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ABSTRACTWe previously demonstrated that mutation of sarA in Staphylococcus aureus limits biofilm formation, cytotoxicity for osteoblasts and osteoclasts, and virulence in osteomyelitis, and that all of these phenotypes can be attributed to the increased production of extracellular proteases. Here we extend these studies to assess the individual importance of these proteases alone and in combination with each other using the methicillin-resistant USA300 strain LAC, the methicillin-susceptible USA200 strain UAMS-1, and isogenic sarA mutants that were also unable to produce aureolysin (Aur), staphopain A (ScpA), staphylococcal serine protease A (subsp.), staphopain B (SspB), and the staphylococcal serine protease-like proteins A-F (SplA-F). Biofilm formation was restored in LAC and UAMS-1 sarA mutants by subsequent mutation of aur and scpA, while mutation of aur had the greatest impact on cytotoxicity to mammalian cells, particularly with conditioned medium (CM) from the more cytotoxic strain LAC. However, SDS-PAGE and western blot analysis of CM confirmed that mutation of sspAB was also required to mimic the phenotype of sarA mutants unable to produce any extracellular proteases. Nevertheless, in a murine model of post-traumatic osteomyelitis, mutation of aur and scpA had the greatest impact on restoring the virulence of LAC and UAMS-1 sarA mutants, with concurrent mutation of sspAB and the spl operon having relatively little effect. These results demonstrate that the increased production of Aur and ScpA in combination with each other is a primary determinant of the reduced virulence of S. aureus sarA mutants in diverse clinical isolates including both methicillin-resistant and methicillin-susceptible strains.IMPORTANCEPrevious work established that SarA plays a primary role in limiting the production of extracellular proteases to prevent them from limiting the abundance of S. aureus virulence factors. Eliminating the production of all 10 extracellular proteases in the methicillin-resistant strain LAC has also been shown to enhance virulence in a murine sepsis model, and this has been attributed to the specific proteases Aur and ScpA. The importance of this work lies in our demonstration that the increased production of these same proteases largely accounts for the decreased virulence of sarA mutants in a murine model of post-traumatic osteomyelitis not only in LAC but also in the methicillin-susceptible human osteomyelitis isolate UAMS-1. This confirms that sarA-mediated repression of Aur and ScpA production plays a critical role in the posttranslational regulation of S. aureus virulence factors in diverse clinical isolates and diverse forms of S. aureus infection.

ABSTRACT Biofilm formation is an important characteristic of many Staphylococcus aureus infections because it limits the efficacy of host defenses and conventional antibiotic therapy. There are many literature reports that describe small molecule inhibitors of S. aureus biofilm formation, but the lack of direct comparisons and differences in the methods used to assess inhibition make it impossible to assess the efficacy of these compounds relative to each other. To address this, we compared 19 compounds reported in the literature to be inhibitors of S. aureus biofilm formation. We used the methicillin-susceptible clinical osteomyelitis isolate UAMS-1 in a microtiter plate biofilm assay shown to maximize biofilm formation and provide results consistent with those observed in vivo. Under these conditions, telithromycin (Ketek) showed the greatest inhibitory activity, limiting biofilm formation to a degree comparable to a UAMS-1 sarA mutant at a concentration of 0.49 µM (0.40 µg/mL). Similar results were obtained for the methicillin-resistant USA300 strain LAC. Telithromycin is a bacteriostatic ketolide antibiotic that is not currently approved in the United States for use as an antibiotic due to its concerning safety profile. However, the concentration required to limit growth in vitro was higher than the concentration required to limit biofilm formation, suggesting that low-dose telithromycin might be useful to limit biofilm formation and increase the efficacy of other antibiotics in biofilm-associated infections. Irrespective of whether telithromycin is ultimately proven clinically useful in this regard, these results emphasize the need for widespread use of a standardized in vitro approach to evaluate prospective inhibitors. IMPORTANCE Because biofilm formation is such a problematic feature of Staphylococcus aureus infections, much effort has been put into identifying biofilm inhibitors. However, the results observed with these compounds are often reported in isolation, and the methods used to assess biofilm formation vary between labs, making it impossible to assess relative efficacy and prioritize among these putative inhibitors for further study. The studies we report address this issue by directly comparing putative biofilm inhibitors using a consistent in vitro assay. This assay was previously shown to maximize biofilm formation, and the results observed with this assay have been proven to be relevant in vivo. Of the 19 compounds compared using this method, many had no impact on biofilm formation under these conditions. Indeed, only one proved effective at limiting biofilm formation without also inhibiting growth.