Acute postoperative endophthalmitis: Microbiology from the laboratory to the bedside.

Postoperative endophthalmitis is a dreaded complication of intraocular surgery. Acute presentations need prompt management and good knowledge of differential diagnoses. In the last 10 years, progress in direct microbial detection and identification from intraocular samples included the use of blood culture systems and, more recently, matrix-assisted laser desorption ionization time-of-flight mass spectrometry, improving the rate of bacterial identification. Whatever the method used, diagnostic sensitivity is better for vitreous samples than for aqueous humor samples. Besides, molecular biology techniques have further improved the identification rate of infectious agents in intraocular samples. They also provide faster results compared to culture-based techniques. Quantitative real-time PCR (qPCR) can also determine the bacterial load in intraocular samples. Several studies have shown that intraocular bacterial loads in endophthalmitis patients are usually high, which helps differentiating infection from contamination. The prognostic value of qPCR remains to be validated. Whole genome DNA sequencing technologies facilitate direct and sequencing of single DNA molecules. They have the potential to increase the rate of microbiological identification. Some antibiotic resistance markers (e.g., methicillin resistance in staphylococci and vancomycin resistance in enterococci) may be detected earlier using molecular techniques (usually real-time PCR tests). Early determination of the involved microorganism and their antibiotic resistances can help establishing an earlier therapeutic strategy.

Effect of prophylactic dextrose gel on the neonatal gut microbiome.

OBJECTIVE: To determine the effect of prophylactic dextrose gel on the infant gut microbiome. DESIGN: Observational cohort study nested in a randomised trial. SETTING: Three maternity hospitals in New Zealand. PATIENTS: Infants at risk of neonatal hypoglycaemia whose parents consented to participation in the hypoglycaemia Prevention in newborns with Oral Dextrose trial (hPOD). Infants were randomised to receive prophylactic dextrose gel or placebo gel, or were not randomised and received no gel (controls). Stool samples were collected on days 1, 7 and 28. MAIN OUTCOME MEASURES: The primary outcome was microbiome beta-diversity at 4 weeks. Secondary outcomes were beta-diversity, alpha-diversity, bacterial DNA concentration, microbial community stability and relative abundance of individual bacterial taxa at each time point. RESULTS: We analysed 434 stool samples from 165 infants using 16S rRNA gene amplicon sequencing. There were no differences between groups in beta-diversity at 4 weeks (p=0.49). There were also no differences between groups in any other microbiome measures including beta-diversity (p=0.53 at day 7), alpha-diversity (p=0.46 for day 7 and week 4), bacterial DNA concentration (p=0.91), microbial community stability (p=0.52) and microbial relative abundance at genus level. There was no evidence that exposure to any dextrose gel (prophylaxis or treatment) had any effect on the microbiome. Mode of birth, type of milk fed, hospital of birth and ethnicity were all associated with differences in the neonatal microbiome. CONCLUSIONS: Clinicians and consumers can be reassured that dextrose gel used for prophylaxis or treatment of neonatal hypoglycaemia does not alter the neonatal gut microbiome. TRIAL REGISTRATION NUMBER: 12614001263684.

Engineering DNA nanoparticles as immunomodulatory reagents that activate regulatory T cells.

Nanoparticles containing DNA complexed with the cationic polymer polyethylenimine are efficient vehicles to transduce DNA into cells and organisms. DNA/polyethylenimine nanoparticles (DNPs) also elicit rapid and systemic release of proinflammatory cytokines that promote antitumor immunity. In this study, we report that DNPs possess previously unrecognized immunomodulatory attributes due to rapid upregulation of IDO enzyme activity in lymphoid tissues of mice. IDO induction in response to DNP treatment caused dendritic cells and regulatory T cells (Tregs) to acquire potent regulatory phenotypes. As expected, DNP treatment stimulated rapid increase in serum levels of IFN type I (IFN-αß) and II (IFN-γ), which are both potent IDO inducers. IDO-mediated Treg activation was dependent on IFN type I receptor signaling, whereas IFN-γ receptor signaling was not essential for this response. Moreover, systemic IFN-γ release was caused by TLR9-dependent activation of NK cells, whereas TLR9 signaling was not required for IFN-αß release. Accordingly, DNPs lacking immunostimulatory TLR9 ligands in DNA stimulated IFN-αß production, induced IDO, and promoted regulatory outcomes, but did not stimulate potentially toxic, systemic release of IFN-γ. DNP treatment to induce IDO and activate Tregs blocked Ag-specific T cell responses elicited in vivo following immunization and suppressed joint pathology in a model of immune-mediated arthritis. Thus, DNPs lacking TLR9 ligands may be safe and effective reagents to protect healthy tissues from immune-mediated destruction in clinical hyperimmune syndromes.

Comprehensive gene expression profiling in lungs of mice infected with Mycobacterium tuberculosis following DNAhsp65 immunotherapy.

BACKGROUND: The continued increase in tuberculosis (TB) rates and the appearance of extremely resistant Mycobacterium tuberculosis strains (XDR-TB) worldwide are some of the great problems of public health. In this context, DNA immunotherapy has been proposed as an effective alternative that could circumvent the limitations of conventional drugs. Nonetheless, the molecular events underlying these therapeutic effects are poorly understood. METHODS: We characterized the transcriptional signature of lungs from mice infected with M. tuberculosis and treated with heat shock protein 65 as a genetic vaccine (DNAhsp65) combining microarray and real-time polymerase chain reaction analysis. The gene expression data were correlated with the histopathological analysis of lungs. RESULTS: The differential modulation of a high number of genes allowed us to distinguish DNAhsp65-treated from nontreated animals (saline and vector-injected mice). Functional analysis of this group of genes suggests that DNAhsp65 therapy could not only boost the T helper (Th)1 immune response, but also could inhibit Th2 cytokines and regulate the intensity of inflammation through fine tuning of gene expression of various genes, including those of interleukin-17, lymphotoxin A, tumour necrosis factor-alpha, interleukin-6, transforming growth factor-beta, inducible nitric oxide synthase and Foxp3. In addition, a large number of genes and expressed sequence tags previously unrelated to DNA-therapy were identified. All these findings were well correlated with the histopathological lesions presented in the lungs. CONCLUSIONS: The effects of DNA therapy are reflected in gene expression modulation; therefore, the genes identified as differentially expressed could be considered as transcriptional biomarkers of DNAhsp65 immunotherapy against TB. The data have important implications for achieving a better understanding of gene-based therapies.

A novel antibiotic free plasmid selection system: advances in safe and efficient DNA therapy.

The presence of antibiotic resistance genes in the delivered plasmids is one of the drawbacks of modern gene therapy and DNA vaccine applications. Here, we describe a strategy that allows for plasmid selection in bacterial hosts, without the requirement of any selection marker. Several bacterial strains were modified, so that the plasmid's replicational inhibitor RNA I could suppress the translation of a growth essential gene by RNA-RNA antisense reaction. An essential gene (murA) was modified such that a repressor protein (tetR) would hamper its expression. Only in the presence of plasmid and, hence, RNA I, was tetR turned down and murA expressed. Different commercially available plasmids could be selected by various modified Escherichia coli strains. We further designed a minimalistic plasmid devoid of any selection marker. All of the clones (n=6) examined, when the modified strain JM109-murselect was used for selection, contained plasmids. Thus, we have designed bacterial host strains that for the first time serve to select and maintain plasmids without the use of any selection marker or other additional sequence on the plasmid. Consequently, such plasmids may not only be safer, but due to their decreased size, advantages for the manufacturer and higher transfection efficiencies are anticipated.

Bacterial targeted tumour therapy-dawn of a new era.

Original observation of patients' spontaneous recovery from advanced tumours after an infection or a "fever" inspired extensive research. As a result, Coley's toxin for the therapy of sarcomas and live Bacillus Calmette-Guerin (BCG) for bladder cancer were born. In addition, three genera of anaerobic bacteria have been shown to specifically and preferentially target solid tumours and cause significant tumour lyses. Initial research had focused on determining the best tumour colonizing bacteria, and assessing the therapeutic efficacy of different strategies either as a single or combination treatment modalities. However, although clinical trials were carried out as early as the 1960s, lack of complete tumour lyses with injection of Clostridial spores had limited their further use. Recent progress in the field has highlighted the rapid development of new tools for genetic manipulation of Clostridia which have otherwise been a hurdle for a long time, such as plasmid transformation using electroporation that bore the problems of inefficiency, instability and plasmid loss. A new Clostridium strain, C. novyi-NT made apathogenic by genetic modification, is under clinical trials. New genetic engineering tools, such as the group II intron has shown promise for genetic manipulation of bacteria and forecast the dawn of a new era for a tumour-targeted bacterial vector system for gene therapy of solid tumours. In this review we will discuss the potential of genetically manipulated bacteria that will usher in the new era of bacterial therapy for solid tumours, and highlight strategies and tools used to improve the bacterial oncolytic capability.

Synthetic agonists of Toll-like receptors 7, 8 and 9.

TLRs (Toll-like receptors) are a family of innate immune receptors that induce protective immune responses against infections. Single-stranded viral RNA and bacterial DNA containing unmethylated CpG motifs are the ligands for TLR7 and TLR8 and 9 respectively. We have carried out extensive structure-activity relationship studies of DNA- and RNA-based compounds to elucidate the impact of nucleotide motifs and structures on these TLR-mediated immune responses. These studies have led us to design novel DNA- and RNA-based compounds, which act as potent agonists of TLR9 and TLR7 and 8 respectively. These novel synthetic agonists produce different immune response profiles depending on the structures and nucleotide motifs present in them. The ability to modulate TLR-mediated immune responses with these novel DNA- and RNA-based agonists in a desired fashion may allow targeting a broad range of diseases, including cancers, asthma, allergies and infections, alone or in combination with other therapeutic agents, and their use as adjuvants with vaccines. IMO-2055, our first lead candidate, is a TLR9 agonist that is currently in clinical evaluation in oncology patients. A second candidate, IMO-2125, is also a TLR9 agonist that has been shown to induce high and sustained levels of IFN (interferon) in non-human primates and is being evaluated in HepC-infected human subjects.

Sera from mice immunized with DNA encoding Porphyromonas gingivalis catalytic or adhesin part of HRgpA inhibit degradation of human fibronectin by HRgpA.

Gingipains are potent virulence factors of Porphyromonas gingivalis and are likely to be associated with the development of periodontitis. It is, therefore, suggested that gingipain inhibition by vaccination could be a useful therapy for adult periodontitis. This study investigated the ability of antibodies raised against the catalytic part and the adhesin/haemagglutinin part of HRgpA to prevent haemagglutination and fibronectin degradation caused by P. gingivalis. We constructed two DNA vaccines, one containing the adhesin part of HRgpA and one with the catalytic part of HRgpA. BALB/c mice were immunized intramuscularly with either catalytic-part-encoding plasmids, adhesin-part-encoding plasmids or empty control plasmids. Sera from mice immunized with the catalytic vaccine or the adhesin vaccine each showed inhibition of human fibronectin degradation. A DNA vaccine encoding the adhesin or catalytic part of HRgpA induces responses that inhibit the degradation of molecules important for the structure and function of gingival and bone tissues.

Bacterial proteins and CpG-rich extrachromosomal DNA in potential cancer therapy.

Bacterial proteins such as azurin and Laz have recently been shown to enter preferentially to cancer cells and kill them by multiple mechanisms. Historically, bacterial DNA, particularly the unmethylated CpG dinucleotides, have been shown to trigger activation of specific Toll-like receptors (TLRs) in immune cells, leading to various cytokine and chemokine production that allows cancer cell death and their regression. However, the enhanced release of specific protein or extrachromosomal DNA by bacteria in response to exposure to cancer cells has not been previously demonstrated. In this review, we discuss how an opportunistic, extracellular pathogenic bacterium, Pseudomonas aeruginosa, senses the presence of cancer cells and releases a specific protein or extrachromosomal DNA with antitumor activity for inhibition of cancer cell growth.

A combination of E. coli DNA fragments and modified lipopolysaccharides as a cancer immunotherapy.

The use of Escherichia coli DNA or lipopolysaccharide (LPS) as an immunotherapy is often associated with unacceptable toxicity and insufficient therapeutic effects. In this study, we investigated the efficacy of using a combination of bacterial DNA fragments and LPS as an anticancer agent. LPS was isolated from an E. coli strain expressing short-carbohydrate-chain-containing LPS and subjected to alkaline hydrolysis to remove lipid A. The ability to induce tumor necrosis factor-alpha (TNF-alpha) release in human whole blood cells was significantly lower for the LPS devoid of lipid A than for its parent form. The immunostimulating activity of E. coli DNA fragments of various sizes were tested. Those of 0.2-0.5 kb in size exhibited the highest activity in whole blood assays, whereas those of size 0.5-2.0 kb exhibited the highest adjuvant activity in mice. A combination of 0.5-2.0-kb DNA fragments and modified LPS at a ratio of 100:1, designated CIA07, exhibited higher immunostimulating activity than each substance alone, and its antitumor activity was significantly higher than that of Bacillus Calmette-Guerin in a mouse bladder cancer model. An intraperitoneal injection of CIA07 at a dose of 25mg/kg body weight caused no apparent adverse effects in mice and guinea pigs. Taken together, these data demonstrate that CIA07 exhibits potent immunostimulating activity with no apparent toxicity, and therefore warrant the further development of CIA07 as an immunotherapy for cancer treatment.

Bacteria in the treatment of cancer.

Incidental observations of cancer regression following spontaneous bacterial infection have led to the preclinical development of bacteria as potential therapeutics in the treatment of cancer. A variety of natural and gene-modified bacterial species have now been explored as potential cancer treatments. The selectivity of bacterial species towards cancer will be discussed, direct bacterial oncolytic activity will be summarized and the use of bacteria as gene and/or protein delivery vehicles will be described. Preclinical and early clinical results presented indicate a high safety profile and demonstrate clear anticancer activity, thereby justifying further investigation of bacteria as a therapeutic approach in the treatment of cancer.

CpG DNA in the prevention and treatment of infections.

Microbial infection is sensed by Toll-like receptors (TLRs) on innate immune cells. Among the ten so far defined TLRs, TLR9 and its ligand are peculiar. TLR9 recognises bacterial DNA characterised by the abundance of unmethylated CpG dinucleotides, which distinguish bacterial DNA (CpG DNA) from mammalian DNA. Moreover, TLR9 shows a restricted cellular and subcellular pattern of expression. In contrast to other TLR agonists, CpG DNA is superior in activation of dendritic dells and induction of costimulatory cytokines such as interleukin (IL)-12 and IL-18. This qualifies CpG DNA as a Th1-promoting adjuvant. During infection, recognition of CpG DNA of intracellular pathogens skews and fine-tunes the ongoing immune response and induces long-lasting Th1 milieus. Thus, CpG DNA might play an important role in driving the immune system to a Th1 profile, preventing undesired Th2 milieus that might favour induction of allergic responses. Since CpG DNA can be synthesised with high purity and sequence fidelity, synthetic CpG DNA will become an important agent for Th1 instruction and be an effective adjuvant during vaccination.

Discovery of immunostimulatory CpG-DNA and its application to tuberculosis vaccine development.

DNA containing an unmethylated CpG motif has a potent immunostimulatory effect on the vertebrate immune system. Because such CpG motifs are relatively common in bacterial DNA, but rare in mammalian animal and plant DNA, they may be an evolutionary adaptation augmenting innate immunity, most likely in response to pathogens that replicate within the host cells, such as viruses and intracellular bacteria. Microbial infection induces innate immunity by triggering pattern-recognition systems. The infected cells produce proinflammatory cytokines that directly combat microbial invaders and express costimulating surface molecules, which develop adaptive immunity by inducing distinct T cell differentiation. Bacterial DNA with unmethylated CpG-DNA stimulates vertebrate immature immune cells to induce maturation and to produce TNF-alpha as well as Th1-type cytokines, IL-12 and IFN-gamma. Therefore, CpG-DNA functions as an adjuvant for regulating the initiation of Th1 differentiation. The roles of immunostimulatory CpG motifs in DNA vaccine developments and in therapeutic applications have been discussed.

Antitumor activity of cationic lipid complexed with immunostimulatory DNA.

We previously reported that treatment of intraperitoneal tumors with complexes of cationic lipid and noncoding plasmid DNA leads to the development of a specific, cytotoxic T-cell response correlating with the rejection of established tumor cells as well as subsequent tumor re-challenge. Here, focusing on an intraperitoneal AB12 mesothelioma model, we show that the anticancer effects of the lipid:DNA complex are associated with DNA containing immunostimulatory CpG motifs. Complexes prepared with cationic lipid and bacterial plasmid DNA, Escherichia coli genomic DNA fragments, or synthetic immunostimulatory CpG oligodeoxynucleotides provided a substantial survival benefit, whereas eukaryotic DNA and methylated bacterial DNA had little or no therapeutic activity. Alternative inflammatory stimuli such as thioglycolate, poly(I:C), and incomplete or complete Freund's adjuvant failed to reproduce the antitumor activity obtained with the lipid:DNA complex. The innate immune response triggered by lipid:DNA complexes led to the development of a systemic immune response against tumor cells that allowed animals to reject tumors not only at the intraperitoneal treatment site, but also at a distal subcutaneous site. These data demonstrate that immunostimulatory DNA complexed with cationic lipid is a potent inducer of innate and adaptive immune responses against tumor cells and represents a potentially useful tool in the immunotherapy of cancers for which tumor-associated antigens have not been identified.

Prophylactic tumor vaccination: comparison of effector mechanisms initiated by protein versus DNA vaccination.

Clinical success in tumor vaccination frequently does not reach expectation. Since vaccination protocols are quite variable, we used the murine renal cell carcinoma line RENCA transfected with the lacZ gene (RENCA-beta-gal) to compare the efficacy of two different vaccination strategies or their combination and to elaborate on the underlying mechanisms. BALB/c mice were vaccinated either with naked lacZ DNA or with attenuated Salmonella typhimurium transformed with lacZ DNA or with dendritic cells (DC) loaded with the beta-galactosidase protein or mice were vaccinated with both DNA and protein. Although all regimens led to a prolongation of survival time, oral vaccination with transfected S. typhimurium followed by i.v. transfer of protein-loaded DC provided the optimal schedule. In this setting, >50% of mice remained tumor free after challenge with 10 times the lethal tumor dose of RENCA-beta-gal. As explored in transfer experiments, the superior efficacy of combining DNA and protein vaccination is due to the facts that 1) optimal protection depends on both activated CD4(+) and CD8(+) cells and 2) CD8(+) CTL are most strongly activated by vaccination with transformed Salmonella, whereas vaccination with protein-loaded DC is superior for the activation of Th. The latter induced sustained activation of CTL and recruitment of nonadaptive defense mechanisms. The data demonstrate the strength of DNA vaccination, particularly by the oral route, and provide evidence that a combined treatment with protein-loaded DC can significantly increase the therapeutic efficacy.

Therapeutic potential of mycobacterial cell wall-DNA complexes.

Cell wall skeletons isolated from many bacteria have been shown to possess anticancer activity. The anticancer activities of such preparations have been attributed to the activation of immune effector cells and not to a direct effect on cancer cell division. A cell wall extract from Mycobacterium phlei, wherein mycobacterial DNA in the form of short oligonulceotides is preserved to the cell wall, has anticancer activity against a wide range of cancer cells. Mycobacterial cell wall-DNA complexes (MCC) exert their anticancer activity by a dual mechanism of action: an indirect effect via the induction of anticancer cytokines and a direct effect on cancer cell division mediated by the induction of apoptosis. In this review, the immunomodulatory and the pro-apoptotic mechanisms of action of MCC will be explored. The identification of the active component in MCC will be discussed, as well as the composition differences with cell wall skeletons and live mycobacteria. Finally, the use of MCC against bladder and prostate cancers will be discussed and compared to standard therapies, particularly therapy using mycobacteria and mycobacteria-derived products.

Anticancer activity of mycobacterial DNA: effect of formulation as chitosan nanoparticles.

Mycobacterium phlei (M. phlei) DNA inhibits cancer cell division but is susceptible to degradation by DNase. Chitosan forms nanoparticulate polyelectrolyte complexes with DNA, and may thus reduce nuclease degradation. We have characterized chitosan-DNA nanoparticle formation, determined DNase susceptibility, and evaluated their antiproliferative activity. Nanoparticle diameter initially decreased with increasing phosphate charge density. However nanoparticle diameter increased above 6 micromol of phosphate. Particle aggregation occurred at 16.2 micromol phosphate and was related to reduced surface charge. Incorporation of DNA within chitosan nanoparticles significantly decreased degradation by DNase. The ability of M. phlei DNA-chitosan nanoparticles to inhibit melanoma cell division was determined relative to M. phlei DNA and a cationic liposomal M. phlei DNA formulation. M. phlei DNA had antiproliferative activity (MTT reduction, IC50 = 0.9 mg/ml) without intrinsic cytotoxicity (LDH release, ED50 > 50 microg/ml). Cationic polyphosphate chitosan nanoparticles were inert (antiproliferative IC50 > 1 mg/ml, ED50 > 1 mg/ml). M. phlei DNA-chitosan nanoparticles were 20-fold more potent than M. phlei DNA. Cationic DOTAP/DOPE liposomes were cytostatic (IC50 = 49 microg/ml) and cytotoxic (ED50 = 87 microg/ml), and complexation of M. phlei DNA resulted in a significant reduction of antiproliferative activity. Chitosan nanoparticles may therefore be appropriate delivery vehicles for M. phlei DNA.