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Nosocomial outbreaks attributable to glutaraldehyde-resistant, rapidly growing mycobacteria are increasing. Here, evidence is provided that defects in porin expression dramatically increase the resistance of Mycobacterium smegmatis and Mycobacterium chelonae to glutaraldehyde and another aldehyde disinfectant, ortho-phthalaldehyde. Since defects in porin activity also dramatically increased the resistance of M. chelonae to drugs, there is thus some concern that the widespread use of glutaraldehyde and ortho-phthalaldehyde in clinical settings may select for drug-resistant bacteria.
Rapidly growing mycobacteria (RGM) are ubiquitous in hospitals' water sources and cause outbreaks in health care settings throughout the world (7, 22, 23, 31). Among the effective options for the disinfection of semicritical, temperature-sensitive medical devices, glutaraldehyde (GTA) remains the most widely used chemical disinfectant in hospitals worldwide due to its effective mycobactericidal activity and relatively low cost (Fig. (Fig.1).1). Recent reports suggest, however, that RGM are being isolated with increasing frequency from washer disinfectors and GTA-processed endoscopes, with recent Mycobacterium chelonae and Mycobacterium massiliense outbreaks being associated with the development of resistance to GTA (4, 8, 10, 17, 30).
GTA is thought to be predominantly a surface-reactive biocide which forms bridges or cross-links with amino groups of proteins exposed at the surface of bacterial cells (17). Although the mechanisms of resistance of mycobacteria to the disinfectant are not known, it is thus reasonable to assume that changes in the cell surface resulting in decreased binding and/or penetration of GTA may be mechanisms through which RGM develop resistance. Because of the significant role played by the mycobacterial outer membrane in drug susceptibility (3, 12) and host-pathogen interactions (5), there is thus some concern that the widespread use of GTA in clinical settings selects for resistant populations of bacteria, with possible consequences on antibiotic resistance and pathogenicity.
Amino group-containing compounds susceptible to binding GTA at the surface of RGM include surface-exposed proteins—among which are porins—and glycopeptidolipids. In addition, cell wall (lipo)polysaccharides have been proposed to affect the susceptibility of M. chelonae to GTA (15). To assess the impact of these cell envelope compounds on the resistance of Mycobacterium smegmatis to GTA, mc2155 isogenic mutants deficient in different aspects of their biosynthesis (Table (Table1)1) were compared to their respective wild-type (WT) parent for GTA resistance, using the suspension test described by Griffiths et al. (10). Mutants deficient in other factors known to significantly affect the susceptibility of M. smegmatis to biocides, such as phosphatidylinositol mannosides, the Lsr2 protein, and mycothiols, were also included in this study. The mutants fell into roughly three categories: (i) those whose susceptibility to GTA was not significantly altered (mc2155ΔMSMEG4250, mc2155ΔpimE, mc2155Δlsr2, Myc55, A1) (data not shown), (ii) those showing a slight increase in susceptibility (mc2155ΔMS-MEG4245, mc2155ΔembA, mc2155ΔembB) (Fig. (Fig.2A),2A), and (iii) those displaying a significantly increased resistance to the disinfectant. The last category clearly included the mspA and mspA-mspC porin mutants, MN01 and ML10 (Fig. (Fig.2B).2B). MspA is the main porin, constituting more than 70% of all pores of M. smegmatis (27). The ML10 mutant has at least 15- and 5-fold less porins than WT M. smegmatis and MN01, respectively (28). Complementation of MN01 and ML10 with plasmid pMN013 carrying a WT copy of the mspA gene restored the sensitivity of both mutants to GTA (Fig. (Fig.2B).2B). Interestingly, ML10 and MN01 were also the only mutants to be significantly more resistant to ortho-phthalaldehyde (OPA) (Fig. (Fig.11 and and2C),2C), implying the existence of at least one common mechanism of resistance to both aldehyde disinfectants.
To investigate whether defects in porin production and/or surface exposure might contribute to GTA and OPA resistance in field isolates of RGM, we next analyzed a clinical isolate of M. chelonae (strain 9917) displaying high levels of resistance to both disinfectants (Fig. (Fig.3).3). A search for msp-like porin genes in the genome of M. chelonae ATCC 35752 identified three clustered open reading frames, MCH_4689c, MCH_4690c, and MCH_4691c, sharing about 73% identity at the amino acid level with the mature MspA protein from M. smegmatis mc2155. Sequencing of these genes in M. chelonae 9917 revealed a frameshift mutation at codon 137 of MCH_4689c, resulting in a 40-amino-acid truncation of its protein product. Unfortunately, attempts to determine porin production in strains 9917 and ATCC 35752 by immunoblot analysis using polyclonal antibodies directed against the MspA protein of M. smegmatis (20) were unsuccessful. No proteins of the expected size were detected, suggesting that the anti-MspA antibodies do not cross-react with the porins of M. chelonae or that porin expression was too low under the experimental conditions used to detect by immunoblot analysis.
The porin-mediated influx of nutrients was shown to be a major determinant of the growth rates of M. smegmatis and Mycobacterium fortuitum (24, 28). Consistent with a defect in porin activity, strain 9917 grew significantly slower than did M. chelonae ATCC 35752 in 7H9 broth at 30°C (Fig. (Fig.4A)4A) and was on average 5.7 ± 0.2-fold less proficient at taking up [U-14C]glucose (Fig. (Fig.4B).4B). As expected, expression of the M. smegmatis mspA gene from the replicative plasmid pZS01 in M. chelonae 9917 partially restored growth (Fig. (Fig.4A).4A). Importantly, expression of mspA in both M. chelonae 9917 and ATCC 35752 also resulted in increased susceptibilities to GTA (Fig. 3A and B) and OPA (Fig. (Fig.3C),3C), although this effect was significantly more marked with the latter disinfectant in strain 9917. These different effects of expressing mspA on the susceptibility of M. chelonae 9917 and ATCC 35752 to OPA and GTA may be accounted for by differences in composition and structure of the outer membranes of these two strains and the different modes of action of the two disinfectants (17).
Compared to the reference strain, M. chelonae ATCC 35752, strain 9917 displayed dramatically increased (4- to >100-fold) resistance to rifampin (rifampicin), vancomycin, ciprofloxacin, clarithromycin, erythromycin, linezolid, and tetracycline (Table (Table2).2). Strongly supporting the involvement of porins in the resistance phenotypes of 9917, expression of the mspA gene from M. smegmatis in this strain increased 5- to >500-fold its susceptibility to these drugs (Table (Table2).2). Interestingly, expression of mspA from pZS01 also increased 5- to 25-fold the susceptibility of the reference strain to erythromycin, rifampin, linezolid, and tetracycline and 2- to >20-fold the susceptibility of both M. chelonae ATCC 35752 and 9917 to ethambutol, ethionamide, and chloramphenicol (Table (Table2).2). These results, which show a much more pronounced effect of porin expression on the drug susceptibility of M. chelonae than on that of M. smegmatis (6, 29), could reflect important differences in the outer membrane organization and drug efflux mechanisms of these two rapidly growing Mycobacterium spp. (21).
Altogether, our data thus suggest that the Msp-like porin content of M. smegmatis and M. chelonae is a major determinant of the susceptibility of both species to GTA and OPA. Given the known functional similarities shared by the outer membranes of mycobacteria and gram-negative bacteria (3, 11-12, 18, 33), it is tempting to speculate that Pseudomonas aeruginosa and other gram-negative opportunistic pathogens may have or could adopt a similar strategy to resist aldehyde disinfectants.
Importantly, the results of this study support the hypothesis that GTA-resistant isolates are likely to develop cross-resistances to multiple antibiotics, including some used in the clinical treatment of RGM infections. Moreover, because porins have been shown to play important roles in the pathogenicity of a number of intracellular and extracellular pathogens (1), including M. smegmatis (25), our results also raise concerns that the selection of GTA-resistant organisms may impact their pathogenicity.
The accession numbers corresponding to the porin genes of M. chelonae ATCC 35752 are FJ981588 (MCH_4689c), FJ981589 (MCH_4690c), and FJ981590 (MCH_4691c).
We wish to thank M. Daffé (CNRS-IPBS, Toulouse, France), J.-M. Reyrat (INSERM U570, Paris, France), J. Dahl (Washington State University, Pullman, WA), Y. Av-Gay (University of British Columbia, Vancouver, British Columbia, Canada), and D. Chatterjee and D. Kaur (CSU, Fort Collins, CO) for providing the M. smegmatis isogenic mutants described in Table Table11 and F. Ripoll for sequence deposition.
This work received partial support from STERIS Corporation.
Published ahead of print on 6 July 2009.