Pseudomonas Aeruginosa

Pathogenesis of Pseudomonas Joanna B. Goldberg, Ph.D. Emory University School of Medicine

March 1, 2017 Nothing to disclose Mandell, Douglas, and Benne's Principles and Pracce of Infecous Diseases, Updated Edion, 221, 2518-2531.e3

P. aeruginosa physiology

• Ubiquitous • Minimal growth requirements • Temperature • Can grow anaerobically with arginine or nitrate • Resistant to anmicrobials • Permeability barrier • Numerous eﬄux pumps • Acquired resistance What is available to the ﬁeld?

• Strains • First sequenced P. aeruginosa strain, PAO1 (Stover et al. Nature 2000) • Large genome, single circular chromosome, ~6.6 Mb • >5580 ORF • 66% G+C • Bioinformac analysis • Ordered transposon (Tn) libraries • PAO1, Jacobs et al. PNAS 2003 • PA14, Libera et al. PNAS 2006 • State of the art genec tools • Reagents for the construcon of speciﬁc mutaons • Tnseq • RNAseq

What is available to the ﬁeld?

• Infecons generally occur in the context of breach of the innate immune system • Healthy animals like healthy humans are typically resistant to infecon Ear infecons Eye infecons Chronic respiratory infecons (parcularly, cysc ﬁbrosis) Hospital-acquired pneumonia

Bloodstream and catheter-related infecons Intra-abdominal infecons

Urinary tract infecons Skin and so ssue infecons Pseudomonas aeruginosa Clinical Presentaon nrmicro_poster_mar11.indd 1 Supplement to Nature Publishing Group Supplement to Nature Publishing Group IMI orMERO More at More as such — pathogens resistant ofnew therapies totreat infections caused byother multi-drug superbug also known asMRSA), Cubist iscurrently building pipelinea methicillin-resistant by caused infections injection),used inthe treatment ofserious skin and bloodstream additiontoits first-in-class I.V. antibiotic CUBICIN® (daptomycin for neededantibiotics for serious, often life-threatening infections. In Pharmaceuticalsisunique inits focus onthe development ofbadly HeadquarteredinLexington, Massachusetts, USA, Cubist Pharmaceuticals Cubist Rates of antibiotic resistance among all metallo- including factors, transposonsand integrons can encode additional antibiotic resistance (RND)and aperiplasmic membrane fusion protein (MFP). Plasmids, formingproteins (OMFs), acytoplasmic membrane-associated antiporter channel- membrane outer of consist pumps Efflux below). (see bacterium includedrug efflux pumps, which remove avariety of antibiotics AmpC from the encoding gene the represses ofcarbapenems) or regulatory systems (such as AmpD, which indirectly targetedby colistin), uptake channels (such as OprD, which mediates influx andgyrase, which are targeted by fluoroquinolones; and LPS, which is mechanismsinclude alteration of antibiotic targets (such as topoisomerase IV drugclass or general, affecting many different types of antibiotics. Specific common.The mechanisms of drug resistance can be specific for aparticular MexM–MexN MexP–MexQ–OpmE MexV–MexW MexG–MexH–MexI–OpmD MexJ–MexK MexX–MexY MexE–MexF–OprN MexC–MexD–OprJ MexA–MexB–OprM pump efflux RND pumps efflux Antibiotic Gyr MICROBIOLOGY PIP orPTZ Chr β ase -lactams, and enzymes that inactivate aminoglycosides. inactivate that enzymes and -lactams, omosome AMK CPM www.cubist.co FQ Fluor Fluor P Cephalospori Aminoglycoside Carbapenem 02 enicillin E To ﬄ poisome ux pump oquinolone oquinolone and integr Tr ansposons RND ampC MFP m OMF ra n se IV on s 04 1 Chloramphenicol macrolideschloramphenicol,tetracycline, FQ, erythromycinchloramphenicol,tetracycline, FQ, FQ erythromycin Tetracycline, chloramphenicolmacrolides, FQ,Anti-PA PCN, CPM, MERO, tetracyline, AG, trimethoprim chloramphenicol, carbapenems, FQ, trimethoprim macrolides,chloramphenicol, FQ,Anti-PA PCN, CPM, MERO, tetracycline, sulphonamides trimethoprim, macrolides, FQ, Substrates s β allconventional antibiotics are increasingly -lactamases,which are active against nearly Pseudomonas aeruginosa Pseudomonas B -lactams (except IMI), tetracyclines,chloramphenicol,IMI), (except -lactams levelsof drug resistance; isolates resistant to % ofstr ismade increasingly difficult by the rising Carbapenem Cephalosporin Pe Aminoglycoside β Staphylococcus aureus Staphylococcus 06 -lactamase).General mechanisms nicillin Plasmid P. aeruginosa Treatment of of Treatment ains r Antibiotic resistance esistant OprD . 0

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and soft tissue infections. tissue soft and burnsand iscommona cause ofnosocomial skin P. a s o n i maceratedskin, leading g to‘hot tub folliculitis’. u r e a P. infections tissue soft and Skin haemorrhage. nodularskin lesion with central ulceration and associatedwith ecthyma gangrenosum, apainless a s o n nosocomial i bloodstream g infections, u which r can be e a P. Bloodstreaminfections tract. urinary the of surgery or body infectionsare usually associated with foreigna a s o n i ofnosocomial urinary tract g infections. These u r e a P. tractinfections Urinary infections. a s o n i hospital-acquired g complicated intra-abdominal u r e a P. Complicatedintra-abdominal infections rate. mortality withaparticularly high patients;itis associated inmechanically ventilated acquiredpneumonia, especially a s o n hospital- of causes i common g u r e a P. Hospital-acquiredpneumonia flow.air ofthe airways and abnormalities in diseasea characterized bynarrowing chronicobstructive pulmonary disease, dilationofthe bronchial tree, and in diseasea characterized byirreversible andinfection also occur in bronchiectasis, thesepatients. Chronic lung colonization accelerateddecline inlung function in cysticfibrosis and isassociated with an a s o n i therespiratory tracts g ofindividuals with u r e a P. Chronicrespiratory infections bone. temporal and cells air deeperstructures, including the middle ear, mastoid canalinvade through the surrounding cartilage to severeinfection that occurs when bacteria inthe ear earafter swimming. Malignant otitis externa isa earcanal that develops when water remains inthe ‘Swimmer’sear’ isan infection ofthe outer infections Ear lenses. contact by caused injury corneal introducedinto the eye bytrauma orfollowing intraocularcavity (endophthalmitis). Bacteria are a s o n i cornea(keratitis) g but may occasionally involve u the r e a P. infections Eye Clinical disease

eruginosa u infections occur after patients have been hospitalized. Several factors account mucociliary clearance (in an individual with cystic fibrosis). Many presence of a foreign body (a patient with a central venous catheter) and altered neutrophils (for example, in a cancer patient receiving chemotherapy), the epithelial barrier (as found in a patient with a burn wound), a depletion of compromised natural defences. Predisposing conditions include a disrupted Pseudomonas aeruginosa also infects wounds ofpatients with causes asubstantial proportion of can survive inhot tubs and infect accounts for substantiala proportion isidentified insome cases of isone ofthe most iscommonly isolated from infections most commonly involve the dismutase1. TLR,Toll-like receptor; SOD1, superoxide PIP,piperacillin; PTZ, piperacillin–tazobactam; lipopolysaccharide;MERO, meropenem; IL,interleukin; IMI, imipenem; LPS, FQ,fluoroquinolones; ICU, intensive-care unit; factor elongation EF2, receptor; conductance cefepime;CTFR, cystic fibrosis transmembrane asialo-gangliotetraocylceramide 1;CPM, PCN,anti-pseudomonal penicillin; Asialo-GM1, AG,aminoglycosides; AMK, amikacin; Anti-PA Abbreviations is an opportunistic pathogen that infects humans with

Pseudomonas aeruginosa

Alan R. Hauser and Egon A. Ozer Bioﬁlm 3. 2. 1. References Phagocyte

Prevention, 2006–2007.Prevention, NationalHealthcare Safety Network atthe Centers for Disease Control and withhealthcare-associated infections: annual summary ofdata reported tothe (2010). 95–104.e2 2009. June issued 2003–2008, for summary data report, resistance mechanisms. mechanisms. resistance aeruginosa: Hidron A. I. A. Hidron Rosenthal V.Rosenthal D. Lister,P. Antibacterial-resistantWolter, D. D., N. Hanson, & J. D. molecule autoinducer sensing Quorum . aeruginosa s o n i g u r e a P. Airway Clinical impact and complex regulation ofchromosomally encoded et al et et al et . NHSN. annual update: antimicrobial-resistant pathogens associated .International Nosocomial Infection Control Consortium (INICC)

Infect. Control Hosp. Epidemiol. Hosp. Control Infect. Clin. Microbiol. Rev.Microbiol. Clin. extracellular matrix. extracellular andtarget the hostcell pathways modulateor disrupt facilitateadhesion, pigmentsthat effectorproteins and toxins,proteases, adhesinsand secreted mediatedby various P. Pathogenesisin Pathogenesis and the lectin LecB. The extracellular polymeric matrixand delaysCupC fimbriae, diffusionwhich mediate of somebacterial antibioticsattachment during initial biofilm cells)and formation, alginate, extracellular DNA (eDNA), and proteins, including polysaccharidesthe CupA, CupB Pel (synthesized by PelA–PelG), Psl (arranged architecturein a helical depends pattern on the around production of the biofilm matrix, which consists motilityof and the the formation of microcolonies, which evolve into mature Biofilmbiofilms. formationBiofilm starts with the attachment of bacteria to a surface,Biofilms followed by twitching u u anadditional level of complexity. largenumber of virulence determinants. Cross regulation of the three systems provides in systems sensing quorum Three Quorum sensing u

aeruginosa by RhlR by N by Lasl. The molecule is detected by LasR. N pqsABCDE 2-heptyl-3-hydroxy-4-quinolone(PQS) issynthesized bythe products ofthe used to interfere with host defences. the host immune system. In addition, a large arsenal of pathogenicity factors is of acquire resistance to many others, making treatment difficult. The propensity P. and can thus grow in hospital drains, sinks and even disinfectant solutions. for the success of -(3-oxododecanoyl)- -butanoyl-

aeruginosa P. Pe Alginate

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22 eDNA is , 582–610 (2009). 582–610 , and l -homoserine lactone (C lactone -homoserine is intrinsically resistant to a large number of antibiotics and can phnAB

29 to form biofilms further protects it from antibiotics and from Am. J. Infect. Control Infect. J. Am. , 996–1011 (2008). 996–1011 , . aeruginosa s o n i g u r e a P. l operons along with PqsH. PQS isdetected byPqsR. Pyocyanin -homoserine lactone (3-O-C lactone -homoserine Pseudomonas to surface Attachment damag Oxidative matrix Extr P sl polysaccharide . aeruginosa s o n i g u r e a P. a Pyover cellular Pe e Elastase lA–P motility Surface-associated 38 . It can utilize a broad spectrum of nutrients Exotoxin 4 , -HSL)isproduced byRhlI and detected di Fe el cytoskeleton Disrupted actin EF n CupB 3+ G CupC CupA 2 Fp LecB vA A regulate biofilm architecture and a LasA pr Autolysi u u u reading: Further 12

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(2000). opportunist. versatile a of Microbiol Med. dispersal. and tolerance, formation, on update An weapons. aeruginosa Pseudomonas LyczakJ.B., Cannon C.L.Pier & G.B. Establishment Yang,M., Harmsen, Tolker-Nielsen,Pamp,& L., J. S. S. Bleves, Tr o Pseudomonas aeruginosa Pseudomonas tease anslatio s formatio Micr AD + Fe P et al. Int. J. Med. Microbiol. Med. J. Int. ocolony 2+ n ‘Sessile Pseudomonas aeruginosa Pseudomonas Protein secretion systems in . n 59 , 253–268 (2010). 253–268 ,

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Ty Bioﬁlm formation steps and biofilms structures that occur during occur that structures biofilms and steps on based arehere shown maturation biofilm of steps The ofneutrophils. Finally, planktonic bacteria are released from MexA–MexB–OprMparts of the mature effluxbiofilm. pumps). Rhamnolipids on(AmpC bacteriafactors resistance of production the induce can colistin or at the surface induce necrosis to exposure antibiotics; to susceptibility their in vary that subpopulations bacterial intothe biofilm. A gradient of oxygen and nutrients induces the formation of distinct

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SecYEG P. Ty Microbiol molecules. signal multifunctional aeruginosa in adaptation environmental Microbiol resistance. bacterial of phenomenon a – (Elsevier,2835–2860 2010). R.) Philadelphia, Dolin, & Diseases Infectious Williams,P. &Cámara, M. Quorum sensing and T.Strateva, Yordanov,& D. in R. Ramphal, Pier,& B. G. aeruginosa pe [O V? phnAB 2 ], [nutrients]andmetabolicactivit . . SOD1 12 58 Ty :atale of regulatory networks and Psc , 182–191 (2009). 182–191 , pe VI , 1133–1148 (2009). 1133–1148 , + Pilin I 3-O-C C PqsH inﬂammasome Inactive Flagellin 4 -HSL (eds Mandell, G. L., Bennett, J. E. 12 Asialo-GM1 Ty -HSL

pe IVpil Principles and Practice of PQ Pseudomonas aeruginosa Pseudomonas Pseudomonas S OprM MexB– MexA– Curr. Opin. AmpC i inﬂammasome Active O LPS O ExoU J.Med. ExoS y N H O Rhamnolipid O H N O TLR4 O Outer membr Inner membr OH in vivo O N H Pe O Vol. 9 no. 3 March 2011 Nature Review Microbiology Alan Hauser and Pseudomonas ptidoglycan High Dispersal

CTFR infections are less clear. IL-18 IL-1 Surface in vitro in ane ane Py posters/pseudomonas/index.html http://www.nature.com/nrmicro/ ¡ Patenall.Philip by designed copy-editedbyLucie Wootton; EditedbyChristiaan van Ooij; poster.this in summarized is work We thank the many investigators whose Acknowledgements -lactams 2011 Nature Publishing Group. ro Colistin studies; the corresponding , , ptosis

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Adaptaon During Chronic Lung Infecon In Cysc Fibrosis Consideraons for development of animal models of P. a e r u g i n o s a • Normal healthy animals are generally resistant to infecon • Some acute infecons can disseminate • Other infecons stay localized • P. aeruginosa adapts during chronic respiratory infecons in cysc ﬁbrosis (CF) • There are >1700 recognized disease-associated mutaons in CFTR in the human populaon (with F508del being most common), but not all are equivalent • Strains from parcular sources may express disnct constellaons of pathogenic factors that may be essenal at diﬀerent infecon sites

Thanks