The Role of Toll-Like Receptor-2 in Clostridioides difficile Infection: Evidence From a Mouse Model and Clinical Patients

Background Clostridioides difficile is the leading cause of nosocomial infectious diarrhea. Toll-like receptors (TLRs) are the major components of innate immunity that sense pathogens. The relationship between TLRs and C. difficile infection (CDI) was analyzed in clinical patients and a mouse model. Materials and Methods A prospective investigation was conducted in medical wards of Tainan Hospital, Ministry of Health and Welfare, Tainan, Taiwan, from January 2011 to January 2013. Adult patients were followed up for the development of CDI. Single nucleotide polymorphisms (SNPs) of TLR2 and TLR4 were analyzed to assess the relationship between genetic polymorphisms and the development of CDI. A mouse model of CDI was used to investigate the pathogenic role of TLRs in CDI, TLR2 and TLR4 knockout (Tlr2-/- and Tlr4-/-) mice. Results In the prospective study, 556 patients were enrolled, and 6.5% (36) of patients, accounting for 3.59 episodes per 1000 patient-days, developed CDI. Of 539 patients with available blood samples, the TLR2 rs3804099 polymorphism was more often noted in those with CDI than in those without CDI (64.5% vs. 46.1%; P = 0.046) but was not significant in multivariate analysis. Because the TLR2 rs3804099 polymorphism was moderately associated with CDI, the role of TLR2 and TLR4 was further evaluated in a mouse model. Both Tlr2-/- and Tlr4-/- mice showed more severe CDI disease than wild-type mice in terms of body weight change and fecal content five days after oral challenge with C. difficile. Furthermore, Tlr2-/- mice suffered from more severe disease than Tlr4-/- mice, as evidenced by stool consistency, cecum weight, and survival rate. Conclusion The TLR2 rs3804099 polymorphism is marginally associated with the development of CDI, and the pathogenic role of TLR2 is further supported by a mouse model.

[1]  Yingchi Zhang,et al.  Toll-Like Receptors Gene Polymorphisms in Autoimmune Disease , 2021, Frontiers in Immunology.

[2]  P. Tsai,et al.  Clostridioides difficile infection in patients with hematological malignancy: A multicenter study in Taiwan. , 2021, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[3]  Yu Man,et al.  Molecular characterization of Clostridioides difficile ribotype 027 in a major Chinese hospital. , 2021, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[4]  D. Golenbock,et al.  Clostridioides difficile Toxin A Remodels Membranes and Mediates DNA Entry Into Cells to Activate Toll Like Receptor 9 Signaling. , 2020, Gastroenterology.

[5]  P. Tsai,et al.  Severe Clostridium difficile infections in intensive care units: Diverse clinical presentations. , 2020, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[6]  A. Tanoğlu,et al.  Polymorphisms in Toll-like receptors 1, 2, 5, and 10 are associated with predisposition to Helicobacter pylori infection , 2020, European journal of gastroenterology & hepatology.

[7]  E. Goloni-Bertollo,et al.  Characterization and strong risk association of TLR2 del -196 to -174 polymorphism and Helicobacter pylori and their influence on mRNA expression in gastric cancer , 2020, World journal of gastrointestinal oncology.

[8]  Ting-Yu Yen,et al.  Recommendations and guidelines for the treatment of Clostridioides difficile infection in Taiwan. , 2020, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[9]  P. Tsai,et al.  Risk factors of Clostridium difficile-associated diarrhea in hospitalized adults: Vary by hospitalized duration. , 2019, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[10]  P. Hsueh,et al.  Increased age and proton pump inhibitors are associated with severe Clostridium difficile infections in children. , 2020, Journal of microbiology, immunology, and infection = Wei mian yu gan ran za zhi.

[11]  A. Jafarzadeh,et al.  Association of a single nucleotide polymorphism in the TLR2 gene (rs3804099), but not in the TLR4 gene (rs4986790), with Helicobacter pylori infection and peptic ulcer. , 2018, The Turkish journal of gastroenterology : the official journal of Turkish Society of Gastroenterology.

[12]  Je Chul Lee,et al.  Clostridium difficile-derived membrane vesicles induce the expression of pro-inflammatory cytokine genes and cytotoxicity in colonic epithelial cells in vitro. , 2017, Microbial pathogenesis.

[13]  P. Machado,et al.  Polymorphisms in genes TLR1, 2 and 4 are associated with differential cytokine and chemokine serum production in patients with leprosy , 2017, Memorias do Instituto Oswaldo Cruz.

[14]  D. Gerding,et al.  Bezlotoxumab for Prevention of Recurrent Clostridium difficile Infection , 2017, The New England journal of medicine.

[15]  P. Tsai,et al.  Proton-Pump Inhibitor Exposure Aggravates Clostridium difficile-Associated Colitis: Evidence From a Mouse Model. , 2015, The Journal of infectious diseases.

[16]  P. Tsai,et al.  The first case of severe Clostridium difficile ribotype 027 infection in Taiwan. , 2015, The Journal of infection.

[17]  D. Aronoff,et al.  The Systemic Inflammatory Response to Clostridium difficile Infection , 2014, PloS one.

[18]  C. Carratelli,et al.  Lactobacillus crispatus modulates epithelial cell defense against Candida albicans through Toll-like receptors 2 and 4, interleukin 8 and human β-defensins 2 and 3. , 2013, Immunology letters.

[19]  P. Tsai,et al.  Risk Factors of Fecal Toxigenic or Non-Toxigenic Clostridium difficile Colonization: Impact of Toll-Like Receptor Polymorphisms and Prior Antibiotic Exposure , 2013, PloS one.

[20]  D. Ho,et al.  Toll-Like Receptor 5-Dependent Immunogenicity and Protective Efficacy of a Recombinant Fusion Protein Vaccine Containing the Nontoxic Domains of Clostridium difficile Toxins A and B and Salmonella enterica Serovar Typhimurium Flagellin in a Mouse Model of Clostridium difficile Disease , 2013, Infection and Immunity.

[21]  Xiang Gao,et al.  Polymorphisms in toll-like receptors 2, 4 and 5 are associated with Legionella pneumophila infection , 2013, Infection.

[22]  H. Yotsuyanagi,et al.  Clostridium difficile flagellin stimulates toll-like receptor 5, and toxin B promotes flagellin-induced chemokine production via TLR5. , 2013, Life sciences.

[23]  I. Brukner,et al.  Host and pathogen factors for Clostridium difficile infection and colonization. , 2011, The New England journal of medicine.

[24]  G. Perdigón,et al.  Oral administration of a probiotic Lactobacillus modulates cytokine production and TLR expression improving the immune response against Salmonella enterica serovar Typhimurium infection in mice , 2011, BMC Microbiology.

[25]  A. Ryan,et al.  A Role for TLR4 in Clostridium difficile Infection and the Recognition of Surface Layer Proteins , 2011, PLoS pathogens.

[26]  Baiyong Shen,et al.  Single Nucleotide Polymorphisms of Toll-Like Receptor 4 Decrease the Risk of Development of Hepatocellular Carcinoma , 2011, PloS one.

[27]  E. Pamer,et al.  Toll-Like Receptor 5 Stimulation Protects Mice from Acute Clostridium difficile Colitis , 2011, Infection and Immunity.

[28]  L. Zeng,et al.  Identification of Haplotype Tag SNPs Within the Entire TLR2 Gene and Their Clinical Relevance in Patients With Major Trauma , 2011, Shock.

[29]  G. Jin,et al.  Polymorphisms in toll-like receptor 4 gene are associated with asthma severity but not susceptibility in a Chinese Han population. , 2011, Journal of investigational allergology & clinical immunology.

[30]  V. Tam,et al.  A common polymorphism in the interleukin-8 gene promoter is associated with an increased risk for recurrent Clostridium difficile infection. , 2010, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[31]  Lena Holm,et al.  Bacteria Penetrate the Inner Mucus Layer before Inflammation in the Dextran Sulfate Colitis Model , 2010, PloS one.

[32]  M. Kleerebezem,et al.  Regulation of human epithelial tight junction proteins by Lactobacillus plantarum in vivo and protective effects on the epithelial barrier. , 2010, American journal of physiology. Gastrointestinal and liver physiology.

[33]  G. Konat,et al.  Rho proteins are negative regulators of TLR2, TLR3, and TLR4 signaling in astrocytes , 2009, Journal of neuroscience research.

[34]  F. Tsai,et al.  STAT2*C related genotypes and allele but not TLR4 and CD40 gene polymorphisms are associated with higher susceptibility for asthma , 2009, International journal of biological sciences.

[35]  C. Kelly,et al.  Clostridium difficile--more difficult than ever. , 2008, The New England journal of medicine.

[36]  M. Wilcox,et al.  Clostridium difficile: changing epidemiology and new treatment options , 2007, Current opinion in infectious diseases.

[37]  J. Chiche,et al.  The importance of Toll-like receptor 2 polymorphisms in severe infections. , 2005, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[38]  D. Schwartz,et al.  Polymorphisms of the Toll-like receptors and human disease. , 2005, Clinical infectious diseases : an official publication of the Infectious Diseases Society of America.

[39]  G. Hansson,et al.  Toll to be paid at the gateway to the vessel wall. , 2005, Arteriosclerosis, thrombosis, and vascular biology.

[40]  A. Blum,et al.  Oral administration of antigens from intestinal flora anaerobic bacteria reduces the severity of experimental acute colitis in BALB/c mice , 2000, Clinical and experimental immunology.

[41]  A. W. van der Velden,et al.  The role of the 5' untranslated region of an mRNA in translation regulation during development. , 1999, The international journal of biochemistry & cell biology.

[42]  T. Monath,et al.  Evaluation of formalin-inactivated Clostridium difficile vaccines administered by parenteral and mucosal routes of immunization in hamsters , 1995, Infection and immunity.