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Mdecine et maladies infectieuses 43 (2013) 322330
General review
Abstract
PCR targeting the gene encoding 16S ribosomal RNA (commonly named broad-range PCR or 16S PCR) has been used for 20 years as a
polyvalent tool to study prokaryotes. Broad-range PCR was first used as a taxonomic tool, then in clinical microbiology. We will describe the use
of broad-range PCR in clinical microbiology. The first application was identification of bacterial strains obtained by culture but whose phenotypic
or proteomic identification remained difficult or impossible. This changed bacterial taxonomy and allowed discovering many new species. The
second application of broad-range PCR in clinical microbiology is the detection of bacterial DNA from clinical samples; we will review the clinical
settings in which the technique proved useful (such as endocarditis) and those in which it did not (such as characterization of bacteria in ascites,
in cirrhotic patients). This technique allowed identifying the etiological agents for several diseases, such as Whipple disease. This review is a
synthesis of data concerning the applications, assets, and drawbacks of broad-range PCR in clinical microbiology.
2013 Elsevier Masson SAS. All rights reserved.
Keywords: 16S ribosomal RNA; Broad-range PCR; Molecular diagnosis
Rsum
La PCR amplifiant le gne codant pour lARN ribosomal 16S (plus communment appele PCR 16S ou PCR universelle) est utilise depuis
20 ans comme outil dtude polyvalent des procaryotes. La PCR 16S a dabord t utilise comme outil dtude taxonomique, puis son usage
sest rpandu en microbiologie clinique. Dans cette revue, nous dtaillons les applications de la PCR 16S en microbiologie clinique. La premire
application a t lidentification de souches bactriennes obtenues par culture, mais dont lidentification phnotypique ou protomique est difficile
ou impossible. Cette utilisation a modifi les perspectives de la taxonomie bactrienne et a permis la dcouverte de nombreuses nouvelles espces.
Lautre application de la PCR 16S en microbiologie clinique est la dtection dADN bactrien directement partir de prlvements cliniques ; nous
proposons une synthse des situations cliniques dans lesquelles cette technique est utile (par exemple les endocardites) et celles dans lesquelles
elle ne lest pas (par exemple pour les infections du liquide dascite chez les patients cirrhotiques). Cette technique a permis didentifier lagent
infectieux responsable de plusieurs pathologies (par exemple la maladie de Whipple). Cette revue fait la synthse des donnes sur les indications,
avantages et inconvnients de la PCR 16S en microbiologie clinique.
2013 Elsevier Masson SAS. Tous droits rservs.
Mots cls : ARN ribosomal 16S ; Diagnostic molculaire ; PCR universelle
1. Introduction
Corresponding author.
E-mail address: alexandra.aubry@upmc.fr (A. Aubry).
0399-077X/$ see front matter 2013 Elsevier Masson SAS. All rights reserved.
http://dx.doi.org/10.1016/j.medmal.2013.06.003
323
Fig. 1. Schematic representation of 16S ribosomal RNA gene. Non-hypervariable regions are those containing conserved regions used as target sequences for
universal primers. Amplification followed by sequencing of hypervariable regions can discriminate between bacterial species. Schematic representations of short
and long amplification of the gene are presented.
Reprsentation schmatique du gne codant pour lARN ribosomique 16S. Les rgions non hypervariables sont celles au sein desquelles on trouve les rgions
conserves utilises comme squences cibles pour les amorces universelles . Les rgions hypervariables sont celles dont lamplication et le squencage permettent
de diffrentier les espces bactriennes. Les reprsentations schmatiques dun 16S long et dun 16S court sont galement gures.
bacteriological diagnosis in hospitals. We reviewed the literature to determine the contribution of this technique to clinical
microbiology.
2. What is 16S? What is its contribution?
2.1. The bacterial ribosome
The ribosome is a ribonucleoprotein complex (made up of
proteins and RNA); it allows synthesizing proteins (also called
translation) by using mRNA as a source of information and
tRNA associated with amino acids as substrates. In bacteria,
ribosomes are composed of a large sub-unit (50S) and a small
sub-unit (30S). The functional ribosome (composed of the two
sub-units assembled around the mRNA) has a molecular mass
of 2.5-megadalton and a sedimentation coefficient of 70S. The
small sub-unit is composed of 16S ribosomal RNA (encoded
by a gene of 1500 nucleotides) and of 20 proteins; it allows
reading mRNA. The large sub-unit is composed of 23S ribosomal RNA (encoded by a gene of 2900 nucleotides), of 5S
ribosomal RNA (encoded by a gene of 120 nucleotides), and
of 30 proteins; it allows synthesizing the protein corresponding to the mRNA read by the small sub-unit. Furthermore,
various protein factors act on the ribosome at various stages of
translation.
In the 1980s, it was demonstrated that the phylogenic relationships among living beings could be determined by comparing
their nucleic sequences [1]. Indeed, since the 16S rRNA gene
encode for an rRNA with a constant function in evolution, it
could be used as a molecular timer to follow changes in bacterial evolution. This gene was used this way in the late 1980s, as
a study tool for bacterial evolution [3], and had a major part in
the study of bacterial phylogeny and taxonomy [4].
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among 1404 isolates for which usual techniques had not been
contributive [15]. Rates of similarity greater than 99% had been
chosen to assign a strain to a previously described species, in
this study; 97 to 99% to assign it at the genus level; and less
than 97% to consider it as a new species. Thus, 16S PCR is tool
of great importance for the exploration of bacterial diversity
[4,15].
Finally, the main problem is the threshold from which a rate
of similarity would allow assigning the studied sequence to a
species, or to a genus, is not clearly determined. Several thresholds have been suggested. Most taxonomists accept thresholds of
97% for the genus and 99% for species [2]. Nevertheless, some
authors suggest using a threshold of 99.5% for species, whereas
for others, it seems impossible to determine a single threshold
for all the bacterial world [6]. Recommendations for the interpretation by bacterial categories were recently suggested by
the Clinical and Laboratory Standard Institute (CLSI), but their
prohibitive costs restrict their availability to routine laboratories
[12].
It should be noted that the rates of similarity obtained differ, whether a short 16S or a long 16S is used, but also
depending on the program used, and the parameters used for a
given program (cf. addendum) [1]. It should also be kept in mind
that the final interpretation of a bacterial identification result
based on 16S rRNA, should obviously also take into account the
phenotypic characteristics.
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Fig. 3. It is essential to select patients for whom a diagnostic test is contributive (thus improving pre-test probability). Defining criteria for a biological test: sensitivity,
specificity, negative predictive value (NPV), and positive predictive value (PPV). This is a previously reported example, with a sensitivity of 93% and a specificity
of 98% for broad-range PCR applied in a population with a prevalence of meningitis at 44% [17]. Broad-range PCR is first performed on cerebrospinal fluid (CSF)
for any patient. This corresponds to a low prevalence of meningitis. Secondly, broad-range PCR is performed on selected samples for patients highly suspect of
meningitis. This corresponds to a high prevalence of the disease. We observe that negative and positive predictive values vary according to the incidence of the
disease. Thus, it is essential to select patients highly suspect of infection (whatever the type of infection) to adequately use broad-range PCR in a targeted population.
This allows improving the pre-test diagnostic probability and consequently the positive predictive value of broad-range PCR.
Illustration de lintrt de dterminer les patients pour lesquels un test diagnostique a un intrt (augmenter la probabilit pr-test). Dnitions des critres dun
test biologique : sensibilit, spcicit, valeur prdictive positive (VPP) et valeur prdictive ngative (VPN). On prend ici lexemple dune publication rapportant
une sensibilit de 93 % et une spcicit de 98 % pour une PCR 16S applique dans une population o la prvalence de la mningite tait de 44 % [17]. On applique
la PCR 16S dans une premire situation o la PCR 16S est effectue sur des prlvements de liquides cphalorachidiens (LCR) tout-venants. On se place donc dans
une situation o la prvalence des infections mninges est faible. On applique ensuite le test dans une seconde situation o seuls les prlvements de LCR suspects
de mningite sont soumis une PCR 16S. On se place alors dans une situation o la prvalence des mningites est leve. On observe que les valeurs prdictives
positives et ngatives du test varient selon que le test est appliqu une population faible (situation 1) ou haute incidence (situation 2) de la maladie. Il est donc
indispensable de slectionner les patients suspects dinfection (cela quel que soit le cadre nosologique) an dutiliser la PCR 16S bon escient dans une population
cible. Cela permet damliorer la probabilit diagnostique pr-test et par consquent la valeur prdictive positive de la PCR 16S.
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Fig. 4. Strategic contribution of mass spectrometry compared to molecular biology (including broad-range PCR) in clinical bacteriology.
Place stratgique de la spectromtrie de masse par rapport la biologie molculaire (dont la PCR 16S) en bactriologie clinique.
Disclosure of interest
The authors declare that they have no conflicts of interest
concerning this article.
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References
[1] Clarridge III JE. Impact of 16S rRNA gene sequence analysis for identification of bacteria on clinical microbiology and infectious diseases. Clin
Microbiol Rev 2004;17:84062.
[2] Petti CA. Detection and identification of microorganisms by gene amplification and sequencing. Clin Infect Dis 2007;44:110814.
[3] Woese CR. Bacterial evolution. Microbiol Rev 1987;51:22171.
[4] Janda JM, Abbott SL. 16S rRNA gene sequencing for bacterial identification in the diagnostic laboratory: pluses, perils, and pitfalls. J Clin Microbiol
2007;45:27614.
[5] Kiratisin P, Li L, Murray PR, Fischer SH. Identification of bacteria recovered from clinical specimens by 16S rRNA gene sequencing. Eur J Clin
Microbiol Infect Dis 2003;22:62831.
[6] Schlaberg R, Simmon KE, Fisher MA. A systematic approach for discovering novel, clinically relevant bacteria. Emerg Infect Dis 2012;18:42230.
[7] Woo PCY, Ng KHL, Lau SKP, Yip KT, Fung AMY, Leung KW, et al.
Usefullness of the MicroSeq 500 16S ribosomal DNA-based bacterial
identification system for identification of clinically significant bacterial isolates with ambiguous biochemical profiles. J Clin Microbiol
2003;41:19962001.
[8] Sontakke S, Cadenas MB, Maggi RG, Diniz PP, Breitschwerdt EB. Use of
broad range16S rDNA PCR in clinical microbiology. J Microbiol Methods
2009;76:21725.
[9] Petti CA, Polage CR, Schreckenberger P. The role of 16S rRNA gene
sequencing in identification of microorganisms misidentified by conventional methods. J Clin Microbiol 2005;43:61235.
[10] Mignard S, Flandrois JP. 16S rRNA sequencing in routine bacterial identification: a 30-month experiment. J Microbiol Methods 2006;67:57481.
[11] Bosshard PP, Abels S, Zbinden R, Bottger EC, Altwegg M. Ribosomal DNA
sequencing for identification of aerobic gram-positive rods in the clinical
laboratory (an 18-month evaluation). J Clin Microbiol 2003;41:413440.
[12] Petti CA, Bosshard PP, Brandt ME, Clarridge III JE, Feldblyum TV, Foxall
P, et al. Interpretive criteria for identification of bacteria and fungi by DNA
target sequencing; approved guideline. CLSI; 2008.
[13] Gevers D, Cohan FM, Lawrence JG, Spratt BG, Coenye T, Feil EJ, et al.
Re-evaluating prokaryotic species. Nat Rev Microbiol 2005;3:7339.
[14] Stackebrandt E, Frederiksen W, Garrity GM, Grimont PAD, Kampfer P,
Maiden MCJ, et al. Report of the ad hoc committee for the re-evaluation
of the species definition in bacteriology. Int J Syst Evol Microbiol
2002;52:10437.
[15] Drancourt M, Berger P, Raoult D. Systematic 16S rRNA gene sequencing
of atypical clinical isolates identified 27 new bacterial species associated
with humans. J Clin Microbiol 2004;42:2197202.
[16] Rampini SK, Bloemberg GV, Keller PM, Buchler AC, Dollenmaier G,
Speck RF, et al. Broad-range 16S rRNA gene polymerase chain reaction for diagnosis of culture-negative bacterial infections. Clin Infect Dis
2011;53:124551.
[17] Rafi W, Chandramuki A, Mani R, Satishchandra P, Shankar SK. Rapid
diagnosis of acute bacterial meningitis: role of a broad range 16S rRNA
polymerase chain reaction. J Emerg Med 2010;38:22530.
[18] Al Masalma M, Armougom F, Scheld WM, Dufour H, Roche PH, Drancourt M, et al. The expansion of the microbiological spectrum of brain
abscesses with use of multiple 16S ribosomal DNA sequencing. Clin Infect
Dis 2009;48:116978.
[19] Fournier PE, Thuny F, Richet H, Lepidi H, Casalta JP, Arzouni JP, et al.
Comprehensive diagnostic strategy for blood culture-negative endocarditis:
a prospective study of 819 new cases. Clin Infect Dis 2010;51:13140.
[20] Greub G, Lepidi H, Rovery C, Casalta JP, Habib G, Collard F, et al. Diagnosis of infectious endocarditis in patients undergoing valve surgery. Am
J Med 2005;118:2308.
[21] Goldenberger D, Kunzli A, Vogt P, Zbinden R, Altwegg M. Molecular
diagnosis of bacterial endocarditis by broad-range PCR amplification and
direct sequencing. J Clin Microbiol 1997;35:27339.
[22] Gauduchon V, Chalabreysse L, Etienne J, Celard M, Benito Y, Lepidi H,
et al. Molecular diagnosis of infective endocarditis by PCR amplification and direct sequencing of DNA from valve tissue. J Clin Microbiol
2003;41:7636.
330
[37]
[38]
[39]
[40]
[41]
[42]
[43]
[44]
[45]
[46]
[47]
[48]
[49]