Impaired Parasite Attachment as Fitness Cost of Metronidazole Resistance in Giardia lamblia

Abstract

ABSTRACTInfections with the diarrheagenic protozoan pathogenGiardia lambliaare most commonly treated with metronidazole (Mz). Treatment failures with Mz occur in 10 to 20% of cases and Mz resistance develops in the laboratory, yet clinically, Mz-resistant (Mzr)G. lambliahas rarely been isolated from patients. To understand why clinical Mzrisolates are rare, we questioned whether Mz resistance entails fitness costs to the parasite. Our studies employed several newly generated and established isogenic Mzrcell lines with stable, high-level resistance to Mz and significant cross-resistance to tinidazole, nitazoxanide, and furazolidone. Oral infection of suckling mice revealed that three of five Mzrcell lines could not establish infection, while two Mzrcell lines infected pups, albeit with reduced efficiencies. Failure to colonize resulted from a diminished capacity of the parasite to attach to the intestinal mucosain vivoand to epithelial cells and plastic surfacesin vitro. The attachment defect was related to impaired glucose metabolism, since the noninfectious Mzrlines consumed less glucose, and glucose promoted ATP-independent parasite attachment in the parental lines. Thus, resistance ofGiardiato Mz is accompanied by a glucose metabolism-related attachment defect that can interfere with colonization of the host. Because glucose-metabolizing pathways are important for activation of the prodrug Mz, it follows that a fitness trade-off exists between diminished Mz activation and reduced infectivity, which may explain the observed paucity of clinical Mzrisolates ofGiardia. However, the data also caution that some forms of Mz resistance do not markedly interfere within vivoinfectivity.