arise. Although AOM is extremely common in early childhood, only 20–60 cases of AM in children are encountered per year in Sweden. In the pre-antibiotic era AM was often lethal and the use of antibiotics has revolutionized the clinical course of severe AOM and AM, radically reducing the rate of complications and mortality. In addition to the new guidelines, in the year 2009, immunisation with pneumococcal conjugate vaccine (PCV) against the most invasive serotypes of Streptococcus pneumoniae, the most common bacteria causing AOM as well as AM, was introduced into the standard immunisation schedule in Sweden. The national study “Mastoiditis in Sweden”, which formed the basis for the research presented in this thesis, gives a good picture of Swedish paediatric patients suffering from AM. The different ways in which AM symptoms are expressed and their development in different age groups are well described in Paper 1. Different surgical methods for treating subperiosteal abscesses were evaluated in Paper 2. It was found that needle aspiration and/or incision to treat SA had no adverse effects when compared to mastoidectomy. Possible effects of the recently introduced immunisation against pneumococci were investigated in the third study (Paper 3). PCV did not offer a complete protection against the serotypes included in the vaccines, even in fully immunised children. Finally, the effects of the altered guidelines on AOM treatment were explored in an attempt to identify risk factors for AM (Paper 4). No overlooked possible risk factors for AM could be identified. Unfortunately, the retroauricular findings indicating an AM, were found to be overlooked by physicians at the primary assessment of some children, which caused a delayed treatment. Thus the AOM treatment guidelines appear to be sufficient, and the greatest challenge lies in detecting complications arising from AOM

The Total Synthesis of Glycolipids from Streptococcus pneumoniae and a Re-evaluation of Their Immunological Activity**

Invariant natural killer (iNK) T cells, Type I iNKTs, are responsible for the production of pro-inflammatory cytokines which induce a systemic immune response. They are distinctive in possessing an semi-invariant T-cell receptor that recognizes glycolipid antigens presented by CD1d, a protein closely related to the class I major histocompatibility complex, conserved across multiple mammalian species in a class of proteins well-renowned for their high degree of polymorphism. This receptor\u27s first potent identified antigen is the α-galactosylceramide, KRN7000, a synthetic glycosphingolipid closely related to those isolated from bacteria that were found on a Japanese marine sponge. A corresponding terrestrial antigen remained unidentified until two specific diacylglycerol-containing glycolipids, reported to activate iNKT cells, were isolated from Streptococcus pneumoniae. We report the total synthesis and immunological re-evaluation of these two glycolipids. The compounds are unable to meaningfully activate iNKT cells. Computational modelling shows that these ligands, while being capable of interacting with the CD1d receptor, create a different surface for the binary complex that makes formation of the ternary complex with the iNKT T-cell receptor difficult. Together these results suggest that the reported activity might have been due to an impurity in the original isolated sample and highlights the importance of taking care when reporting biological activity from isolated natural products

Antibacterial activities of both combined and individual medicinal plants extracts traditionally used to treat pneumonia

Pneumonia is one of the five major leading causes of death in children under-fives years and the elderly worldwide. Antibiotics used for its treatment are less potent due to bacteria development of bacteria resistant to antibiotics. This has led to a surge in search of novel drugs. There are already some drugs in clinical use that have natural products and derivatives such as quinine, morphine, vincristine, and taxol among others. The healing value of medicinal plants has been well accepted since Stone Age across the globe. This plant therapy has been prescribed and prepared independently or in combination. The following plants: Terminalia sericea, Warburgia salutaris, Dodonea angustofolia, Eucalyptus camaldulensis, Ballota africana, Kigelia africana and Acorus gramineus. These plants are most commonly used for treatment of pneumonia and other ailment, were studied to validate their antimicrobial activity based on scientific determination. The primary aim of this study was to evaluate the efficacy of these plants against bacteria pneumonia pathogens. Seven medicinal plants, independently and in combinations were relatively analysed for their antimicrobial activity against Staphylococcus aureus, Streptococcus pyogenes, and Klebsiella pneumoniae. Ground plant material of roots, bark and leafs were prepared with acetone, ethanol and distilled water. Dimethyl sulfoxide (10 &100%) was used as a reconstitution solvent and ciprofloxacin (10 %) as a positive control. The antimicrobial efficacy was determined using agar well diffusion and microtiter plate methods. Interaction between plants was evaluated by calculating fraction inhibitory concentration index (ΣFIC). Noteworthy activity for individual studies with all test organisms was observed with T. sericea. However, highest ZOI (30 mm) was observed for B. africana ethanol extract for S. pyogenes. Weak microbial activity was noted in W. salutaris and D. angustofolia extracts with all test organisms. Good antimicrobial activity was observed in combination studies with all organisms. The potency of different plant combinations varied with highest ZOI observed with B. africana and W. salutaris ranging from 33-35 mm, conversely ZOI of 35 mm was also noted for S. aureus in B. africana and E. camaldulensis ethanol extract. Noteworthy antimicrobial activity was observed in T. sericea and D. angustofolia against all test pathogens. weak antimicrobial activity with highest MICs was observed in combinations where W. salutaris was involved. After calculating ΣFICs, strongest synergistic effect was displayed for W. salutaris and D. angustofolia against all test organisms (lowest ΣFICs 0.0491). Most plant extract combinations, displayed either synergistic, additive or indifferent effect, with few demonstrating antagonistic interactions. Significant antagonism effect was noted for S. pyogenes with T. sericea ethanol extract ΣFIC value of 15.51. Based on results of this study use of plants in combination increase antimicrobial efficacy. The antimicrobial activities; synergistic and additive effects observed adds credibility in the use of plant combination for therapeutic value in treatment of pneumonia. Future studies are recommended to identify and isolate specific active compounds involved in plant combination interactions. The importance of combination studies for possible development of new antimicrobials that can succumb bacterial resistance need to be highlighted

Cytokine Expression in Staphylococcal and Streptococcal Endophthalmitis

Background: Endophthalmitis is an infection of ocular tissues, often with devastating outcomes for vision. Immunomodulation is an emerging avenue for therapeutic intervention in endophthalmitis, with the expression of cytokines central to potential mechanisms. This literature review with a systematic approach characterizes the cytokine expression in both animal and human staphylococcal and streptococcal endophthalmitis. Method and Results: Four online databases were searched for studies profiling cytokine levels in animal models or human populations with staphylococcal and/or streptococcal endophthalmitis. Of the 1,060 articles identified, 14 studies were included in this review comprising eight animal models and six human populations. Mouse, rat, and rabbit models of Staphylococcus aureus, Staphylococcus epidermidis, and Streptococcus pneumoniae endophthalmitis had elevated levels of IL-1β, IL-6, IFN-γ, TNF-α, and IL-8, with earlier peaks observed in S. epidermidis infection. Human endophthalmitis demonstrated significantly increased mediator levels compared to controls for a range of pro-inflammatory and anti-inflammatory cytokines, chemokines, and growth factors. Several associations were established between cytokine concentrations and both initial visual acuity and visual prognosis, with no consistent correlations across trials. Conclusions: It may be that virulence factors and the combinations of toll-like receptors activated influence the pathogen-specific visual outcomes observed in endophthalmitis. Furthermore, disease severity and potential therapeutic targets may be dependent on synergistic and compensatory cytokine pathways and the expression of anti-inflammatory mediators. Future research should aim to better characterize the roles of inflammatory mediators and solidify associations between pathogens, inflammation, and endophthalmitis outcomes. This has exciting implications for the prevention and treatment of endophthalmitis in clinical settings