You are here: Home Research Themes Invasive Disease

Invasive Disease

Article Reference Shielding of a lipooligosaccharide IgM epitope allows evasion of neutrophil-mediated killing of an invasive strain of nontypeable Haemophilus influenzae.
Nontypeable Haemophilus influenzae is a frequent cause of noninvasive mucosal inflammatory diseases but may also cause invasive diseases, such as sepsis and meningitis, especially in children and the elderly. Infection by nontypeable Haemophilus influenzae is characterized by recruitment of neutrophilic granulocytes. Despite the presence of a large number of neutrophils, infections with nontypeable Haemophilus influenzae are often not cleared effectively by the antimicrobial activity of these immune cells. Herein, we examined how nontypeable Haemophilus influenzae evades neutrophil-mediated killing. Transposon sequencing (Tn-seq) was used on an isolate resistant to neutrophil-mediated killing to identify genes required for its survival in the presence of human neutrophils and serum, which provided a source of complement and antibodies. Results show that nontypeable Haemophilus influenzae prevents complement-dependent neutrophil-mediated killing by expression of surface galactose-containing oligosaccharide structures. These outer-core structures block recognition of an inner-core lipooligosaccharide epitope containing glucose attached to heptose HepIII-β1,2-Glc by replacement with galactose attached to HepIII or through shielding HepIII-β1,2-Glc by phase-variable attachment of oligosaccharide chain extensions. When the HepIII-β1,2-Glc-containing epitope is expressed and exposed, nontypeable Haemophilus influenzae is opsonized by naturally acquired IgM generally present in human serum and subsequently phagocytosed and killed by human neutrophils. Clinical nontypeable Haemophilus influenzae isolates containing galactose attached to HepIII that are not recognized by this IgM are more often found to cause invasive infections. Importance: Neutrophils are white blood cells that specialize in killing pathogens and are recruited to sites of inflammation. However, despite the presence of large numbers of neutrophils in the middle ear cavity and lungs of patients with otitis media or chronic obstructive pulmonary disease, respectively, the bacterium nontypeable Haemophilus influenzae is often not effectively cleared from these locations by these immune cells. In order to understand how nontypeable Haemophilus influenzae is able to cause inflammatory diseases in the presence of neutrophils, we determined the mechanism that underlies resistance to neutrophil-mediated killing. We have shown that nontypeable Haemophilus influenzae prevents binding of antibodies of the IgM subtype through changes in their surface lipooligosaccharide structure, thereby preventing complement activation and clearance by human neutrophils.
Article Reference Non-typeable Haemophilus influenzae, an under-recognised pathogen.
Non-typeable Haemophilus influenzae (NTHi) is a major cause of mucosal infections such as otitis media, sinusitis, conjunctivitis, and exacerbations of chronic obstructive pulmonary disease. In some regions, a strong causal relation links this pathogen with infections of the lower respiratory tract. In the past 20 years, a steady but constant increase has occurred in invasive NTHi worldwide, with perinatal infants, young children, and elderly people most at risk. Individuals with underlying comorbidities are most susceptible and infection is associated with high mortality. β-lactamase production is the predominant mechanism of resistance. However, the emergence and spread of β-lactamase-negative ampicillin-resistant strains in many regions of the world is of substantial concern, potentially necessitating changes to antibiotic treatment guidelines for community-acquired infections of the upper and lower respiratory tract and potentially increasing morbidity associated with invasive NTHi infections. Standardised surveillance protocols and typing methodologies to monitor this emerging pathogen should be implemented. International scientific organisations need to raise the profile of NTHi and to document the pathobiology of this microbe.
Article Reference Non-typeable Haemophilus influenzae carbonic anhydrase is important for environmental and intracellular survival.
Non-typeable Haemophilus influenzae (NTHi) is one of the leading causes of non-invasive mucosal infections, such as otitis media, sinusitis and conjunctivitis. During its life cycle, NTHi is exposed to different CO2 levels, which vary from ∼0.04% in ambient air during transmission to a new host to over 5 % in the respiratory tract and tissues of the human host during colonization and disease. We used the next generation sequencing Tn-seq technology to identify genes essential for NTHi adaptation to changes in environmental CO2-levels. It appeared that H. influenzae carbonic anhydrase (HICA), which catalyzes the reversible hydration of CO2 to bicarbonate, is a molecular factor that is conditionally essential for NTHi survival in ambient air. Growth of NTHi ΔHICA strains was restored in a 5% CO2-enriched condition, by supplementation of the growth medium with sodium bicarbonate, or by genetic complementation with the HICA gene. Finally, we showed that HICA is not only essential for environmental survival, but also appeared to be important for intracellular survival in host cells. Hence, HICA is important for NTHi niche adaptation.
Article Reference The Haemophilus Sap Transporter Mediates Bacterial-Epithelial Cell Homeostasis.
Nontypeable Haemophilus influenzae (NTHI) is a commensal inhabitant of the human nasopharynx, and causative agent of otitis media and other diseases of the upper and lower human airway. During colonization within the host, NTHI must acquire essential nutrients and evade immune attack. We previously demonstrated that the NTHI Sap transporter, an inner membrane protein complex, mediates resistance to antimicrobial peptides and is required for heme homeostasis. We hypothesized that Sap transporter functions are critical for NTHI interaction with the host epithelium and establishment of colonization. Thus, we co-cultured the parent or the sapA mutant on polarized epithelial cells grown at an air-liquid interface, as a physiological model of NTHI colonization, to determine the contribution of the Sap transporter on bacterial-host cell interactions. Although SapA-deficient NTHI were less adherent to epithelial cells, we observed a significant increase in invasive bacteria compared to the parent strain. Upon internalization, the sapA mutant appeared free in the cytoplasm whereas the parent strain was primarily found in endosomes, indicating differential subcellular trafficking. Additionally, we observed reduced inflammatory cytokine production by the epithelium to the sapA mutant strain compared to the parental strain. Furthermore, chinchilla middle ears challenged with the sapA mutant demonstrated a decrease in disease severity compared to ears challenged with the parental strain. Collectively, our data suggest that NTHI sense host environmental cues via Sap transporter function to mediate interaction with host epithelial cells. Epithelial cell invasion and modulation of host inflammatory cytokine responses may promote NTHI colonization and access to essential nutrients.
Article Reference Non-typeable Haemophilus influenzae isolates from invasive disease and otitis media present higher biofilm formation than strains recovered from respiratory infections.
Biofilm formation by non-typeable Haemophilus influenzae (NTHi) remains a controversial topic. Nevertheless, biofilm-like structures have been observed in the middle-ear mucosa of experimental chinchilla models of otitis media (OM). To date, there have been no studies of biofilm formation in large collections of clinical isolates. This study aimed to investigate the initial adhesion to a solid surface and biofilm formation by NTHi by comparing isolates from healthy carriers, those with non-invasive respiratory disease, and those with invasive respiratory disease. We used 352 isolates from patients with non-bacteremic community acquired pneumonia (NB-CAP), chronic obstructive pulmonary disease (COPD), OM, invasive disease, and a group of healthy colonized children. We then determined the speed of initial adhesion to a solid surface by the biofilm ring test methodology, and quantified biofilm formation by crystal violet staining. Isolates from different clinical sources displayed high levels of biofilm formation on a static solid support after growth for 24 hours. We observed clear differences in initial attachment and biofilm formation depending on the pathology associated with NTHi isolation, with significantly increased biofilm formation for NTHi isolates collected from patients with invasive disease and OM compared with NTHi isolates from patients with NB-CAP, COPD or healthy colonization. In all cases, biofilm structures were detached by proteinase K treatment, suggesting an important role for proteins in the initial adhesion and static biofilm formation measured by crystal violet staining.
Article Reference 10-Valent pneumococcal non-typeable haemophilus influenzae protein D-conjugate vaccine: a review in infants and children.
The 10-valent pneumococcal non-typeable Haemophilus influenzae protein D-conjugate vaccine (PHiD-CV) (Synflorix™) includes ten serotype-specific polysaccharides of Streptococcus pneumoniae, eight of which are conjugated individually to a nonlipidated cell-surface lipoprotein (protein D) of non-typeable H. influenzae and two of which are conjugated to nontoxic tetanus or diphtheria toxoid carrier proteins. This article provides an overview of the well-established immunogenicity of PHiD-CV, including functional immune responses and immunologic memory, as well as immune responses in preterm infants and HIV-infected children. It also includes a brief discussion of cross-protection against vaccine-related serotypes (6A and 19A) and focuses on labelling in the EU, where PHiD-CV is approved for active immunization against invasive disease, pneumonia, and acute otitis media (AOM) caused by S. pneumoniae in infants and young children up to 5 years of age. Evidence of the protective efficacy and effectiveness of PHiD-CV against pneumococcal diseases is available from several studies, including the randomized, double-blind trials COMPAS (Clinical Otitis Media and Pneumonia Study) and FinIP (Finnish Invasive Pneumococcal disease), as well as postmarketing studies from various countries. As would be expected, protection against pneumonia or AOM is substantially lower than that against invasive pneumococcal disease, as many micro-organisms other than pneumococcal vaccine serotypes can cause pneumonia and AOM, thereby limiting the overall protection of PHiD-CV against these diseases. PHiD-CV has a safety and reactogenicity profile similar to that of other pneumococcal conjugate vaccines.
Article Reference The Haemophilus influenzae Sap transporter mediates bacterium-epithelial cell homeostasis.
Nontypeable Haemophilus influenzae (NTHI) is a commensal inhabitant of the human nasopharynx and a causative agent of otitis media and other diseases of the upper and lower human airway. During colonization within the host, NTHI must acquire essential nutrients and evade immune attack. We previously demonstrated that the NTHI Sap transporter, an inner membrane protein complex, mediates resistance to antimicrobial peptides and is required for heme homeostasis. We hypothesized that Sap transporter functions are critical for NTHI interaction with the host epithelium and establishment of colonization. Thus, we cocultured the parent or the sapA mutant on polarized epithelial cells grown at an air-liquid interface, as a physiological model of NTHI colonization, to determine the contribution of the Sap transporter to bacterium-host cell interactions. Although SapA-deficient NTHI was less adherent to epithelial cells, we observed a significant increase in invasive bacteria compared to the parent strain. Upon internalization, the sapA mutant appeared free in the cytoplasm, whereas the parent strain was primarily found in endosomes, indicating differential subcellular trafficking. Additionally, we observed reduced inflammatory cytokine production by the epithelium in response to the sapA mutant strain compared to the parental strain. Furthermore, chinchilla middle ears challenged with the sapA mutant demonstrated a decrease in disease severity compared to ears challenged with the parental strain. Collectively, our data suggest that NTHI senses host environmental cues via Sap transporter function to mediate interaction with host epithelial cells. Epithelial cell invasion and modulation of host inflammatory cytokine responses may promote NTHI colonization and access to essential nutrients.
Article Reference Haemophilus haemolyticus isolates causing clinical disease.
We report seven cases of Haemophilus haemolyticus invasive disease detected in the United States, which were previously misidentified as nontypeable Haemophilus influenzae. All cases had different symptoms and presentations. Our study suggests that a testing scheme that includes reliable PCR assays and standard microbiological methods should be used in order to improve H. haemolyticus identification.
Article Reference Cost-effectiveness of 2 + 1 dosing of 13-valent and 10-valent pneumococcal conjugate vaccines in Canada.
Thirteen-valent pneumococcal conjugate vaccine (PCV13) and 10-valent pneumococcal conjugate vaccine (PCV10) are two recently approved vaccines for the active immunization against Streptococcus pneumoniae causing invasive pneumococcal disease in infants and children. PCV13 offers broader protection against Streptococcus pneumoniae; however, PCV10 offers potential protection against non-typeable Haemophilus influenza (NTHi). We examined public health and economic impacts of a PCV10 and PCV13 pediatric national immunization programs (NIPs) in Canada.
Article Reference Towards a vaccine for chronic obstructive pulmonary disease.
This review discusses chronic obstructive pulmonary disease as an outcome of two pathogenic pathways: the first resulting from inhalation of toxins and the second a consequence of bacterial colonisation of damaged airways. Earlier assessment of the role played by bacteria in acute exacerbations was compromised by a deficiency of quality data and the use of parameters more relevant to invasive infection. Data are reviewed to support a hypothesis that states intrabronchial inflammation reflects an excessive and inappropriate host response (largely mediated by Th17 cells derived from gut-associated lymphoid tissues) to colonising bacteria acting as an 'antigen sump' (in essence, a hypersensitivity reaction). It is proposed that both viral and bacterial infections exacerbate inflammation through a common pathway that involves colonising bacteria. An oral vaccine containing inactivated non-typeable Haemophilus influenzae augments a protective loop that involves the aspiration of bronchus content into the gut and reduces the severity of acute exacerbations including the need for hospital admission by reducing the 'load' of bacteria comprising this final common path. The positive clinical results from trials using oral NTHi support both the concept that bacterial colonisation of damaged airways is a potent second pathogenic pathway and that oral immunotherapy provides a significant therapeutic advance in limiting damage in chronic obstructive pulmonary disease.
Article Reference Antibody against Haemophilus influenzae protein D in patients with chronic conditions causing secondary immunodeficiency.
Prevalence of non-typeable Haemophilus influenzae (NTHi) in the etiology of invasive infections in immunocompromised individuals is increasing. Serum IgG antibody levels to H. influenzae protein D (PD) were significantly lower in adults suffering from chronic conditions causing secondary immunodeficiency (COPD, cancer, chronic renal failure, and diabetes) compared to age-matched healthy controls. A lack of naturally acquired antibody against this highly conserved antigen may contribute to an increased susceptibility to invasive NTHi disease. As COPD patients frequently infected with NTHi during disease exacerbations were unable to develop antibody response to PD, such defect could potentially contribute to the pathogenesis. Considering that pediatric PD-containing vaccines show protective effect against NTHi-caused otitis media, our data suggest the possibility of improving the defense against NTHi in COPD patients using immunization against PD. Although more research on the role of anti-PD antibody in protection against invasive NTHi disease is warranted, development of adult formulations of PD-based vaccines may be advantageous for prevention of severe infections in immunocompromised individuals.
Article Reference Primary vaccination with the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) in infants in Mali and Nigeria: a randomized controlled trial.
Pneumonia is still the leading cause of death among children in Africa, and pneumococcal serotypes 1 and 5 are frequently isolated from African children with invasive pneumococcal disease below the age of 5 years. The immunogenicity, safety and reactogenicity of 3-dose primary vaccination with the 10-valent pneumococcal non-typeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) were evaluated in infants in Mali and Nigeria.
Article Reference Economic evaluation of second generation pneumococcal conjugate vaccines in Norway.
A seven valent pneumococcal conjugate vaccine (PCV7) was introduced in the Norwegian childhood immunization programme in 2006, and since then the incidence of invasive pneumococcal disease has declined substantially. Recently, two new second generation pneumococcal conjugate vaccines have become available, and an update of the economic evidence is needed. The aim of this study was to estimate incremental costs, health effects and cost-effectiveness of the pneumococcal conjugate vaccines PCV7, PCV13 and PHiD-CV in Norway.
Article Reference [Nontypeable Haemophilus influenzae (NTHi) epidemiology].
While most systemic pediatric Haemophilus influenzae infections are caused by the type b strain (Hib), nontypeable H. influenzae: (NTHi) has been considered a respiratory tract pathogen common in local infection such as acute otitis media, acute pneumonia, secondary chronic respiratory disease and other otorhinolaryngologic infections. Recent findings show, however, that NTHi also causes invasive infections such as meningitis, bacteremia, and lower respiratory tract infections such as pneumonia. A review of NTHi epidemiology from the 1990s onward shows that NTHi causes significant morbidity in pediatric acute otitis media, sinusitis, conjunctivitis and lower respiratory diseases such as pneumonia in Japan. This summary also reviews the worldwide influence of Streptococcus pneumoniae and Hib vaccines on causative pathogens, and several studies about increasing incidence of invasive infections due to NTHi. This review also touches on the emergence of treatment- and drug-resistant H. influenzae, which are now major public health challenges. As a cause of bacterial pediatric infection, NTHi is an important target for prevention.
Article Reference Nontypeable Haemophilus influenzae invasive disease in The Netherlands: a retrospective surveillance study 2001-2008.
Nontypeable (unencapsulated) strains of Haemophilus influenzae (ntHi) are usually involved in respiratory tract infections and otitis media but may also cause invasive disease. The epidemiology, the course of disease, and the outcome of ntHi invasive disease are not well established. For prevention, risk groups that might benefit from vaccination have to be defined.
Article Reference Transcutaneous immunization as preventative and therapeutic regimens to protect against experimental otitis media due to nontypeable Haemophilus influenzae.
We have developed three nontypeable Haemophilus influenzae (NTHI) adhesin-derived immunogens that are significantly efficacious against experimental otitis media (OM) due to NTHI when delivered parenterally. We now expanded our preventative immunization strategies to include transcutaneous immunization (TCI) as a less invasive, but potentially equally efficacious, regimen to prevent OM due to NTHI. Additionally, we examined the potential of TCI as a therapeutic immunization regimen to resolve ongoing experimental OM. Preventative immunization with NTHI outer membrane protein (OMP) P5- and type IV pilus-targeted immunogens, delivered with the adjuvant LT(R192G-L211A), induced significantly earlier clearance of NTHI from the nasopharynges and middle ears of challenged chinchillas compared with receipt of immunogen or adjuvant alone. Moreover, therapeutic immunization resulted in significant resolution of established NTHI biofilms from the middle ear space of animals compared with controls. These data advocate TCI with the adhesin-directed immunogens as an efficacious regimen for prevention and resolution of experimental NTHI-induced OM.
Article Reference A steady-state, population-based model to estimate the direct and indirect effects of pneumococcal vaccines.
This paper estimated the clinical impact of routine vaccination of infants with a new 10-valent pneumococcal nontypeable Haemophilus influenzae protein D conjugate vaccine (PHiD-CV) compared with the 7-valent pneumococcal conjugate vaccine (PCV-7) and no vaccination in Canada using a new steady-state, population-based model. A deterministic, compartmental model was developed to simulate the effect of vaccination for a 1-year time period for a steady-state population, allowing for the incorporation of herd and replacement effects across all age groups. Annual clinical outcomes in the steady-state year for a population of 32.9 million were calculated for all three vaccination strategies. The no vaccination strategy was included for the purpose of validating the model. The model estimated that PHiD-CV prevented more cases of disease and more deaths than PCV-7 and no vaccination, with the largest incremental impact on acute otitis media (AOM). Compared with PCV-7, vaccination with PHiD-CV was estimated to prevent an additional 10 cases of invasive disease, 416 cases of pneumonia, 155,757 cases of AOM, 8943 myringotomy procedures, and 6 deaths nationwide. For the comparison between PCV-7 and no vaccination, the model estimated a 36.8% reduction in invasive disease; this result was similar to other models and a recent observational study in Canada, providing preliminary validation of the model.
Article Reference Invasive disease caused by Haemophilus influenzae in Sweden 1997-2009; evidence of increasing incidence and clinical burden of non-type b strains.
Introduction of a conjugated vaccine against encapsulated Haemophilus influenzae type b (Hib) has led to a dramatic reduction of invasive Hib disease. However, an increasing incidence of invasive disease by H. influenzae non-type b has recently been reported. Non-type b strains have been suggested to be opportunists in an invasive context, but information on clinical consequences and related medical conditions is scarce. In this retrospective study, all H. influenzae isolates (n = 410) from blood and cerebrospinal fluid in three metropolitan Swedish regions between 1997 and 2009 from a population of approximately 3 million individuals were identified. All available isolates were serotyped by PCR (n = 250). We observed a statistically significant increase in the incidence of invasive H. influenzae disease, ascribed to non-typeable H. influenzae (NTHi) and encapsulated strains type f (Hif) in mainly individuals >60 years of age. The medical reports from a subset of 136 cases of invasive Haemophilus disease revealed that 48% of invasive NTHi cases and 59% of invasive Hif cases, respectively, met the criteria of severe sepsis or septic shock according to the ACCP/SCCM classification of sepsis grading. One-fifth of invasive NTHi cases and more than one-third of invasive Hif cases were admitted to intensive care units. Only 37% of patients with invasive non-type b disease had evidence of immunocompromise, of which conditions related to impaired humoral immunity was the most common. The clinical burden of invasive non-type b H. influenzae disease, measured as days of hospitalization/100 000 individuals at risk and year, increased significantly throughout the study period.
Article Reference Binding of complement regulators to invasive nontypeable Haemophilus influenzae isolates is not increased compared to nasopharyngeal isolates, but serum resistance is linked to disease severity.
The aim of the present study was to analyze the importance of nontypeable Haemophilus influenzae (NTHi) isolated from patients with sepsis (invasive isolates) compared to nasopharyngeal isolates from patients with upper respiratory tract infection for resistance to complement-mediated attack in human serum and to correlate this result with disease severity. We studied and characterized cases of invasive NTHi disease in detail. All patients with invasive NTHi isolates were adults, and 35% had a clinical presentation of severe sepsis according to the ACCP/SCCM classification of sepsis grading. Moreover, 41% of the patients had evidence of immune deficiency. The different isolates were analyzed for survival in human serum and for binding of 125I-labeled, purified human complement inhibitors C4b-binding protein (C4BP), factor H, and vitronectin, in addition to binding of regulators directly from serum. No significant differences were found when blood-derived and nasopharyngeal isolates were compared, suggesting that interactions with the complement system are equally important for NTHi strains, irrespective of isolation site. Interestingly, a correlation between serum resistance and invasive disease severity was found. The ability to resist the attack of the complement system seems to be important for NTHi strains infecting the respiratory tract as well as the bloodstream.
Article Reference [Progress toward molecular determinants of the pathogenesis of disease due to nontypeable Haemophilus influenzae].
Haemophilus influenzae (Hi) is a pathogen exclusively found in humans. It causes a wide range of infections from the upper respiratory tract to serious invasive diseases. Such as pneumonia, septicemia and meningitis. Strains of Hi are usually classified into six serotypes a to f and nontypeable H. influenzae (NTHI) according to the antigenicities and compositions of their polysaccharide capsules. Hib was a common cause of serious infections in younger children. The polysaccharide-protein conjugate vaccines against Hib had almost eliminated H. influenzae as a cause of pediatric meningitis. However, NTHI remains an important pathogen, particularly in children and the elderly. Efforts to understand and control NTHI disease have been hampered by the diversity of these bacteria. This review introduced the study progress about pathogenic mechanism of NTHI. In order to provide the help for development of vaccine, clinic treatment and prevent the occurrence of diseases causing by NTHI.