Abstract
Antivirulence drugs are a new type of therapeutic drug that target virulence factors, potentially revitalising the drug-development pipeline with new targets. As antivirulence drugs disarm the pathogen, rather than kill or halt pathogen growth, it has been hypothesized that they will generate much weaker selection for resistance than traditional antibiotics. However, recent studies have shown that mechanisms of resistance to antivirulence drugs exist, seemingly damaging the 'evolution-proof' claim. In this Opinion article, we highlight a crucial distinction between whether resistance can emerge and whether it will spread to a high frequency under drug selection. We argue that selection for resistance can be reduced, or even reversed, using appropriate combinations of target and treatment environment, opening a path towards the development of evolutionarily robust novel therapeutics.
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References
Davies, J. & Davies, D. Origins and evolution of antibiotic resistance. Microbiol. Mol. Biol. Rev. 74, 417–433 (2010).
Toprak, E. et al. Evolutionary paths to antibiotic resistance under dynamically sustained drug selection. Nature Genet. 44, 101–105 (2012).
D'Costa, V. M. et al. Antibiotic resistance is ancient. Nature 477, 457–461 (2011).
Wright, G. D. The antibiotic resistome: the nexus of chemical and genetic diversity. Nature Rev. Microbiol. 5, 175–186 (2007).
Habets, M. G. J. L. & Brockhurst, M. A. Therapeutic antimicrobial peptides may compromise natural immunity. Biol. Lett. 8, 416–418 (2012).
Lipsitch, M. & Samore, M. H. Antimicrobial use and antimicrobial resistance: a population perspective. Emerg. Infect. Dis. 8, 347–354 (2002).
Andersson, D. I. & Hughes, D. Antibiotic resistance and its cost: is it possible to reverse resistance? Nature Rev. Microbiol. 8, 260–271 (2010).
Schrag, S. J. & Perrot, V. Reducing antibiotic resistance. Nature 381, 120–121 (1996).
Levin, B. R., Perrot, V. & Walker, N. Compensatory mutations, antibiotic resistance and the population genetics of adaptive evolution in bacteria. Genetics 154, 985–997 (2000).
Coates, A. R. M., Halls, G. & Hu, Y. Novel classes of antibiotics or more of the same? Br. J. Pharmacol. 163, 184–194 (2011).
Clatworthy, A. E., Pierson, E. & Hung, D. T. Targeting virulence: a new paradigm for antimicrobial therapy. Nature Chem. Biol. 3, 541–548 (2007).
Rasko, D. A. & Sperandio, V. Anti-virulence strategies to combat bacteria-mediated disease. Nature Rev. Drug Discov. 9, 117–128 (2010).
García-Contreras, R. et al. Resistance to the quorum-quenching compounds brominated furanone C-30 and 5-fluorouracil in Pseudomonas aeruginosa clinical isolates. Pathog. Dis. 68, 8–11 (2013).
Maeda, T. et al. Quorum quenching quandary: resistance to antivirulence compounds. ISME J. 6, 493–501 (2012).
Hung, D. T., Shakhnovich, E. A., Pierson, E. & Mekalanos, J. J. Small-molecule inhibitor of Vibrio cholerae virulence and intestinal colonization. Science 310, 670–674 (2005).
Smith, M. A. et al. Identification of the binding site of Brucella virB8 interaction inhibitors. Chem. Biol. 19, 1041–1048 (2012).
Defoirdt, T., Boon, N. & Bossier, P. Can bacteria evolve resistance to quorum sensing disruption? PLoS Pathog. 6, e1000989 (2010).
García-Contreras, R., Maeda, T. & Wood, T. K. Resistance to quorum quenching compounds. Appl. Environ. Microbiol. 79, 6840–6846 (2013).
Read, A. F., Day, T. & Huijben, S. The evolution of drug resistance and the curious orthodoxy of aggressive chemotherapy. Proc. Natl Acad. Sci. USA 108, 10871–10877 (2011).
D'Costa, V. M., McGrann, K. M., Hughes, D. W. & Wright, G. D. Sampling the antibiotic resistome. Science 311, 374–377 (2006).
Alizon, S., Hurford, A., Mideo, N. & Van Baalen, M. Virulence evolution and the trade-off hypothesis: history, current state of affairs and the future. J. Evol. Biol. 22, 245–259 (2009).
Anderson, R. M. & May, R. M. Coevolution of hosts and parasites. Parasitology 85, 411–426 (1982).
Levin, B. R. & Eden, C. S. Selection and evolution of virulence in bacteria — an ecuminical excursion and modest suggestion. Parasitol. 100, S103–S115 (1990).
Brown, S. P., Cornforth, D. M. & Mideo, N. Evolution of virulence in opportunistic pathogens: generalism, plasticity, and control. Trends Microbiol. 20, 336–342 (2012).
Silverstein, S. C. & Steinberg, T. H. in Microbiology 485–505 (J. B. Lippincott, 1990).
Bae, T. et al. Staphylococcus aureus virulence genes identified by Bursa aurealis mutagenesis and nematode killing. Proc. Natl Acad. Sci. USA 101, 12312–12317 (2004).
Köhler, C.-D. & Dobrindt, U. What defines extraintestinal pathogenic Escherichia coli? Int. J. Med. Microbiol. 301, 642–647 (2011).
Nowrouzian, F. L., Adlerberth, I. & Wold, A. E. Enhanced persistence in the colonic microbiota of Escherichia coli strains belonging to phylogenetic group B2: role of virulence factors and adherence to colonic cells. Microbes Infect. 8, 834–840 (2006).
Diard, M. et al. Pathogenicity-associated islands in extraintestinal pathogenic Escherichia coli are fitness elements involved in intestinal colonization. J. Bacteriol. 192, 4885–4893 (2010).
Alsam, S. et al. Escherichia coli interactions with Acanthamoeba: a symbiosis with environmental and clinical implications. J. Med. Microbiol. 55, 689–694 (2006).
Gall, T. L. et al. Extraintestinal virulence is a coincidental by-product of commensalism in B2 phylogenetic group Escherichia coli strains. Mol. Biol. Evol. 24, 2373–2384 (2007).
Pinkner, J. S. et al. Rationally designed small compounds inhibit pilus biogenesis in uropathogenic bacteria. Proc. Natl Acad. Sci. USA 103, 17897–17902 (2006).
Steinberg, K. M. & Levin, B. R. Grazing protozoa and the evolution of the Escherichia coli O157:H7 Shiga toxin-encoding prophage. Proc. Biol. Sci. 274, 1921–1929 (2007).
Montarry, J., Hamelin, F. M., Glais, I., Corbi, R. & Andrivon, D. Fitness costs associated with unnecessary virulence factors and life history traits: evolutionary insights from the potato late blight pathogen Phytophthora infestans. BMC Evol. Biol. 10, 283 (2010).
Wu, H. et al. Synthetic furanones inhibit quorum-sensing and enhance bacterial clearance in Pseudomonas aeruginosa lung infection in mice. J. Antimicrob. Chemother. 53, 1054–1061 (2004).
Christensen, L. D. et al. Synergistic antibacterial efficacy of early combination treatment with tobramycin and quorum-sensing inhibitors against Pseudomonas aeruginosa in an intraperitoneal foreign-body infection mouse model. J. Antimicrob. Chemother. 67, 1198–1206 (2012).
Oogai, Y. et al. Expression of virulence factors by Staphylococcus aureus grown in serum. Appl. Environ. Microbiol. 77, 8097–8105 (2011).
Genco, C. A. & Dixon, D. W. Emerging strategies in microbial haem capture. Mol. Microbiol. 39, 1–11 (2001).
Stecher, B. et al. Salmonella enterica serovar typhimurium exploits inflammation to compete with the intestinal microbiota. PLoS Biol. 5, 2177–2189 (2007).
Lysenko, E. S., Lijek, R. S., Brown, S. P. & Weiser, J. N. Within-host competition drives selection for the capsule virulence determinant of Streptococcus pneumoniae. Curr. Biol. 20, 1222–1226 (2010).
Levin, B. R. & Bull, J. J. Short-sighted evolution and the virulence of pathogenic microorganisms. Trends Microbiol. 2, 76–81 (1994).
Liu, C.-I. et al. A cholesterol biosynthesis inhibitor blocks Staphylococcus aureus virulence. Science 319, 1391–1394 (2008).
Hall, A. R., Griffiths, V. F., MacLean, R. C. & Colegrave, N. Mutational neighbourhood and mutation supply rate constrain adaptation in Pseudomonas aeruginosa. Proc.Biol. Sci. 277, 643–650 (2010).
Dyken, J. D. V. & Wade, M. J. The genetic signature of conditional expression. Genetics 184, 557–570 (2010).
Sokurenko, E. V., Gomulkiewicz, R. & Dykhuizen, D. E. Source-sink dynamics of virulence evolution. Nature Rev. Microbiol. 4, 548–555 (2006).
Meyers, L. A., Levin, B. R., Richardson, A. R. & Stojiljkovic, I. Epidemiology, hypermutation, within-host evolution and the virulence of Neisseria meningitidis. Proc. Biol. Sci. 270, 1667–1677 (2003).
Nogueira, T., Touchon, M. & Rocha, E. P. C. Rapid evolution of the sequences and gene repertoires of secreted proteins in bacteria. PLoS ONE 7, e49403 (2012).
Brown, S. P., Hochberg, M. E. & Grenfell, B. T. Does multiple infection select for raised virulence? Trends Microbiol. 10, 401–405 (2002).
Buckling, A. et al. Siderophore-mediated cooperation and virulence in Pseudomonas aeruginosa. FEMS Microbiol. Ecol. 62, 135–141 (2007).
Nogueira, T. et al. Horizontal gene transfer of the secretome drives the evolution of bacterial cooperation and virulence. Curr. Biol. 19, 1683–1691 (2009).
Rumbaugh, K. P. et al. Quorum sensing and the social evolution of bacterial virulence. Curr. Biol. 19, 341–345 (2009).
West, S. A., Diggle, S. P., Buckling, A., Gardner, A. & Griffins, A. S. The social lives of microbes. Annu. Rev. Ecol. Evol. Systemat. 38, 53–77 (2007).
André, J. & Godelle, B. Multicellular organization in bacteria as a target for drug therapy. Ecol. Lett. 8, 800–810 (2005).
Griffin, A. S., West, S. A. & Buckling, A. Cooperation and competition in pathogenic bacteria. Nature 430, 1024–1027 (2004).
Brown, S. P., West, S. A., Diggle, S. P. & Griffin, A. S. Social evolution in micro-organisms and a Trojan horse approach to medical intervention strategies. Philos. Trans. R. Soc.Lond. B. Biol. Sci. 364, 3157–3168 (2009).
Harrison, F., Browning, L. E., Vos, M. & Buckling, A. Cooperation and virulence in acute Pseudomonas aeruginosa infections. BMC Biol. 4 (2006).
Mellbye, B. & Schuster, M. The sociomicrobiology of antivirulence drug resistance: a proof of concept. mBio 2, e00131–11 (2011).
Ross-Gillespie, A., Weigert, M., Brown, S. P. & Kümmerli, R. Gallium-mediated siderophore quenching as an evolutionarily robust antibacterial treatment. Evol. Med. Public Health 1, 18–29 (2014).
Hamilton, W. Genetical evolution of social behaviour I. J. Theor. Biol. 7, 1–16 (1964).
Diggle, S. P., Griffin, A. S., Campbell, G. S. & West, S. A. Cooperation and conflict in quorum-sensing bacterial populations. Nature 450, 411–417 (2007).
Kümmerli, R., Griffin, A. S., West, S. A., Buckling, A. & Harrison, F. Viscous medium promotes cooperation in the pathogenic bacterium Pseudomonas aeruginosa. Proc. Biol. Sci. 276, 3531–3538 (2009).
Grant, A. J. et al. Modelling within-host spatiotemporal dynamics of invasive bacterial disease. PLoS Biol. 6, 757–770 (2008).
Willner, D. et al. Spatial distribution of microbial communities in the cystic fibrosis lung. ISME J. 6, 471–474 (2012).
Costerton, J. W., Stewart, P. S. & Greenberg, E. P. Bacterial biofilms: a common cause of persistent infections. Science 284, 1318–1322 (1999).
Kreft, J. U. Biofilms promote altruism. Microbiology 150, 2751–2760 (2004).
Zhu, J. et al. Analogs of the autoinducer 3-oxooctanoyl-homoserine lactone strongly inhibit activity of the traR protein of Agrobacterium tumefaciens. J. Bacteriol. 180, 5398–5405 (1998).
Koch, B. et al. The LuxR receptor: the sites of interaction with quorum-sensing signals and inhibitors. Microbiology 151, 3589–3602 (2005).
Eldar, A. Social conflict drives the evolutionary divergence of quorum sensing. Proc. Natl Acad. Sci. USA 108, 13635–13640 (2011).
Wright, J. S. et al. The agr radiation: an early event in the evolution of staphylococci. J. Bacteriol. 187, 5585–5594 (2005).
Joelsson, A., Liu, Z. & Zhu, J. Genetic and phenotypic diversity of quorum-sensing systems in clinical and environmental isolates of Vibrio cholerae. Infect. Immun. 74, 1141–1147 (2006).
Defoirdt, T. et al. The natural furanone (5Z)-4-bromo-5-(bromomethylene)-3-butyl-2(5H)-furanone disrupts quorum sensing-regulated gene expression in Vibrio harveyi by decreasing the DNA-binding activity of the transcriptional regulator protein luxR. Environ. Microbiol. 9, 2486–2495 (2007).
Chugani, S. et al. Strain-dependent diversity in the Pseudomonas aeruginosa quorum-sensing regulon. Proc. Natl Acad. Sci. USA 109, E2823–E2831 (2012).
Dandekar, A. A., Chugani, S. & Greenberg, E. P. Bacterial quorum sensing and metabolic incentives to cooperate. Science 338, 264–266 (2012).
Schramm, V. L. et al. Transition state analogues in quorum sensing and SAM recycling. Nucleic Acids Symp. Ser. 52, 75–76 (2008).
Park, J. et al. Infection control by antibody disruption of bacterial quorum sensing signaling. Chem. Biol. 14, 1119–1127 (2007).
Wilder, C. N., Diggle, S. P. & Schuster, M. Cooperation and cheating in Pseudomonas aeruginosa: the roles of the las, rhl and pqs quorum-sensing systems. ISME J. 5, 1332–1343 (2011).
Schuster, M. & Greenberg, E. P. A network of networks: quorum-sensing gene regulation in Pseudomonas aeruginosa. Int. J. Med. Microbiol. 296, 73–81 (2006).
Schuster, M., Lostroh, C., Ogi, T. & Greenberg, E. P. Identification, timing, and signal specificity of Pseudomonas aeruginosa quorum-controlled genes: a transcriptome analysis. J. Bacteriol. 185, 2066–2079 (2003).
O'Loughlin, C. T. et al. A quorum-sensing inhibitor blocks Pseudomonas aeruginosa virulence and biofilm formation. Proc. Natl Acad. Sci. USA 110, 17981–17986 (2013).
Vale, P. F., Fenton, A. & Brown, S. P. Limiting damage during infection: lessons from infection tolerance for novel therapeutics. PLoS Biol. 12, e1001769 (2014).
Gandon, S., Mackinnon, M. J., Nee, S. & Read, A. F. Imperfect vaccines and the evolution of pathogen virulence. Nature 414, 751–756 (2001).
Köhler, T., Perron, G. G., Buckling, A. & van Delden, C. Quorum sensing inhibition selects for virulence and cooperation in Pseudomonas aeruginosa. PLoS Pathog. 6, e1000883 (2010).
Soubeyrand, B. & Plotkin, S. A. Microbial evolution — antitoxin vaccines and pathogen virulence. Nature 417, 609–610 (2002).
Pappenheimer, A. in Bacterial Vaccines (Ed. Germanier, R. ) 1–36 (Academic Press, 1984).
Gandon, S. & Day, T. Evidences of parasite evolution after vaccination. Vaccine 26, (Suppl. 3), C4–C7 (2008).
Lowy, I. et al. Treatment with monoclonal antibodies against Clostridium difficile toxins. N. Engl. J. Med. 362, 197–205 (2010).
López, E. L. et al. Safety and pharmacokinetics of urtoxazumab, a humanized monoclonal antibody, against Shiga-like toxin 2 in healthy adults and in pediatric patients infected with Shiga-like toxin-producing Escherichia coli. Antimicrob. Agents Chemother. 54, 239–243 (2010).
Filippov, A. A. et al. Bacteriophage-resistant mutants in Yersinia pestis: identification of phage receptors and attenuation for mice. PLoS ONE 6, e25486 (2011).
Smith, H. W., Huggins, M. B. & Shaw, K. M. The control of experimental Escherichia coli diarrhoea in calves by means of bacteriophages. J. Gen. Microbiol. 133, 1111–1126 (1987).
Rasmussen, T. B. et al. Screening for quorum-sensing inhibitors (QSI) by use of a novel genetic system, the QSI selector. J. Bacteriol. 187, 1799–1814 (2005).
Felise, H. B. et al. An inhibitor of Gram-negative bacterial virulence protein secretion. Cell Host Microbe 4, 325–336 (2008).
Hong, K.-W., Koh, C.-L., Sam, C.-K., Yin, W.-F. & Chan, K.-G. Quorum quenching revisited — from signal decays to signalling confusion. Sensors 12, 4661–4696 (2012).
Chait, R., Craney, A. & Kishony, R. Antibiotic interactions that select against resistance. Nature 446, 668–671 (2007).
Fernebro, J. Fighting bacterial infections — future treatment options. Drug Resist. Updat. 14, 125–139 (2011).
Wang, D. et al. Identification of bacterial target proteins for the salicylidene acylhydrazide class of virulence-blocking compounds. J. Biol. Chem. 286, 29922–29931 (2011).
Yamagami, S. et al. Efficacy of postinfection treatment with anti-shiga toxin (stx) 2 humanized monoclonal antibody tma-15 in mice lethally challenged with stx-producing Escherichia coli. J. Infect. Dis. 184, 738–742 (2001).
Dong, Y. H. et al. Quenching quorum-sensing-dependent bacterial infection by an N-acyl homoserine lactonase. Nature 411, 813–817 (2001).
Hentzer, M. et al. Inhibition of quorum sensing in Pseudomonas aeruginosa biofilm bacteria by a halogenated furanone compound. Microbiology 148, 87–102 (2002).
Rutherford, S. T. & Bassler, B. L. Bacterial quorum sensing: its role in virulence and possibilities for its control. Cold Spring Harb. Perspect. Med. 2, a012427 (2012).
Gilbert, K. B., Kim, T. H., Gupta, R., Greenberg, E. P. & Schuster, M. Global position analysis of the Pseudomonas aeruginosa quorum-sensing transcription factor LasR. Mol. Microbiol. 73, 1072–1085 (2009).
Wright, J. S., Jin, R. & Novick, R. P. Transient interference with staphylococcal quorum sensing blocks abscess formation. Proc. Natl Acad. Sci. USA 102, 1691–1696 (2005).
Papaioannou, E. et al. Quorum-quenching acylase reduces the virulence of Pseudomonas aeruginosa in a Caenorhabditis elegans infection model. Antimicrob. Agents Chemother. 53, 4891–4897 (2009).
Smith, J. M. & Harper, D. Animal Signals. (OUP Oxford, 2003).
Ishida, T. et al. Inhibition of quorum sensing in Pseudomonas aeruginosa by N-acyl cyclopentylamides. Appl. Environ. Microbiol. 73, 3183–3188 (2007).
Brackman, G. et al. Structure–activity relationship of cinnamaldehyde analogs as inhibitors of ai-2 based quorum sensing and their effect on virulence of Vibrio spp. PLoS ONE 6, e16084 (2011).
Ni, N., Li, M., Wang, J. & Wang, B. Inhibitors and antagonists of bacterial quorum sensing. Med. Res. Rev. 29, 65–124 (2009).
Kaufmann, G. F. et al. Antibody interference with N-acyl homoserine lactone-mediated bacterial quorum sensing. J. Am. Chem. Soc. 128, 2802–2803 (2006).
Acknowledgements
The authors thank D. Cornforth, P. Vale, R. Kümmerli, A. Ross-Gillespie, R. Fitzgerald and three anonymous reviewers for comments and discussion. S.P.B. was funded by the Wellcome Trust, UK (grant number WT082273), and the Engineering and Physical Sciences Research Council (EPSRC), UK (grant number EP/H032436/1). S.P.D. was funded by the Royal Society, UK, and the Natural Environment Research Council (NERC), UK (grant number NE/J007064/1). R.C.A. was funded by the Natural Environment Research Council (NERC).
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Allen, R., Popat, R., Diggle, S. et al. Targeting virulence: can we make evolution-proof drugs?. Nat Rev Microbiol 12, 300–308 (2014). https://doi.org/10.1038/nrmicro3232
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DOI: https://doi.org/10.1038/nrmicro3232