The Chlamydiaceae are widespread pathogens of both humans and animals. Chlamydia trachomatis infection causes blinding trachoma and reproductive complications in humans. Chlamydia pneumoniae causes human respiratory tract infections and atypical pneumonia. Chlamydia suis infection is associated with conjunctivitis, diarrhea, and failure to gain weight in domestic swine. Chlamydial infections in humans and domesticated animals are generally controlled by antibiotic treatment—particularly macrolides (usually azithromycin) and tetracyclines (tetracycline and doxycycline). Tetracycline-containing feed has also been used to limit infections and promote growth in livestock populations, although its use has decreased because of growing concerns about antimicrobial resistance development. Because Sandoz and Rockey published an elegant review of chlamydial anti-microbial resistance in 2010, we will review the following: (i) antibiotic resistance in C. suis, (ii) recent evidence for acquired resistance in human chlamydial infections, and (iii) recent non-genetic mechanisms of antibiotic resistance that may contribute to treatment failure.

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.

The obligate intracellular bacterium, Chlamydia trachomatis, and Herpes Simplex Virus Type-2 (HSV-2) are the leading sexually transmitted pathogens in the world. These infections are usually asymptomatic and clinically mild, but complications can be severe. Reports of dual detection of Chlamydia and HSV within the genital tracts of humans led our laboratory to develop an in vitro Chlamydia/HSV co-infection model. Little is known regarding the specific pathogenesis of Chlamydia and HSV co-infections, but HSV-super-infection of Chlamydia-infected cells caused the chlamydiae to deviate from their normal developmental cycle into a non-replicative state termed persistence, or the chlamydial stress response. Interactions between HSV envelope protein, gD with host cell junction protein, nectin-1, were enough to stimulate the departure from normal chlamydial development. Additional data also suggested that there might be differences between single infection and co-infection outcomes in vivo. Thus, two diverging hypotheses were investigated here: i) that host nectin-1 is required for normal chlamydial development; and ii) that pathogen shedding and/or disease progression in Chlamydia and HSV-2 co-infected animals will differ from that observed in singly-infected animals. Chlamydial infection of nectin-1 knockdown cell lines revealed no inhibition of chlamydial entry, but significant reductions in inclusion size and production of infectious chlamydiae. Additionally, nectin-1 knockout mice shed fewer Chlamydia compared to wild type mice. In other studies, we developed a novel in vivo Chlamydia and HSV-2 intravaginal super-infection model in BALB/c mice. Infection with Chlamydia muridarum, followed up to 9 days later by HSV-2 super-infection, both reduced HSV shedding and protected mice from HSV-induced fatal neurologic disease compared to HSV singly-infected animals. Protection is lost when: i) infected animals are no longer shedding C. muridarum; ii) when mice are inoculated with UV-inactivated C. muridarum; or iii) when viable chlamydiae are eliminated from the genital tract using antibiotics prior to HSV-2 super-infection. Altogether, we have determined that host nectin-1 is required for chlamydial development both in vitro and in vivo, and that chlamydial pre-infection protects mice from subsequent HSV infection. We predict that these observations may lead to novel approaches to prevent human infection by these two common sexually transmitted pathogens.

Chlamydia trachomatis is the most common sexually transmitted bacterial disease agent worldwide, and, though frequently asymptomatic, can cause extreme pathology including infertility. Chlamydial species exhibit a unique biphasic developmental cycle. Once attached to a cell surface, infectious elementary bodies (EB) are internalized within an inclusion, the membrane-bound structure in which EB transform to noninfectious, replicable reticulate bodies (RB). After multiple rounds of division, RB condense to form EB, which are released and can infect new host cells. In culture, exposure to stressors, such as beta-lactam antibiotics, induce chlamydiae to reversibly detour from normal development into a noninfectious, viable state termed persistence. Cell culture data suggest that persistent forms are resistant to azithromycin (AZM), a front-line antibiotic, and are able to alter the host transcriptome. Though persistence has been described in culture for over 50 years, whether or not it: i) occurs in vivo; and ii) influences chlamydial pathogenesis, transmission and therapy has remained unresolved. To address these questions, we developed an animal model of persistent chlamydial infection using amoxicillin (AMX) treatment. AMX exposure decreased shedding of infectious chlamydiae in C. muridarum-infected mice without affecting chlamydial viability, demonstrating the presence of persistent chlamydiae. Shedding of infectious EB resumed following AMX cessation. Shedding data and microarray analyses suggested that host immunity might limit chlamydia’s exit from persistence in our model. Thus, we hypothesized that cyclophosphamide (CTX) treatment would increase the magnitude of chlamydial shedding observed after AMX-treatment cessation. CTX treatment increased post-AMX shedding by more than 10-fold compared to AMX-only controls. To determine whether persistent chlamydiae are resistant to antibiotic eradication in vivo, we induced persistence by administering AMX and treated mice with various AZM dosing regimes. Persistently infected mice demonstrated increased treatment failure following AZM therapy compared to productively infected controls. These data suggest that persistent chlamydiae are refractory to treatment in vivo and provide an explanation for the observation that treatment fails in some patients. In addition to creating the first fully characterized, experimentally tractable, in vivo model of chlamydial persistence, these experiments provide evidence that persistent/stressed chlamydial forms may serve as a long-term reservoir of infectious organisms in vivo.