1. Introduction
Species within the former
Bacteroides fragilis group (BFG) (which are now classified within the
Bacteroides,
Parabacteroides, and
Phocaeicola genera) are the most frequently isolated opportunistic anaerobic pathogens that are also important members of the mammalian intestinal microbiota. Of these,
B. fragilis is the most pathogenic and accounts for 50 % of clinical isolates; however, it is only a minor population among intestinal strains [
1]. They are highly resistant to most antimicrobial agents through the use of several antibiotic resistance mechanisms. Metronidazole is a prominent choice to treat infections of
B. fragilis because it is an anti-anaerobic drug that usually elicits low levels of resistance among obligately anaerobic pathogens [
2]. However, metronidazole resistance levels among
Bacteroides have either increased somewhat or increased greatly in developed and developing countries, respectively [
3,
4]. The best known and most investigated metronidazole resistance mechanism of BFG strains is mediated by the
nim genes, a few of which were originally discovered in the 1980s and 1990s [
5]. There are now 12 known homologs of
nim (i.e.,
nimA-L) that share 50%–80% amino acid homologies, and they are all proposed to act as nitro-reductases [
6,
7]. They have been localized to both the plasmid and chromosome, and they all require an upstream copy of a
Bacteroides-specific insertion sequence (IS) element with promoter sequences to function in metronidazole resistance [
5]. Besides
nim genes, the other proposed metronidazole resistance mechanisms among BFG strains include increased lactate dehydrogenase, decreased pyruvate-ferredoxin oxidoreductase (PFOR), efflux, reduced iron uptake, and increased DNA repair [
5]. However, these latter diverse mechanisms do not operate in all
nim-negative resistant strains and are sometimes found only in laboratory strains after the induction of metronidazole resistance. The
nim-mediated mechanism, which is most prevalent among
Bacteroides, has not been completely resolved. However, it is known that the metronidazole MICs of
nim-positive strains are sometimes low and unstable, and the expression level of the
nim genes correlates poorly with metronidazole MICs, which tend to be flexible. To explain this low correlation, the action of auxiliary factors has been proposed [
8].
B. fragilis strains can be classified into two divergent divisions based on genetic differences (e.g., differences in alleles or genetic elements, most importantly the carbapenem resistance gene,
cfiA) that can be mapped to specific loci in the genome of this important species [
9] and by our observations it is also related to the gene expressions of the
B. fragilis strains.
The aim of this study was to search for factors, in addition to
nim genes, that affect metronidazole resistance of
B. fragilis. We have previously revealed that hemin and iron uptake mechanisms are involved in metronidazole resistance and
nim-negative and
nim-positive
B. fragilis strains differ behaviorally [
10]. Previously we analyzed the proteomics of
nimA-positive and -negative
B. fragilis laboratory strains [
11]. In addition, here we analyzed the expression of 18 genes previously identified as resistance candidates in a proteomic study, in a collection of
nim-positive and -negative clinical
B. fragilis strains; and we correlated the expression levels of these genes to measurements of metronidazole MICs to identify possible auxiliary factor(s) involved in metronidazole resistance of
B. fragilis. Finally, we studied the effects of C
4-dicarboxylic acid supplementation on metronidazole MICs to understand better the hemin dependence of metronidazole resistance.
2. Results and Discussion
Table 1 shows the results of the metronidazole MICs and the expression levels of the
nim genes of the 8
nim-positive strains. Similarly to the results of our previous studies [
8,
11], metronidazole MICs and the expression levels of the
nim genes were independent of each other (r = 0.185, p = 0.619, r
2 = 0.0342).
However,
nim genes are known resistance factors, because they transfer the resistance phenotype in conjugation experiments [
19,
20,
21], and they are associated with metronidazole resistance in field studies [
4,
22]. Therefore, there is a need to account for this lack of correlation even with the same
nim gene and IS element pairs. Previously, we proposed the existence of rate-limiting factors that influence metronidazole resistance of
B. fragilis strains [
8]. To investigate this possibility, we measured the expression levels of 18 genes selected according to the results of previous research or from our recent investigations [
11] using RT-qPCR to study in 15
B. fragilis strains. The cross-correlations between gene expressions and the correlation between gene expression and metronidazole MICs for all 15
B. fragilis strains are shown in
Table 2. Cross-correlations between certain genes were very strong (r > 0.7, p < 0.01) indicating their common regulation, although all genes (except for
frdA and
frdC, whose expressions correlated well – r = 0.593, p = 0.0192,
Table 2) are not located on the same operon [
23]. Moreover, we detected highly significant correlations between the expression of some genes and metronidazole MICs. In particular, lactate dehydrogenase (
ldh) expression correlated positively, whereas cytochrome b fumarate reductase/succinate dehydrogenase (
frdC), malate dehydrogenase (
mdh), phosphoglycerate kinase (
pgk) catabolic and
gat (GCN5-related acetyltransferase toxin), and
relA (stringent response regulator) regulatory gene expressions correlated negatively with metronidazole MICs. Within the
nim-positive and
nim-negative strains, we detected cross-correlations between gene expressions; however, we found no significant association between metronidazole MICs and gene expressions, except
mdh and
gat tended to correlate with metronidazole MICs in the
nim-positive and
nim-negative groups (
Tables S2 and S3), respectively. In addition, the gene cross-correlations of the full set did not overlap with those in the
nim-positive and nim-negative groups of strains (
cf. Table S2 and
Table 3). The lack of statistical confirmation may be due to the low number of strains in each group (8
nim-positive and 7
nim-negative strains).
However, one-way variance analysis (
Table 3) demonstrated
frdC,
gat,
mdh,
nanH (sialidase),
pgk, and
relA gene expression depended on the presence of the
nim gene; however, the
cfiA gene status did not affect the expression of the studied genes (
Table 3). The genes listed above differs from the list in
Table 3 because it excludes and includes
ldh and
nanH, respectively. We are currently unable to explain this finding, although the inclusion of
nanH indicates a link between metronidazole resistance/
nim positivity and virulence.
Although we found no significant association of the examined genes among the
nim-negative and
nim-positive strainsseparately, the combined data signalized some good associations in the case of the whole strain set (see above). Therefore, we conclude that no particular enzyme is exclusively correlated with metronidazole resistance in both the
nim-negative and -positive strains; however, some genes have been previously linked to metronidazole resistance, e.g.,
feoAB (described in [
24]) and
por (described in [
25]). This applies to both
nim-positive and nim-negative strains (with the possible exceptions of
gat and
mdh mentioned above).
In addition, the roles of enzymes involved in central metabolism in
B. fragilis should be also considered. Central metabolism varies greatly among bacteria [
26], e.g., the central metabolism of
Bacteroides differs greatly from that of γ-Proteobacteria; and the latter comprises glycolysis and parts of the tricarboxylic cycle (TCA). However, instead of a complete TCA cycle,
Bacteroides have a reductive or reverse TCA (rTCA) branch that is heme-dependent as well a branch that is heme-independent (
Figure S1) [
27]. Previously, we found that hemin depletion causes metronidazole susceptibility in both
nim-negative and
nim-positive strains of
B. fragilis [
10]. Thus, heme may be a rate-limiting factor in metronidazole resistance of
B. fragilis, as proposed above. Our results show that the expression of genes from the glycolytic and rTCA pathways (
pgk,
frdC , and
mdh) correlate negatively with the metronidazole MICs, whereas that of
ldh correlates positively. These latter changes can decrease the cellular concentrations of reducing cofactor, which diminishes metronidazole activation, thus inducing resistance.
The Nim enzymes are nitro-reductases that can transfer either six [
6] or two electrons to the nitro group of metronidazole, yielding either an amino or a nitroso imidazole, respectively [
20]. Recently,
in vivo and
in vitro experiments demonstrated that a
nim group enzyme encoded by
Clostridioides difficile strains is a nitro-reductase [
7]. In this latter study, it was also confirmed that metronidazole resistance in
C. difficile is dependent on hemin [
28] through experiments involving the direct addition of metronidazole to assay its modification by recombinant NimB and by transcriptomic analysis. Moreover, genetic (transposon mutagenesis) and biochemical (aromatic nitro-reduction to amine) tests have proven that the
nimB gene of some
C. difficile strains is responsible for their metronidazole resistance. However, in the
in vitro experiments, the metronidazole concentration used, 5 mM, was much higher than that to which the bacteria are usually exposed (the 4 μg/ml breakpoint concentration corresponds to 23.4 μM – a ca. 160-fold difference). It is possible that the hemin dependence of metronidazole resistance is due to the hemin dependence of the NimB protein; however, this does not explain hemin dependence of
nim-negative strains.
We were also interested in how the addition of intermediates of the rTCA pathway affects metronidazole MICs. We expected that higher oxaloacetate or fumarate concentrations would decrease the redox intermediate concentration (e.g., NADH), thus decreasing metronidazole activation and MICs. In these experiments, we used modified M9 minimal medium supplemented with Tryptone, hemin, vitamin K1, and glucose or C
4-dicarboxylic acid. The results are shown in
Table S5, with some representative plates shown in
Figure S2. Out of six
nim-negative or
nim-positive strains, four showed no significant difference in metronidazole MICs compared to those obtained on supplemented Columbia agars. However, the MICs of one
nim-positive and one
nim-negative strains increased in response to glucose, malate, and succinate addition, whereas no changes were observed in response to oxaloacetate or fumarate addition. This latter finding supports our assumption that is noted above (e.g. that the metronidazole resistance is highly dependent on reducing cofactor(s)). Moreover, our findings are consistent with the previous observation on the flexibility of metronidazole MICs and the idea of a rate-limiting step(s) involved in nim action in metronidazole resistance. We propose the following mechanism: the addition of malate and succinate forces the cells to reduce the levels these compounds at the expense of the pool of reducing cofactors, thus leading to decreased metronidazole activation. We also argue that the C
4-dicarboxylic acid uptake rates probably do not affect these processes of because one transport protein, the anaerobic C
4-dicarboxylic carrier protein, is responsible for their uptake with similar efficiencies in
Escherichia coli [
29]. The ortholog of this carrier protein is present in the genomes of
B. fragilis strains (our unpublished analysis). The observed increase in
ldh gene expression is consistent with previous findings showing the importance of reducing cofactors in metronidazole resistance in anaerobic bacteria [
25]. This means that pyruvate level is the main mediator in this latter process. However, we did not observe the differential expression of
por during our experiment. It is possible that withdrawing hydrogen/reducing cofactors from metronidazole activation may be involved in this process. The involvement of
frdC (a cytochrome b enzyme) in metronidazole resistance is noteworthy because it can explain at least partly the heme-dependence of metronidazole resistance of
B. fragilis. Additionally, the negative correlation of the regulatory genes (
relA and
gat) suggests that a high metabolic state is required for metronidazole to act on cells, because these genes have a role in decreasing cellular metabolism.
This study is the first to examine the role of multiple proteins/genes on metronidazole resistance in clinical
B. fragilis strains. Earlier modeling studies have focused only on laboratory strains of
B. fragilis. For example, based on the roles of a limited set of proteins analyzed by two-dimensional protein electrophoresis and northern blotting, Diniz
et al. proposed that
ldh and
por participate in metronidazole activation at certain low levels [
25,
30]. However, their model was not confirmed by Paunkov et al. [
31]. de Freitas
et al. analyzed the transcriptome-wide effect of metronidazole on a large number of proteins, and they confirmed that, along with some other proteins, the concentration of activating ferredoxin is important in alleviating metronidazole stress [
32]. Based the results of proteomic studies, Paunkov
et al. developed models of how
nim and other proteins act in
nim-dependent and -independent metronidazole-resistant
B. fragilis strains [
11].
Here, we propose that a limited number of genes/proteins are correlated with metronidazole resistance in
B. fragilis at the population level. In this study, we highlight the importance of reducing cofactors that are needed for both metronidazole activation and inactivation. The activated metronidazole radical acts by reducing
nim and redox cofactor proteins and thiol compounds of the proteome [
33]. Thus, the metronidazole resistance mechanism of
B. fragilis is complex and nonlinear. This complexity can explain why metronidazole MICs and
nim gene expression do not always correlate, especially long after the isolation of strains from clinical specimens. Thus, the process of developing resistance to metronidazole is also complex (
Figure 1).
Earlier work suggested that ferredoxin is responsible for reducing metronidazole [
25]; however, we were unable to find a role for PFOR (negative association), as we observed increased PFOR and PFOR activities in laboratory, metronidazole-resistant
B. fragilis strains [
31]. Thus, more work is needed to determine significant associations between gene expression and metronidazole MICs in “field” stains
nim-negative and -positive
B. fragilis. In particular, more strains need to be analyzed to prove the roles of those genes. In addition, the roles of the genes that had positive or negative correlations with metronidazole resistance should be confirmed by deletion–complementation analysis. In particular,
frdC is a good candidate for these experiments because it also contains heme. Identifying with more certainty which redox cofactor activates metronidazole remains a future task.