Composition and dynamics of the vaginal microbiota : associated factors and role in Chlamydia trachomatis infection

Chlamydia trachomatis (CT) est une bactérie sexuellement transmissible responsable d’infections génitales hautes pouvant conduire à une infertilité tubaire ou à des grossesses extra-utérines. C’est l’infection sexuellement transmissible la plus fréquente dans le monde, y compris en France. Les données épidémiologiques indiquent que l’incidence de cette infection est en augmentation malgré les mesures de contrôle mises en place, ce qui motive la révision des recommandations actuelles de dépistage de l’infection à CT. Le microbiote vaginal pourrait jouer un rôle majeur dans la prévention des IST via la compétition écologique et la production de métabolites, dont l’acide lactique. Le microbiote vaginal correspond à un équilibre dynamique fragile et susceptible d’être modifié par un ensemble d’expositions, parmi lesquelles les pratiques sexuelles et d’hygiène intime, l’exposition aux antibiotiques mais aussi la présence de pathogènes. L’objectif général de cette thèse est d’étudier ce triangle d’associations entre expositions, microbiote vaginal et infection par CT, à travers l’étude de la composition et de la dynamique du microbiote vaginal. Nous avons cherché à répondre aux questions suivantes : existe-t-il des marqueurs de l’infection par CT au niveau du microbiote vaginal ? La composition et la structure du microbiote vaginal sont-elles modifiées par l’infection par CT et la prise d’antibiotiques ? Quels sont les expositions associées à des perturbations du microbiote vaginal ? Une première étape a consisté à réaliser un état de l’art et d'estimer l’association entre microbiote vaginal et infection par CT dans la littérature, ainsi que pour trois autres IST d’importance clinique, et à évaluer le rôle de plusieurs facteurs dans l’hétérogénéité des mesures d’association observées. Dans un second temps, nous avons estimé cette association en s'appuyant sur la caractérisation moléculaire du microbiote vaginal, dans deux études en France et aux Etats-Unis. Nous avons montré qu’il y avait une surreprésentation des communautés bactériennes dominées par Lactobacillus iners (CST III) et de celles dépourvues de Lactobacillus spp. (CST IV) chez les femmes infectées par CT. En étudiant l’évolution du microbiote vaginal dans l’étude américaine, après traitement par azithromycine et clairance de CT, nous avons montré que le microbiote vaginal ne parvenait pas à évoluer vers un état optimal. Ce résultat laisse supposer qu’il persiste après traitement un risque vis-à-vis des réinfections. Enfin, dans deux études longitudinales à échantillonnage fréquent aux Etats-Unis, nous avons étudié les expositions associées à l’incidence et à la clairance d’un CST IV. Nous avons montré que lorsque le microbiote vaginal n’était pas dominé par L. iners, les facteurs associés à l’incidence d’un CST IV et à sa clairance étaient essentiellement les menstruations, tandis que chez les femmes dont le microbiote vaginal est dominé par L. iners, les menstruations mais aussi l’usage de lubrifiant, les douches vaginales, l’origine ethnique, l’âge et les rapports sexuels non protégés étaient associés à l’incidence d’un CST IV ou à sa clairance. Ainsi, ce travail de thèse a permis d'une part de confirmer l’association entre microbiote vaginal dépourvu de Lactobacillus et infection par CT en population en s'appuyant sur le séquençage génomique, et d'autre part de distinguer l’espèce L. iners des autres espèces de Lactobacillus et d’évaluer le risque associé au CST III. En permettant une meilleure compréhension de l’histoire naturelle de CT et des dynamiques du microbiote vaginal, nous espérons proposer des pistes pour améliorer les stratégies de contrôle de l’infection par CT et d’autres IST. Le potentiel innovant du projet réside dans l’usage de méthodes moléculaires nous permettant d’affiner notre approche de la santé en intégrant la prédisposition individuelle aux infections sexuellement transmissibles, ainsi ouvrant la voie vers la médecine personnalisée.Chlamydia trachomatis (CT) is a sexually transmitted bacteria responsible for cervicitis, urethritis, and pelvic inflammatory diseases leading to subsequent tubal infertility and ectopic pregnancies. It is the most frequent sexually transmitted infection worldwide, including in France. Epidemiological data indicate that the incidence rate is increasing despite the implementation of control measures, which motivates the revision of current screening strategies. The vaginal microbiota could play a major role in preventing sexually transmitted infections through ecological competition and metabolites, such as lactic acid production. The vaginal microbiota corresponds to a fine-tuned equilibrium likely to be modified by exposures such as sexual practices, hygiene practices, antibiotics but also presence of pathogens. The overall objective of this thesis is to study the association in this triangle composed of external exposures, vaginal microbiota and CT infection, through the study of the vaginal microbiota composition and dynamics. We aimed at answering these questions: are there biomarkers of CT infection in the vaginal microbiota? Are the vaginal microbiota composition and structure modified by CT infection and antibiotic consumption? What are the exposures associated with perturbations of the vaginal microbiota? To answer these questions, the first step consisted of a state of the art to estimate the association between vaginal microbiota and CT infection in the literature, as well as three other clinically relevant sexually transmitted infections, and to evaluate the role of several factors in the observed heterogeneity between studies. In a second step, we estimated this association using molecular characterization of the vaginal microbiota in two studies in France and in the United States. We showed that Lactobacillus iners-dominated communities (CST III) and Lactobacillus-deprived communities (CST IV) were over-represented among CT-positive women. By studying the vaginal microbiota after azithromycin treatment and CT clearance in the American study, we showed that the vaginal microbiota did not evolve towards an optimal state, suggesting that women may stay at risk of CT reinfections. Finally, in two longitudinal studies using frequent sampling in the United States, we studied exposures associated with incidence and clearance of a CST IV. We showed that when the vaginal microbiota was not dominated by L. iners, menses was the main factor associated with incidence and clearance of a CST IV, while for women whose vaginal microbiota is dominated by L. iners, menses but also lubricant use, douching, ethnic origins, age and condomless vaginal sex were associated with CST IV incidence and/or clearance. Therefore, this thesis allowed on the one hand to confirm the association between Lactobacillus-deprived vaginal microbiota and CT infection using genome sequencing, and on the other hand to single out L. iners from other Lactobacillus spp. and to evaluated the risk associated with CST III. By enabling a better understanding of the natural history of CT and of the vaginal microbiota dynamics, we hope to contribute to improving strategies for the control of CT infection and other STIs. The innovative potential of the project lies in the use of molecular methods, which allows refining of our approach of health management by integrating individual predisposition to sexually transmitted infections, thus paving the way for personalized medicine

Composition et dynamique du microbiote vaginal : facteurs associés et rôle dans l’infection par Chlamydia trachomatis

Chlamydia trachomatis (CT) is a sexually transmitted bacteria responsible for cervicitis, urethritis, and pelvic inflammatory diseases leading to subsequent tubal infertility and ectopic pregnancies. It is the most frequent sexually transmitted infection worldwide, including in France. Epidemiological data indicate that the incidence rate is increasing despite the implementation of control measures, which motivates the revision of current screening strategies. The vaginal microbiota could play a major role in preventing sexually transmitted infections through ecological competition and metabolites, such as lactic acid production. The vaginal microbiota corresponds to a fine-tuned equilibrium likely to be modified by exposures such as sexual practices, hygiene practices, antibiotics but also presence of pathogens. The overall objective of this thesis is to study the association in this triangle composed of external exposures, vaginal microbiota and CT infection, through the study of the vaginal microbiota composition and dynamics. We aimed at answering these questions: are there biomarkers of CT infection in the vaginal microbiota? Are the vaginal microbiota composition and structure modified by CT infection and antibiotic consumption? What are the exposures associated with perturbations of the vaginal microbiota? To answer these questions, the first step consisted of a state of the art to estimate the association between vaginal microbiota and CT infection in the literature, as well as three other clinically relevant sexually transmitted infections, and to evaluate the role of several factors in the observed heterogeneity between studies. In a second step, we estimated this association using molecular characterization of the vaginal microbiota in two studies in France and in the United States. We showed that Lactobacillus iners-dominated communities (CST III) and Lactobacillus-deprived communities (CST IV) were over-represented among CT-positive women. By studying the vaginal microbiota after azithromycin treatment and CT clearance in the American study, we showed that the vaginal microbiota did not evolve towards an optimal state, suggesting that women may stay at risk of CT reinfections. Finally, in two longitudinal studies using frequent sampling in the United States, we studied exposures associated with incidence and clearance of a CST IV. We showed that when the vaginal microbiota was not dominated by L. iners, menses was the main factor associated with incidence and clearance of a CST IV, while for women whose vaginal microbiota is dominated by L. iners, menses but also lubricant use, douching, ethnic origins, age and condomless vaginal sex were associated with CST IV incidence and/or clearance. Therefore, this thesis allowed on the one hand to confirm the association between Lactobacillus-deprived vaginal microbiota and CT infection using genome sequencing, and on the other hand to single out L. iners from other Lactobacillus spp. and to evaluated the risk associated with CST III. By enabling a better understanding of the natural history of CT and of the vaginal microbiota dynamics, we hope to contribute to improving strategies for the control of CT infection and other STIs. The innovative potential of the project lies in the use of molecular methods, which allows refining of our approach of health management by integrating individual predisposition to sexually transmitted infections, thus paving the way for personalized medicine.Chlamydia trachomatis (CT) est une bactérie sexuellement transmissible responsable d’infections génitales hautes pouvant conduire à une infertilité tubaire ou à des grossesses extra-utérines. C’est l’infection sexuellement transmissible la plus fréquente dans le monde, y compris en France. Les données épidémiologiques indiquent que l’incidence de cette infection est en augmentation malgré les mesures de contrôle mises en place, ce qui motive la révision des recommandations actuelles de dépistage de l’infection à CT. Le microbiote vaginal pourrait jouer un rôle majeur dans la prévention des IST via la compétition écologique et la production de métabolites, dont l’acide lactique. Le microbiote vaginal correspond à un équilibre dynamique fragile et susceptible d’être modifié par un ensemble d’expositions, parmi lesquelles les pratiques sexuelles et d’hygiène intime, l’exposition aux antibiotiques mais aussi la présence de pathogènes. L’objectif général de cette thèse est d’étudier ce triangle d’associations entre expositions, microbiote vaginal et infection par CT, à travers l’étude de la composition et de la dynamique du microbiote vaginal. Nous avons cherché à répondre aux questions suivantes : existe-t-il des marqueurs de l’infection par CT au niveau du microbiote vaginal ? La composition et la structure du microbiote vaginal sont-elles modifiées par l’infection par CT et la prise d’antibiotiques ? Quels sont les expositions associées à des perturbations du microbiote vaginal ? Une première étape a consisté à réaliser un état de l’art et d'estimer l’association entre microbiote vaginal et infection par CT dans la littérature, ainsi que pour trois autres IST d’importance clinique, et à évaluer le rôle de plusieurs facteurs dans l’hétérogénéité des mesures d’association observées. Dans un second temps, nous avons estimé cette association en s'appuyant sur la caractérisation moléculaire du microbiote vaginal, dans deux études en France et aux Etats-Unis. Nous avons montré qu’il y avait une surreprésentation des communautés bactériennes dominées par Lactobacillus iners (CST III) et de celles dépourvues de Lactobacillus spp. (CST IV) chez les femmes infectées par CT. En étudiant l’évolution du microbiote vaginal dans l’étude américaine, après traitement par azithromycine et clairance de CT, nous avons montré que le microbiote vaginal ne parvenait pas à évoluer vers un état optimal. Ce résultat laisse supposer qu’il persiste après traitement un risque vis-à-vis des réinfections. Enfin, dans deux études longitudinales à échantillonnage fréquent aux Etats-Unis, nous avons étudié les expositions associées à l’incidence et à la clairance d’un CST IV. Nous avons montré que lorsque le microbiote vaginal n’était pas dominé par L. iners, les facteurs associés à l’incidence d’un CST IV et à sa clairance étaient essentiellement les menstruations, tandis que chez les femmes dont le microbiote vaginal est dominé par L. iners, les menstruations mais aussi l’usage de lubrifiant, les douches vaginales, l’origine ethnique, l’âge et les rapports sexuels non protégés étaient associés à l’incidence d’un CST IV ou à sa clairance. Ainsi, ce travail de thèse a permis d'une part de confirmer l’association entre microbiote vaginal dépourvu de Lactobacillus et infection par CT en population en s'appuyant sur le séquençage génomique, et d'autre part de distinguer l’espèce L. iners des autres espèces de Lactobacillus et d’évaluer le risque associé au CST III. En permettant une meilleure compréhension de l’histoire naturelle de CT et des dynamiques du microbiote vaginal, nous espérons proposer des pistes pour améliorer les stratégies de contrôle de l’infection par CT et d’autres IST. Le potentiel innovant du projet réside dans l’usage de méthodes moléculaires nous permettant d’affiner notre approche de la santé en intégrant la prédisposition individuelle aux infections sexuellement transmissibles, ainsi ouvrant la voie vers la médecine personnalisée

Vaginal microbiota stability over 18 months in young student women in France

International audiencePurpose. Non-optimal vaginal microbiota lacking lactobacilli and comprising a wide array of anaerobic bacteria, typified by community state type (CST) IV, have been associated with adverse gynecological and pregnancy outcomes. Here, we investigate the stability of the vaginal microbiota sampled every 6 months over 18 months and how samples distantly collected combined with exposures could provide insight on future microbiota compositional changes.Methods. Vaginal microbiota dynamics were analyzed in 241 female students aged 18-24 years and negative for Chlamydia trachomatis and Neisseria gonorrhoeae. The vaginal microbiota was characterized using 16S rRNA gene amplicon sequencing and assigned to CSTs. Vaginal microbiota longitudinal profiles were determined through hierarchical clustering. Results. At baseline, 11.2% of participants had a CST IV, 40.5% a CST I (Lactobacillus crispatus-dominated), and 38.1% a CST III (Lactobacillus iners-dominated). A total of 345 CST transitions were observed over the study period. Pain during sexual intercourse was associated with a higher probability of transition from CST III to CST IV, while self-reported yeast infection was associated with a higher probability of transition from CST IV to CST I. Over the study period, 32.0% participants displayed a stable CST trajectory. Composition of the vaginal microbiota of a single sample predicted with good accuracy the CST trajectory over the following 18 months.Conclusion. Vaginal longitudinal CST patterns over 18 months could be clustered into three main groups of trajectories. Performing molecular characterization at a single time point could contribute to improved preventive care and optimization of young women’s reproductive and sexual health

A community survey of antibiotic consumption among children in Madagascar and Senegal: the importance of healthcare access and care quality

International audienceBackground: Antibiotic resistance is growing in low-income countries (LICs). Children in LICs are particularly at risk. Information on antibiotic consumption is needed to control the development and spread of resistant bacteria. Methods: To measure antibiotic consumption and related factors, a community survey was undertaken in two sites in Madagascar (Antananarivo and Moramanga) and in Senegal (Guediawaye) among children under 2. Face-to-face interviews were conducted with parents or caregivers of eligible children. Regression analysis was used to determine variables associated with reported antibiotic consumption. Availability of health structures and health policies were also investigated. Results: Population estimates for antibiotic consumption in the last 3 months were 37.2% (95% CI 33.4%–41.2%) in Guediawaye, 29.3% (95% CI 25.0%–34.1%) in Antananarivo and 24.6% (95% CI 20.6%–29.1%) in Moramanga. In all sites, the large majority of antibiotics were taken with a prescription (92.2%, 87.0% and 92.0% for Antananarivo, Moramanga and Guediawaye, respectively) and purchased in pharmacies (89.4%, 73.5% and 78.5%, respectively). Living in houses without flushing toilets and baby age were significantly associated with any antibiotic consumption after adjusting for site. A higher density of public health structures was associated with lower antibiotic consumption levels, while a higher density of private pharmacies was associated with higher levels across sites. Conclusions: These data are crucial for the implementation of local programmes aimed at optimizing antibiotic consumption. Factors such as density of healthcare facilities, prescriber training and national policy must be taken into account when developing strategies to optimize antibiotic consumption in LICs

Nonoptimal Vaginal Microbiota after Azithromycin Treatment for Chlamydia trachomatis Infection

International audienceWe characterized the composition and structure of the vaginal microbiota in a cohort of 149 women with genital Chlamydia trachomatis infection at baseline who were followed quarterly for 9 months after antibiotic treatment. At time of diagnosis, the vaginal microbiota was dominated by Lactobacillus iners or a diverse array of bacterial vaginosis-associated bacteria including Gardnerella vaginalis. Interestingly, L. iners-dominated communities were most common after azithromycin treatment (1 g monodose), consistent with the observed relative resistance of L. iners to azithromycin. Lactobacillus iners-dominated communities have been associated with increased risk of C. trachomatis infection, suggesting that the impact of antibiotic treatment on the vaginal microbiota could favor reinfections. These results provide support for the dual need to account for the potential perturbing effect(s) of antibiotic treatment on the vaginal microbiota, and to develop strategies to protect and restore optimal vaginal microbiota

Early screening for Chlamydia trachomatis in young women for primary prevention of pelvic inflammatory disease (i-Predict): study protocol for a randomised controlled trial

International audienceBackground.Genital infection with Chlamydia trachomatis (Ct) is the most common bacterial sexually transmitted infection, especially among young women. Mostly asymptomatic, it can lead, if untreated, to pelvic inflammatory disease (PID), tubal factor infertility and ectopic pregnancy. Recent data suggest that Ct infections are not controlled in France and in Europe. The effectiveness of a systematic strategy for Ct screening in under-25 women remains controversial. The main objective of the i-Predict trial (Prevention of Diseases Induced by Chlamydia trachomatis) is to determine whether early screening and treatment of 18- to-24-year-old women for genital Ct infection reduces the incidence of PID over 24 months.Methods/design.This is a randomised prevention trial including 4000 eighteen- to twenty-four-year-old sexually active female students enrolled at five universities. The participants will provide a self-collected vaginal swab sample and fill in an electronic questionnaire at baseline and at 6, 12 and 18 months after recruitment. Vaginal swabs in the intervention arm will be analysed immediately for Ct positivity, and participants will be referred for treatment if they have a positive test result. Vaginal swabs from the control arm will be analysed at the end of the study. All visits to general practitioners, gynaecologists or gynaecology emergency departments for pelvic pain or other gynaecological symptoms will be recorded to evaluate the incidence of PID, and all participants will attend a final visit in a hospital gynaecology department. The primary endpoint measure will be the incidence of PID over 24 months. The outcome status (confirmed, probable or no PID) will be assessed by two independent experts blinded to group assignment and Ct status.Discussion.This trial is expected to largely contribute to the development of recommendations for Ct screening in young women in France to prevent PID and related complications. It is part of a comprehensive approach to gathering data to facilitate decision-making regarding optimal strategies for Ct infection control. The control group of this randomised trial, following current recommendations, will allow better documentation of the natural history of Ct infection, a prerequisite to evaluating the impact of Ct screening. Characterisation of host immunogenetics will also allow identification of women at risk for complications.Trial registration.ClinicalTrials.gov, NCT02904811. Registered on September 14, 2016.World Health Organisation International Clinical Trials Registry, NCT02904811.AOM, 15-0063 and P150950. Registered on September 26, 2016. A completed Standard Protocol Items : Recommendations for International Trials (SPIRIT) Checklist is available in additional file 1

The Cervicovaginal Microbiota-Host Interaction Modulates Chlamydia trachomatis Infection

The mechanism(s) by which Lactobacillus-dominated cervicovaginal microbiota provide a barrier to Chlamydia trachomatis infection remain(s) unknown. Here we evaluate the impact of different Lactobacillus spp. identified via culture-independent metataxonomic analysis of C. trachomatis-infected women on C. trachomatis infection in a three-dimensional (3D) cervical epithelium model. Lactobacillus spp. that specifically produce d(-) lactic acid were associated with long-term protection against C. trachomatis infection, consistent with reduced protection associated with Lactobacillus iners, which does not produce this isoform, and with decreased epithelial cell proliferation, consistent with the observed prolonged protective effect. Transcriptomic analysis revealed that epigenetic modifications involving histone deacetylase-controlled pathways are integral to the cross talk between host and microbiota. These results highlight a fundamental mechanism whereby the cervicovaginal microbiota modulates host functions to protect against C. trachomatis infection.IMPORTANCE The vaginal microbiota is believed to protect women against Chlamydia trachomatis, the etiologic agent of the most prevalent sexually transmitted infection (STI) in developed countries. The mechanism underlying this protection has remained elusive. Here, we reveal the comprehensive strategy by which the cervicovaginal microbiota modulates host functions to protect against chlamydial infection, thereby providing a novel conceptual mechanistic understanding. Major implications of this work are that (i) the impact of the vaginal microbiota on the epithelium should be considered in future studies of chlamydial infection and other STIs and (ii) a fundamental understanding of the cervicovaginal microbiota's role in protection against STIs may enable the development of novel microbiome-based therapeutic strategies to protect women from infection and improve vaginal and cervical health

The Cervicovaginal Microbiota-Host Interaction Modulates Chlamydia trachomatis Infection

The vaginal microbiota is believed to protect women against Chlamydia trachomatis, the etiologic agent of the most prevalent sexually transmitted infection (STI) in developed countries. The mechanism underlying this protection has remained elusive. Here, we reveal the comprehensive strategy by which the cervicovaginal microbiota modulates host functions to protect against chlamydial infection, thereby providing a novel conceptual mechanistic understanding. Major implications of this work are that (i) the impact of the vaginal microbiota on the epithelium should be considered in future studies of chlamydial infection and other STIs and (ii) a fundamental understanding of the cervicovaginal microbiota’s role in protection against STIs may enable the development of novel microbiome-based therapeutic strategies to protect women from infection and improve vaginal and cervical health.The mechanism(s) by which Lactobacillus-dominated cervicovaginal microbiota provide a barrier to Chlamydia trachomatis infection remain(s) unknown. Here we evaluate the impact of different Lactobacillus spp. identified via culture-independent metataxonomic analysis of C. trachomatis-infected women on C. trachomatis infection in a three-dimensional (3D) cervical epithelium model. Lactobacillus spp. that specifically produce d(−) lactic acid were associated with long-term protection against C. trachomatis infection, consistent with reduced protection associated with Lactobacillus iners, which does not produce this isoform, and with decreased epithelial cell proliferation, consistent with the observed prolonged protective effect. Transcriptomic analysis revealed that epigenetic modifications involving histone deacetylase-controlled pathways are integral to the cross talk between host and microbiota. These results highlight a fundamental mechanism whereby the cervicovaginal microbiota modulates host functions to protect against C. trachomatis infection