Identifying resistance genes in tuberculosis

Newly published in PLOS Biology is our work identifying genes that confer resistance to common and last-resort antibiotics in bacteria that cause tuberculosis. Resistance to these drugs contributes to mortality and sickness on a pandemic scale every year, and disproportionately affects the poorest people in the world.

This new article is one of a series presenting results generated by more than 100 scientists across 23 countries across 5+ years as part of a collaboration called CRyPTIC.

Our role in CRyPTIC was the discovery of genes and mutations likely to cause drug resistance by applying a tool known as a genome-wide association study (GWAS), an approach we helped adapt to bacteria.

Using GWAS, we identified previously uncatalogued genes and mutations underlying resistance to every one of the 13 drugs we investigated. These include new and repurposed drugs, as well as the first- and second-line drugs more often used to treat tuberculosis.

Thanks to its generous funders, CRyPTIC dedicated scale (10,000+ genomes) and technical innovation (new high-throughput MIC assays) to help decode the DNA blueprint of antibiotic resistance. Pushing these boundaries has yielded a steep increase of up to 36% in the variation in resistance attributable to the genome for the important and previously understudied new and repurposed drugs.

Science at this scale can produce a seemingly overwhelming wealth of new information. We avoided the temptation to over-emphasize any individual result for the sake of simple narrative. Instead, we highlighted discoveries of uncatalogued genes or genetic variants that we found for every drug investigated:

• The amidase AmiA2 and GTPase Era for bedaquiline.

• The cytochrome P450 enzyme Cyp142 for clofazimine.

• The serine/threonine protein kinase PknH for delaminid.

• The antitoxin VapB20 for linezolid.

• The PPE-motif family outer membrane protein PPE42 for amikacin and kanamycin.

• The antibiotic-induced transcriptional regulator WhiB7 for ethionamide.

• The rRNA methylase TlyA for levofloxacin.

• The DNA gyrase subunit B GyrB for moxifloxacin.

• The putative rhodaneses CysA2 and CysA3 for rifabutin.

• The tRNA/rRNA methylase SpoU for ethambutol and rifampicin.

• The multidrug efflux transport system repressor Rv1219 for isoniazid.

All these hits passed stringent evidence thresholds that take into account the large amount of data crunched. For each hit, we identified possible relationships between gene functions, such as they are known, and the mechanism of action of the antibiotics.

Beyond the biological discoveries of primary interest, this new paper unveils methodological advances in bacterial GWAS. We introduced a systematic, whole-genome approach to analysing not just short DNA sequences (so called oligonucleotide or “kmer”-based approaches), but also short sequences of the proteins that the DNA codes for (an oligopeptide-based approach). We have released our software on an open-source GitHub repository.

We also discovered a relationship that may help disentangle a technical issue in bacterial GWAS where the co-occurence of traits can trick us into thinking that a gene influences one trait when it influences another instead. For antimicrobial resistance, this issue is known as artefactual cross resistance. We observed that true associations tended to produce larger associations (as measured by the 'coefficient', rather than the p-value), providing a possible way to prioritize signals in the future.

This paper was published alongside the CRyPTIC Data Compendium in PLOS Biology, in which we released our data open source to the community, with resources provided by the European Bioinformatics Institute.

Some of the results of CRyPTIC have already been rushed into service by the World Health Organization on the grounds of exceptional importance based on a candidate gene approach; this includes the DNA gyrase subunit B – moxifloxacin association spotlighted above (Walker et al 2022). However, the new results go beyond a candidate gene approach, detecting a range of previously uncatalogued genes via its agnostic, whole-genome strategy.

Unpicking the genetics of antimicrobial resistance is a priority for improving rapid susceptibility tests for individual patients, selecting drug regimens that inhibit the evolution of multidrug resistance, and developing improved treatment options. The need is particularly great in M. tuberculosis, which killed 1.4 million people in 2019, owing to the slow (6-12 week) turnaround of traditional susceptibility testing, and the alarming threat of multidrug resistant tuberculosis. The discovery of many new candidate resistance variants therefore represents an advance that we hope will contribute to progress in reducing the burden of disease.

Royal Society Summer Science Exhibition Stall July 2-8

Next week researchers from the Modernising Medical Microbiology consortium, collaborating groups and I will exhibit the Resistance is Futile stall at the Royal Society Summer Science Exhibition. The exhibition is a free event in central London open to all visitors. Our stall is an opportunity to tell visitors about our research, and how advances in genetics are influencing day-to-day life. On show at the Resistance is Futile stall:

Oxford Nanopore Technology Demos

DNA sequencing in the NHS is shortening the time to diagnose antibiotic resistance in serious infections

Evolution Dance Mat

Resistance mutants arise spontaneously through chance copying errors during DNA replication

Antibiotic Resistance Coconut Shy

Antibiotic use gives resistance mutants a strong advantage so they rapidly increase in frequency.

The exhibition runs from Monday 2 July - Sunday 8 July at Carlton House Terrace, London, SW1Y 5AG. For more information about our stall click here and for general visitor information about the exhibition click here. Please spread the word!

During the exhibition we will be tweeting from @ResistanceIF

Our stall is generously supported by Oxford Nanopore Technology, the Nuffield Department of Medicine, and through public engagement research funding awarded to our research groups by the Wellcome Trust, the Royal Society, the National Institute for Health Research, the Oxford Biomedical Research Centre, the Natural Environment Research Council, the Medical Research Council, the Newton Fund and the Bill & Melinda Gates Foundation.

Postdoctoral Scientist in Statistical Genomics

We are recruiting for a Postdoctoral Scientist in Statistical Genomics working on Antimicrobial Resistance (AMR) gene discovery and focused on Tuberculosis. This will be a joint position at the University of Oxford between Derrick Crook's group and mine, and part of the large international CRyPTIC consortium.

The role is for a population geneticist or statistical geneticist to develop and apply statistical methods, including genome-wide association studies, for discovering rare and common genetic variants underlying antimicrobial resistance in Mycobacterium tuberculosis.

One third of the world's population - 2.5 billion people - are thought to be infected with tuberculosis (TB). This post offers an opportunity to work with global TB experts from five continents, statistical geneticists, clinicians, medical statisticians and software engineers; integrating statistical genetics, bioinformatics and machine learning methods with the aim of uncovering all genomic variants causing at least 1% resistance to first line anti-TB drugs.

We're looking for candidates with a PhD in genomics, evolutionary biology, statistics or a related subject. The post is full-time and fixed-term for up to 3 years initially.

The deadline for applications is noon on Friday 6th May 2016.

Making the most of bacterial GWAS: new paper in Nature Microbiology

In a new paper published this week in Nature Microbiology, we report the performance of genome wide association studies (GWAS) in bacteria to identify causal mechanisms of antibiotic resistance in four major pathogens, and introduce a new method, bugwas,  to make the most of bacterial GWAS for traits under less strong selection.

As explained by Sarah Earle, joint first author with Jessie Wu and Jane Charlesworth, the problem with GWAS in bacteria is strong population structure and the consequent strong coinheritance of genetic variants throughout the genome. This phenomenon - known as genome-wide linkage disequilibrium (LD) - comes about because exchange of genes is relatively infrequent in bacteria, which reproduce clonally, compared to organisms that exchange genes every generation through sexual reproduction.

Genome-wide LD makes it difficult for GWAS to distinguish variants that causally influence a trait from other, coinherited variants that have no direct effect on the trait.

In the case of antibiotic resistance - a trait of high importance to human health - bacteria are under extraordinary selection pressures because resistance is a matter of life and death, to them as well as their human host. This helps overcome coinheritance and pinpoint causal variants because antibiotic usage selects for the independent evolution of the same resistance-causing variants in different genetic backgrounds.

Consequently, bacterial GWAS works very efficiently for antibiotic resistance: the variants most significantly associated with antibiotic resistance in 26 out of the 27 GWAS we performed were genuine resistance-conferring mutations. In the 27th we uncovered a putative novel mechanism of resistance to cefazolin in E. coli. These results for 17 antibiotics (ampicillin, cefazolin, cefuroxime, ceftriaxone, ciprofloxacin, erythromycin, ethambutol, fusidic acid, gentamicin, isoniazid, penicillin, pyrazinamide, methicillin, rifampicin, tetracycline, tobramycin and trimethoprim) across four species (E. coli, K. pneumoniae, M. tuberculosis and S. aureus) build on earlier work investigating beta-lactam resistance in S. pneumoniae, and convincingly demonstrate the potential for bacterial GWAS to discover new genes underlying important traits under strong selection.

What about traits under less strong selection, which probably includes pretty much every other bacterial trait? We show in this context that coinheritance poses a major challenge, based on detailed simulations. Often it may not be possible to use GWAS to pinpoint individual variants responsible for different traits because they are coinherited with - possibly many - other uninvolved variants.

But all is not lost. We show that even when individual locus-level effects cannot be pinpointed, there is often excellent power to characterize lineage-level differences in phenotype between strains. This is helpful for multiple reasons: (1) we often conceptualize trait variability in bacteria at the level of strain-to-strain differences (2) these differences can be highly predictive (3) we can prioritize variants for functional follow-up based on their contribution to strain-level differences.

These concepts represent a substantial departure from regular GWAS. In the human setting for instance, lineage-level differences are usually discarded as uninteresting or artefactual, and variants are almost always prioritized based on statistical evidence for involvement over-and-above any contribution to lineage-level differences. In the bacterial setting, we are forced to depart from these conventions because a large proportion of all genetic variation is strongly strain-stratified. To find out more, see the paper and try our methods.

CRyPTIC: rapid diagnosis of drug resistance in TB

The Modernising Medical Microbiology consortium has announced a new worldwide collaboration called CRyPTIC to speed up diagnosis of antibiotic resistant tuberculosis (TB).

TB infects nearly 10 million people each year and kills 1.5 million, making it one of the leading causes of death worldwide. Almost half a million people each year develop multidrug-resistant (MDR) TB, which defies common TB treatments. Time consuming tests must be run to identify MDR-TB and which drugs will work or fail. This delays diagnosis and creates uncertainty about the best drugs to prescribe to individual patients.

CRyPTIC aims to hasten the identification of MDR-TB using whole genome sequencing to identify genetic variants that give resistance to particular drugs. The project is funded by a $2.2m grant from the Bill & Melinda Gates Foundation and a £4m grant from the Wellcome Trust and MRC Newton Fund.

CRyPTIC aims to collect and analyse 100,000 TB cases from across the world, providing a database of MDR-TB that will underpin diagnosis using WGS. Samples from across Africa, Asia, Europe and the Americas will be collected by teams at more than a dozen centres They will conduct drug resistance testing and much of the genome sequencing. Read more information here.

Cheltenham Science Festival

Earlier this week members of the group represented the Nuffield Department of Medicine at the Cheltenham Science Festival with our Modernising Medical Microbiology stall, featuring the Antibiotic Resistance Coconut Shy and the Genome Evolution Dance Mat.

Antibiotic Resistance Coconut Shy

Antibiotic Resistance Coconut Shy: The children (and adults) visiting the stall were given five bean bags (antibiotics) to throw at the coconuts (bacterial pathogens) to try to knock them off. The front row of coconuts, representing bacteria more susceptible to antibiotics, were easier to knock off than the back row, which represented more resistant bacteria. The aim was to show the children that an unwanted side effect of using antibiotics is to increase the frequency of resistant bacteria, because they were usually the ones left standing.

The game was more difficult than it looks, and just one visitor knocked off all five coconuts. We gave out NDM pens to the sixty visitors who managed to knock off three or more.

Microscope and Top Trumps

Digital Microscope: We brought along a light microscope to show the children what bacteria really look like, which helps emphasize how small they are since they are difficult to see even under the highest magnification. We prepared slides for several Gram positive and Gram negative species, and provided a key to help identify them. We also brought along a number of games that have been used in previous departmental outreach activities, including Pathogen Top Trumps and Fact or Fiction.

Genome Evolution Dance Mat

Genome Evolution Dance Mat: In this game, the children had to copy a bacterial DNA sequence by replicating a sequence of dance moves (up=A, left=C, right=G, down=T) without introducing new errors (mutations). Any mutations that were introduced were passed on to the next template sequence. In this way we aimed to show how mutations occur by errors in DNA replication, and that they are inherited. This generates unique DNA fingerprints for bacteria, which we can use to track the spread of outbreaks.

Outbreak Map

The game, which was kindly programmed by Gareth Jenkin-Jones, included a form of natural selection, so that if too many errors were introduced at once, the sequence was considered inviable and did not survive to be passed on. There was also a speed control, which was handy since some people appear to have spent a lot more of their youth playing dance mats than others.

Outbreak Map: We made an Outbreak Map to show the reach of our stall over the day, with visitors that scored highly on the coconut shy pushing in pins to show where they had travelled from. Had we been handing out germs instead of pens, we could have started outbreaks as far afield as Edinburgh, France and Spain, as well as a large cluster in Cheltenham and the surrounding counties.

Other research groups are representing the department throughout the week.

NDM Microbiology Stall at the Cheltenham Science Festival (L-R): Sarah Earle, Louise Pankhurst, Danny Wilson, Liz Batty, Dilrini De Silva, Jess Hedge, Catrin Moore. Amy Mason, Gareth Jenkin-Jones and Jane Charlesworth also helped with the preparations, and Jen Bardsley co-ordinated all the NDM Stalls.

New paper: Mobile elements drive recombination hotspots in the core genome of Staphylococcus aureus

This week published in Nature Communications we have a new open access paper looking at what drives variability in rates of recombination (horizontal gene transfer, HGT) in the core genome of Staphylococcus aureus. HGT in the core genome is important for eliminating harmful mutations and promoting the spread of beneficial mutations, such as those that make the bacteria resistant to antibiotics.

Compared to recent work focusing on individual, highly-related strains of S. aureus, we found much higher rates of core HGT across the species as a whole. We saw that the frequency of HGT varies along the genome. At broad scales, core HGT is higher near the origin of replication, a pattern reminiscent of the one described by Eduardo Rocha and colleagues in E. coli, who hypothesized that the over-abundance of DNA near the origin during rapid growth could promote HGT.

At fine scales, we found more frequent HGT in regions of the core genome close to mobile elements. The hottest regions occurred near mobile regions called ICE6013, SCC and genomic island α. The insertion and excision of mobile elements from the genome represents a type of HGT, so our finding that nearby core regions also experience more HGT suggests there is some sort of "spill over". This idea is supported by work in Ashley Robinson's group that found similarities between ICE6013 and a class of mobile elements in Streptococcus agalactiae called TnGBS2. TnGBS2 was discovered by Phillipe Glaser's lab who showed it sometimes transfers large tracts of adjacent core material during conjugation.

Whether conjugation alone can explain the high levels of core HGT we saw in S. aureus is unclear - our results suggest there is detectable HGT even in core regions far from mobile elements. Transformation is another possible mechanism of core HGT, but S. aureus is generally thought to be naturally incapable of transformation. However, intriguing work published by Tarek Msadek and colleagues in 2012 indicates there may be cryptic mechanisms of transformation in S. aureus after all. It remains to be seen whether the relative contributions of transformation, transduction and conjugation to the long-term evolution of S. aureus can be disentangled.

Science Bomb!

On Friday Chris Spencer gave the PPS (Pritchard/Przeworski/Stephens) lab meeting as part of a trip to Chicago. Chris talked about his work in Oxford on association studies in a number of common genetic diseases being studied by the Wellcome Trust Case Control Consortium.

Beforehand I dropped the Science Bomb, a new innovation this year (for which I think Barbara Engelhardt is responsible) where someone talks about a particularly interesting or timely article. Dan Gaffney pointed me in the direction of a PLoS Biology paper titled Reawakening Retrocyclins: Ancestral Human Defensins Active Against HIV-1.

The subject of the study is a human pseudogene known as retrocyclin, which has been shown to confer resistance to HIV-1 infection in human cell lines. The pseudogene is expressed naturally in several human tissues, but not translated into protein owing to a premature stop codon. The paper's authors reawakened retrocyclin using aminoglycosides, a class of antibiotics that cause (as a side effect) a degree of mis-translation and hence allow "read-through" of the stop codon. You can see the slides from my Science Bomb here.