Chlamydia trachomatis and Chlamydia pneumoniae Interaction with the Host: Latest Advances and Future Prospective

Research in Chlamydia trachomatis and Chlamydia pneumoniae has gained new traction due to recent advances in molecular biology, namely the widespread use of the metagenomic analysis and the development of a stable genomic transformation system, resulting in a better understanding of Chlamydia pathogenesis. C. trachomatis, the leading cause of bacterial sexually transmitted diseases, is responsible of cervicitis and urethritis, and C. pneumoniae, a widespread respiratory pathogen, has long been associated with several chronic inflammatory diseases with great impact on public health. The present review summarizes the current evidence regarding the complex interplay between C. trachomatis and host defense factors in the genital micro-environment as well as the key findings in chronic inflammatory diseases associated to C. pneumoniae.

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title: Female genital Chlamydia trachomatis infection: where are we heading?
abstract: IntroductionUrogenital infection by Chlamydia trachomatis is the most common bacterial sexually transmitted disease in the world. C. trachomatis is the etiologic agent of several common genital tract syndromes such as urethritis, cervicitis, and pelvic inflammatory disease in women.Materials and methodsIn this review, the pathophysiology of a chlamydial infection as well as diagnosis, therapy and prevention strategies regarding female chlamydial infection are reviewed.ResultsA chlamydial infection results in minimal or even no symptoms in approximately two-thirds of women, remaining therefore clinically apparent and undiagnosed. C. trachomatis infections are of great socioeconomic and public health concern due to the potential for severe long-term consequences in women, including an increased risk of ectopic pregnancy, tubal infertility and chronic pelvic pain. Moreover, if the bacterium is transmitted during labor to a newborn, it can cause ophthalmia neonatorum and atypical neonatal pneumonia. Due to the documented increased risk of morbidity, several national guidelines are available, including a routine screening for young women and screening during pregnancy that is recommended in several countries.DiscussionA routine screening for young women and screening during pregnancy is recommended in several countries. However, additional prospective studies of the effectiveness of chlamydia screening are warranted and might be feasible within established screening programs. Moreover, the transition from cervicitis to infertility should be also evaluated in future controlled studies to underline the existing evidence. Additionally, there is an urgent need to educate and inform health-care providers about implementation of screening programs to reduce the spread of chlamydial infection. Moreover, awareness and use of screening programs by the public is needed, which requires informational campaigns for the general public using different media. For improved screening strategies and public awareness, novel approaches have to be developed and evaluated. Finally, guidelines should be actively disseminated to all medical practitioners to increase their use in daily practice. Although the major socioeconomic and public health concerns of C. trachomatis infection are recognized, several considerations and additional measures for addressing this increasingly urgent health problem remain.

title: Infections caused by Chlamydophila pneumoniae.
abstract: High affinity to the epithelial lining of the airways makes Chlamydophila pneumoniae a common etiological agent of respiratory tract infections (RTI). It causes among others: pharyngitis, tracheitis, sinusitis, otitis media, bronchitis and bronchiolitis, and pneumonia. It is estimated that Chlamydophila pneumoniae infection is responsible for about 20% of lower respiratory tract infections. Chlamydophila pneumoniae infection may play an important role in the pathogenesis and course of bronchial asthma. The recent results indicate that Chlamydophila pneumoniae infection may be a factor responsible for 4-16% of COPD (Chronic obstructive pulmonary disease) exacerbations. A relationship of chlamydial infection with atherosclerosis raises huge interest. A connection of Chlamydophila pneumoniae infection with other non-communicable diseases such as lung cancer, arthritis, Alzheimer's disease, multiple sclerosis, sarcoidosis and erythema nodosum is also recognized, although the role of these bacteria has not been fully understood in any of the listed diseases.

title: Development of a Transformation System for Chlamydia trachomatis: Restoration of Glycogen Biosynthesis by Acquisition of a Plasmid Shuttle Vector
abstract: Chlamydia trachomatis remains one of the few major human pathogens for which there is no transformation system. C. trachomatis has a unique obligate intracellular developmental cycle. The extracellular infectious elementary body (EB) is an infectious, electron-dense structure that, following host cell infection, differentiates into a non-infectious replicative form known as a reticulate body (RB). Host cells infected by C. trachomatis that are treated with penicillin are not lysed because this antibiotic prevents the maturation of RBs into EBs. Instead the RBs fail to divide although DNA replication continues. We have exploited these observations to develop a transformation protocol based on expression of β-lactamase that utilizes rescue from the penicillin-induced phenotype. We constructed a vector which carries both the chlamydial endogenous plasmid and an E.coli plasmid origin of replication so that it can shuttle between these two bacterial recipients. The vector, when introduced into C. trachomatis L2 under selection conditions, cures the endogenous chlamydial plasmid. We have shown that foreign promoters operate in vivo in C. trachomatis and that active β-lactamase and chloramphenicol acetyl transferase are expressed. To demonstrate the technology we have isolated chlamydial transformants that express the green fluorescent protein (GFP). As proof of principle, we have shown that manipulation of chlamydial biochemistry is possible by transformation of a plasmid-free C. trachomatis recipient strain. The acquisition of the plasmid restores the ability of the plasmid-free C. trachomatis to synthesise and accumulate glycogen within inclusions. These findings pave the way for a comprehensive genetic study on chlamydial gene function that has hitherto not been possible. Application of this technology avoids the use of therapeutic antibiotics and therefore the procedures do not require high level containment and will allow the analysis of genome function by complementation.

title: The Vaginal Microbiota: What Have We Learned after a Decade of Molecular Characterization?
abstract: We conducted a systematic review of the Medline database (U.S. National Library of Medicine, National Institutes of Health, Bethesda, MD, U.S.A) to determine if consistent molecular vaginal microbiota (VMB) composition patterns can be discerned after a decade of molecular testing, and to evaluate demographic, behavioral and clinical determinants of VMB compositions. Studies were eligible when published between 1 January 2008 and 15 November 2013, and if at least one molecular technique (sequencing, PCR, DNA fingerprinting, or DNA hybridization) was used to characterize the VMB. Sixty three eligible studies were identified. These studies have now conclusively shown that lactobacilli-dominated VMB are associated with a healthy vaginal micro-environment and that bacterial vaginosis (BV) is best described as a polybacterial dysbiosis. The extent of dysbiosis correlates well with Nugent score and vaginal pH but not with the other Amsel criteria. Lactobacillus crispatus is more beneficial than L. iners. Longitudinal studies have shown that a L. crispatus-dominated VMB is more likely to shift to a L. iners-dominated or mixed lactobacilli VMB than to full dysbiosis. Data on VMB determinants are scarce and inconsistent, but dysbiosis is consistently associated with HIV, human papillomavirus (HPV), and Trichomonas vaginalis infection. In contrast, vaginal colonization with Candida spp. is more common in women with a lactobacilli-dominated VMB than in women with dysbiosis. Cervicovaginal mucosal immune responses to molecular VMB compositions have not yet been properly characterized. Molecular techniques have now become more affordable, and we make a case for incorporating them into larger epidemiological studies to address knowledge gaps in etiology and pathogenesis of dysbiosis, associations of different dysbiotic states with clinical outcomes, and to evaluate interventions aimed at restoring and maintaining a lactobacilli-dominated VMB.

title: Vaginal Microbiome and Its Relationship to Behavior, Sexual Health, and Sexually Transmitted Diseases.
abstract: The vaginal microbiota has great significance in maintaining vaginal health and protecting the host from disease. Recent advances in molecular techniques and informatics allow researchers to explore microbial composition in detail and to compare the structure of vaginal microbial communities with behavior and health outcomes, particularly acquisition and transmission of sexually transmitted diseases (STDs) and poor birth outcomes. Vaginal flora have been found to cluster into a limited number of communities, although community structure is dynamic. Certain community types are more associated with poor reproductive outcomes and STDs; communities dominated by Lactobacillus species, particularly Lactobacillus crispatus, are most associated with vaginal health. Modifiable and nonmodifiable factors are strongly associated with community composition, including behavior, race or ethnicity, and hygiene. In this review, we describe the state of the science on the vaginal microbiome and its relationship to behavior, sexual health, and STDs, including determinants of the microbiome that go beyond an individual level.

title: Global, regional, and national incidence, prevalence, and years lived with disability for 328 diseases and injuries for 195 countries, 1990–2016: a systematic analysis for the Global Burden of Disease Study 2016
abstract: As mortality rates decline, life expectancy increases, and populations age, non-fatal outcomes of diseases and injuries are becoming a larger component of the global burden of disease. The Global Burden of Diseases, Injuries, and Risk Factors Study 2016 (GBD 2016) provides a comprehensive assessment of prevalence, incidence, and years lived with disability (YLDs) for 328 causes in 195 countries and territories from 1990 to 2016.  We estimated prevalence and incidence for 328 diseases and injuries and 2982 sequelae, their non-fatal consequences. We used DisMod-MR 2.1, a Bayesian meta-regression tool, as the main method of estimation, ensuring consistency between incidence, prevalence, remission, and cause of death rates for each condition. For some causes, we used alternative modelling strategies if incidence or prevalence needed to be derived from other data. YLDs were estimated as the product of prevalence and a disability weight for all mutually exclusive sequelae, corrected for comorbidity and aggregated to cause level. We updated the Socio-demographic Index (SDI), a summary indicator of income per capita, years of schooling, and total fertility rate. GBD 2016 complies with the Guidelines for Accurate and Transparent Health Estimates Reporting (GATHER).  Globally, low back pain, migraine, age-related and other hearing loss, iron-deficiency anaemia, and major depressive disorder were the five leading causes of YLDs in 2016, contributing 57·6 million (95% uncertainty interval [UI] 40·8–75·9 million [7·2%, 6·0–8·3]), 45·1 million (29·0–62·8 million [5·6%, 4·0–7·2]), 36·3 million (25·3–50·9 million [4·5%, 3·8–5·3]), 34·7 million (23·0–49·6 million [4·3%, 3·5–5·2]), and 34·1 million (23·5–46·0 million [4·2%, 3·2–5·3]) of total YLDs, respectively. Age-standardised rates of YLDs for all causes combined decreased between 1990 and 2016 by 2·7% (95% UI 2·3–3·1). Despite mostly stagnant age-standardised rates, the absolute number of YLDs from non-communicable diseases has been growing rapidly across all SDI quintiles, partly because of population growth, but also the ageing of populations. The largest absolute increases in total numbers of YLDs globally were between the ages of 40 and 69 years. Age-standardised YLD rates for all conditions combined were 10·4% (95% UI 9·0–11·8) higher in women than in men. Iron-deficiency anaemia, migraine, Alzheimer's disease and other dementias, major depressive disorder, anxiety, and all musculoskeletal disorders apart from gout were the main conditions contributing to higher YLD rates in women. Men had higher age-standardised rates of substance use disorders, diabetes, cardiovascular diseases, cancers, and all injuries apart from sexual violence. Globally, we noted much less geographical variation in disability than has been documented for premature mortality. In 2016, there was a less than two times difference in age-standardised YLD rates for all causes between the location with the lowest rate (China, 9201 YLDs per 100 000, 95% UI 6862–11943) and highest rate (Yemen, 14 774 YLDs per 100 000, 11 018–19 228).  The decrease in death rates since 1990 for most causes has not been matched by a similar decline in age-standardised YLD rates. For many large causes, YLD rates have either been stagnant or have increased for some causes, such as diabetes. As populations are ageing, and the prevalence of disabling disease generally increases steeply with age, health systems will face increasing demand for services that are generally costlier than the interventions that have led to declines in mortality in childhood or for the major causes of mortality in adults. Up-to-date information about the trends of disease and how this varies between countries is essential to plan for an adequate health-system response.

title: Public health policies and management strategies for genital Chlamydia trachomatis infection
abstract: Genital Chlamydia trachomatis is a sexually transmissible bacterial infection that is asymptomatic in the majority of infected individuals and is associated with significant short-term and long-term morbidity. The population prevalence of the infection appears to be increasing. C. trachomatis is of public health significance because of the impacts of untreated disease on reproductive outcomes, transmission of other sexually acquired infections, and the costs to health systems. At the individual level, C. trachomatis infection is readily treatable with antibiotics, although antibiotic resistance appears to be increasing. At the population level, public health control of spread of infection is more problematic. Approaches to control include primary preventive activities, increased access to testing and treatment for people with or at risk of infection, partner notification and treatment, and screening either opportunistically or as part of an organized population screening program. A combination of all of the above approaches is likely to be required to have a significant effect on the burden of disease associated with genital chlamdyia infection and to reduce population prevalence. The development of a vaccine for genital chlamydia infection could significantly reduce the public health burden associated with infection; however a vaccine is not expected to be available in the near future.

title: European guideline for the management of Chlamydia trachomatis infections
abstract: Chlamydia trachomatis is an obligate intracellular bacterium that infects over 90 million people each year by sexual transmission. It is the most common bacterial sexually transmitted infection worldwide, especially among young adults. C. trachomatis belongs to the genus Chlamydia together with Chlamydia muridarum and Chlamydia suis. Other chlamydiae infecting human beings, Chlamydophila pneumoniae and Chlamydophila psittaci, have been classified in a separate genus. Three biovars comprising all 15 classical serovars and several additional serovars and genotypes are recognized within C. trachomatis: the trachoma biovar (serovars A–C), the urogenital biovar (serovars D–K) and the lymphogranuloma venereum (LGV) biovar (serovars L1–L3). This guideline only covers urogenital infections caused by the urogenital and the LGV biovar of C. trachomatis. Usually transmission takes place by direct mucosal contact between two individuals during sexual contact or at birth. Occasionally, other ways of transmission (fomites, enemas, sex toys) may play a role, as has been suggested in the LGV proctitis epidemic. The rate of transmission between sexual partners may be as high as 75%. Thus, partner notification and subsequent treatment are very important.

title: Chlamydia trachomatis infection: implications for HPV status and cervical cancer
abstract: Genital Chlamydia trachomatis (CT) infections have been identified as a major health problem concern. CT is associated with adverse effect on women reproduction and also associated with cervical hypertrophy and induction of squamous metaplasia, providing a possible relationship with human papillomavirus (HPV) infection. Infection by high-risk HPV types is crucial to the pathogenesis of invasive cervical cancer (ICC), but other co-variants/cofactors must be present for the development of malignancy. CT biological effect may damage the mucosal barrier, improving HPV infection, or may interfere in immune response and viral clearance supporting the persistence of HPV infection. Moreover, CT-related chronic cervical inflammation, decrease of lower genital tract antigen-presenting cells, inhibition of cell-mediated immunity, and anti-apoptotic capacity may influence the natural history of HPV infection, namely persistence progression or resolution. Although several epidemiological studies have stated a positive association involving CT and HPV-related cervical neoplastic lesions and/or cervical cancer (CC), the specific role of this bacterium in the pathogenesis of cervical neoplasia has not been completely clarified. The present review summarizes several studies on CT role in cervical cancer and suggests future research directions on HPV and CT interaction.

title: Evidence that Chlamydia pneumoniae causes pneumonia and bronchitis.
abstract: An epidemic often provides an opportunity to obtain evidence of the etiologic association of a microorganism with disease. Chlamydia pneumoniae TWAR is a newly recognized organism whose relationship to disease is not completely understood. An outbreak of C. pneumoniae infections from November 1990 to February 1991 was studied in University of Washington students. Twelve TWAR infections were identified serologically in 54 students with acute respiratory disease. The organism was isolated from 7 of the 12 and identified by the polymerase chain reaction (PCR) in 2 that were isolation-negative. The organism was not found in any of the 42 serologically negative patients or in 51 control student patients without respiratory illness cultured in 1991. There was no evidence of infection with Mycoplasma pneumoniae or respiratory viruses in the 12 patients with C. pneumoniae infection. During the 4-month outbreak, there was an increase in total pneumonia cases. These findings provide evidence for an etiologic association of C. pneumoniae with pneumonia and bronchitis.

title: Evidence of systemic dissemination of Chlamydia pneumoniae via macrophages in the mouse.
abstract: Chlamydia pneumoniae has been postulated to cause systemic disease by infection of monocytes/macrophages and spread via the blood or lymphatics. To investigate how C. pneumoniae disseminates, the ability of the organism to infect murine macrophages in vivo and whether infection can be transferred via macrophages were determined. C. pneumoniae was detected by direct plating, isolation, and polymerase chain reaction in alveolar macrophages from intranasally inoculated mice and peritoneal macrophages from intraperitoneally inoculated mice. C. pneumoniae were also detected in peripheral blood mononuclear cells, but not plasma, of intranasally and intraperitoneally inoculated mice. When alveolar or peritoneal macrophages were adoptively transferred by intraperitoneal injection from infected to uninfected mice, C. pneumoniae DNA was detected by polymerase chain reaction in lung, thymus, spleen, and/or abdominal lymph nodes. These results demonstrate the ability of C. pneumoniae to infect macrophages in vivo and to disseminate systemically via infected macrophages by hematogenous and lymphatic routes.

title: Chlamydia pneumoniae infection promotes the transmigration of monocytes through human brain endothelial cells
abstract: We have investigated the effects of Chlamydia pneumoniae on human brain endothelial cells (HBMECs) and human monocytes as a mechanism for breaching the blood‐brain barrier (BBB) in Alzheimer's disease (AD). HBMECs and peripheral blood monocytes may be key components in controlling the entry of C. pneumoniae into the human brain. Our results indicate that C. pneumoniae infects blood vessels and monocytes in AD brain tissues compared with normal brain tissue. C. pneumoniae infection stimulates transendothelial entry of monocytes through HBMECs. This entry is facilitated by the up‐regulation of VCAM‐1 and ICAM‐1 on HBMECs and a corresponding increase of LFA‐1, VLA‐4, and MAC‐1 on monocytes. C. pneumoniae infection in HBMECs and THP‐1 monocytes up‐regulates monocyte transmigration threefold in an in vitro brain endothelial monolayer. In this way, C. pneumoniae infection in these cell types may contribute to increased monocyte migration and promote inflammation within the CNS resulting from infection at the level of the vasculature. Thus, infection at the level of the vasculature may be a key initiating factor in the pathogenesis of neurodegenerative diseases such as sporadic AD.

title: Chlamydia pneumoniae DNA in patients with symptomatic carotid atherosclerotic disease.
abstract: We evaluated the correlation between the presence of Chlamydia pneumoniae in atherosclerotic carotid plaques, lymph nodes, and peripheral blood mononuclear cells (PBMCs), and symptomatic carotid atherosclerotic disease.



Fifty-one consecutive patients undergoing carotid endarterectomy were enrolled; 18 of the 51 patients had symptomatic disease, whereas 33 had asymptomatic disease. Detection of C pneumoniae DNA in atherosclerotic carotid plaques, lymph nodes, and PBMCs was performed with polymerase chain reaction (PCR). C pneumoniae antibodies were measured with a microimmunofluorescence test.



C pneumoniae DNA in atherosclerotic carotid plaques was detected in 44.4% of patients with symptomatic disease and in 30.3% of those with asymptomatic disease (P =.48). C pneumoniae DNA in lymph nodes was detected in 33.3% of patients with symptomatic disease and 18.2% of those with asymptomatic disease (P =.19). Prevalence of C pneumoniae DNA in PBMCs was significantly higher in patients with symptomatic disease (72.2%) compared with those with asymptomatic disease (30.3%) (P =.01). Serologic results support the association between C pneumoniae DNA in PBMCs and symptomatic carotid atherosclerotic disease, because seropositivity for anti-chlamydial immunoglobulin (Ig) A antibodies was significantly higher in PCR-positive PBMCs in patients with symptomatic disease compared with patients with asymptomatic disease (P =.02).



Detection of C pneumoniae in PBMCs shows that C pneumoniae may be associated with symptomatic carotid atherosclerotic disease. Although we believe there is need for standardization of PCR methods and for assessing sensitivity, specificity, and predictive values of the tests, we suggest that presence of C pneumoniae DNA in PBMCs is a valid surrogate marker of risk for endovascular chlamydial infection. Only long-term cohort studies and interventional trials will clarify the etiopathogenic role of C pneumoniae.

title: Measurement of Chlamydia pneumoniae bacterial load in peripheral blood mononuclear cells may be helpful to assess the state of chlamydial infection in patients with carotid atherosclerotic disease.
abstract: Chlamydia pneumoniae has been repeatedly associated with atherosclerotic cardiovascular diseases. We investigated the pattern of distribution of C. pneumoniae among patients with carotid atherosclerotic disease evaluating chlamydial load in carotid plaque, peripheral blood mononuclear cells (PBMC) and lymph node from same patient.



Thirty carotid plaques, 30 PBMC and 30 lymph nodes were examined by real-time PCR assay. C. pneumoniae DNA was detected, in carotid plaques, PBMC and lymph nodes in 11 patients; in carotid plaques and PBMC in five patients; in PBMC and lymph nodes in four patients; in lymph nodes in two patients; and in PBMC only in one patient. C. pneumoniae DNA in PBMC significantly coincided with the presence of the respective DNA in carotid plaque (p=0.0001) and lymph node (p=0.02). A higher chlamydial load was detected in PBMC than in lymph nodes and carotid plaques. More than 90% of patients with carotid plaques, PBMC and lymph nodes positive to C. pneumoniae were symptomatic, smokers, hypertensives, dyslipidemics and showed carotid plaques with rupture on the surface, hemorrhage and thrombosis.



The measurement of chlamydial load in PBMC may be helpful in the future to assess the state of C. pneumoniae infection and the risk of developing sequelae.

title: Chlamydia pneumoniae and osteoporosis-associated bone loss: a new risk factor?
abstract: SummaryWe found an association between the presence of Chlamydia pneumoniae DNA both in osteoporotic bone tissue and peripheral blood mononuclear cells (PBMCs) and the increase in circulating resorptive cytokines.IntroductionOur study was designed to determine whether C. pneumoniae infection may be involved in osteoporosis-associated bone loss.MethodsThe study included 59 women undergoing hip joint replacement surgery for femoral neck fracture: 32 with osteoporosis and 27 with osteoarthritis. A total of 118 tissue specimens (59 bone tissues, 59 PBMCs) were examined for C. pneumoniae DNA by real-time polymerase chain reaction (PCR). Serum levels of soluble receptor activator of nuclear factor kappa B ligand (sRANKL), osteoprotegerin (OPG), interleukin (IL)-1β, tumor necrosis factor-α, and IL-6 were also measured.ResultsC. pneumoniae DNA was detected in osteoporotic bone tissue whereas it was not found in non-osteoporotic bone tissue (p < 0.05). A significantly higher rate of C. pneumoniae DNA (p < 0.05) was found in PBMCs of osteoporotic patients than in those of osteoarthritis patients. Among osteoporotic patients, serum sRANKL, IL-1, and IL-6 concentrations as well as sRANKL/OPG ratio significantly differ between patients with bone tissue and PBMCs positive to C. pneumoniae and C. pneumoniae-negative patients.ConclusionThe association between the presence of C. pneumoniae DNA, both in bone tissue and PBMCs, and the increase in sRANKL/OPG ratio as well as in IL-1β and IL-6 levels observed in osteoporotic patients suggests C. pneumoniae infection as a new risk factor for osteoporosis.

title: Chlamydia Pneumoniae and Atherosclerosis: Current State and Future Prospectives
abstract: Chlamydia pneumoniae, an intracellular bacterial pathogen, is known as a leading cause of human respiratory tract infections worldwide. Over the last decade, several reports in the literature have suggested that infection with C. pneumoniae may contribute to the pathogenesis of atherosclerosis. In order to play a causative role in chronic disease, C. pneumoniae would need to persist within infected tissue for extended periods of time, thereby stimulating a chronic inflammatory response. C. pneumoniae has been shown to disseminate systemically from the lungs through infected peripheral blood mononuclear cells and to localize in arteries where it may infect endothelial cells, vascular smooth muscle cells, monocytes/macrophages and promote inflammatory atherogenous process. The involvement of C. pneumoniae in atherosclerosis was investigated by seroepidemiological and pathological studies, in vivo and in vitro studies, and in clinical antibiotic treatment trials. This review will provide an update on the role of C. pneumoniae in atherosclerosis focusing on the recent insights and suggesting areas for future research.

title: Chlamydia pneumoniae infection as a risk factor for accelerated atherosclerosis in hemodialysis patients.
abstract: Atherosclerotic cardiovascular disease is the main cause of morbidity and mortality for end-stage renal disease patients undergoing chronic haemodialysis (HD). Several studies in recent years have identified Chlamydia pneumoniae, a respiratory pathogen, as risk factor for cardiovascular diseases in the general population. The aim of our study is to evaluate chlamydial load, in peripheral blood mononuclear cells (PBMC) of HD patients. Furthermore, the correlation between DNA chlamydial load and markers of inflammation was also examined. PBMC specimens isolated from 49 HD patients and 46 blood donors were analyzed for the presence of C. pneumoniae DNA by real-time PCR and ompA nested touchdown PCR. In HD patients, plasma levels of several inflammatory markers were also determined. A significantly higher rate of C. pneumoniae DNA was found in HD patients (44.9 percent) than in blood donors (19.6 percent) (p=0.016); HD patients were also more likely to have a significantly high chlamydial load (p=0.0004). HD patients with atherosclerotic cardiovascular diseases have a significantly greater chlamydial load than HD patients without cardiovascular diseases (p= 0.006). A significantly higher value of C-reactive protein, IL-6 and advanced oxidative protein products was found in HD patients with a greater chlamydial load (p less than 0.05). Likewise, a significantly lower monocyte HLA-DR percentage (p=0.011) as well as a lower monocyte HLA-DR expression were found in such patients (p= 0.007). In conclusion, our results show that HD patients are at high risk of C. pneumoniae infection correlated with chronic inflammatory response which in turn can lead to accelerated atherosclerosis and other long-term clinical complications such as myocardial infarction and stroke.

title: Infection and Atherosclerosis Development.
abstract: Atherosclerosis is a chronic disease hallmarked by chronic inflammation, endothelial dysfunction and lipid accumulation in the vasculature. Although lipid modification and deposition are thought to be a major source of the continuous inflammatory stimulus, a large body of evidence suggests that infectious agents may contribute to atherosclerotic processes. This could occur by either direct effects through infection of vascular cells and/or through indirect effects by induction of cytokine and acute phase reactant proteins by infection at other sites. Multiple bacterial and viral pathogens have been associated with atherosclerosis by seroepidemiological studies, identification of the infectious agent in human atherosclerotic tissue, and experimental studies demonstrating an acceleration of atherosclerosis following infection in animal models of atherosclerosis. This review will focus on those infectious agents for which biological plausibility has been demonstrated in animal models and on the challenges of proving a role of infection in human atherosclerotic disease.

title: Chlamydia pneumoniae Infection and Inflammatory Diseases.
abstract: Chlamydia pneumoniae, an obligate intracellular bacterial pathogen, has long been investigated as a potential developmental or exacerbating factor in various pathologies. Its unique lifestyle and ability to disseminate throughout the host while persisting in relative safety from the immune response has placed this obligate intracellular pathogen in the crosshairs as a potentially mitigating factor in chronic inflammatory diseases. Many animal model and human correlative studies have been performed to confirm or deny a role for C. pneumoniae infection in these disorders. In some cases, antibiotic clinical trials were conducted to prove a link between bacterial infections and atherosclerosis. In this review, we detail the latest information regarding the potential role that C. pneumoniae infection may have in chronic inflammatory diseases.

title: Causality of Chlamydiae in Arthritis and Spondyloarthritis: a Plea for Increased Translational Research
abstract: Current molecular genetic understanding of the metabolically active persistent infection state of Chlamydia trachomatis and Chlamydia pneumoniae in the synovium in patients with arthritis and spondyloarthritis favors a causal relationship. Here, we examine how adequately the accepted criteria for that etiologic relationship are fulfilled, emphasizing the situation in which these microorganisms cannot be cultivated by standard or other means. We suggest that this unusual situation of causality by chlamydiae in rheumatic disease requires establishment of a consensus regarding microorganism-specific terminology as well as the development of new diagnostic and classification criteria. Recent studies demonstrate the value of molecular testing for diagnosis of reactive arthritis, undifferentiated spondyloarthritis, and undifferentiated arthritis caused by C. trachomatis and C. pneumoniae in clinical practice. Data regarding combination antibiotic therapy is consistent with the causative role of chlamydiae for these diseases. Observations of multiple intra-articular coinfections require more research to understand the implications and to respond to them.

title: Recent advances and future directions in understanding and treating Chlamydia-induced reactive arthritis
abstract: Reactive arthritis (ReA) is an inflammatory disease that can follow gastrointestinal or genitourinary infections. The primary etiologic agent for post-venereal ReA is the bacterium Chlamydia trachomatis; its relative, C pneumoniae, has also been implicated in disease induction although to a lesser degree. Studies have indicated that the arthritis is elicited by chlamydiae infecting synovial tissue in an unusual biologic state designated persistence. We review clinical aspects, host-pathogen interactions, and treatments for the disease.  We briefly discuss both the historic and,more extensively, the current medical literature describing ReA, and we provide a discussion of the biology of the chlamydiae as it relates to elicitation of the disease. A summary of clinical aspects of Chlamydia-induced ReA is included to give context for approaches to treatment of the arthritis.  Basic research into the biology and host-pathogen interactions characteristic of C trachomatis has provided a wealth of information that underlies our current understanding of the pathogenic processes occurring in the ReA synovium. Importantly, a promising approach to cure of the disease is at hand. However, both basic and clinical research into Chlamydia-induced ReA has lagged over the last 5 years, including required studies relating to cure of the disease.

title: Infectious Agents in Atherosclerotic Cardiovascular Diseases through Oxidative Stress
abstract: Accumulating evidence demonstrates that vascular oxidative stress is a critical feature of atherosclerotic process, potentially triggered by several infectious agents that are considered as risk co-factors for the atherosclerotic cardiovascular diseases (CVDs). C. pneumoniae has been shown to upregulate multiple enzymatic systems capable of producing reactive oxygen species (ROS) such as NADPH oxidase (NOX) and cyclooxygenase in vascular endothelial cells, NOX and cytochrome c oxidase in macrophages as well as nitric oxide synthase and lipoxygenase in platelets contributing to both early and late stages of atherosclerosis. P. gingivalis seems to be markedly involved in the atherosclerotic process as compared to A. actinomycetemcomitans contributing to LDL oxidation and foam cell formation. Particularly interesting is the evidence describing the NLRP3 inflammasome activation as a new molecular mechanism underlying P. gingivalis-induced oxidative stress and inflammation. Amongst viral agents, immunodeficiency virus-1 and hepatitis C virus seem to have a major role in promoting ROS production, contributing, hence, to the early stages of atherosclerosis including endothelial dysfunction and LDL oxidation. In conclusion, oxidative mechanisms activated by several infectious agents during the atherosclerotic process underlying CVDs are very complex and not well-known, remaining, thus, an attractive target for future research.

title: Chlamydia pneumoniae: An Etiologic Agent for Late-Onset Dementia
abstract: The disease known as late-onset Alzheimer’s disease is a neurodegenerative condition recognized as the single most commonform of senile dementia. The condition is sporadic and has been attributed to neuronal damage and loss, both of which have been linked to the accumulation of protein deposits in the brain. Significant progress has been made over the past two decades regarding our overall understanding of the apparently pathogenic entities that arise in the affected brain, both for early-onset disease, which constitutes approximately 5% of all cases, as well as late-onset disease, which constitutes the remainder of cases. Observable neuropathology includes: neurofibrillary tangles, neuropil threads, neuritic senile plaques and often deposits of amyloid around the cerebrovasculature. Although many studies have provided a relatively detailed knowledge of these putatively pathogenic entities, understanding of the events that initiate and support the biological processes generating them and the subsequent observable neuropathology and neurodegeneration remain limited. This is especially true in the case of late-onset disease. Although early-onset Alzheimer’s disease has been shown conclusively to have genetic roots, the detailed etiologic initiation of late-onset disease without such genetic origins has remained elusive. Over the last 15 years, current and ongoing work has implicated infection in the etiology and pathogenesis of late-onset dementia. Infectious agents reported to be associated with disease initiation are various, including several viruses and pathogenic bacterial species. We have reported extensively regarding an association between late-onset disease and infection with the intracellular bacterial pathogen Chlamydia pneumoniae. In this article, we review previously published data and recent results that support involvement of this unusual respiratory pathogen in disease induction and development. We further suggest several areas for future research that should elucidate details relating to those processes, and we argue for a change in the designation of the disease based on increased understanding of its clinical attributes.

title: The chlamydial developmental cycle.
abstract: Intracellular parasitism by bacterial pathogens is a complex, multi-factorial process that has been exploited successfully by a wide variety of organisms. Members of the Order Chlamydiales are obligate intracellular bacteria that are transmitted as metabolically inactive particles and must differentiate, replicate, and re-differentiate within the host cell to carry out their life cycle. Understanding the developmental cycle has been greatly advanced by the availability of complete genome sequences, DNA microarrays, and advanced cell biology techniques. Measuring transcriptional changes throughout the cycle has allowed investigators to determine the nature of the temporal gene expression changes required for bacterial growth and development.

title: Developmental stage-specific metabolic and transcriptional activity of Chlamydia trachomatis in an axenic medium
abstract: Chlamydia trachomatis is among the most clinically significant human pathogens, yet their obligate intracellular nature places severe restrictions upon research. Chlamydiae undergo a biphasic developmental cycle characterized by an infectious cell type known as an elementary body (EB) and an intracellular replicative form called a reticulate body (RB). EBs have historically been described as metabolically dormant. A cell-free (axenic) culture system was developed, which showed high levels of metabolic and biosynthetic activity from both EBs and RBs, although the requirements differed for each. EBs preferentially used glucose-6-phosphate as an energy source, whereas RBs required ATP. Both developmental forms showed increased activity when incubated under microaerobic conditions. Incorporation of isotopically labeled amino acids into proteins from both developmental forms indicated unique expression profiles, which were confirmed by genome-wide transcriptional analysis. The described axenic culture system will greatly enhance biochemical and physiological analyses of chlamydiae.

title: Quantitative Proteomics of the Infectious and Replicative Forms of Chlamydia trachomatis
abstract: The obligate intracellular developmental cycle of Chlamydia trachomatis presents significant challenges in defining its proteome. In this study we have applied quantitative proteomics to both the intracellular reticulate body (RB) and the extracellular elementary body (EB) from C. trachomatis. We used C. trachomatis L2 as a model chlamydial isolate for our study since it has a high infectivity:particle ratio and there is an excellent quality genome sequence. EBs and RBs (>99% pure) were quantified by chromosomal and plasmid copy number using PCR, from which the concentrations of chlamydial proteins per bacterial cell/genome were determined. RBs harvested at 15h post infection (PI) were purified by three successive rounds of gradient centrifugation. This is the earliest possible time to obtain purified RBs, free from host cell components in quantity, within the constraints of the technology. EBs were purified at 48h PI. We then used two-dimensional reverse phase UPLC to fractionate RB or EB peptides before mass spectroscopic analysis, providing absolute amount estimates of chlamydial proteins. The ability to express the data as molecules per cell gave ranking in both abundance and energy requirements for synthesis, allowing meaningful identification of rate-limiting components. The study assigned 562 proteins with high confidence and provided absolute estimates of protein concentration for 489 proteins. Interestingly, the data showed an increase in TTS capacity at 15h PI. Most of the enzymes involved in peptidoglycan biosynthesis were detected along with high levels of muramidase (in EBs) suggesting breakdown of peptidoglycan occurs in the non-dividing form of the microorganism. All the genome-encoded enzymes for glycolysis, pentose phosphate pathway and tricarboxylic acid cycle were identified and quantified; these data supported the observation that the EB is metabolically active. The availability of detailed, accurate quantitative proteomic data will be invaluable for investigations into gene regulation and function.

title: Chlamydia cell biology and pathogenesis
abstract: Chlamydia spp. are important causes of human disease for which no effective vaccine exists. These obligate intracellular pathogens replicate in a specialized membrane compartment and use a large arsenal of secreted effectors to survive in the hostile intracellular environment of the host. In this Review, we summarize the progress in decoding the interactions between Chlamydia spp. and their hosts that has been made possible by recent technological advances in chlamydial proteomics and genetics. The field is now poised to decipher the molecular mechanisms that underlie the intimate interactions between Chlamydia spp. and their hosts, which will open up many exciting avenues of research for these medically important pathogens.

title: Conserved type III secretion system exerts important roles in Chlamydia trachomatis.
abstract: Upon infection, Chlamydiae alter host cellular functions in a variety of ways. Chlamydial infection prevents host cell apoptosis, induces re-organization of the actin cytoskeleton and alters host cellular signaling mechanisms. Chlamydia is among the many pathogenic Gram-negative bacteria that employ the type III secretion system (T3SS) to overcome host defenses and exploit available resources. T3SS are used by many Gram-negative bacterial pathogens to manipulate eukaryotic host cells through the delivery of effector proteins into their cytosol and membranes. T3SS is an evolutionarily refined, virulence determinant of Gram-negative bacteria where more than 20 proteins form an apparatus, generally termed injectisome, to achieve the vectorial secretion and translocation of anti-host effector proteins. This review describes challenges and recent advances that have revealed how Chlamydia trachomatis utilizes diversification to produce a conserved T3SS that exerts an important role in Chlamydia trachomatis.

title: The Chlamydia protease CPAF regulates host and bacterial proteins to maintain pathogen vacuole integrity and promote virulence.
abstract: The obligate intracellular bacterial pathogen Chlamydia trachomatis injects numerous effector proteins into the epithelial cell cytoplasm to manipulate host functions important for bacterial survival. In addition, the bacterium secretes a serine protease, chlamydial protease-like activity factor (CPAF). Although several CPAF targets are reported, the significance of CPAF-mediated proteolysis is unclear due to the lack of specific CPAF inhibitors and the diversity of host targets. We report that CPAF also targets chlamydial effectors secreted early during the establishment of the pathogen-containing vacuole ("inclusion"). We designed a cell-permeable CPAF-specific inhibitory peptide and used it to determine that CPAF prevents superinfection by degrading early Chlamydia effectors translocated during entry into a preinfected cell. Prolonged CPAF inhibition leads to loss of inclusion integrity and caspase-1-dependent death of infected epithelial cells. Thus, CPAF functions in niche protection, inclusion integrity and pathogen survival, making the development of CPAF-specific protease inhibitors an attractive antichlamydial therapeutic strategy.

title: The chlamydial periplasmic stress response serine protease cHtrA is secreted into host cell cytosol
abstract: BackgroundThe periplasmic High Temperature Requirement protein A (HtrA) plays important roles in bacterial protein folding and stress responses. However, the role of chlamydial HtrA (cHtrA) in chlamydial pathogenesis is not clear.ResultsThe cHtrA was detected both inside and outside the chlamydial inclusions. The detection was specific since both polyclonal and monoclonal anti-cHtrA antibodies revealed similar intracellular labeling patterns that were only removed by absorption with cHtrA but not control fusion proteins. In a Western blot assay, the anti-cHtrA antibodies detected the endogenous cHtrA in Chlamydia-infected cells without cross-reacting with any other chlamydial or host cell antigens. Fractionation of the infected cells revealed cHtrA in the host cell cytosol fraction. The periplasmic cHtrA protein appeared to be actively secreted into host cell cytosol since no other chlamydial periplasmic proteins were detected in the host cell cytoplasm. Most chlamydial species secreted cHtrA into host cell cytosol and the secretion was not inhibitable by a type III secretion inhibitor.ConclusionSince it is hypothesized that chlamydial organisms possess a proteolysis strategy to manipulate host cell signaling pathways, secretion of the serine protease cHtrA into host cell cytosol suggests that the periplasmic cHtrA may also play an important role in chlamydial interactions with host cells.

title: Chlamydial Persistence: beyond the Biphasic Paradigm
abstract: The chlamydiae are an evolutionarily distinct group of eubacteria sharing an obligate intracellular lifestyle and a unique developmental cycle that has been well characterized under favorable cell culture conditions. This cycle begins when infectious, metabolically inert elementary bodies (EB)

title: Chlamydia trachomatis persistence in vitro: an overview.
abstract: Chlamydiae growing in target mucosal human epithelial cells in vitro can transition from their normal developmental cycle progression, alternating between infectious but metabolically inactive elementary bodies to metabolically active but noninfectious reticulate bodies (RBs) and back to elementary bodies, into a state of persistence. Persistence in vitro is defined as viable but noncultivable chlamydiae involving morphologically enlarged, aberrant, and nondividing RBs. The condition is reversible, yielding infectious elementary bodies after removal of the inducers, including penicillin, interferon-gamma, iron or nutrient starvation, concomitant herpes infection, or maturation of the host cell into its physiologically differentiated state. All aberrant RB phenotypes are not the same, owing to differing up- or down-regulated chlamydial gene sets and subsequent host responses. Although all persistence-inducing conditions exist in vivo, key questions include (1) whether or not aberrant chlamydial RBs occur in vivo during the alternating acute-silent chronic-acute chlamydial infection scenario that exists in infected patients and animals and (2) whether such aberrant RBs can contribute to prolonged, chronic inflammation, fibrosis, and scarring.

title: Response of Chlamydia trachomatis serovar E to iron restriction in vitro and evidence for iron-regulated chlamydial proteins
abstract: Iron is a well-established mediator of virulence in several bacterial pathogens, yet little is known about the role of iron in infectious disease processes caused by obligate intracellular bacterial pathogens. In this study, the effect of iron limitation was examined for the sexually transmitted infectious agent Chlamydia trachomatis in an in vitro model of human genital infection using the intracellular iron-chelating reagent deferoxamine mesylate (Desferal). Iron restriction caused a significant reduction in infectivity of C. trachomatis elementary bodies (EB) harvested from Desferal-exposed polarized epithelial cells when compared to that of EB harvested from iron-sufficient control cell cultures. Replacement of the Desferal exposure medium with medium containing iron-saturated transferrin restored chlamydial infectivity, whereas replacement with growth medium alone had no effect. The following three prominent morphological features were observed by electron microscopic examination of chlamydia-infected cells exposed to Desferal: (i) inclusions containing chlamydiae greatly delayed in maturation, (ii) substantial blebbing within chlamydial inclusions, and (iii) electron-dense material surrounding inclusions. Protein analyses of highly purified EB by two-dimensional polyacrylamide gel electrophoresis revealed that there were at least 19 candidate iron-repressible proteins in C. trachomatis and at least one protein which was iron inducible. One putative iron-repressible protein was confirmed by Western blot (immunoblot) analysis to be the chlamydial heat shock protein 60 (hsp60). The enhanced production of this antigen by chlamydiae as a result of iron limitation is of particular importance since there is a well-documented association between chlamydial hsp60 and destructive immunopathological sequelae in infected patients.

title: Commonly prescribed β-lactam antibiotics induce C. trachomatis persistence/stress in culture at physiologically relevant concentrations
abstract: Chlamydia trachomatis, the most common bacterial sexually transmitted disease agent worldwide, enters a viable, non-dividing and non-infectious state (historically termed persistence and more recently referred to as the chlamydial stress response) when exposed to penicillin G in culture. Notably, penicillin G-exposed chlamydiae can reenter the normal developmental cycle upon drug removal and are resistant to azithromycin-mediated killing. Because penicillin G is less frequently prescribed than other β-lactams, the clinical relevance of penicillin G-induced chlamydial persistence/stress has been questioned. The goal of this study was to determine whether more commonly used penicillins also induce C. trachomatis serovar E persistence/stress. All penicillins tested, as well as clavulanic acid, induced formation of aberrant, enlarged reticulate bodies (RB) (called aberrant bodies or AB) characteristic of persistent/stressed chlamydiae. Exposure to the penicillins and clavulanic acid also reduced chlamydial infectivity by >95%. None of the drugs tested significantly reduced chlamydial unprocessed 16S rRNA or genomic DNA accumulation, indicating that the organisms were viable, though non-infectious. Finally, recovery assays demonstrated that chlamydiae rendered essentially non-infectious by exposure to ampicillin, amoxicillin, carbenicillin, piperacillin, penicillin V, and clavulanic acid recovered infectivity after antibiotic removal. These data definitively demonstrate that several commonly used penicillins induce C. trachomatis persistence/stress at clinically relevant concentrations.

title: Interaction of herpes simplex virus type 2 (HSV-2) glycoprotein D with the host cell surface is sufficient to induce Chlamydia trachomatis persistence.
abstract: When presented with certain unfavourable environmental conditions, Chlamydia trachomatis reticulate bodies (RBs) enter into a viable, yet non-cultivable state called persistence. Previously, we established an in vitro C. trachomatis and herpes simplex virus type 2 (HSV-2) co-infection model. These data indicate that (i) viral co-infection stimulates chlamydial persistence, (ii) productive HSV replication is not required for persistence induction, and (iii) HSV-induced persistence is not mediated by any currently characterized anti-chlamydial pathway or persistence inducer. In this study we demonstrated that chlamydial infectivity, though initially suppressed, recovered within 44 h of co-infection with UV-inactivated HSV-2, demonstrating that HSV-induced persistence is reversible. Co-incubation of chemically fixed, HSV-2-infected inducer cells with viable, C. trachomatis-infected responder cells both suppressed production of infectious chlamydial progeny and stimulated formation of swollen, aberrantly shaped RBs. In addition, pre-incubation of viral particles with viral glycoprotein D (gD)-specific neutralizing antibody prevented co-infection-induced persistence. Finally, exposure of C. trachomatis-infected cells to a soluble, recombinant HSV-2 gD : Fc fusion protein decreased production of infectious EBs to a degree similar to that observed in co-infected cultures. Thus, we conclude that interaction of HSV gD with the host cell surface is sufficient to trigger a novel host anti-chlamydial response that restricts chlamydial development.

title: A novel co‐infection model with Toxoplasma and Chlamydia trachomatis highlights the importance of host cell manipulation for nutrient scavenging
abstract: Toxoplasma and Chlamydia trachomatis are obligate intracellular pathogens that have evolved analogous strategies to replicate within mammalian cells. Both pathogens are known to extensively remodel the cytoskeleton, and to recruit endocytic and exocytic organelles to their respective vacuoles. However, how important these activities are for infectivity by either pathogen remains elusive. Here, we have developed a novel co‐infection system to gain insights into the developmental cycles of Toxoplasma and C. trachomatis by infecting human cells with both pathogens, and examining their respective ability to replicate and scavenge nutrients. We hypothesize that the common strategies used by Toxoplasma and Chlamydia to achieve development results in direct competition of the two pathogens for the same pool of nutrients. We show that a single human cell can harbour Chlamydia and Toxoplasma. In co‐infected cells, Toxoplasma is able to divert the content of host organelles, such as cholesterol. Consequently, the infectious cycle of Toxoplasma progresses unimpeded. In contrast, Chlamydia's ability to scavenge selected nutrients is diminished, and the bacterium shifts to a stress‐induced persistent growth. Parasite killing engenders an ordered return to normal chlamydial development. We demonstrate that C. trachomatisenters a stress‐induced persistence phenotype as a direct result from being barred from its normal nutrient supplies as addition of excess nutrients, e.g. amino acids, leads to substantial recovery of Chlamydia growth and infectivity. Co‐infection of C. trachomatis with slow growing strains of Toxoplasma or a mutant impaired in nutrient acquisition does not restrict chlamydial development. Conversely, Toxoplasma growth is halted in cells infected with the highly virulent Chlamydia psittaci. This study illustrates the key role that cellular remodelling plays in the exploitation of host intracellular resources by Toxoplasma and Chlamydia. It further highlights the delicate balance between success and failure of infection by intracellular pathogens in a co‐infection system at the cellular level.

title: Chlamydia muridarum enters a viable but non-infectious state in amoxicillin-treated BALB/c mice.
abstract: In culture, exposure to penicillin and other stressors induce chlamydiae to enter a non-infectious but viable state termed persistence. Chlamydiae may reenter their normal developmental cycle after stressor removal. Though aberrant RB similar to those present in culture models of persistence have been observed within infected tissues, the existence of persistent chlamydiae has not been definitively demonstrated in vivo. As a result, the role of persistent organisms in pathogenesis is undefined. In order to establish an experimentally tractable model of in vivo persistence, Chlamydia muridarum vaginally-infected mice were gavaged with either water or amoxicillin (amox). Vaginal swabs were collected for chlamydial titration and RNA isolated for quantification of pre-16s rRNA. Uterine tissue was analyzed by transmission electron microscopy (TEM). Although amox-treatment reduced vaginal shedding by >99%, C. muridarum pre-16s rRNA accumulation was unchanged by treatment. These data indicate that the amox-exposed organisms were viable but not infectious. Furthermore, TEM analyses demonstrated that inclusions in amox-treated animals contained primarily large, aberrant RB, but those observed in untreated control animals were normal. Collectively, these data suggest that amoxicillin treatment induces C. muridarum to enter the persistent state in vivo. This model also represents the first experimentally tractable animal model of chlamydial persistence.

title: Induction of the Chlamydia muridarum Stress/Persistence Response Increases Azithromycin Treatment Failure in a Murine Model of Infection
abstract: Viable but noninfectious (stressed/persistent) chlamydiae are more resistant to azithromycin (AZM) in culture than are organisms in the normal developmental cycle. Chlamydia muridarum-infected mice were exposed to amoxicillin to induce the organisms to enter the persistent/stressed state and subsequently treated with AZM. AZM treatment failure was observed in 22% of persistently infected mice, with an average of 321,667 inclusion-forming units (IFU) shed after AZM treatment. Productively infected mice had a 9% rate of AZM treatment failure and shed an average of 12,083 IFU. These data suggest that stressed chlamydiae are more resistant to frontline antichlamydial drugs in vivo.

title: Evidence for persistent Chlamydia pneumoniae infection of human coronary atheromas.
abstract: To date, structures representing developmental stages of Chlamydia pneumoniae, especially persistent forms of this intracellular bacteria, have not been described in human atherosclerotic tissues using specific antibody labeling and transmission electron microscopy. Staining of atherosclerotic tissue from five patients seeking heart transplantation with gold-labeled antibodies specific for up-regulated chlamydial heat shock proteins, GroEL and GroES, and visualisation via transmission electron microscopy revealed intracellular, atypical, round to oval structures of variable diameter. These structures resembled reticulate bodies of Chlamydia, were surrounded by membranes and were located within smooth muscle cells, macrophages or fibroblasts. By using double immunogold electron microscopy technique (GroEL and GroES in combination with chlamydial LPS/MOMP antibodies), we demonstrated these structures were of chlamydial origin. In the current study, we demonstrated the presence of aberrant bodies of C. pneumoniae in vivo in archival coronary atheromatous heart tissues by the immunogold electron microscopy technique.

title: Morphologic and molecular evaluation of Chlamydia trachomatis growth in human endocervix reveals distinct growth patterns
abstract: In vitro models of Chlamydia trachomatis growth have long been studied to predict growth in vivo. Alternative or persistent growth modes in vitro have been shown to occur under the influence of numerous stressors but have not been studied in vivo. Here, we report the development of methods for sampling human infections from the endocervix in a manner that permits a multifaceted analysis of the bacteria, host and the endocervical environment. Our approach permits evaluating total bacterial load, transcriptional patterns, morphology by immunofluorescence and electron microscopy, and levels of cytokines and nutrients in the infection microenvironment. By applying this approach to two pilot patients with disparate infections, we have determined that their contrasting growth patterns correlate with strikingly distinct transcriptional biomarkers, and are associated with differences in local levels of IFNγ. Our multifaceted approach will be useful to dissect infections in the human host and be useful in identifying patients at risk for chronic disease. Importantly, the molecular and morphological analyses described here indicate that persistent growth forms can be isolated from the human endocervix when the infection microenvironment resembles the in vitro model of IFNγ-induced persistence.

title: Pre-exposure of infected human endometrial epithelial cells to penicillin in vitro renders Chlamydia trachomatis refractory to azithromycin.
abstract: The clinical significance of the potential for persistent human chlamydial infections in vivo is being actively reassessed because of the increased frequency of recurrent infection with the same serovar despite compliance with an effective antibiotic regimen. The ability to extend the length of time of in vitro cultivation of polarized human endometrial epithelial cells (HEC-1B) provided the opportunity to establish a model system to determine if a persistent form of Chlamydia trachomatis had the same susceptibility as the actively growing form to a cidal concentration of azithromycin.



Polarized HEC-1B cells cultivated on extracellular matrix were infected with C. trachomatis serovar E and exposed to penicillin at 24 h post-infection (hpi) to induce a persistent infection characterized by slowly metabolizing but non-dividing, ultrastructurally aberrant reticulate bodies within the chlamydial inclusion; at 48 hpi, infected cultures were exposed to a bactericidal concentration of azithromycin for 72 h.



Persistent chlamydiae were phenotypically resistant to azithromycin; the number of chlamydial inclusions on subpassage of progeny from persistent chlamydiae following removal of penicillin and recovery was essentially the same as from progeny from persistent chlamydiae following removal of penicillin and azithromycin and recovery. Neutrophils were attracted in vitro to persistently infected HEC-1B cells that had been exposed to penicillin and azithromycin.



Thus, this study provides evidence at the cellular microbiology level in vitro for mechanisms that could exist in vivo to create sustained, but perhaps clinically inapparent inflammation, which might eventually lead to conditions such as silent pelvic inflammatory disease.

title: Characteristics of the Chlamydia trachomatis species - immunopathology and infections.
abstract: Chlamydiae are microorganisms exhibiting characteristics intermediate between bacteria and viruses. Chlamydia is widespread in the natural world, intracellular parasites of people and animals. They are capable of independent reproduction, because they do not synthesize ATP, in its development cycle using the host cell metabolic pathways. The life cycle of these microorganisms is original, unique among bacteria and lasts from 24 to 48 hours. Chlamydia antigens consist of 4 groups: group-specific, species-specific, type-specific and subspecies-specific. The group of species-specific antigens consists of MOMP and heat shock proteins. C. trachomatis is a potent immunogen, stimulating the immune processes of microorganisms. In the course of C. trachomatis infection, the response mechanisms involved are: non-specific, specific, humoral and cellular. Chronic infection is characterized by maintenance of microorganisms in the host cell. Inflammation is formed in less time and with increased intensity and has a rapid immune response on the part of previously sensitized lymphocytes. C. trachomatis infections are the most common bacterial sexually-transmitted infections. It represents an important clinical problem for doctors in many areas of medicine such as dermatology, venereology, ophthalmology, gynecology and obstetrics, rheumatology and others. Chlamydial infections are important pathogens in medical practice, not only because they cause disease in various fields of medicine, but also because of the large proportion of the population suffering and exposed to these microbial infections. Chlamydial infections are characterized by multifocality and polymorphism changes. Chlamydia causes inflammation in the adult urethra and cervix with the possibility of serious complications, and can cause perinatal infections in infants.

title: Expression of recombinant DNA introduced into Chlamydia trachomatis by electroporation.
abstract: Electroporation was used to introduce DNA into the elementary bodies of the obligate parasitic bacterium Chlamydia trachomatis. The source of DNA for these experiments was the chimeric plasmid pPBW100, which was constructed from the well-characterized 7.5-kb plasmid of C. trachomatis and the Escherichia coli plasmid pBGS9. To select directly for C. trachomatis carrying pPBW100, an in-frame gene fusion between the chlamydial promoter P7248 and a promoterless chloramphenicol acetyltransferase (cat) cassette was incorporated into the plasmid. After infection of McCoy cells with electroporated elementary bodies containing pPBW100, the following were observed: (i) the plasmid DNA was detected inside the chloramphenicol-resistant chlamydial inclusions by in situ and Southern hybridization analyses; (ii) both physical and biochemical evidence showed that chloramphenicol acetyltransferase was synthesized by the electroporated C. trachomatis; (iii) expression of P7248::cat was developmentally regulated and occurred during the early stages of chlamydial reticulate body development; and (iv) although the expression from P7248::cat was mainly transient, there were rare instances where chloramphenicol-resistant C. trachomatis were observed after four passages.

title: The chlamydial functional homolog of KsgA confers kasugamycin sensitivity to Chlamydia trachomatis and impacts bacterial fitness
abstract: BackgroundrRNA adenine dimethyltransferases, represented by the Escherichia coli KsgA protein, are highly conserved phylogenetically and are generally not essential for growth. They are responsible for the post-transcriptional transfer of two methyl groups to two universally conserved adenosines located near the 3'end of the small subunit rRNA and participate in ribosome maturation. All sequenced genomes of Chlamydia reveal a ksgA homolog in each species, including C. trachomatis. Yet absence of a S-adenosyl-methionine synthetase in Chlamydia, the conserved enzyme involved in the synthesis of the methyl donor S-adenosyl-L-methionine, raises a doubt concerning the activity of the KsgA homolog in these organisms.ResultsLack of the dimethylated adenosines following ksgA inactivation confers resistance to kasugamycin (KSM) in E. coli. Expression of the C. trachomatis L2 KsgA ortholog restored KSM sensitivity to the E. coli ksgA mutant, suggesting that the chlamydial KsgA homolog has specific rRNA dimethylase activity. C. trachomatis growth was sensitive to KSM and we were able to isolate a KSM resistant mutant of C. trachomatis containing a frameshift mutation in ksgA, which led to the formation of a shorter protein with no activity. Growth of the C. trachomatis ksgA mutant was negatively affected in cell culture highlighting the importance of the methylase in the development of these obligate intracellular and as yet genetically intractable pathogens.ConclusionThe presence of a functional rRNA dimethylase enzyme belonging to the KsgA family in Chlamydia presents an excellent chemotherapeutic target with real potential. It also confirms the existence of S-adenosyl-methionine - dependent methylation reactions in Chlamydia raising the question of how these organisms acquire this cofactor.

title: A C. trachomatis Cloning Vector and the Generation of C. trachomatis Strains Expressing Fluorescent Proteins under the Control of a C. trachomatis Promoter
abstract: Here we describe a versatile cloning vector for conducting genetic experiments in C. trachomatis. We successfully expressed various fluorescent proteins (i.e. GFP, mCherry and CFP) from C. trachomatis regulatory elements (i.e. the promoter and terminator of the incDEFG operon) and showed that the transformed strains produced wild type amounts of infectious particles and recapitulated major features of the C. trachomatis developmental cycle. C. trachomatis strains expressing fluorescent proteins are valuable tools for studying the C. trachomatis developmental cycle. For instance, we show the feasibility of investigating the dynamics of inclusion fusion and interaction with host proteins and organelles by time-lapse video microscopy.

title: A Co-infection Model System and the Use of Chimeric Proteins to Study Chlamydia Inclusion Proteins Interaction
abstract: Chlamydia trachomatis is an obligate intracellular bacterium associated with trachoma and sexually transmitted diseases. During its intracellular developmental cycle, Chlamydia resides in a membrane bound compartment called the inclusion. A subset of Type III secreted effectors, the inclusion membrane proteins (Inc), are inserted into the inclusion membrane. Inc proteins are strategically positioned to promote inclusion interaction with host factors and organelles, a process required for bacterial replication, but little is known about Inc proteins function or host interacting partners. Moreover, it is unclear whether each Inc protein has a distinct function or if a subset of Inc proteins interacts with one another to perform their function. Here, we used IncD as a model to investigate Inc/Inc interaction in the context of Inc protein expression in C. trachomatis. We developed a co-infection model system to display different tagged Inc proteins on the surface of the same inclusion. We also designed chimeric Inc proteins to delineate domains important for interaction. We showed that IncD can self-interact and that the full-length protein is required for dimerization and/or oligomerization. Altogether our approach can be generalized to any Inc protein and will help to characterize the molecular mechanisms by which Chlamydia Inc proteins interact with themselves and/or host factors, eventually leading to a better understanding of C. trachomatis interaction with the mammalian host.

title: Conditional Gene Expression in Chlamydia trachomatis Using the Tet System
abstract: Chlamydia trachomatis is maintained through a complex bi-phasic developmental cycle that incorporates numerous processes that are poorly understood. This is reflective of the previous paucity of genetic tools available. The recent advent of a method for transforming Chlamydia has enabled the development of essential molecular tools to better study these medically important bacteria. Critical for the study of Chlamydia biology and pathogenesis, is a system for tightly controlled inducible gene expression. To accomplish this, a new shuttle vector was generated with gene expression controlled by the Tetracycline repressor and anhydryotetracycline. Evaluation of GFP expression by this system demonstrated tightly controlled gene regulation with rapid protein expression upon induction and restoration of transcription repression following inducer removal. Additionally, induction of expression could be detected relatively early during the developmental cycle and concomitant with conversion into the metabolically active form of Chlamydia. Uniform and strong GFP induction was observed during middle stages of the developmental cycle. Interestingly, variable induced GFP expression by individual organisms within shared inclusions during later stages of development suggesting metabolic diversity is affecting induction and/or expression. These observations support the strong potential of this molecular tool to enable numerous experimental analyses for a better understanding of the biology and pathogenesis of Chlamydia.

title: Generation of targeted Chlamydia trachomatis null mutants
abstract: Chlamydia trachomatis is an obligate intracellular bacterial pathogen that infects hundreds of millions of individuals globally, causing blinding trachoma and sexually transmitted disease. More effective chlamydial control measures are needed, but progress toward this end has been severely hampered by the lack of a tenable chlamydial genetic system. Here, we describe a reverse-genetic approach to create isogenic C. trachomatis mutants. C. trachomatis was subjected to low-level ethyl methanesulfonate mutagenesis to generate chlamydiae that contained less then one mutation per genome. Mutagenized organisms were expanded in small subpopulations that were screened for mutations by digesting denatured and reannealed PCR amplicons of the target gene with the mismatch specific endonuclease CEL I. Subpopulations with mutations were then sequenced for the target region and plaque-cloned if the desired mutation was detected. We demonstrate the utility of this approach by isolating a tryptophan synthase gene (trpB) null mutant that was otherwise isogenic to its parental clone as shown by de novo genome sequencing. The mutant was incapable of avoiding the anti-microbial effect of IFN-γ–induced tryptophan starvation. The ability to genetically manipulate chlamydiae is a major advancement that will enhance our understanding of chlamydial pathogenesis and accelerate the development of new anti-chlamydial therapeutic control measures. Additionally, this strategy could be applied to other medically important bacterial pathogens with no or difficult genetic systems.

title: Virulence determinants in the obligate intracellular pathogen Chlamydia trachomatis revealed by forward genetic approaches
abstract: Chlamydia trachomatis, a pathogen responsible for diseases of significant clinical and public health importance, remains poorly characterized because of its intractability to routine molecular genetic manipulation. We have developed a combinatorial approach to rapidly generate a comprehensive library of genetically defined mutants. Chemical mutagenesis, coupled with whole-genome sequencing (WGS) and a system for DNA exchange within infected cells, was used to generate Chlamydia mutants with distinct phenotypes, map the underlying genetic lesions, and generate isogenic strains. As a result, we identified mutants with altered glycogen metabolism, including an attenuated strain defective for type II secretion. The coupling of chemically induced gene variation and WGS to establish genotype–phenotype associations should be broadly applicable to the large list of medically and environmentally important microorganisms currently intractable to genetic analysis.

title: Integrating chemical mutagenesis and whole-genome sequencing as a platform for forward and reverse genetic analysis of Chlamydia.
abstract: Gene inactivation by transposon insertion or allelic exchange is a powerful approach to probe gene function. Unfortunately, many microbes, including Chlamydia, are not amenable to routine molecular genetic manipulations. Here we describe an arrayed library of chemically induced mutants of the genetically intransigent pathogen Chlamydia trachomatis, in which all mutations have been identified by whole-genome sequencing, providing a platform for reverse genetic applications. An analysis of possible loss-of-function mutations in the collection uncovered plasticity in the central metabolic properties of this obligate intracellular pathogen. We also describe the use of the library in a forward genetic screen that identified InaC as a bacterial factor that binds host ARF and 14-3-3 proteins and modulates F-actin assembly and Golgi redistribution around the pathogenic vacuole. This work provides a robust platform for reverse and forward genetic approaches in Chlamydia and should serve as a valuable resource to the community.

title: The Genetic Transformation of Chlamydia pneumoniae
abstract: The absence of tools for the genetic manipulation of C. pneumoniae has hampered research into all aspects of its biology. In this study, we established a novel reproducible method for C. pneumoniae transformation based on a plasmid shuttle vector system. We constructed a C. pneumoniae plasmid backbone shuttle vector, pRSGFPCAT-Cpn. The construct expresses the red-shifted green fluorescent protein (RSGFP) fused to chloramphenicol acetyltransferase in C. pneumoniae. C. pneumoniae transformants stably retained pRSGFPCAT-Cpn and expressed RSGFP in epithelial cells, even in the absence of chloramphenicol. The successful transformation in C. pneumoniae using pRSGFPCAT-Cpn will advance the field of chlamydial genetics and is a promising new approach to investigate gene functions in C. pneumoniae biology. In addition, we demonstrated that pRSGFPCAT-Cpn overcame the plasmid species barrier without the need for recombination with an endogenous plasmid, indicating the potential probability of horizontal chlamydial pathogenic gene transfer by plasmids between chlamydial species.  We demonstrate the genetic transformation of Chlamydia pneumoniae using a plasmid shuttle vector system which generates stable transformants. The equine C. pneumoniae N16 isolate harbors the 7.5-kb plasmid pCpnE1. We constructed the plasmid vector pRSGFPCAT-Cpn containing a pCpnE1 backbone, plus the red-shifted green fluorescent protein (RSGFP), as well as the chloramphenicol acetyltransferase (CAT) gene used for the selection of plasmid shuttle vector-bearing C. pneumoniae transformants. Using the pRSGFPCAT-Cpn plasmid construct, expression of RSGFP in koala isolate C. pneumoniae LPCoLN was demonstrated. Furthermore, we discovered that the human cardiovascular isolate C. pneumoniae CV-6 and the human community-acquired pneumonia-associated C. pneumoniae IOL-207 could also be transformed with pRSGFPCAT-Cpn. In previous studies, it was shown that Chlamydia spp. cannot be transformed when the plasmid shuttle vector is constructed from a different plasmid backbone to the homologous species. Accordingly, we confirmed that pRSGFPCAT-Cpn could not cross the species barrier in plasmid-bearing and plasmid-free C. trachomatis, C. muridarum, C. caviae, C. pecorum, and C. abortus. However, contrary to our expectation, pRSGFPCAT-Cpn did transform C. felis. Furthermore, pRSGFPCAT-Cpn did not recombine with the wild-type plasmid of C. felis. Taken together, we provide for the first time an easy-to-handle transformation protocol for C. pneumoniae that results in stable transformants. In addition, the vector can cross the species barrier to C. felis, indicating the potential of horizontal pathogenic gene transfer via a plasmid.  The absence of tools for the genetic manipulation of C. pneumoniae has hampered research into all aspects of its biology. In this study, we established a novel reproducible method for C. pneumoniae transformation based on a plasmid shuttle vector system. We constructed a C. pneumoniae plasmid backbone shuttle vector, pRSGFPCAT-Cpn. The construct expresses the red-shifted green fluorescent protein (RSGFP) fused to chloramphenicol acetyltransferase in C. pneumoniae. C. pneumoniae transformants stably retained pRSGFPCAT-Cpn and expressed RSGFP in epithelial cells, even in the absence of chloramphenicol. The successful transformation in C. pneumoniae using pRSGFPCAT-Cpn will advance the field of chlamydial genetics and is a promising new approach to investigate gene functions in C. pneumoniae biology. In addition, we demonstrated that pRSGFPCAT-Cpn overcame the plasmid species barrier without the need for recombination with an endogenous plasmid, indicating the potential probability of horizontal chlamydial pathogenic gene transfer by plasmids between chlamydial species.

title: The Human Vaginal Bacterial Biota and Bacterial Vaginosis
abstract: The bacterial biota of the human vagina can have a profound impact on the health of women and their neonates. Changes in the vaginal microbiota have been associated with several adverse health outcomes including premature birth, pelvic inflammatory disease, and acquisition of HIV infection. Cultivation-independent molecular methods have provided new insights regarding bacterial diversity in this important niche, particularly in women with the common condition bacterial vaginosis (BV). PCR methods have shown that women with BV have complex communities of vaginal bacteria that include many fastidious species, particularly from the phyla Bacteroidetes and Actinobacteria. Healthy women are mostly colonized with lactobacilli such as Lactobacillus crispatus, Lactobacillus jensenii, and Lactobacillus iners, though a variety of other bacteria may be present. The microbiology of BV is heterogeneous. The presence of Gardnerella vaginalis and Atopobium vaginae coating the vaginal epithelium in some subjects with BV suggests that biofilms may contribute to this condition.

title: Candida and its dual lifestyle as a commensal and a pathogen.
abstract: Candida spp. are part of the normal vaginal microflora in 20-30% of healthy women. However, if the balance between these yeasts and the host is disturbed, Candida spp. can cause vulvovaginal candidiasis (VVC), with Candida albicans being the major causative agent. Different studies have been performed in order to better understand Candida's dual lifestyle in the vagina. The potential of C. albicans to switch from the yeast cell morphology to its hyphal form is considered a key element in VVC pathogenesis. Candida spp. also express other virulence factors, such as hydrolytic extracellular enzymes and heat shock proteins and can form biofilms.

title: Biofilm in Genital Ecosystem: A Potential Risk Factor for Chlamydia trachomatis Infection
abstract: In healthy women, the cervicovaginal microbiota is mostly populated by Lactobacillus spp., the main host defense factor of the female genital tract. In addition to Lactobacilli, other microorganisms populate the cervicovaginal microbiota, like Candida spp. and Gardnerella vaginalis. The overgrowth of Candida spp. or G. vaginalis, known as biofilm-producing microorganisms in the genital ecosystem, may lead to microbial dysbiosis that increases the risk of acquiring sexually transmitted infections, like Chlamydia trachomatis. C. trachomatis, the leading cause of bacterial sexually transmitted diseases, is still considered an important public health problem worldwide because of the impact of asymptomatic infections on long-term reproductive sequelae, including pelvic inflammatory disease and infertility. The aim of our study was to investigate the interaction between C. trachomatis and the biofilm produced by Candida albicans or Gardnerella vaginalis, evaluating whether the biofilm can harbor C. trachomatis and influence its survival as well as its infectious properties. In order to do so, we developed an in vitro coculture transwell-based biofilm model. Our findings proved, for the first time, that C. trachomatis, an intracellular obligate pathogen, survived, for up to 72 hours after exposure, inside the biofilm produced by C. albicans or G. vaginalis, retaining its infectious properties, as evidenced by the typical chlamydial inclusions observed in the cell monolayer (chlamydial inclusion-forming units at 72 h: 9255 ± 1139 and 9873 ± 1015, respectively). In conclusion, our results suggest that the biofilm related to Candida or Gardnerella genital infections may act as a reservoir of C. trachomatis and, thus, contribute to the transmission of the infection in the population as well as to its dissemination into the upper genital tract, increasing the risk of developing severe reproductive sequelae.

title: Hydrogen peroxide producing lactobacilli in women with vaginal infections.
abstract: Hydrogen peroxide producing lactobacilli are isolated from the vaginas of a majority of healthy reproductive age women. Their toxic and inhibitory effect against the overgrowth of pathogens in the vagina is documented by in vitro studies. Clinical studies concerning the role of hydrogen peroxide producing lactobacilli in vaginal infections are controversial.



The aim of this study was to isolate lactobacilli from women with major vaginal infections: bacterial vaginosis (BV), vulvovaginal candidiasis (VVC) and trichomoniasis (TV), and from women with normal flora (NF), to test their ability to produce hydrogen peroxide, to quantitate lactobacilli and to evaluate factors related to the colonization of vagina with hydrogen peroxide producing lactobacilli. The study group comprised 108 women: 27 with VVC, 26 with BV, 20 with TV and 35 with NF. Data was analysed with Fisher exact test, chi2-test, and ANOVA.



Lactobacilli were isolated from 81.5% of women with VVC, 58% of women with BV (p=0019), 55% of women with TV (p=0.015) and from 86% of women with NF. The majority of isolates of lactobacilli from women with VVC, TV and NF produced hydrogen peroxide (77%, 63.5% and 80%, respectively), compared with women with BV where only 26.5% of isolates produced hydrogen peroxide (p=0.01). Quantitative analysis showed that in an overwhelming majority of women colonized with lactobacilli, their count was >10(7) CFU/ml. Upon evaluation of behavioural and demographic characteristics, we found that smokers had a lower incidence of isolation of hydrogen peroxide producing lactobacilli (p=0.018). Our results showed that women with BV lack lactobacilli, especially hydrogen peroxide producing ones. Women with TV had a lower rate of lactobacilli. In women with VVC, there was neither significant difference in the isolation of lactobacilli, nor in their ability to produce hydrogen peroxide, compared to women with NF.



Our results point out that hydrogen peroxide producing lactobacilli could protect against the development of BV, but not against VVC and TV.

title: Adherence of clinically isolated lactobacilli to human cervical cells in competition with Neisseria gonorrhoeae.
abstract: Lactobacilli are normal inhabitants of our microbiota and are known to protect against pathogens. Neisseria gonorrhoeae is a human specific pathogenic bacterium that colonises the urogenital tract where it causes gonorrhoea. In this study we analysed early interactions between lactobacilli and gonococci and investigated how they compete for adherence to human epithelial cervical cells. We show that lactobacilli adhere at various levels and that the number of adherent bacteria does not correlate to the level of protection against gonococcal infection. Protection against gonococcal adhesion varied between Lactobacillus species. Lactobacillus crispatus, Lactobacillus gasseri and Lactobacillus reuteri were capable of reducing gonococcal adherence while Lactobacillus rhamnosus was not. Lactobacillus strains of vaginal origin had the best capacity to remain attached to the host cell during gonococcal adherence. Further, we show that gonococci and lactobacilli interact with each other with resultant lactobacilli incorporation into the gonococcal microcolony. Hence, gonococci bind to colonised lactobacilli and this complex frequently detaches from the epithelial cell surface, resulting in reduced bacterial colonisation. Also, purified gonococcal pili are capable of removing adherent lactobacilli from the cell surface. Taken together, we reveal novel data regarding gonococcal and lactobacilli competition for adherence that will benefit future gonococcal prevention and treatments.

title: Lactobacillus species as biomarkers and agents that can promote various aspects of vaginal health
abstract: The human body is colonized by a vast number of microorganisms collectively referred to as the human microbiota. One of the main microbiota body sites is the female genital tract, commonly dominated by Lactobacillus spp., in approximately 70% of women. Each individual species can constitute approximately 99% of the ribotypes observed in any individual woman. The most frequently isolated species are Lactobacillus crispatus, Lactobacillus gasseri, Lactobacillus jensenii and Lactobacillus iners. Residing at the port of entry of bacterial and viral pathogens, the vaginal Lactobacillus species can create a barrier against pathogen invasion since mainly products of their metabolism secreted in the cervicovaginal fluid can play an important role in the inhibition of bacterial and viral infections. Therefore, a Lactobacillus-dominated microbiota appears to be a good biomarker for a healthy vaginal ecosystem. This balance can be rapidly altered during processes such as menstruation, sexual activity, pregnancy and various infections. An abnormal vaginal microbiota is characterized by an increased diversity of microbial species, leading to a condition known as bacterial vaginosis. Information on the vaginal microbiota can be gathered from the analysis of cervicovaginal fluid, by using the Nugent scoring or the Amsel's criteria, or at the molecular level by investigating the number and type of Lactobacillus species. However, when translating this to the clinical setting, it should be noted that the absence of a Lactobacillus-dominated microbiota does not appear to directly imply a diseased condition or dysbiosis. Nevertheless, the widely documented beneficial role of vaginal Lactobacillus species demonstrates the potential of data on the composition and activity of lactobacilli as biomarkers for vaginal health. The substantiation and further validation of such biomarkers will allow the design of better targeted probiotic strategies.

title: Effects of vaginal lactobacilli in Chlamydia trachomatis infection.
abstract: Increasing evidence indicates that abnormal vaginal flora lacking lactobacilli facilitates the acquisition of several sexually transmitted diseases including Chlamydia trachomatis. C. trachomatis, the most common bacterial agent of genital infections worldwide, can progress from the lower to upper reproductive tract and induce severe sequelae. The ability of C. trachomatis to develop into a persistent form has been suggested as key pathogenetic mechanism underlying chronic infections and sequelae. The aim of our study was to investigate the C. trachomatis interaction with vaginal microbiota analyzing the effects of Lactobacillus strains (L. brevis and L. salivarius) on the different phases of C. trachomatis developmental cycle. In addition, the effect of lactobacilli on persistent chlamydial forms induced by HSV-2 coinfection has also been evaluated. Our results demonstrated significant inhibition of C. trachomatis multiplication by vaginal lactobacilli. L. brevis was significantly more effective than L. salivarius (p<0.05) on all the steps of chlamydial infection cycle suggesting that the ability of lactobacilli to protect from infection is strain-dependent. Lactobacilli had an adverse effect on elementary chlamydial bodies (p<0.05), on chlamydial adsorption to epithelial cells (p<0.001) and on intracellular phases of chlamydial replication (p<0.0001). Our study also demonstrated a protective effect of lactobacilli toward persistent C. trachomatis forms induced by HSV-2 coinfection. A significant increase in the production of C. trachomatis infectious progeny was observed in C. trachomatis/HSV-2 coinfection in the presence of L. brevis (p=0.01) despite a significant inhibition of C. trachomatis multiplication (p=0.028). Our data suggest that a healthy vaginal microbiota can reduce the risk of acquiring C. trachomatis infection and counteract the development of persistent chlamydial forms.

title: Lactobacillus crispatus inhibits the infectivity of Chlamydia trachomatis elementary bodies, in vitro study
abstract: Lactobacillus species dominate the vaginal microbiota of healthy reproductive-age women and protect the genitourinary tract from the attack of several infectious agents. Chlamydia trachomatis, a leading cause of sexually transmitted disease worldwide, can induce severe sequelae, i.e. pelvic inflammatory disease, infertility and ectopic pregnancy. In the present study we investigated the interference of Lactobacillus crispatus, L. gasseri and L. vaginalis, known to be dominant species in the vaginal microbiome, with the infection process of C. trachomatis. Lactobacilli exerted a strong inhibitory effect on Chlamydia infectivity mainly through the action of secreted metabolites in a concentration/pH dependent mode. Short contact times were the most effective in the inhibition, suggesting a protective role of lactobacilli in the early steps of Chlamydia infection. The best anti-Chlamydia profile was shown by L. crispatus species. In order to delineate metabolic profiles related to anti-Chlamydia activity, Lactobacillus supernatants were analysed by 1H-NMR. Production of lactate and acidification of the vaginal environment seemed to be crucial for the activity, in addition to the consumption of the carbonate source represented by glucose. The main conclusion of this study is that high concentrations of L. crispatus inhibit infectivity of C. trachomatis in vitro.

title: Lactobacillus crispatus BC5 Interferes With Chlamydia trachomatis Infectivity Through Integrin Modulation in Cervical Cells
abstract: Lactobacilli play a crucial role in maintaining the ecological equilibrium of the vaginal niche, preventing the colonization of exogenous microorganisms. Although many studies have discussed the mechanisms displayed by lactobacilli in counteracting several urogenital pathogens, a few data are available on the interaction between lactobacilli and Chlamydia trachomatis. This study aimed to elucidate the molecular bases of the interaction among vaginal lactobacilli, the sexually transmitted pathogen C. trachomatis and the epithelial cervical cells. We evaluated the in vitro activity of 15 Lactobacillus strains, belonging to different species (i.e., L. crispatus, L. gasseri, L. vaginalis), against C. trachomatis. In particular, we evaluated the capability of lactobacilli cells to interfere with C. trachomatis infection in HeLa cells, by exclusion assays. Lactobacilli significantly reduced C. trachomatis infectivity, being L. crispatus the most active species. Although a dose-dependent effect was noticed, a significant antagonistic activity was maintained even at lower doses. As other Gram-positive bacteria (i.e., Streptococcus agalactiae, Enterococcus faecalis, and Bacillus subtilis) failed to interfere with C. trachomatis infectivity, Lactobacillus activity proved to be specific. The potential mechanism of protection was investigated in Lactobacillus crispatus BC5, chosen as the model strain. The incubation of HeLa cell line with BC5 cells induced important modifications in the epithelial plasma membrane, by altering lipid composition and α5 integrin subunit exposure. When α5 integrin subunits were masked by a specific blocking antibody or ITGA5 gene expression was silenced, Chlamydia infection was significantly reduced. It follows that α5 integrin subunit is crucial for the pathogen infection process, and the anti-Chlamydia activity can be directly linked to membrane properties modifications in cervical cells. The three Gram-positive bacteria used as controls failed to modify the expression of α5β1 integrin. In conclusion, we identified a potential molecular mechanism at the basis of the protection exerted by L. crispatus BC5 against C. trachomatis, getting insights into the role of the cervico-vaginal microbiota for the woman’s health.

title: Lactobacillus crispatus mediates anti-inflammatory cytokine interleukin-10 induction in response to Chlamydia trachomatis infection in vitro.
abstract: Chlamydia trachomatis, a human pathogen, is a Gram-negative bacillus and a compulsory intracellular parasite. It is the most common cause of bacterial sexually transmitted infections in both industrialized and developing countries. In women, untreated genital infections can result in devastating consequences such as pelvic inflammatory disease, ectopic pregnancy, and even infertility. Lactobacillus crispatus is an important urogenital species that is routinely found in the vagina of healthy women. Lactobacilli are involved in the maintenance of the normal vaginal microbiota and their dominance in the vagina suggests that they play a crucial role in protecting the genitourinary tract against pathological conditions. Lactobacilli can act through the activation of the immune system, but C. trachomatis is able to effectively evade immune surveillance in some individuals. The aim of our study was to investigate the immunomodulatory efficacy of the potential probiotic strain L. crispatus in HeLa and J774 cells subjected to C. trachomatis infection by studying the expression of the inflammatory cytokines IL-6, IL-8, TNF-α and IL-10. Our results demonstrated, firstly, the lack of any cytotoxic effect on the epithelial cells and macrophages when treated with L. crispatus and its supernatant; in addition, L. crispatus and its supernatant inhibited C. trachomatis adhesion and infectivity in human epithelial cells and macrophages. Our study then showed that L. crispatus and its supernatant reduced IL-6, IL-8 and TNF-α production in C. trachomatis-infected HeLa and J774 cells. In contrast, a significant upregulation of the IL-10 expression in HeLa and J774 cells by L. crispatus and supernatant was also demonstrated. Our data indicate that L. crispatus specifically enhances the production of the IL-10 anti-inflammatory cytokine in contrast to the inhibitory effect of L. crispatus on the pro-inflammatory cytokines.

title: Lactoferrin and lactoferricin inhibit Herpes simplex 1 and 2 infection and exhibit synergy when combined with acyclovir.
abstract: Lactoferrin (LF) is a multifunctional glycoprotein, which plays an important role in immune regulation and defense mechanisms against bacteria, fungi, and viruses. Upon peptic digestion of LF, a peptide called lactoferricin (Lfcin) is generated. Lfcin corresponds to the N-terminal part of the protein. In this study we investigated the antiviral activity of bovine and human Lfcin against Herpes simplex virus (HSV)-1 and HSV-2. The 50% effective concentrations (EC(50)) for LF and Lfcin against several clinical isolates of HSV-1 and HSV-2, including acyclovir (ACV)-resistant strains, were determined. We further evaluated the effect of the combination of either LF or Lfcin with ACV against HSV-1 and HSV-2. Synergy was observed between both LF or Lfcin in combination with ACV against the HSV laboratory strains. The 50% effective concentration (EC(50)) for ACV and LF or Lfcin, when combined with ACV, could be reduced by two- to sevenfold compared to the EC(50) when the drugs were used alone.

title: Activated lactoferrin's ability to inhibit Candida growth and block yeast adhesion to the vaginal epithelial monolayer.
abstract: To study in vitro growth-inhibitory effects of activated lactoferrin (ALF) against vaginal isolates of Candida species and to measure the ability of ALF to block interactions of Candida albicans and Candida glabrata to the vaginal epithelial (VE) monolayer.



In vitro effects of ALF on growth of C albicans and C glabrata in Sabouraud dextrose (SD) broth were measured as change in broth turbidity by microscale optical density assay. ALF was tested at 5 and 2.5 mg/mL concentrations against 105 yeast cell inoculum at 370 degrees C for 96 hours and compared with native lactoferrin and control (growth in broth without ALF). VE cells were isolated from human vaginal tissue biopsies to establish a functional monolayer for yeast interaction studies. ALF effects on Candida interactions with the VE monolayer were tested using 3H-thymidine-labeled yeast. Prophylactic (treatment prior to yeast inoculation onto VE) and therapeutic (treatment to detach VE-adherent yeast) potential of ALF (5 mg/mL) was evaluated against vaginal isolates of C albicans strain NTRL809A and C glabrata strain NTRL131G.



Growth of Candida species indicated that a 105 yeast inoculum in SD broth proliferated to a stationary growth equilibrium (approximately 10(9) yeast cell density) in 18 hours (approximately 2 hours of generation time). ALF (5 mg/mL) elicited >96 hours of total stasis (100% growth inhibition) and was significantly effective against both Candida species (p < 0.0001). At 2.5 mg/mL dilution, ALF sustained total stasis activity to an average of 18 hours and 24 hours for C albicans (n = 5) and C glabrata (n = 5), respectively. Interaction studies indicated avid binding of C albicans (70 - 140 x 10(3) yeast) and C glabrata (50 - 75 x 10(3) yeast) per square centimeter of VE monolayer. ALF-treated VE showed significant blockade (p < 0.05) of yeast adhesion by 33% and 58% with C albicans and C glabrata, respectively. ALF treatment of yeast-VE complexes resulted in significant detachment (p < 0.05) of C albicans and C glabrata, by 58% and 51%, respectively.



ALF is a natural fungistatic agent with potent yeast adhesion-blocking and detachment properties and is effective against the vaginal pathogens C albicans and C glabrata.

title: Potential lactoferrin activity against pathogenic viruses.
abstract: Lactoferrin (LF) is an 80-kDa globular glycoprotein with high affinity for metal ions, particularly for iron. This protein possesses many biological functions, including the binding and release of iron and serves as one of the important components of the innate immune system, where it acts as a potent inhibitor of several pathogens. LF has efficacious antibacterial and antiviral activities against a wide range of Gram-positive and Gram-negative bacteria and against both naked and enveloped DNA and RNA viruses. In its antiviral pursuit, LF acts predominantly at the acute phase of the viral infection or even at the intracellular stage, as in hepatitis C virus infection. LF inhibits the entry of viral particles into host cells, either by direct attachment to the viral particles or by blocking their cellular receptors. This wide range of activities may be attributed to the capacity of LF to bind iron and its ability to interfere with the cellular receptors of both hosts and pathogenic microbes.

title: Lactobacilli‐lactoferrin interplay in Chlamydia trachomatis infection
abstract: &NA; In the cervicovaginal microenvironment, lactobacilli are known to protect against genital infections and, amongst the host defence compounds, lactoferrin has recently acquired importance for its anti‐microbial and anti‐inflammatory properties. An abnormal genital microenvironment facilitates the acquisition of pathogens like Chlamydia trachomatis, the leading cause of bacterial sexually transmitted infections worldwide. The aim of our study is to investigate the effects of Lactobacillus crispatus, Lactobacillus brevis and bovine lactoferrin on chlamydial infection, in order to shed light on the complex interplay between host defence mechanisms and C. trachomatis. We have also evaluated the effect of these defence factors to modulate the chlamydia‐mediated inflammatory state. To this purpose, we have determined the infectivity and progeny production of C. trachomatis as well as interleukin‐8 and interleukin‐6 synthesis. The main result of our study is that the combination of L. brevis and bovine lactoferrin is the most effective in inhibiting the early phases (adhesion and invasion) of C. trachomatis infection of cervical epithelial cells and in decreasing the levels of both cytokines. In conclusion, the interaction between L. brevis and lactoferrin seems to play a role in the protection against C. trachomatis, reducing the infection and regulating the immunomodulatory activity, thus decreasing the risk of severe complications. &NA;   The interaction between Lactobacillus brevis and lactoferrin seems to play a role in the protection against Chlamydia trachomatis genital infection.

title: Multiplex Immunoassay of Lower Genital Tract Mucosal Fluid from Women Attending an Urban STD Clinic Shows Broadly Increased IL1ß and Lactoferrin
abstract: More than one million new cases of sexually transmitted diseases (STDs) occur each day. The immune responses and inflammation induced by STDs and other frequent non-STD microbial colonizations (i.e. Candida and bacterial vaginosis) can have serious pathologic consequences in women including adverse pregnancy outcomes, infertility and increased susceptibility to infection by other pathogens. Understanding the types of immune mediators that are elicited in the lower genital tract by these infections/colonizations can give important insights into the innate and adaptive immune pathways that are activated and lead to strategies for preventing pathologic effects.  immune mediators were measured by multiplexed immunoassays to assess the immune environment of the lower genital tract mucosa in 84 women attending an urban STD clinic. IL-3, IL-1ß, VEGF, angiogenin, IL-8, ß2Defensin and ß3Defensin were detected in all subjects, Interferon-α was detected in none, while the remaining mediators were detected in 40% to 93% of subjects. Angiogenin, VEGF, FGF, IL-9, IL-7, lymphotoxin-α and IL-3 had not been previously reported in genital mucosal fluid from women. Strong correlations were observed between levels of TNF-α, IL-1ß and IL-6, between chemokines IP-10 and MIG and between myeloperoxidase, IL-8 and G-CSF. Samples from women with any STD/colonization had significantly higher levels of IL-8, IL-3, IL-7, IL-1ß, lactoferrin and myeloperoxidase. IL-1ß and lactoferrin were significantly increased in gonorrhea, Chlamydia, cervicitis, bacterial vaginosis and trichomoniasis.  These studies show that mucosal fluid in general appears to be an environment that is rich in immune mediators. Importantly, IL-1ß and lactoferrin are biomarkers for STDs/colonizations providing insights into immune responses and pathogenesis at this mucosal site.

title: Activity of Novispirin G-10, a novel antimicrobial peptide against Chlamydia trachomatis and vaginosis-associated bacteria.
abstract: We tested the activity of Novispirin G-10, a novel antimicrobial alpha-helical octadecapeptide structurally related to cathelicidins and other innate immunity peptides, against Chlamydia trachomatis serovars L2, D, and E and three organisms associated with bacterial vaginosis (BV). The peptide's activity against C. trachomatis was measured in 48-h shell vial assays with McCoy cell targets. Exposure to 100 micro g/ml of Novispirin G-10 reduced the infectivity of serovars D and E by 99.4-100% and serovar L2 by 91.7-99.1%. At the same concentration of 100 micro g/ml, Novispirin G-10 rapidly killed >99% of Mobiluncus curtisii, Gardnerella vaginalis, and Prevotella bivia, in standard colony-forming unit (CFU) assays. Given its simple structure and relative lack of cytotoxic and hemolytic activity, Novispirin G-10 may be a useful component of microbicide preparations designed to prevent chlamydial infection and/or remediate the abnormal vaginal flora associated with BV.

title: Activity of Cathelicidin Peptides against Chlamydia spp
abstract: The in vitro activity of six cathelicidin peptides against 25 strains of Chlamydia was investigated. SMAP-29 proved to be the most active peptide, reducing the inclusion numbers of all 10 strains of Chlamydia trachomatis tested by ≥50% at 10 μg/ml. This peptide was also active against C. pneumoniae and C. felis.

title: Host defense peptides: general overview and an update on their activity against Chlamydia spp.
abstract: Chlamydiae are obligate intracellular bacteria that cause serious diseases in a wide range of hosts. Chlamydia trachomatis is one of the leading sexually transmitted pathogens in the world. Because vaccines are not currently available, effective drugs are essential. In both animals and humans, chlamydial infections are often treated with tetracycline or its derivatives. A stable tetracycline-resistant phenotype was described in Chlamydia suis strains from pigs in the USA and in Europe. In humans, there are reports of tetracycline treatment failure and the in vitro adaptability of C. trachomatis to evolve to antibiotic resistance has been described, suggesting the pressing need to search for alternative and effective classes of antimicrobial drugs. Host defense peptides (HDPs) are known as direct antimicrobial agents as well as innate immune modulators. Being active against multidrug-resistant bacteria, HDPs are attractive candidates as templates for new drugs. A number of studies evaluated the activity of natural and synthetic HDPs against Chlamydia spp., showing C. trachomatis to be the most sensitive among chlamydia species tested. Protegrins and α-helical peptides were the most active among the HDPs assessed.

title: Cervicovaginal Levels of Human &bgr;-Defensin 1, 2, 3, and 4 of Reproductive-Aged Women With Chlamydia trachomatis Infection
abstract: This study included women attending primary health care units in Botucatu, São Paulo, Brazil, to assess the cervicovaginal levels of human &bgr;-defensin (hBD) 1, 2, 3, and 4 during Chlamydia trachomatis infection.  Cervicovaginal samples were collected for Pap testing and assessing the presence of infection by C. trachomatis, human papillomavirus, Neisseria gonorrhoeae, and Trichomonas vaginalis. Vaginal smears were taken to evaluate local microbiota. Human &bgr;-defensin levels were determined using enzyme-linked immunosorbent assay in cervicovaginal fluid samples. Seventy-four women with normal vaginal microbiota and no evidence of infection were included in hBD quantification assays; 37 tested positive for C. trachomatis and 37 were negative. Statistical analysis was performed using Mann-Whitney U test.  Women positive for C. trachomatis had significantly lower cervicovaginal hBD-1, hBD-2, and hBD-3 compared with those who tested negative (hBD-1: 0 pg/mL [0–2.1] vs 1.6 pg/mL [0–2.4], p < .0001; hBD-2: 0 pg/mL [0–3.9] vs 0.61 pg/mL [0–8.9], p = .0097; and hBD-3: 0 pg/mL [0–4.3] vs 0.28 pg/mL [0–8.4], p = .0076). Human &bgr;-defensin 4 was not detected.  Lower levels of hBD-1, hBD-2, and hBD-3 in cervicovaginal fluid were detected in the presence of C. trachomatis infection.

title: The vaginal microbiome: new information about genital tract flora using molecular based techniques
abstract: Please cite this paper as: Lamont R, Sobel J, Akins R, Hassan S, Chaiworapongsa T, Kusanovic J, Romero R. The vaginal microbiome: new information about genital tract flora using molecular based techniques. BJOG 2011;118:533–549.

title: Temporal Dynamics of the Human Vaginal Microbiota
abstract: The vaginal microbiome is dynamic, varying over time in composition and function with implications for women’s health. What’s Up with Vaginal Microbes? The ability to properly identify women at risk of acquiring sexually transmitted infectious diseases or who might suffer from adverse obstetric sequelae is a critical first step in reducing their incidence and the unnecessary use of antibiotics. Currently, patients undergo a clinical examination of the vagina that includes measuring the pH and evaluating the amount and type of discharge and the presence of odor. These criteria are thought to be surrogates for the presence of an “abnormal” vaginal microbiota. Although these kinds of tests, done only once, could be used to diagnose conditions such as bacterial vaginosis, it is debatable whether they are accurate predictors of risk because little is known about how the composition and function of the vaginal microbiome changes over time. Previous studies have established that in healthy asymptomatic women, five types of vaginal microbiota exist that differ in the kinds of microbes they contain. It was thought that each type carries its own risks and particular response to environmental disturbances, such as sexual activity or hygiene practices. In an exciting new study, Gajer and colleagues now describe changes in the identity and abundance of bacteria in the vaginal communities of 32 women by analyzing vaginal samples obtained twice weekly over a 16-week period. The kinds of bacteria present in the samples were identified by classifying thousands of 16S rRNA gene sequences in each sample using high-throughput next-generation sequencing. The authors further characterized vaginal community function by determining the metabolites produced throughout the 16-week period. Gajer and colleagues found that there were five longitudinal patterns of change in vaginal microbial community composition. Moreover, in some women, the vaginal microbial community composition changed markedly and rapidly over time, whereas in others it was relatively stable. Using statistical modeling, the authors showed that the menstrual cycle influenced the stability of the vaginal communities. In many cases, the metabolite profiles indicated that vaginal community function was maintained despite changes in bacterial composition. Intervals of increased susceptibility to disease may occur because the vaginal microbiota varies over time. The authors envision that better knowledge of the causes and consequences of these changes to the host will lead to the development of new strategies to manage vaginal microbiomes in ways that promote health and minimize the use of antibiotics. Elucidating the factors that impinge on the stability of bacterial communities in the vagina may help in predicting the risk of diseases that affect women’s health. Here, we describe the temporal dynamics of the composition of vaginal bacterial communities in 32 reproductive-age women over a 16-week period. The analysis revealed the dynamics of five major classes of bacterial communities and showed that some communities change markedly over short time periods, whereas others are relatively stable. Modeling community stability using new quantitative measures indicates that deviation from stability correlates with time in the menstrual cycle, bacterial community composition, and sexual activity. The women studied are healthy; thus, it appears that neither variation in community composition per se nor higher levels of observed diversity (co-dominance) are necessarily indicative of dysbiosis.

title: Vaginal microbiome: rethinking health and disease.
abstract: Vaginal microbiota form a mutually beneficial relationship with their host and have a major impact on health and disease. In recent years our understanding of vaginal bacterial community composition and structure has significantly broadened as a result of investigators using cultivation-independent methods based on the analysis of 16S ribosomal RNA (rRNA) gene sequences. In asymptomatic, otherwise healthy women, several kinds of vaginal microbiota exist, the majority often dominated by species of Lactobacillus, while others are composed of a diverse array of anaerobic microorganisms. Bacterial vaginosis is the most common vaginal condition and is vaguely characterized as the disruption of the equilibrium of the normal vaginal microbiota. A better understanding of normal and healthy vaginal ecosystems that is based on their true function and not simply on their composition would help better define health and further improve disease diagnostics as well as the development of more personalized regimens to promote health and treat diseases.

title: Lactobacillus iners: Friend or Foe?
abstract: The vaginal microbial community is typically characterized by abundant lactobacilli. Lactobacillus iners, a fairly recently detected species, is frequently present in the vaginal niche. However, the role of this species in vaginal health is unclear, since it can be detected in normal conditions as well as during vaginal dysbiosis, such as bacterial vaginosis, a condition characterized by an abnormal increase in bacterial diversity and lack of typical lactobacilli. Compared to other Lactobacillus species, L. iners has more complex nutritional requirements and a Gram-variable morphology. L. iners has an unusually small genome (ca. 1 Mbp), indicative of a symbiotic or parasitic lifestyle, in contrast to other lactobacilli that show niche flexibility and genomes of up to 3-4 Mbp. The presence of specific L. iners genes, such as those encoding iron-sulfur proteins and unique σ-factors, reflects a high degree of niche specification. The genome of L. iners strains also encodes inerolysin, a pore-forming toxin related to vaginolysin of Gardnerella vaginalis. Possibly, this organism may have clonal variants that in some cases promote a healthy vagina, and in other cases are associated with dysbiosis and disease. Future research should examine this friend or foe relationship with the host.

title: O05.4 Association Between Chlamydia Trachomatis Genital Infection and the Vaginal Microbiome
abstract: Chlamydia trachomatis (CT) genital infection is one of the most widespread sexually transmitted infections (STIs). It is thought that certain types of vaginal microbiota are better able to prevent STIs, however, very little is known about the relationships between species and genomic composition of the vaginal microbiome and risk of infection. Information about these can be used to advance prevention strategies for STIs. We sought to characterise the vaginal microbiome at the time of diagnosis and after treatment of CT infection.  101 women with CT genital infection were recruited to a longitudinal study in Baltimore, MD. Participants were treated at diagnosis and returned for clinical visits every 3 months for 9 months, at which times the vaginal microbiota was determined using 16S rRNA analysis. We further applied high-throughput metagenomics to characterise the genomic makeup of the vaginal microbiome.  The average age of participants was 19.3 (range 14–28) and 92% were African-American. During CT infection, comprehensive surveys of the vaginal microbiota demonstrated two distinct community state types characterised by: (1) a complex assemblage of strict anaerobes with low proportions of Lactobacillus spp. (60% of samples) or (2) a high relative abundance of Lactobacillus iners-dominated communities (37% of samples) . Metagenomic evaluation suggested unique characteristics of the genomes of the dominant species in these communities (i.e., L. iners, Gardnerella vaginalis). L. iners appeared more genetically diverse than other Lactobacillus species.  Complex communities of strict anaerobes with low proportions of Lactobacillus or specific L. iners genome types represented a hallmark of the chlamydia -infected state in this population. Some L. iners may be better suited to adapt to diverse environments while others may be contributing factors to an at-risk microbiome. In the era of personalised medicine, future work will enhance our ability to intervene and establish a protective vaginal microbiome.

title: The Cervicovaginal Microbiota in Women Notified for Chlamydia trachomatis Infection: A Case-Control Study at the Sexually Transmitted Infection Outpatient Clinic in Amsterdam, The Netherlands
abstract: Increasing evidence suggests that the cervicovaginal microbiota (CVM) plays an important role in acquiring sexually transmitted infections (STIs). Here we study the CVM in a population of women notified by a sex partner for Chlamydia trachomatis infection. We included 98 women who were contact-traced by C. trachomatis–positive sex partners at the STI outpatient clinic in Amsterdam, the Netherlands, and analyzed their cervicovaginal samples and clinical data. CVMs were characterized by sequencing the V3/V4 region of the 16S ribosomal RNA gene and by hierarchical clustering. Characteristics associating with C. trachomatis infection were examined using bivariable and multivariable logistic regression analysis. The CVM was characterized for 93 women, of whom 52 tested C. trachomatis positive and 41 C. trachomatis negative. We identified 3 major CVM clusters. Clustered CVM predominantly comprised either diverse anaerobic bacteria (n = 39 [42%]), Lactobacillus iners (n = 32 [34%]), or Lactobacillus crispatus (n = 22 [24%]). In multivariable analysis, we found that CVM was significantly associated with C. trachomatis infection (odds ratio [OR], 4.2 [95% confidence interval {CI}, 1.2–15.4] for women with diverse anaerobic CVM and OR, 4.4 [95% CI, 1.3–15.6], for women with L. iners–dominated CVM, compared with women with L. crispatus–dominated CVM), as was younger age (OR, 3.1 [95% CI, 1.1–8.7] for those ⩽21 years old) and reporting a steady sex partner (OR, 3.6 [95% CI, 1.4–9.4]).  Women who tested positive for Chlamydia trachomatis infection after having been contact-traced by a chlamydia-positive partner were more likely to have CVM dominated by L. iners or by diverse anaerobic bacteria, than by L. crispatus.

title: Endocervical and vaginal microbiota in South African adolescents with asymptomatic Chlamydia trachomatis infection
abstract: Adolescent girls and young women represent a key risk group for sexually transmitted infections (STIs). The vaginal microbiota is thought to play an important role in susceptibility to STIs such as Chlamydia trachomatis. We compared the microbiota of the lateral vaginal wall and endocervix, and assessed associations with C. trachomatis infection in South African adolescents. The endocervical and vaginal lateral wall microbiota were characterized by amplifying and sequencing the V4 region of the 16S rRNA gene and C. trachomatis diagnosed using molecular methods. Of the 72 girls included, 30 had asymptomatic C. trachomatis infections. Three major vaginal community types were identified; one Lactobacillus crispatus, one L. iners and one diverse, Gardnerella vaginalis dominant. The microbiota of the endocervix was significantly different from that of the lateral wall in terms of diversity. There were many differentially abundant taxa between the endocervix and lateral vaginal wall, including Achromobacter spanius and Enterococcus faecium. Women with C. trachomatis had higher relative abundance of G. vaginalis and other anaerobes. In this African adolescent cohort, significant differences between the lateral vaginal wall and endocervical microbiota diversity and composition were evident, although neither were strongly associated with C. trachomatis infection.

title: HPV/Chlamydia trachomatis co-infection: metagenomic analysis of cervical microbiota in asymptomatic women.
abstract: HPV and Chlamydia trachomatis are the most common causes of sexually transmitted diseases worldwide. Most infections are asymptomatic and left untreated lead to severe reproductive tract sequelae such as cervical cancer and infertility. Interestingly, C. trachomatis may also increase the susceptibility to HPV infection as well as contribute to viral persistence. Recently, a growing body of evidence has suggested that the composition of the cervico-vaginal microbiota plays a key role in the susceptibility and outcome of genital infections caused by several pathogens, including HPV and C. trachomatis. The aim of our study was to undertake a metagenomic analysis of sequenced 16s rRNA gene amplicons to characterize the cervical microbiota from asymptomatic women with HPV/C. trachomatis co-infection. The composition of the cervical microbiota from HPV-positive or C. trachomatis-positive women was also analysed. The main finding of our study showed that the cervical microbiota in HPV/C. trachomatis co-infected women had a higher microbial diversity than the cervical microbiota in healthy controls (p<0.05). In addition, Aerococcus christensenii was associated with C. trachomatis infection. In conclusion, the increased cervical microbial diversity observed in HPV/C. trachomatis co-infected women and the detection of potential microbiological biomarkers of C. trachomatis infection will open the way to innovative approaches that may be helpful to identify women at risk of co-infection.

title: Insights Into Vaginal Bacterial Communities and Metabolic Profiles of Chlamydia trachomatis Infection: Positioning Between Eubiosis and Dysbiosis
abstract: The vaginal microbiota plays a crucial role in maintaining the health and functioning of the female genital tract, preventing the colonization of urogenital pathogens and sexually transmitted infections. In this study, we characterized the vaginal bacterial communities and the metabolome associated to Chlamydia trachomatis infection (CT: 20 women), compared to healthy condition (H: 22 women) and bacterial vaginosis (BV: 19 women). A microarray-based tool (VaginArray), implemented with a real-time PCR for Gardnerella vaginalis, was used to determine the vaginal bacterial composition, whereas the metabolic profiles were assessed by a proton-based nuclear magnetic resonance (1H-NMR) spectroscopy. CT infection was characterized by bacterial and metabolic signatures similar to healthy condition, even though higher amounts of Lactobacillus iners, as well as depletion of some amino acids, biogenic amines, and succinate marked CT infection. Moreover, the frequency of Lactobacillus crispatus was higher in asymptomatic CT-positive patients than in women with CT-correlated symptoms. We also confirmed the marked differences in the microbiome and metabolome between healthy and BV-affected women. In conclusion, we highlighted microbial and metabolic peculiarities of the vaginal ecosystem in the case of CT infection, even though further studies are needed to understand if the observed alterations precede the infection onset or if the pathogen itself perturbs the vaginal environment.

title: Lactobacillus iners-dominated vaginal microbiota is associated with increased susceptibility to Chlamydia trachomatis infection in Dutch women: a case–control study
abstract: This prospective study aimed to study the composition and structure of the vaginal microbiota prior to Chlamydia trachomatis infection.  A nested case–control study was performed in 122 women, half of which acquired C. trachomatis within a year after their first visit. At the first visit, the composition and structure of vaginal microbial communities were analysed using 16S rRNA sequencing in the context of the sociodemographic and sexual risk behaviour information using logistic regression.  Five vaginal community state types (CSTs) were identified. Four CSTs were dominated by Lactobacillus spp., of which L. crispatus (37%) and L. iners (33%) were the most common. One CST was characterised by the absence of Lactobacillus spp. (25%) and the presence of an array of strict and facultative anaerobes. Multivariate logistic regression analysis revealed that women with a L. iners-dominated CST had an increased risk of C. trachomatis infection (p=0.04; OR: 2.6, 95% CI 1.0 to 6.6).  The distribution of CSTs dominated by Lactobacillus spp. agreed with previous studies. However, the frequency of dysbiosis among Caucasian women was relatively high (24%). Having vaginal microbiota dominated by L. iners was associated with an increased risk for C. trachomatis infection. Therefore, we hypothesise that specific signatures of vaginal microbiota are indicative of increased host predisposition to acquiring STIs.

title: Dysbiosis of the Vaginal Microbiota and Higher Vaginal Kynurenine/Tryptophan Ratio Reveals an Association with Chlamydia trachomatis Genital Infections
abstract: The natural course of Chlamydia trachomatis urogenital tract infections varies between individuals. While protective immunity can occur, some women can become reinfected, contributing to the development of severe pathology. While the reasons for these differences are unknown, an individual's response to induced interferon-γ (IFN-γ) is suggested to be critical. IFN-γ induction of the enzyme indoleamine 2,3-dioxygenase, which depletes tryptophan, may be the key. One hypothesis suggests that indole-producing bacteria in the vaginal microbiota can provide a substrate for the Chlamydia to synthesize tryptophan, rescuing the Chlamydia from host IFN-γ attack. We studied a cohort of 25 women who were either, Chlamydia negative, Chlamydia positive with a single infection, or Chlamydia positive with repeated infection, to test our hypothesis. We characterized their vaginal microbiota, cytokine response, as well as their tryptophan, kynurenine and indole concentrations directly in vaginal secretions. We found that C. trachomatis urogenital tract infections either initial or repeat infections, were associated with elevated vaginal kynurenine/tryptophan ratios, primarily as a result of elevated kynurenine levels. In addition, vaginal microbiota of community state type (CST) IV showed significantly lower vaginal tryptophan levels compared to CST I and III, which might be related to a higher abundance of indole producers found within this group. Furthermore, we found a higher abundance of indole producers in women who cleared their Chlamydia infection post antibiotic treatment. This study demonstrates for the first time in vivo, the association between high vaginal kynurenine/tryptophan ratios and C. trachomatis infections. In addition, tryptophan depletion was associated with vaginal microbiota of CST IV.

title: The vaginal microbiota and its association with human papillomavirus, Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium infections: a systematic review and meta-analysis.
abstract: The vaginal microbiota may modulate susceptibility to human papillomavirus (HPV), Chlamydia trachomatis, Neisseria gonorrhoeae and Mycoplasma genitalium infections. Persistent infection with a carcinogenic HPV is a prerequisite for cervical cancer, and C. trachomatis, N. gonorrheae and M. genitalium genital infections are all associated with pelvic inflammatory disease and subsequent infertility issues.



To evaluate the association between these infections and the vaginal microbiota.



The search was conducted on Medline and the Web of Science for articles published between 2000 and 2016.



Inclusion criteria included a measure of association for vaginal microbiota and one of the considered STIs, female population, cohort, cross-sectional and interventional designs, and the use of PCR methods for pathogen detection.



The vaginal microbiota was dichotomized into high-Lactobacillus vaginal microbiota (HL-VMB) and low-Lactobacillus vaginal microbiota (LL-VMB), using either Nugent score, Amsel's criteria, presence of clue cells or gene sequencing. A random effects model assuming heterogeneity among the studies was used for each STI considered.



The search yielded 1054 articles, of which 39 met the inclusion criteria. Measures of association with LL-VMB ranged from 0.6 (95% CI 0.3-1.2) to 2.8 (95% CI 0.3-28.0), 0.7 (95% CI 0.4-1.2) to 5.2 (95% CI 1.9-14.8), 0.8 (95% CI 0.5-1.4) to 3.8 (95% CI 0.4-36.2) and 0.4 (95% CI 0.1-1.5) to 6.1 (95% CI 2.0-18.5) for HPV, C. trachomatis, N. gonorrhoeae and M. genitalium infections, respectively.



Although no clear trend for N. gonorrhoeae and M. genitalium infections could be detected, our results support a protective role of HL-VMB for HPV and C. trachomatis. Overall, these findings advocate for the use of high-resolution characterization methods for the vaginal microbiota and the need for longitudinal studies to lay the foundation for its integration in prevention and treatment strategies.

title: Influence of the tryptophan-indole-IFNγ axis on human genital Chlamydia trachomatis infection: role of vaginal co-infections
abstract: The natural history of genital Chlamydia trachomatis infections can vary widely; infections can spontaneously resolve but can also last from months to years, potentially progressing to cause significant pathology. The host and bacterial factors underlying this wide variation are not completely understood, but emphasize the bacterium's capacity to evade/adapt to the genital immune response, and/or exploit local environmental conditions to survive this immune response. IFNγ is considered to be a primary host protective cytokine against endocervical C. trachomatis infections. IFNγ acts by inducing the host enzyme indoleamine 2,3-dioxgenase, which catabolizes tryptophan, thereby depriving the bacterium of this essential amino acid. In vitro studies have revealed that tryptophan deprivation causes Chlamydia to enter a viable but non-infectious growth pattern that is termed a persistent growth form, characterized by a unique morphology and gene expression pattern. Provision of tryptophan can reactivate the bacterium to the normal developmental cycle. There is a significant difference in the capacity of ocular and genital C. trachomatis serovars to counter tryptophan deprivation. The latter uniquely encode a functional tryptophan synthase to synthesize tryptophan via indole salvage, should indole be available in the infection microenvironment. In vitro studies have confirmed the capacity of indole to mitigate the effects of IFNγ; it has been suggested that a perturbed vaginal microbiome may provide a source of indole in vivo. Consistent with this hypothesis, the microbiome associated with bacterial vaginosis includes species that encode a tryptophanase to produce indole. In this review, we discuss the natural history of genital chlamydial infections, morphological and molecular changes imposed by IFNγ on Chlamydia, and finally, the microenvironmental conditions associated with vaginal co-infections that can ameliorate the effects of IFNγ on C. trachomatis.

title: Chlamydia trachomatis Genital Tract Infections: When Host Immune Response and the Microbiome Collide.
abstract: Genital infections with Chlamydia trachomatis continue to be a major health problem worldwide. While some individuals clear their infection (presumed to be the result of an effective Th1/interferon-γ response), others develop chronic infections and some are prone to repeat infections. In females in particular, chronic asymptomatic infections are common and can lead to pelvic inflammatory disease and infertility. Recent studies suggest that the genital tract microbiota could be a significant factor and explain person-to-person variation in C. trachomatis infections. One hypothesis suggests that C. trachomatis can use its trpBA genes to rescue tryptophan from indole, which is a product of anaerobic members of the genital tract microbiota. Women with particular microbiota types, such as seen in bacterial vaginosis, have increased numbers of anaerobes, and this would enable the chlamydia in these individuals to overcome the host's interferon-γ attempts to eliminate it, resulting in more repeat and/or chronic infections.

title: Infectious burden and atherosclerosis: A clinical issue.
abstract: Atherosclerotic cardiovascular diseases, chronic inflammatory diseases of multifactorial etiology, are the leading cause of death worldwide. In the last decade, more infectious agents, labeled as "infectious burden", rather than any single pathogen, have been showed to contribute to the development of atherosclerosis through different mechanisms. Some microorganisms, such as Chlamydia pneumoniae (C. pneumoniae), human cytomegalovirus, etc. may act directly on the arterial wall contributing to endothelial dysfunction, foam cell formation, smooth muscle cell proliferation, platelet aggregation as well as cytokine, reactive oxygen specie, growth factor, and cellular adhesion molecule production. Others, such as Helicobacter pylori (H. pylori), influenza virus, etc. may induce a systemic inflammation which in turn may damage the vascular wall (e.g., by cytokines and proteases). Moreover, another indirect mechanism by which some infectious agents (such as H. pylori, C. pneumoniae, periodontal pathogens, etc.) may play a role in the pathogenesis of atherosclerosis is molecular mimicry. Given the complexity of the mechanisms by which each microorganism may contribute to atherosclerosis, defining the interplay of more infectious agents is far more difficult because the pro-atherogenic effect of each pathogen might be amplified. Clearly, continued research and a greater awareness will be helpful to improve our knowledge on the complex interaction between the infectious burden and atherosclerosis.

title: Detection of bacteria and analyses of Chlamydia trachomatis viability in patients with postvenereal reactive arthritis
abstract: Postvenereal reactive arthritis is an inflammatory form of arthritis that commonly develops after urogenital infection, predominantly in human leucocyte antigen‐B27‐positive men in the third decade of life. In our hospital, patients underwent synovectomy before a 4‐month course of antibiotics (ciprofloxacin, tetracycline and roxithromicin). The clinical remission was achieved in approximately 70% patients. At molecular level, the remission was associated with the negative polymerase chain reaction findings of bacteria.

title: A study on the association between infectious burden and Alzheimer's disease
abstract: Previous studies suggested that the overall burden of prior infections contributes to cardiovascular diseases and stroke. In the present study, the association between infectious burden (IB) and Alzheimer's disease (AD) was examined.

title: SEROLOGICAL EVIDENCE OF AN ASSOCIATION OF A NOVEL CHLAMYDIA, TWAR, WITH CHRONIC CORONARY HEART DISEASE AND ACUTE MYOCARDIAL INFARCTION
abstract: Paired sera from 40 male patients with acute myocardial infarction (AMI), 30 male patients with chronic coronary heart disease (CCHD), and 41 controls, matched for sex, age, time, and locality were investigated for antibodies to a novel type of Chlamydia sp, TWAR, and to chlamydial lipopolysaccharide (LPS) group antigen. 27 patients with AMI (68%), and 15 (50%) patients with CCHD had raised IgG (greater than or equal to 128) and/or IgA (greater than or equal to 32) titres in the microimmunofluorescence test with chlamydia TWAR. Both frequencies were significantly higher than in the controls (7, 17%). 26 (68%) of 38 patients with AMI also showed a significant seroconversion in enzyme immunoassay with LPS antigen; this response was absent in all patients with CCHD and all but 1 of the controls. Chronic chlamydial infection could be a factor in the pathogenesis of cardiovascular diseases.

title: Isolation and Continuous Growth of Chlamydia pneumoniae from Arterectomy Specimens
abstract: Chlamydia pneumoniae strains of vascular origin that could be grown continuously in vitro, a cell culture system has been established. Using different types of vascular specimens obtained from 38 patients, Chlamydia pneumoniae could be isolated in three (7.9%) cases. The strains were obtained from specimens of the carotid artery, the femoral artery and an infrarenal aneurysm of the abdominal aorta of three male atherosclerosis patients. Thus, viable Chlamydia pneumoniae strains are also present in vascular regions other than those hitherto described.

title: Chlamydia pneumoniae infection is associated with coronary artery disease but not implicated in inducing plaque instability.
abstract: Many authors have shown an association between Chlamydia pneumoniae (C. pneumoniae) infection and coronary artery disease. However, whether C. pneumoniae infection plays an important role in triggering an acute coronary event remains to be elucidated.



Sixty-four consecutive patients with unstable angina (group A), 56 consecutive patients with stable exertional angina (group B) and 74 control subjects (group C) were studied. The IgM, IgG and IgA anti-C. pneumoniae titers were assessed (microimmunofluorescence test Labsystem), values > or =1:16, > or =1:32 and > or =1:16 being respectively considered positive.



IgM antibodies were found in 10.9% of group A and 12.5% of group B patients, whereas no subject of group C showed IgM titers (A vs. B, p=ns; C vs. A and B, p<0.05). Positive IgG titers were found in 76.6%, 82% and 44.6% in groups A, B and C, respectively (A vs. B, p=ns; C vs. A and B, p<0.05). Positive IgA titers were found in 62.5%, 61% and 31.1% in groups A, B and C, respectively (A vs. B, p=ns; C vs. A and B, p<0.05). Acute infection was observed in 10.9% and 12.5% of patients in groups A and B, respectively (p=ns); reinfection in 17% and 11%; no patient of the control group had signs of acute infection or reinfection. Chronic infection was observed in 34.4% and 37.5% in group A and B, respectively (p=ns).



C. pneumoniae infection is associated with coronary artery disease, but no difference in serology is present between unstable and stable angina. Therefore, it does not seem implicated in triggering an acute coronary event.

title: Chlamydophila Pneumoniae Infection and Cardiovascular Disease
abstract: Atherosclerosis is a multifactorial vascular inflammatory process; however, the inciting cause for inflammation remains unclear. Two decades ago, Chlamydophila pneumoniae (formerly Chlamydia pneumoniae) infection was proposed as a putative etiologic agent. We performed a PubMed search using the keywords Chlamydia and atherosclerosis in a Boolean query to identify published studies on C. pneumoniae and its role in atherogenesis, and to understand research interest in this topic. We found 1,652 published articles on this topic between 1991 and 2011. We analyzed relevant published studies and found various serological, molecular, and animal modeling studies in the early period. Encouraged by positive results from these studies, more than a dozen antibiotic clinical-trials were subsequently conducted, which did not find clinical benefits of anti-Chlamydophila drug therapy. While many researchers believe that the organism is still important, negative clinical trials had a similar impact on overall research interest. With many novel mechanisms identified for atherogenesis, there is a need for newer paradigms in Chlamydophila-atherosclerosis research.

title: Acute Chlamydia pneumoniae infection causes coronary endothelial dysfunction in pigs.
abstract: Coronary endothelial dysfunction contributes to the pathogenesis of acute coronary syndromes (ACSs).  Chlamydia pneumoniae infection has been epidemiologically associated with ACS. In this study, we investigated whether acute C. pneumoniae infection could alter the endothelial vasomotor function of porcine coronary vessels.



Twenty pigs, 7-9 kg in weight, were inoculated intratracheally with C. pneumoniae (n=12) or saline (n=8), and investigated at 3 days (five infected/four non-infected) and 2 weeks (5+2 infected/four non-infected) after inoculation. The endothelium-dependent reactivity of coronary microcirculation was assessed at both time points by measuring peak coronary flow velocity (CFV) in response to bradykinin, before and after infusions with glutathione, an antioxidant, and L-arginine, a substrate for nitric oxide synthase (NOS). CFV after bradykinin was significantly decreased in infected animals at both time points. At 2 weeks, both glutathione and L-arginine significantly improved CFV after bradykinin. CFV after sodium nitroprusside (SNP) was similar in both groups. At 3 days, the relaxation responses of bradykinin-induced pre-contracted left anterior descending (LAD) coronary rings to bradykinin were significantly less in infected animals. N(G)-nitro-L-arginine-methyl-ester, an NOS inhibitor, had significantly greater inhibitory effect on bradykinin-induced relaxation in infected animals. Plasma nitrate-nitrite and fibrinogen, and NOS activity from LAD coronary samples were significantly increased in infected animals.



Acute C. pneumoniae infection causes endothelial dysfunction of both resistance and epicardial coronary vessels, and favours a pro-coagulant status. These effects could in part account for the epidemiologically suggested association between acute infection and ACS.

title: Chlamydia pneumoniae infections in mouse models: relevance for atherosclerosis research.
abstract: Mouse models have been frequently used in the study of Chlamydia pneumoniae (also known as Chlamydophila pneumoniae) infections. This gram-negative obligate intracellular bacterium causes respiratory infections, followed by dissemination of the bacterium to various organs throughout the body, including cardiovascular tissues, supporting the current hypothesis of a relationship between C. pneumoniae and atherosclerosis. Recently, clinical trials evaluated the effect of antichlamydial antibiotics on secondary cardiovascular events. Although small studies showed some effect, the large WIZARD study did not confirm these results, and the role of antichlamydial antibiotics in prevention of secondary events was questioned. To address these issues, data obtained from mouse models were systematically reviewed here. C. pneumoniae infections showed atherogenic properties in mice that were reproducible and confirmed by different research groups. However, antibiotic therapy was of limited value in these mouse models. Antibiotic therapy effectively cleared the acute infection, but did not influence the atherogenic properties of C. pneumoniae unless the therapy was started early during the acute infection. The results summarized here may help to better understand the results of the clinical antibiotic trials.

title: Resveratrol in Chlamydia pneumoniae-induced foam cell formation and interleukin-17A synthesis.
abstract: The involvement of Chlamydia pneumoniae in the pathogenesis of atherosclerosis has been suggested by numerous seroepidemiological, in vivo and in vitro studies. In particular, it has been shown that C. pneumoniae is able to promote the accumulation of low-density lipoproteins into macrophages, thus facilitating foam cell formation. The aim of our study was to investigate the effects of resveratrol on macrophage derived foam cell formation induced by C. pneumoniae, examining its underlying biochemical mechanisms. Our results showed a relevant decrease in the number of foam cells, in the production of thiobarbituric acid reactive substances, superoxide anion and IL 17A while treating C. pneumoniae infected macrophages with resveratrol. Furthermore, the inhibition of Peroxisome Proliferator-Activated Receptors gamma by a specific antagonist (GW 9662), in presence of resveratrol and C. pneumoniae, enhanced intracellular lipid and cholesterol accumulation and the subsequent foam cell formation. In conclusion, the main result of our study is the evidence of an antiatherogenic effect of resveratrol on macrophage-derived foam cell formation and IL-17A production induced by C. pneumoniae.

title: Chlamydia pneumoniae and Oxidative Stress in Cardiovascular Disease: State of the Art and Prevention Strategies
abstract: Chlamydia pneumoniae, a pathogenic bacteria responsible for respiratory tract infections, is known as the most implicated infectious agent in atherosclerotic cardiovascular diseases (CVDs). Accumulating evidence suggests that C. pneumoniae-induced oxidative stress may play a critical role in the pathogenesis of CVDs. Indeed, the overproduction of reactive oxygen species (ROS) within macrophages, endothelial cells, platelets and vascular smooth muscle cells (VSMCs) after C. pneumoniae exposure, has been shown to cause low density lipoprotein oxidation, foam cell formation, endothelial dysfunction, platelet adhesion and aggregation, and VSMC proliferation and migration, all responsible for the typical pathological changes of atherosclerotic plaque. The aim of this review is to improve our insight into C. pneumoniae-induced oxidative stress in order to suggest potential strategies for CVD prevention. Several antioxidants, acting on multi-enzymatic targets related to ROS production induced by C. pneumoniae, have been discussed. A future strategy for the prevention of C. pneumoniae-associated CVDs will be to target chlamydial HSP60, involved in oxidative stress.

title: C. pneumoniae disrupts eNOS trafficking and impairs NO production in human aortic endothelial cells
abstract: Endothelial nitric oxide synthase (eNOS) generated NO plays a crucial physiological role in the regulation of vascular tone. eNOS is a constitutively expressed synthase whose enzymatic function is regulated by dual acylation, phosphorylation, protein‐protein interaction and subcellular localization. In endothelial cells, the enzyme is primarily localized to the Golgi apparatus (GA) and the plasma membrane where it binds to caveolin‐1. Upon stimulation, the enzyme is translocated from the plasma membrane to the cytoplasm where it generates NO. When activation of eNOS ceases, the majority of the enzyme is recycled back to the membrane fraction. An inability of eNOS to cycle between the cytosol and the membrane leads to impaired NO production and vascular dysfunction. Chlamydia pneumoniae is a Gram‐negative obligate intracellular bacterium that primarily infects epithelial cells of the human respiratory tract, but unlike any other chlamydial species, C. pneumoniae displays tropism toward atherosclerotic tissues. In this study, we demonstrate that C. pneumoniae inclusions colocalize with eNOS, and the microorganism interferes with trafficking of the enzyme from the GA to the plasma membrane in primary human aortic endothelial cells. This mislocation of eNOS results in significant inhibition of NO release by C. pneumoniae‐infected cells. Furthermore, we show that the distribution of eNOS in C. pneumoniae‐infected cells is altered due to an intimate association of the Golgi complex with chlamydial inclusions rather than by direct interaction of the enzyme with the chlamydial inclusion membrane.

title: Growth in vascular cells and cytokine production by Chlamydia pneumoniae.
abstract: The proposed pathogenesis of Chlamydia pneumoniae in atherosclerosis is supported by the finding that C. pneumoniae can initiate and sustain growth in human vascular cells. In vitro growth of C. pneumoniae is found in macrophages, peripheral blood monocyte (PBMC)-derived macrophages, endothelial cells, and aortic artery smooth muscle cells. U-937 macrophages infected with C. pneumoniae are capable of transmitting the infection to human coronary artery endothelial cells (CAEC) with direct cellular contact. Production of cytokines by cells infected with C. pneumoniae indicates that the organism can stimulate the immune system. CAEC infected with C. pneumoniae produce more interleukin-8 than cells sham inoculated with negative control cells. When interferon-gamma is used to stimulate HEp-2 cells, U-937 cells, and PBMC (before infection with C. pneumoniae), inhibition of a productive growth cycle occurs in a dose-related response. Studies are needed to learn the relationship between productive infection and persistence, the ability of C. pneumoniae to affect the immune response, and the potential for C. pneumoniae to influence atheromatous lesions.

title: Chlamydia pneumoniae Infection in Atherosclerotic Lesion Development through Oxidative Stress: A Brief Overview
abstract: Chlamydia pneumoniae, an obligate intracellular pathogen, is known as a leading cause of respiratory tract infections and, in the last two decades, has been widely associated with atherosclerosis by seroepidemiological studies, and direct detection of the microorganism within atheroma. C. pneumoniae is presumed to play a role in atherosclerosis for its ability to disseminate via peripheral blood mononuclear cells, to replicate and persist within vascular cells, and for its pro-inflammatory and angiogenic effects. Once inside the vascular tissue, C. pneumoniae infection has been shown to induce the production of reactive oxygen species in all the cells involved in atherosclerotic process such as macrophages, platelets, endothelial cells, and vascular smooth muscle cells, leading to oxidative stress. The aim of this review is to summarize the data linking C. pneumoniae-induced oxidative stress to atherosclerotic lesion development.

title: Chlamydia pneumoniae Hijacks a Host Autoregulatory IL-1β Loop to Drive Foam Cell Formation and Accelerate Atherosclerosis.
abstract: Pathogen burden accelerates atherosclerosis, but the mechanisms remain unresolved. Activation of the NLRP3 inflammasome is linked to atherogenesis. Here we investigated whether Chlamydia pneumoniae (C.pn) infection engages NLRP3 in promoting atherosclerosis. C.pn potentiated hyperlipidemia-induced inflammasome activity in cultured macrophages and in foam cells in atherosclerotic lesions of Ldlr-/- mice. C.pn-induced acceleration of atherosclerosis was significantly dependent on NLRP3 and caspase-1. We discovered that C.pn-induced extracellular IL-1β triggers a negative feedback loop to inhibit GPR109a and ABCA1 expression and cholesterol efflux, leading to accumulation of intracellular cholesterol and foam cell formation. Gpr109a and Abca1 were both upregulated in plaque lesions in Nlrp3-/- mice in both hyperlipidemic and C.pn infection models. Mature IL-1β and cholesterol may compete for access to the ABCA1 transporter to be exported from macrophages. C.pn exploits this metabolic-immune crosstalk, which can be modulated by NLRP3 inhibitors to alleviate atherosclerosis.

title: Chlamydia and Lipids Engage a Common Signaling Pathway That Promotes Atherogenesis.
abstract: Recent studies indicate that Toll-like receptor 4 (TLR4) and myeloid differentiation factor 88 (MyD88) signaling promote the development of high fat diet-induced atherosclerosis in hypercholesterolemic mice.



The authors investigated the role of TLR4/MyD88 signaling in hematopoietic and stromal cells in the development and infection-mediated acceleration of atherosclerosis.



The authors generated bone marrow chimeras between wild-type and Tlr4-/- mice, as well as wild-type and Myd88-/- mice. All mice were on the Apoe-/- background and fed high fat diet. The authors infected the chimeric mice with C. pneumoniae (CP) and fed them high fat diet.



Aortic sinus plaques and lipid content were significantly reduced in Apoe-/- mice that received Tlr4-/-or Myd88-/- bone marrow compared with control animals despite similar cholesterol levels. Similarly, Tlr4 or Myd88 deficiency in stromal cells also led to a reduction in the lesion area and lipid in aortic sinus plaques. MyD88 expression only in CD11c+ dendritic cells (myeloid cells) in cells was sufficient in otherwise MyD88-deficient mice to induce CP infection-mediated acceleration of atherosclerosis, underlining the key role of MyD88 in CD11c+ dendritic cells (myeloid cells). Whereas CP infection markedly accelerated atherosclerosis in TLR4- or MyD88-positive chimeras, CP infection had a minimal effect on atherosclerosis in TLR4- or MyD88-deficient mice (either in the hematopoietic or stromal cell compartments).



The authors show that both CP infection and metabolic stress associated with dyslipidemia use the same innate immune response pathway, utilizing TLR4/MyD88 signaling, with similar relative contributions in bone marrow-derived hematopoietic cells and in stromal cells. Further studies are required to understand this intricate and complex cross talk among innate and adaptive immune systems in various conditions to more effectively design dendritic cell-mediated atheroprotective vaccines and other therapeutic strategies.

title: Chlamydia pneumoniae-Mediated Inflammation in Atherosclerosis: A Meta-Analysis
abstract: Several studies have attempted to relate the C. pneumoniae-mediated inflammatory state with atherosclerotic cardiovascular diseases, providing inconsistent results. Therefore, we performed a meta-analysis to clarify whether C. pneumoniae may contribute to the pathogenesis of atherosclerosis by enhancing inflammation. 12 case-control, 6 cross-sectional, and 7 prospective studies with a total of 10,176 patients have been included in this meta-analysis. Odds Ratio (OR) with a 95% confidence interval was used to assess the seroprevalence of C. pneumoniae and differences between levels of inflammatory markers were assessed by standard mean differences. Publication bias was performed to ensure the statistical power. hsCRP, fibrinogen, interleukin- (IL-) 6, TNF-α, and IFN-γ showed a significant increase in patients with atherosclerosis compared to healthy controls (P < 0.05), along with a higher seroprevalence of C. pneumoniae (OR of 3.11, 95% CI: 2.88–3.36, P < 0.001). More interestingly, hsCRP, IL-6, and fibrinogen levels were significantly higher in C. pneumoniae IgA seropositive compared to seronegative atherosclerotic patients (P < 0.0001). In conclusion, the present meta-analysis suggests that C. pneumoniae infection may contribute to atherosclerotic cardiovascular diseases by enhancing the inflammatory state, and, in particular, seropositivity to C. pneumoniae IgA, together with hsCRP, fibrinogen, and IL-6, may be predictive of atherosclerotic cardiovascular risk.

title: Persistent C. pneumoniae infection in atherosclerotic lesions: rethinking the clinical trials
abstract: The hypothesis that infectious agents are a risk factor for atherosclerosis has implicated multiple viral and bacterial pathogens in contributing either directly or indirectly to disease progression (Rosenfeld and Campbell, 2011). One of the most vigorously studied organisms has been Chlamydia pneumoniae, which has been associated with cardiovascular disease by seroepidemiological studies, detection of the organism by multiple methods in atherosclerotic tissue, and experimental studies demonstrating biological plausibility. Significantly, C. pneumoniae accelerates lesion progression in mouse and rabbit models of atherosclerosis (Muhlestein et al., 1998; Hu et al., 1999; Moazed et al., 1999; Fong, 2000; Blessing et al., 2001). Early small clinical trials determined whether treatment with macrolides (Azithromycin, Roxithromycin, and Clarithromycin) would be efficacious in secondary prevention of coronary heart disease. These studies yielded mixed results and had several limitations including the small numbers of patients and short duration of treatment and follow-up period (Grayston, 2003). However, half of them demonstrated some beneficial effects, which provided enthusiasm for the potential of antibiotic intervention in coronary artery disease. There have since been four large clinical trials collectively enrolling over 20,000 patients with stable coronary artery disease (WIZARD, ACES, and CLARICOR) or acute coronary syndrome (PROVE-IT–TIMI) (O'Connor et al., 2003; Cannon et al., 2005; Grayston et al., 2005; Jespersen et al., 2006). As there were short term beneficial effects in the WIZARD trial following a 3 month course of Azithromycin, two subsequent studies addressed whether longer term treatment would be efficacious in reducing coronary events. In the ACES study, patients were treated with Azithromycin for 1 year and followed for 46.8 months (Grayston et al., 2005). The PROVE IT-TIMI trial treated with gatifloxacin for a mean duration of 2 years (Cannon et al., 2005). Overall, none of these well-designed trials demonstrated any long term benefit of antibiotic treatment. Furthermore, two large scale trials subsequently found that treatment with either roxithromycin or rifalizil (PROVIDENCE-1) had no beneficial effects in patients with peripheral artery disease (Joensen et al., 2008; Jaff et al., 2009). Cumulatively, these trials clearly demonstrated that anti-chlamydial antibiotics should not be recommended for treatment of patients with coronary heart disease or peripheral artery disease. Prior to the completion of the PROVE-IT and ACES trials, Grayston commented that if the trials demonstrated a beneficial effect of antibiotics, this would provide additional evidence for a role of C. pneumoniae in pathogenesis, but would not prove causality (Grayston, 2003). Alternatively, he predicted that negative results would mostly likely dampen interest in the association of C. pneumoniae and atherosclerosis, but noted that failure of the clinical trials would not rule out a pathogenic role (Grayston, 2003). Indeed, the negative outcome led some to conclude that this proved that C. pneumoniae did not play a role in the pathogenesis of atherosclerosis (Danesh, 2005) and diminished interest in infectious agents as contributing factors for cardiovascular disease (Epstein et al., 2009).

title: Helicobacter Pylori Infection and Metabolic Parameters: Is There an Association in Elderly Population?
abstract: The association between Helicobacter pylori (HP), as one of the most prevalent infections, and serum glucose level was inconsistent with previous studies. Moreover, there are contradictory reports about the relationship between HP infection and lipid profile. The purpose of this study was to determine the relationship between HP infection with glycemic and lipid profiles in elderly people.  This cross-sectional study was conducted on 1,300 subjects over 60 years in Amirkola Health and Ageing Project. After using a standard questionnaire, the venous sampling was done to determine FBS, triglyceride (TG), cholesterol, low density lipoprotein (LDL), high-density lipoprotein (HDL) and IgG anti-HP after a 12-h overnight fast. The information about the individuals was analyzed using SPSS-17. The P < 0.05 was considered statistically significant.  The prevalence of HP infection in diabetic and nondiabetic subjects was 77.5% and 75.7%, respectively, which had no statistically significant difference. Also, there was no significant difference between the serum lipid level including TG, LDL and HDL cholesterol with levels of anti-HP antibodies. The rate of HP infection in patients with hypertension was 75% and 78.3% in healthy patients, in which the difference was not statistically significant. In terms of body mass index (BMI), the prevalence of infection in the group with normal BMI was 77.3% and for the overweight and obese elderly population, it was 74.7%, and 77.5%, respectively (P = 0.445).  The findings revealed that in a large population of elderly in the northern part of Iran, HP infection is not associated with BMI, serum glucose and lipid profile as well as blood pressure.

title: Estimation of the worldwide seroprevalence of cytomegalovirus: A systematic review and meta‐analysis
abstract: Cytomegalovirus (CMV) infection does not usually produce symptoms when it causes primary infection, reinfection, or reactivation because these three types of infection are all controlled by the normal immune system. However, CMV becomes an important pathogen in individuals whose immune system is immature or compromised, such as the unborn child. Several vaccines against CMV are currently in clinical trials that aim to induce immunity in seronegative individuals and/or to boost the immunity of those with prior natural infection (seropositives). To facilitate estimation of the burden of disease and the need for vaccines that induce de novo immune responses or that boost pre‐existing immunity to CMV, we conducted a systematic survey of the published literature to describe the global seroprevalence of CMV IgG antibodies. We estimated a global CMV seroprevalence of 83% (95%UI: 78‐88) in the general population, 86% (95%UI: 83‐89) in women of childbearing age, and 86% (95%UI: 82‐89) in donors of blood or organs. For each of these three groups, the highest seroprevalence was seen in the World Health Organisation (WHO) Eastern Mediterranean region 90% (95%UI: 85‐94) and the lowest in WHO European region 66% (95%UI: 56‐74). These estimates of the worldwide CMV distribution will help develop national and regional burden of disease models and inform future vaccine development efforts.

title: Effects of total pathogen burden on coronary artery disease risk and C-reactive protein levels.
abstract: Infection and inflammation have been suggested to play roles in coronary artery disease (CAD). We hypothesized that: (1) CAD risk is associated with the aggregate number of pathogens (pathogen burden), and (2) increased pathogen burden is associated with elevated levels of C-reactive protein (CRP), a marker of inflammation. We evaluated 233 patients for CAD. Blood samples from each patient were tested for immunoglobulin-G (IgG) antibodies to cytomegalovirus (CMV), Chlamydia pneumoniae, hepatitis A virus (HAV), herpes simplex virus type 1 (HSV-1) and HSV type 2 (HSV-2), and for the CRP levels. Of the 233 study subjects, 68% had evidence of CAD by coronary angiography. Although the prevalence of seropositivity for each pathogen tended to be higher in the patients with CAD than those without, only the association between CAD and seropositivity to HAV was significant in multivariate analysis. Over 75% of study subjects had been exposed to > or =3 of the 5 pathogens tested, and analysis determined that increasing pathogen burden was significantly associated with increasing CAD risk, even after adjustment for traditional CAD risk factors. The prevalence of CAD was 48%, 69%, and 85% in individuals with antibodies to < or =2 pathogens, to 3 or 4 pathogens, and to 5 pathogens, respectively. A similar association between increasing pathogen burden and CRP levels was also found. The pathogen burden remained a significant predictor of CRP levels after multivariate analysis. Our data suggest that infection does play a role in the genesis of atherosclerosis. However, the risk posed by infection is related to the pathogen burden that may contribute to CAD through inflammatory responses.

title: Association between Bacterial Infection and Peripheral Vascular Disease: A Review.
abstract: There are an increasing number of data showing a clinically important association between bacterial infection and peripheral artery disease (PAD). Bacteria suspected of being involved in PAD pathogenesis are: periodontal bacteria, gut microbiota, Helicobacter pylori, and Chlamydia pneumoniae. Infectious agents may be involved in the pathogenesis of atherosclerosis via activation of a systemic or local host immunological response to contamination of extravascular tissues or the vascular wall, respectively. A systemic immunological reaction may damage vascular walls in the course of autoimmunological cross-reactions between anti-pathogen antibodies and host vascular antigens (immunological mimicry), pathogen burden mechanisms (nonspecific activation of inflammatory processes in the vascular wall), and neuroendocrine-immune cross-talk. Besides activating the inflammatory pathway, bacterial infection may trigger PAD progression or exacerbation by enhancement of platelet reactivity, by a stimulatory effect on von Willebrand factor binding, factor VIII, fibrinogen, P-selectin activation, disturbances in plasma lipids, increase in oxidative stress, and resistance to insulin. Local inflammatory host reaction and induction of atherosclerotic plaque progression and/or instability result mainly from atherosclerotic plaque colonization by microorganisms. Despite these premises, the role of bacterial infection in PAD pathogenesis should still be recognized as controversial, and randomized, controlled trials are required to evaluate the outcome of periodontal or gut bacteria modification (through diet, prebiotics, and probiotics) or eradication (using antibiotics) in hard and surrogate cardiovascular endpoints.

title: Bacterial profile in human atherosclerotic plaques.
abstract: Several studies have confirmed the presence of bacterial DNA in atherosclerotic plaques, but its contribution to plaque stability and vulnerability is unclear. In this study, we investigated whether the bacterial plaque-profile differed between patients that were asymptomatic or symptomatic and whether there were local differences in the microbial composition within the plaque.



Plaques were removed by endarterectomy from asymptomatic and symptomatic patients and divided into three different regions known to show different histological vulnerability: A, upstream of the maximum stenosis; B, site for maximum stenosis; C, downstream of the maximum stenosis. Bacterial DNA composition in the plaques was determined by performing 454 pyrosequencing of the 16S rRNA genes, and total bacterial load was determined by qPCR.



We confirmed the presence of bacterial DNA in the atherosclerotic plaque by qPCR analysis of the 16S rRNA gene but observed no difference (n.s.) in the amount between either asymptomatic and symptomatic patients or different plaque regions A, B and C. Unweighted UniFrac distance metric analysis revealed no distinct clustering of samples by patient group or plaque region. Operational taxonomic units (OTUs) from 5 different phyla were identified, with the majority of the OTUs belonging to Proteobacteria (48.3%) and Actinobacteria (40.2%). There was no difference between asymptomatic and symptomatic patients, or plaque regions, when analyzing the origin of DNA at phylum, family or OTU level (n.s.).



There were no major differences in bacterial DNA amount or microbial composition between plaques from asymptomatic and symptomatic patients or between different plaque regions, suggesting that other factors are more important in determining plaque vulnerability.

title: The gut microbiota: An emerging risk factor for cardiovascular and cerebrovascular disease
abstract: Commensal gut microbiota have recently been implicated in cardiovascular disease (CVD) and cerebrovascular disease. Atherosclerotic plaque formation depends on the colonization status of the host. In addition to host nutrition and the related microbiota‐dependent metabolic changes, activation of innate immune pathways triggers the development of atherosclerosis and supports arterial thrombosis. Gnotobiotic mouse models have uncovered that activation of Toll‐like receptor‐2 by gut microbial ligands supports von Willebrand factor‐integrin mediated platelet deposition to the site of vascular injury. Depending on nutritional factors, the microbiota‐derived choline‐metabolite trimethylamine N‐oxide (TMAO) increases atherosclerotic plaque size, triggers prothrombotic platelet function and promotes arterial thrombus growth. Hence, the composition of the commensal microbiota is an emerging risk factor for CVD. Here, we provide an overview on microbiota‐dependent pathomechanisms that drive the development of CVD and arterial thrombosis.

title: Immunotherapeutic Approaches for Alzheimer’s Disease
abstract: Alzheimer's disease (AD) is the most prevalent form of dementia worldwide and is an emerging global epidemic. It is characterized by an imbalance between production and clearance of amyloid β (Aβ) and tau proteins. Oligomeric forms of Aβ and tau are believed to be the most toxic. Dramatic results from AD animal models showed great promise for active and passive immune therapies targeting Aβ. However, there is very limited evidence in human studies of the clinical benefits from these approaches. Immunotherapies targeting only tau pathology have had some success but are limited so far to mouse models. The majority of current methods is based on immunological targeting of a self-protein; hence, benefits need to be balanced against risks of stimulating excessive autoimmune toxic inflammation. For greater efficacy the next generation of vaccines needs to focus more on concurrently targeting all the intermediate toxic conformers of oligomeric Aβ and tau species.

title: Identification and localization of Chlamydia pneumoniae in the Alzheimer's brain
abstract: We assessed whether the intracellular bacterium Chlamydia pneumoniae was present in post-mortem brain samples from patients with and without late-onset Alzheimer's disease (AD), since some indirect evidence seems to suggest that infection with the organism might be associated with the disease. Nucleic acids prepared from those samples were screened by polymerase chain reaction (PCR) assay for DNA sequences from the bacterium, and such analyses showed that brain areas with typical AD-related neuropathology were positive for the organism in 17/19 AD patients. Similar analyses of identical brain areas of 18/19 control patients were PCR-negative. Electron- and immunoelectron-microscopic studies of tissues from affected AD brain regions identified chlamydial elementary and reticulate bodies, but similar examinations of non-AD brains were negative for the bacterium. Culture studies of a subset of affected AD brain tissues for C. pneumoniae were strongly positive, while identically performed analyses of non-AD brain tissues were negative. Reverse transcription (RT)-PCR assays using RNA from affected areas of AD brains confirmed that transcripts from two important C. pneumoniae genes were present in those samples but not in controls. Immunohistochemical examination of AD brains, but not those of controls, identified C. pneumoniae within pericytes, microglia, and astroglia. Further immunolabelling studies confirmed the organisms' intracellular presence primarily in areas of neuropathology in the AD brain. Thus, C. pneumoniae is present, viable, and transcriptionally active in areas of neuropathology in the AD brain, possibly suggesting that infection with the organism is a risk factor for late-onset AD.

title: Chlamydophila (Chlamydia) pneumoniae Infection of Human Astrocytes and Microglia in Culture Displays an Active, Rather than a Persistent, Phenotype
abstract: The intracellular pathogen Chlamydia pneumoniae can cause persistent infections during which its morphologic, molecular, and pathogenic characteristics differ importantly from those of active infection. This bacterium was identified within astrocytes and microglia in the brain of late-onset Alzheimer disease patients. We investigated whether infection of these two host cell types displays an active or persistent growth phenotype.  The human astrocytoma and microglioma cell lines U-87 MG and CHME-5 (respectively) and the human epithelial cell line HEp-2 were infected by the standard method with C pneumoniae strain AR-39. Cultures were harvested at 24, 48, and 72 hours postinfection and subjected to analysis of inclusion morphology. DNA and RNA were prepared from portions of each infected culture sample and analyzed for relative chromosome accumulation and presence or absence of several specific bacterial mRNAs.  Astrocytes and microglial cells infected in vitro with C pneumoniae displayed inclusions that were indistinguishable from those characteristic of active infection of the standard HEp-2 host cell line. Real time polymerase chain reaction (PCR) showed that the relative accumulation of chlamydial chromosome over time during infection of these two cell lines also was virtually identical to that in actively infected HEp-2 cells. Reverse transcriptase PCR (RT-PCR) analyses showed that mRNA from ftsK, pyk, and other chlamydial genes whose expression is abrogated during persistent infection were easily identifiable in infected CHME-5 and U-87 MG cells.  In cultured human astrocytes and microglia, C pneumoniae displays an active, not a persistent, growth phenotype. This indicates normal passage through the developmental cycle with its probable concomitant destruction by lysis of some portion of host cells at the termination of that cycle.

title: Real time PCR for detection of Chlamydophila pneumoniae in peripheral blood mononuclear cells of patients with multiple sclerosis
abstract: Since the initial report  suggesting an association between infection with Chlamydophila pneumoniae (C. pneumoniae) and multiple sclerosis (MS), a possible involvement of this common respiratory pathogen as etiologic agent has been investigated with conflicting results [2–8]. C. pneumoniae is presumed to play a role for its ability to cause a systemic dissemination following respiratory infection, promoting surviving of infected cells of immune system as macrophages, monocytes and lymphocytes. In vivo studies have confirmed that C. pneumoniae disseminates systemically from lungs via peripheral blood mononuclear cells (PBMC) ]. This event is thought to promote transmigration of monocytes through endothelial cells of brain vessels, resulting in a chronic injury on central nervous system (CNS). A major obstacle for the detection of C. pneumoniae is the lack of a reliable and standardized method. Culture and serology are the traditional methods of isolation of C. pneumoniae, but they suffer from limitations. There are difficulties in growing C. pneumoniae in cell culture, and serology is inadequate in discriminating recent from chronic infections. Lastly, there are a variety of molecular methods available for C. pneumoniae detection but they are in-house assays with different primers, reaction conditions, and DNA extraction procedures. Realtime quantitative PCR offers an attractive alternative to conventional PCR, since it combines amplification and quantitative product detection minimizing the risk of cross-contamination. Previous in vivo studies have suggested that detection of C. pneumoniae DNA by PCR in PBMC is a useful technique for identifying, even at low concentration, C. pneumoniae in the circulation or in the vascular walls in patients with atherosclerotic carotid disease [11, 12]. Up to now, only two studies have investigated the association between C. pneumoniae infection and MS by using conventional PCR in PBMC, reporting contradictory results (rate of detection ranging from 0 to 54%) [4, 13]. Here, we presented the results of the first study using real-time PCR to detect C. pneumoniae DNA in PBMC from MS patients. The cohort consisted of 112 consecutive MS outpatients (88 relapsing-remitting, 17 secondary progressive and 7 primary progressive MS), 39 men and 73 women, regularly attended the S.Andrea MS Centre of the University of Rome ‘‘La Sapienza’’ from January to June 2005. Mean age was 41.1 years (range 21–67), mean disease duration 5.7 years (range 1.5–23) and mean EDSS 3.0 (range 1.0–6.5). Sixty patients were treated with immunomodulatory agents (41 with interferon beta, 5 with glatiramer acetate), 14 patients received immunosuppressive drugs (4 with azathioprine and 10 with mitoxantrone), and 52 patients had no therapy. Whole blood specimens (5 ml) from each patient were processed to isolate PBMC. DNA was extracted by using a Qiagen DNA Mini-kit according to the manufacturer’s instructions. DNA was eluted in a final volume of 50 ll, aliquot, and stored at )20 C. In order to minimize the risk of falsepositive results, negative reagent controls obtained replacing clinical specimens with an equal volume of ultra pure water PCR grade were both included and processed throughout the whole extraction procedure. Detection and quantification of C. pneumoniae DNA were performed by real-time PCR assay, as previously described . Briefly, real-time PCR was based on FRET hybridization probes and LightCycler instrument (Roche Diagnostics, Germany). PCR primers and probes target on an internal, 128 bp region of C. pneumoniae PstI species-specific fragment. All amplification reactions were carried out in a total volume of 10 ll containing 1 ll of extracted DNA. R. Sessa, MD AE G. Schiavoni, MD C. Zagaglia, MD AE M. del Piano, MD Dept. of Public Health Sciences University of Rome ‘‘La Sapienza’’ Rome, Italy

title: Immunohistological detection of Chlamydia pneumoniae in the Alzheimer's disease brain
abstract: BackgroundSporadic late-onset Alzheimer's disease (AD) appears to evolve from an interplay between genetic and environmental factors. One environmental factor that continues to be of great interest is that of Chlamydia pneumoniae infection and its association with late-onset disease. Detection of this organism in clinical and autopsy samples has proved challenging using a variety of molecular and histological techniques. Our current investigation utilized immunohistochemistry with a battery of commercially available anti-C. pneumoniae antibodies to determine whether C. pneumoniae was present in areas typically associated with AD neuropathology from 5 AD and 5 non-AD control brains.ResultsImmunoreactivity for C. pneumoniae antigens was observed both intracellularly in neurons, neuroglia, endothelial cells, and peri-endothelial cells, and extracellularly in the frontal and temporal cortices of the AD brain with multiple C. pneumoniae-specific antibodies. This immunoreactivity was seen in regions of amyloid deposition as revealed by immunolabeling with two different anti-beta amyloid antibodies. Thioflavin S staining, overlaid with C. pneumoniae immunolabeling, demonstrated no direct co-localization of the organism and amyloid plaques. Further, the specificity of C. pneumoniae labeling of AD brain sections was demonstrated using C. pneumoniae antibodies pre-absorbed against amyloid β 1-40 and 1-42 peptides.ConclusionsAnti-C. pneumoniae antibodies, obtained commercially, identified both typical intracellular and atypical extracellular C. pneumoniae antigens in frontal and temporal cortices of the AD brain. C. pneumoniae, amyloid deposits, and neurofibrillary tangles were present in the same regions of the brain in apposition to one another. Although additional studies are required to conclusively characterize the nature of Chlamydial immunoreactivity in the AD brain, these results further implicate C. pneumoniae infection with the pathogenesis of Alzheimer's disease.

title: 
 Chlamydia pneumoniae induces Alzheimer-like amyloid plaques in brains of BALB/c mice
abstract: Amyloid deposits resembling plaques found in Alzheimer's disease (AD) brains were formed in the brains of non-transgenic BALB/c mice following intranasal infection with Chlamydia pneumoniae. The mice were infected at 3 months of age with C. pneumoniae isolated from an AD brain. Infection was confirmed by light and electron microscopy in olfactory tissues of the mice. C. pneumoniae was still evident in these tissues 3 months after the initial infection indicating that a persistent infection had been established. Amyloid beta (Abeta) 1-42 immunoreactive deposits were identified in the brains of infected BALB/c mice up to 3 months post-infection with the density, size, and number of deposits increasing as the infection progressed. A subset of deposits exhibited thioflavin-s labeling. Intracellular Abeta1-42 labeling was observed in neuronal cells. Experimental induction of amyloid deposition in brains of non-transgenic BALB/c mice following infection with C. pneumoniae may be a useful model for furthering our understanding of mechanisms, linked to infection, involved in the initiation of the pathogenesis of sporadic AD.

title: Detection of bacterial antigens and Alzheimer’s disease-like pathology in the central nervous system of BALB/c mice following intranasal infection with a laboratory isolate of Chlamydia pneumoniae
abstract: Pathology consistent with that observed in Alzheimer’s disease (AD) has previously been documented following intranasal infection of normal wild-type mice with Chlamydia pneumoniae (Cpn) isolated from an AD brain (96-41). In the current study, BALB/c mice were intranasally infected with a laboratory strain of Cpn, AR-39, and brain and olfactory bulbs were obtained at 1–4 months post-infection (pi). Immunohistochemistry for amyloid beta or Cpn antigens was performed on sections from brains of infected or mock-infected mice. Chlamydia-specific immunolabeling was identified in olfactory bulb tissues and in cerebrum of AR-39 infected mice. The Cpn specific labeling was most prominent at 1 month pi and the greatest burden of amyloid deposition was noted at 2 months pi, whereas both decreased at 3 and 4 months. Viable Cpn was recovered from olfactory bulbs of 3 of 3 experimentally infected mice at 1 and 3 months pi, and in 2 of 3 mice at 4 months pi. In contrast, in cortical tissues of infected mice at 1 and 4 months pi no viable organism was obtained. At 3 months pi, only 1 of 3 mice had a measurable burden of viable Cpn from the cortical tissues. Mock-infected mice (0 of 3) had no detectable Cpn in either olfactory bulbs or cortical tissues. These data indicate that the AR-39 isolate of Cpn establishes a limited infection predominantly in the olfactory bulbs of BALB/c mice. Although infection with the laboratory strain of Cpn promotes deposition of amyloid beta, this appears to resolve following reduction of the Cpn antigen burden over time. Our data suggest that infection with the AR-39 laboratory isolate of Cpn results in a different course of amyloid beta deposition and ultimate resolution than that observed following infection with the human AD-brain Cpn isolate, 96-41. These data further support that there may be differences, possibly in virulence factors, between Cpn isolates in the generation of sustainable AD pathology.

title: Could past Chlamydial vascular infection promote the dissemination of Chlamydia pneumoniae to the brain?
abstract: Chlamydia pneumoniae, a pathogen responsible for respiratory tract infections, has been associated with atherosclerosis which, along with hypertension, hyperlipidemia, cardiovascular and/or cerebrovascular ischemia and stroke, is a risk factor for chronic neurological disorders. Several studies have demonstrated the ability of C. pneumoniae to disseminate from lungs to arteries through peripheral blood mononuclear cells. Once inside the vascular tissue, C. pneumoniae infection may disseminate via peripheral monocytes to the brain over the intact blood-brain barrier, and contribute to the development of chronic neurological disorders. The aim of our study was to evaluate whether past C. pneumoniae vascular infection may promote the dissemination of this microorganism to the brain, therefore we investigated the presence of C. pneumoniae in post-mortem brain tissue specimens of patients with past chlamydial vascular infection. Seventy six post-mortem brain tissue specimens from 19 patients with past chlamydial vascular infection were investigated for the presence of C. pneumoniae by immunohistochemistry, polymerase chain reaction, in situ polymerase chain reaction and in situ reverse transcription polymerase chain reaction. As control, 28 brain tissue specimens were taken from 7 age and sex matched subjects without chlamydial infection. C. pneumoniae was detected in 16 (84.2%) out of 19 patients with chlamydial vascular infection whereas it was not detected in control subjects (p= 0.0002). In conclusion, the main result of our study is the evidence that a chlamydial vascular infection can disseminate to the brain. It will be important for current and future researches to perform large-scale prospective studies on cardiovascular patients with chlamydial vascular infection in order to evaluate the long-term pathological alterations of the brain.

title: Chlamydia pneumoniae as a triggering infection in reactive arthritis.
abstract: To determine the role of Chlamydia pneumoniae as a triggering infection in reactive arthritis (ReA).



Sixty patients with acute arthritis were screened for the evidence of triggering infections. In all patients, bacterial stool cultures, culture of Chlamydia trachomatis in urethra/cervix, and/or bacterial serology were studied. Chlamydia pneumoniae antibodies were measured by specific microimmunofluorescence test.



Thirty-five of 60 patients fulfilled the diagnostic criteria for ReA. Thirty-one patients had microbial/serological evidence of preceding infection due to Salmonella, Yersinia, Campylobacter or Chlamydia trachomatis, or they had enteritis or urethritis prior to arthritis. Four additional patients had high antibody titre for C. pneumoniae. Three of these four patients had preceding lower respiratory symptoms, and were positive for HLA-B27. The clinical picture of C. pneumoniae-positive ReA patients was similar to that of ReA patients with other definite aetiology.



Chlamydia pneumoniae is a triggering factor in approximately 10% of patients with acute ReA.

title: Lower prevalence of Chlamydia pneumoniae DNA compared with Chlamydia trachomatis DNA in synovial tissue of arthritis patients.
abstract: To assess the presence of Chlamydia pneumoniae DNA in the joints of patients with reactive arthritis (ReA) and other arthritides.



DNA was prepared from synovial tissue (ST) and several synovial fluid (SF) samples from 188 patients with either ReA, undifferentiated oligoarthritis, or other forms of arthritis, and from 24 normal (non-arthritis) individuals. Preparations were screened using polymerase chain reaction (PCR) assays that independently targeted the C. pneumoniae 16S ribosomal RNA and major outer membrane protein genes.



Twenty-seven of 212 ST samples (12.7%) were PCR positive for C. pneumoniae DNA; 10 SF samples from these 27 patients were similarly positive. Among the PCR-positive patients, 3 had ReA, 2 had Reiter's syndrome, 7 had undifferentiated oligoarthritis, 4 had undifferentiated monarthritis, 6 had rheumatoid arthritis, and 5 had other forms of arthritis. No samples from normal control individuals were PCR positive.



DNA of C pneumoniae is present in synovial specimens from some arthritis patients. The prevalence of this organism in the joints was lower than that of C trachomatis, and synovial presence of the organism was not associated with any distinct clinical syndrome. Widely disseminated nucleic acids such as those of C. pneumoniae might have some role in the pathogenesis of several arthritides, since the organism was not found in the ST from normal control individuals.

title: Chlamydia pneumoniae present in the human synovium are viable and metabolically active.
abstract: We demonstrated that chromosomal DNA from Chlamydia pneumoniae is present in synovial tissue in at least some patients with reactive arthritis/Reiter's syndrome and other arthritides. Here, we provide initial molecular evidence that the bacterium is viable and metabolically active when present in the synovium. We used reverse transcription-polymerase chain reaction (RT-PCR) assays targeting primary transcripts from the chlamydial rRNA operons, and mRNA from several C. pneumoniae genes (hsp60, ompA, KDO transferase, Mr=76000 protein), to analyse RNA preparations from synovial tissue of 10 patients with various forms of arthritis; each patient was known to be PCR-positive for C. pneumoniae DNA in synovium prior to RT-PCR assays. Two PCR-negative patients served as controls for RT-PCR assays. In the 10 patients PCR-positive for C. pneumoniae DNA, RT-PCR assays targeting primary transcripts from the rRNA operons of the organism showed that these molecules were present in each sample, as were transcripts from the bacterial hsp60 gene. Assays targeting mRNAs from the Mr=76000 protein and the KDO transferase genes of C. pneumoniae gave positive results for 6/10 preparations. We were unable to identify mRNA from the chlamydial major outer membrane protein gene (ompA) in any preparation. RNA preparations from the two control patients were negative in all RT-PCR assays targeting C. pneumoniae transcripts. These results indicate that in patients infected with the organism, synovial C. pneumoniae are viable and metabolically active, as are C. trachomatis cells in the same context. Such viability is consistent with a role in long-term contribution to pathogenesis in joint disease.

title: Cutaneous vasculitis and reactive arthritis following respiratory infection due to Chlamydia pneumoniae: report of a case.
abstract: Unlike Chlamydia trachomatis and C. psittaci, the association of C. pneumoniae infection with immunological complications, such as reactive arthritis (ReA) or erythema nodosum (EN) has been rarely reported. Here we present the case history of a patient with C. pneumoniae community acquired pneumonia (CAP) who subsequently developed a ReA and a cutaneous vasculitis. A 45-year-old HLA B27 negative male developed an asymmetric and additive arthritis and a cutaneous leukocytoclastic vasculitis with IgM and complement papillary deposition along hypodermic vessel walls about three weeks after the onset of respiratory symptoms. The diagnosis of chronic Chlamydia pneumoniae infection was based on serology and PCR. Cultural and serological investigations for other infectious agents commonly involved in ReA were negative. This is the first report on the occurrence of two immune-based complications, associated to Chlamydia pneumoniae infection. Therefore, since this infection is very common in our population, although often asymptomatic, should be systematically considered as a common causative agent of ReA and of vasculitis.

title: Chlamydiae as etiologic agents in chronic undifferentiated spondylarthritis.
abstract: The majority of patients with Chlamydia-induced reactive arthritis do not present with the classic triad of arthritis, conjunctivitis/iritis, and urethritis. Moreover, acute chlamydial infections are often asymptomatic. The aim of the present study was to assess the prevalence of synovial Chlamydia trachomatis and Chlamydia pneumoniae infections in patients with chronic undifferentiated spondylarthritis (uSpA).



Study patients met the European Spondylarthropathy Study Group criteria for SpA, without evidence of ankylosing spondylitis, psoriasis, inflammatory bowel disease, or preceding dysentery. Symptoms were present for >or=6 months. Each patient underwent a synovial biopsy; tissue and concomitantly obtained peripheral blood mononuclear cells (PBMCs) were analyzed by polymerase chain reaction (PCR) for C trachomatis and C pneumoniae DNA. Other data collected on the day of the biopsy included standard demographic information and medical history, including any known history of C trachomatis or C pneumoniae. Physical examination (including joint count, evaluation for dactylitis and/or enthesitis, and skin examination) and HLA-B27 typing were performed. Synovial tissue (ST) samples from 167 patients with osteoarthritis (OA) were used as controls.



Twenty-six patients met the entry criteria and underwent synovial biopsy (25 knee, 1 wrist). Sixteen of them (62%) were positive for C trachomatis and/or C pneumoniae DNA (10 for C trachomatis, 4 for C pneumoniae, and 2 for both). PCR analysis of ST revealed the presence of Chlamydia significantly more frequently in patients with uSpA than in OA controls (P<0.0001). No specific clinical characteristics differentiated Chlamydia-positive from Chlamydia-negative patients. PBMCs from 4 of the 26 uSpA patients (15%) were positive for Chlamydia, and Chlamydia was found in ST from 2 of these 4 patients. No significant correlation between PCR positivity and HLA-B27 positivity was found.



The frequency of Chlamydia-positive ST samples, as determined by PCR, was found to be significantly higher in patients with uSpA than in patients with OA. Our results suggest that in many patients with uSpA, chlamydial infection, which is often occult, may be the cause.

title: Detection of Chlamydophila pneumoniae in patients with arthritis: significance and diagnostic value
abstract: The aim of this study was to assess the potential clinical implications of Chlamydophila pneumoniae in patients with acute and chronic arthritic diseases and to investigate whether blood monocytes might reflect a concomitant synovial or persistent systemic infection. C. pneumoniae was investigated with advanced PCR and reverse transcriptase (RT) PCR techniques targeting different genes and combined with cell line cultures, in synovial fluid (SF) and peripheral blood mononuclear cell (PBMC) specimens collected from 28 patients with arthritis. Five out of twenty-eight patients (17.8%) were found to have C. pneumoniae DNA in either SF or PBMC specimens. Their diagnosis was reactive arthritis (ReA), S.A.P.H.O syndrome, psoriatic arthritis, undifferentiated oligoarthritis (UOA) and ankylosing spondylitis (AS). Specimens from patients with UOA and AS had also mRNA transcripts but those from AS yielded C. pneumoniae growth after co-culture. Moreover, C. pneumoniae DNA levels measured by Real-Time PCR (LightCycler) were higher in PBMC specimens compared to those found in SF at the end of antibiotic treatment. C. pneumoniae may have a role as triggering factor also in chronic arthritides including AS. The combined use of culture and molecular tools increases detection rates and improves the overall sensitivity, suggesting their potential use to detect C. pneumoniae. The different kinetics of bacterial DNA at both peripheral and synovial levels should be taken into consideration when monitoring and evaluating the effectiveness of antibiotic treatment.

title: The role of Chlamydia and Chlamydophila infections in reactive arthritis.
abstract: Chlamydia trachomatis and Chlamydophila pneumoniae are human pathogens; the former being the etiologic agent for trachoma as well as a prevalent sexually transmitted bacterium, while C. pneumoniae is a respiratory pathogen responsible for community-acquired pneumonia. Patients with reactive arthritis show evidence of present or past Chlamydial infection. Chlamydia spp., has been strongly implicated as a triggering factor for reactive arthritis. We describe the simultaneous occurrence of C. pneumoniae and C. trachomatis infections in a subject with reactive arthritis. We suggest treatment for a patient with Chlamydia-associated arthritis to define a means by which persistent organisms can be induced to return to the active developmental cycle, thereby making them more accessible to antibiotic activity.

title: Reactive arthritis: incidence, triggering agents and clinical presentation.
abstract: To study the incidence and presenting clinical and microbiological features in subgroups of reactive arthritides.



In a defined community and during a 2-year period, we studied prospectively patients between 18 and 60 years with onset of suspected reactive arthritis, primarily seen by general practitioners.



Annual minimum incidence of Chlamydia induced arthritis (n = 25) was 4.6 and of arthritis triggered by enterobacteria (n = 27) 5.0/100,000 individuals between 18 and 60 years. Triggering infections were asymptomatic in 36 and 26%, respectively. Patients with self-limiting arthritis without identified triggering agents (n = 60, incidence 11.0/100,000) had a normal prevalence of HLA-B27 and a more heterogeneous pattern of arthritis.



Our epidemiological study confirms suggested high incidence rates of reactive arthritides. Reactive arthritides must be considered in early arthritis, even without symptoms of triggering infections.

title: Prior exposure to infection with Chlamydia pneumoniae can influence the T-cell-mediated response to Chlamydia trachomatis.
abstract: Using T-cell clones derived from patients with Chlamydia trachomatis (CT)-induced reactive arthritis, we identified target antigens and mapped the peptide epitopes that were recognized. Several epitopes were conserved in homologous proteins of Chlamydia pneumoniae (CPN), and it was shown that these epitopes were generated following processing of the CPN proteins or CPN elementary bodies, i.e. the T-cell clones were indeed CT and CPN cross-reactive. Given that CPN infection is frequent, we wished to determine whether prior infection with CPN could have an effect on the response to subsequent infection with CT. First, we showed that the CPN antigen, OmcB, was recognized by polyclonal peripheral blood T cells from additional subjects with CT-induced reactive arthritis; they were chosen to be HLA-DR-matched with the T-cell clones used to map epitopes in OmcB. Responses to a peptide previously shown to be conserved in CT and CPN OmcB were also seen, but only in CPN-seropositive individuals. These subjects also produced interferon-gamma (IFN-gamma) in response to CPN OmcB, and did not recognize a nonconserved epitope in OmcB. Secondly, OmcB-responsive clones from CPN-seropositive subjects were dominated by those recognizing the cross-reactive epitope, despite the recent exposure of these subjects to CT. Lastly, healthy CPN-seropositive subjects, without evidence of exposure to CT, showed greater responses, measured as IFN-gamma secretion, to CT proteins in vitro than those shown by seronegative subjects. This is consistent with the idea that prior CPN infection primes a Th1 T-cell response to CT antigens. This finding is relevant to the pathogenesis of the sequelae of CT infection (trachoma, infertility and arthritis), which may be influenced by prior exposure to CPN, and to the choice of CT antigens as vaccine candidates.

title: Reiter's syndrome--disease of young men-- analysis of 312 patients.
abstract: Reiter's syndrome is reactive arthritis occurring after acute urogenital (urethritis, cervicitis) or enterocolitis infections. The associated ophthalmological and/or mucocutaneous changes are full clinical manifestations of this disease. This paper was aimed at analyzing clinical and radiological characteristics and findings of possible etiological factors and protocol for Reiter's syndrome therapy.



Of 312 patients included in the study, 279 were men and 33 were women, the ratio between them being 8.5:1. The disease was diagnosed based on clinical evidence of two basic characteristics of Reiter's syndrome: arthritis preceded by acute urogenital or enteral infection.



Urogenital and enterocolitic form of disease was found in 242 (77.5%) and 52 (16.5%) patients, respectively; whereas the initial cause was not discovered in 18 patients (6%). Three or two main signs of Reiter's syndrome were present in approximately the same number of patients (41.7% and 44.2%), whereas all four signs of disease were present in 14.1% of the patients. Acute or sub-acute form was present in 40.5%, while recurrent and chronic disease was diagnosed in 31% and 28.5% of the patients, respectively. The most frequent clinical manifestation of this disease was on the locomotor system as asymmetrical oligoarthritis localized in lower extremities, present in 69.4% of the patients. Chlamydia trachomatis was found in the synovial fluid in 54% of patients (20/37), ureaplasma or mycoplasma was isolated in the synovial tissue of 73.1% of patients (30/41) and in the peripheral blood mononuclear cells in 93.2% of patients (41/44). Human leukocyte antigen B27 was present in 83.3% of patients.



Reiter's syndrome is a multisystem disease, predominantly occurring in human leukocyte antigen B27 positive young males. The fact that the causative agents are found in the synovial membrane or synovial fluid is indicative of infectious rather than reactive arthritis.

title: Biofilm formation on intrauterine devices in relation to duration of use.
abstract: Intrauterine devices (IUDs) are highly effective, long-term methods of contraception; however, IUD use is limited due to concerns about an increased risk of pelvic inflammatory disease (PID) and subsequent complications. A retrospective review of clinical and microbiological data of 127 participants was carried out over a 3 year period. IUDs were removed and sent for microbiological examination. A 10 year old IUD, removed because of the symptoms of PID, was investigated via both microbial culture and scanning electron microscopy. The primary objective of this study was to examine the bacteria present on removed IUDs after different times in situ by using aerobic and anaerobic culture methods. A close association of the distribution of aerobic and anaerobic bacteria on the IUDs with different times in situ was found.

title: Biofilm formation on intrauterine devices in patients with recurrent vulvovaginal candidiasis.
abstract: A biofilm is a complex community of surface-associated cells enclosed in a polymer matrix. They attach to solid surfaces and their formation can be affected by growth conditions and co-infection with other pathogens. The presence of biofilm may protect the microorganisms from host defenses, as well as significantly reduce their susceptibility to antifungal agents. Pathogenic microbes can form biofilms on the inert surfaces of implanted devices such as catheters, prosthetic cardiac valves and intrauterine devices (IUDs). The present study was carried out to analyze the presence of biofilm on the surface of intrauterine devices in patients with recurrent vulvovaginal candidiasis, and to determine the susceptibility profile of the isolated yeasts to amphotericin B and fluconazole. Candida albicans was recovered from the IUDs and it was found to be susceptible to the antifungal agents when tested under planktonic growing conditions. These findings indicate the presence of the biofilm on the surface of the IUD as an important risk factor for recurrent vulvovaginal candidiasis.

title: Evidence for long-term cervical persistence of Chlamydia trachomatis by omp1 genotyping.
abstract: Recurrent Chlamydia trachomatis infections are common among sexually active women. Although recurrences with a new chlamydial serovar indicate reinfection, same-serovar recurrences may be due to persistence. Because persistence has important implications for pathogenesis and patient management, we identified 552 women with >3 recurrences over 2 years. Among these, 130 women (24%) had same-serovar recurrences; 58 (45%) were C class serovars (odds ratio, 2.4; 95% confidence interval, 1.7-3.5; P<.0001). Forty-five isolates from 7 women with 3-10 repeated, same-serovar infections over 2-5 years were studied. As determined by omp1 genotyping, 4 women had identical genotypes at each recurrence; 2 women had 1 or 2 amino acid changes following treatment, and one was persistently infected with a unique genotype, Ja. Many intervening culture-negative samples were positive when tested by ligase chain reaction, which suggests persistence. These data demonstrate that cervical infections with C class serovars can persist for years and may have specific biologic properties that allow for modulation of the major outer membrane protein in response to immune selection.

title: Demonstration of Persistent Infections and Genome Stability by Whole-Genome Sequencing of Repeat-Positive, Same-Serovar Chlamydia trachomatis Collected From the Female Genital Tract
abstract: The biology of recurrent or long-term infections of humans by Chlamydia trachomatis is poorly understood. Because repeated or persistent infections are correlated with serious complications in humans, understanding these processes may improve clinical management and public health disease control.



We conducted whole-genome sequence analysis on C. trachomatis isolates collected from a previously described patient set in which individuals were shown to be infected with a single serovar over a lengthy period.



Data from 5 of 7 patients showed compelling evidence for the ability of these patients to harbor the same strain for 3-5 years. Mutations in these strains were cumulative, very uncommon, and not linked to any single protein or pathway. Serovar J strains isolated from 1 patient 3 years apart did not accumulate a single base change across the genome. In contrast, the sequence results of 2 patients, each infected only with serovar Ia strains, revealed multiple same-serovar infections over 1-5 years.



These data demonstrate examples of long-term persistence in patients in the face of repeated antibiotic therapy and show that pathogen mutational strategies are not important in persistence of this pathogen in patients.

title: Membrane vesicle production by Chlamydia trachomatis as an adaptive response
abstract: Bacteria have evolved specific adaptive responses to cope with changing environments. These adaptations include stress response phenotypes with dynamic modifications of the bacterial cell envelope and generation of membrane vesicles (MVs). The obligate intracellular bacterium, Chlamydia trachomatis, typically has a biphasic lifestyle, but can enter into an altered growth state typified by morphologically aberrant chlamydial forms, termed persistent growth forms, when induced by stress in vitro. How C. trachomatis can adapt to a persistent growth state in host epithelial cells in vivo is not well understood, but is an important question, since it extends the host-bacterial relationship in vitro and has thus been indicated as a survival mechanism in chronic chlamydial infections. Here, we review recent findings on the mechanistic aspects of bacterial adaptation to stress with a focus on how C. trachomatis remodels its envelope, produces MVs, and the potential important consequences of MV production with respect to host-pathogen interactions. Emerging data suggest that the generation of MVs may be an important mechanism for C. trachomatis intracellular survival of stress, and thus may aid in the establishment of a chronic infection in human genital epithelial cells.