Bangladeshi children with acute diarrhea show fecal

ID EMI-2017-0646 Re-submission Title: Bangladeshi children with acute diarrhea show fecal microbiomes with increased Streptococcus abundance, irrespective of diarrhea etiology Short title: Fecal Streptococcus increase in acute diarrhea Authors: Silas Kieser1*, Shafiqul A. Sarker2*, Olga Sakwinska1*, Francis Foata1*, Shamima Sultana2, Zeenat Khan2, Shoheb Islam2, Nadine Porta1, Séverine Combremont1, Bertrand Betrisey3, Coralie Fournier3, Aline Charpagne3, Patrick Descombes3, Annick Mercenier1, Bernard Berger1° , Harald Brüssow1+ * these authors contributed equally to this work ° Corresponding author Bernard Berger P.O. Box 44 CH-1000 Lausanne 26 Switzerland e-mail: [email protected] Phone: +41 21 785 8955 + Current address: KU Leuven, Division of Animal and Human Health Engineering, Kasteelpark, Arenberg 21, Box 2462, 3001 Leuven, Belgium, e-mail:

This article has been accepted for publication and undergone full peer review but has not been through the copyediting, typesetting, pagination and proofreading process which may lead to differences between this version and the Version of Record. Please cite this article as an ‘Accepted Article’, doi: 10.1111/1462-2920.14274 This article is protected by copyright. All rights reserved.

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[email protected]

1 Gut Ecosystem Department, Institute of Nutritional Science, Nestlé Research Centre, Verschez-les-Blanc, CH-1000 Lausanne 26, Switzerland 2 International Centre for Diarrheal Diseases Research, Bangladesh (icddr,b), 68 Shaheed Tajuddin Ahmed Sharani, Mohakhali, Dhaka 1212, Bangladesh, 3 Nestlé Institute of Health Sciences, EPFL Innovation Park, CH-1015 Lausanne, Switzerland

2 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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Summary We report streptococcal dysbiosis in acute diarrhea irrespective of etiology. Compared to 20 healthy local controls, 71 Bangladeshi children hospitalized with acute diarrhea (AD) of viral, mixed viral /bacterial, bacterial and unknown etiology showed a significantly decreased bacterial diversity with loss of pathways characteristic for the healthy distal colon microbiome (mannan degradation, methylerythritol phosphate and thiamin biosynthesis), an increased proportion of fecal streptococci belonging to the Streptococcus bovis and Streptococcus salivarius species complexes, and an increased level of E. coli-associated virulence genes. No enteropathogens could be attributed to a subgroup of patients. Elevated lytic coliphage DNA was detected in 2 out of 5 investigated enteroaggregative E. coli (EAEC)-infected patients. Streptococcal outgrowth in AD is discussed as a potential nutrient-driven consequence of glucose provided with oral rehydration solution.

Keywords: acute diarrhea; gut microbiota; streptococcal dysbiosis; oral glucose; bacteriophages; Bangladesh.

Originality-Significance Statement Our observations are challenging widely shared concepts in acute diarrhea pathogenesis, by raising questions on its etiology and the potential impact of the carbohydrates supplied in the oral rehydration solution used in the WHO recommended treatment.


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Introduction Worldwide, diarrhea is the second most important cause of childhood morbidity and mortality (Black et al., 2008). The introduction of oral rehydration solution (ORS) (Munos et al., 2010) and zinc supplementation (Walker and Black, 2010) have decreased diarrheal mortality. Efficient vaccines have been introduced for rotavirus (RV) (Breiman et al., 2012), but not yet for Escherichia coli (Ahmed et al. 2013), which was described as an important cause of childhood diarrhea in developing countries (Qadri et al., 2005). Since E. coli is resistant to many antibiotics (Jiang et al., 2002), we previously explored bacteriophages for the treatment of diarrhea in Bangladeshi children hospitalized mostly with enterotoxigenic E. coli (ETEC) infection (Sarker and Brüssow, 2016). No clinical amelioration was achieved with two oral bacteriophage cocktails over standard of care consisting of reduced glucose ORS-zinc therapy in a placebo-controlled, randomized clinical trial (Sarker et al., 2016). Strikingly, stool microbiota analysis in these children showed only low median ETEC titers of 105 cfu / g stool (Sarker et al., 2016). ETEC titers were probably lower than needed for in vivo replication of T4 phage (Wiggins and Alexander, 1985). Low pathogen titers of 3x105 cfu/ g stool, just 10fold higher than in controls, were also reported for enteropathogenic E. coli (EPEC) infections in Peruvian children (Barletta et al., 2011). Furthermore, large epidemiological studies reported a low pathogenicity index for several pathotypes of diarrhea-associated E. coli in children from low-income countries (Kotloff et al., 2013; Liu et al., 2015). In Bangladeshi diarrhea patients, pathogenic E. coli was frequently detected in association with other pathogens (Taniuchi et al. 2013), raising doubts about their pathogenic role. In the phage trial, fecal Streptococcus but not Escherichia abundance correlated with diarrhea symptoms both quantitatively and temporally (Sarker et al., 2016). Fecal streptococci are considered as commensals of the small intestine (Booijink et al., 2010), but were also suggested as a candidate diarrhea pathogen in children lacking enteropathogens in the stool (Jin et al., 2013). 4 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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In the present report, we specifically asked whether elevated abundance of streptococci in stools as described in E. coli diarrhea (Sarker et al., 2016) occurs in pediatric diarrhea patients independent of etiology. Since the pathogenesis of diarrhea in the absence of known pathogen detection remains poorly understood, we also investigated with molecular pathogen detection tests and metagenome analysis a subgroup of patients without pathogen diagnosis and compared them to health controls and to patients with diagnosed enteroaggregative E. coli (EAEC) diarrhea.

Results Patient characteristics Between November 2014 and March 2015, 71 children, hospitalized with acute watery diarrhea (AD), were enrolled into an observational study. AD cases differed from 20 local healthy control (HC) children for increased stool frequency, vomiting, elevated body temperature, increased blood pressure, heart and respiration rates (Table 1). Anthropometric parameters defining underweight (weight for age Z-score < -2 standard deviation of WHO reference values), stunting (height for age Z score < -2) and wasting (weight for height Zscore< -2) did not differ significantly between cases and controls (Table 1). Controls were 3 months older, had less illiterate mothers and a higher rate of completed immunizations than cases (Table 2). Cases and controls did not differ for age of mother, number of siblings, prevalence of low family income, length of exclusive breastfeeding or home medication (one case received antibiotics at home, antibiotics were not used in the hospital) (Table 2). Pathogen analysis Etiology was established with standard methods at icddr,b (Harris et al., 2008). Twenty-six patients revealed a RV infection without detection of a bacterial co-pathogen. Sixteen patients 5 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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showed RV associated with enteroaggregative E. coli (EAEC), while 7 patients displayed only E. coli infections (6 EAEC, 1 ETEC). Seven patients harbored other bacterial pathogens (Aeromonas; Aeromonas + RV; Aeromonas + Vibrio ; Vibrio; Vibrio + ETEC; Campylobacter + RV; Shigella + ETEC). Fifteen patients did not yield a pathogen (AD-p) with standard procedures. TaqMan Array Card analysis tested for the presence of 19 pathogens in 11 randomly selected healthy control children and these 15 AD-p patients. Only two enteropathogens, namely rotavirus, and Cryptosporidium, returned significantly higher detection in AD-p (Fig. 1A and suppl. Table 4). Surprisingly, half of the controls showed higher PCR signals than AD-p for Campylobacter jejuni. Only the higher prevalence of C. jejuni in HC was confirmed by metagenome sequencing (Fig 1C, see below and suppl. Table 4 for the metagenomics results), possibly because the other identified pathogens detected in the diagnostic tests did not represent a sufficient part of the fecal microbiota to be measured by standard metagenomics sequencing depth. In all samples but one, a positive signal was observed for more than one enteropathogen, with no difference in the distribution of infection multiplicity between HC and AD-p (Fig 1 B). Stool microbiota composition by 16S rRNA gene sequencing Next we investigated the stool microbiota composition by 16S rRNA gene sequencing in 20 controls and 71 AD patients, including 26 RV, 16 RV + EAEC, 7 ETEC + EAEC, 15 AD-p and 7 patients with a diversity of other bacterial pathogens. There was no consistent correlation between iccdr,b diagnosis and 16S rRNA gene sequencing (data not shown), partly explained by the low resolution of the latter particularly for Enterobacteriaceae. Compared to controls, a higher abundance of Streptococcus was observed in all AD categories (Fig. 2A) and in most individual AD patients (Fig. 3A). The increase was statistically significant (Fig. 2D). On the species level, most streptococci were represented by two species complexes (Gao et al., 2014; Pontigo et al., 2015): S. bovis (including S. equinus 6 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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and S. gallolyticus) and S. salivarius (Fig. 3B). Other typical small intestine bacterial groups either were not detected (Bilophila) or were decreased in cases over controls (Veillonella) (P= 0.0008) (Fig. 3A). In contrast to cases, controls showed a variety of commensal bacteria typical for a healthy colon: Bifidobacterium, Prevotella, Streptococcus, Escherichia, Megamonas, Blautia, Bacteroides, Ruminococcus, Faecalibacterium and Megasphaera (Fig. 2A, 3A). Cases showed lower α (Fig. 2B) and within group β diversity than controls (Fig. 2C) suggesting a loss of diversity and convergence to a similar state. Cases also showed a decreased abundance (P< 10-5) of Prevotella, Bifidobacterium, Bacteroides, and Megamonas compared to controls (Fig. 2A, 3A). Escherichia abundance was increased in all diarrhea groups except RV patients (Fig. 2F, 3A), but overall did not reach statistical significance in cases over controls (Fig. 2F). No significant difference was seen for the stool microbiota composition with respect to Streptococcus and Escherichia genus between day 1 and day 2 of the hospitalized diarrhea patients (Fig. 2D, F). Abundance analysis based on 16S rRNA sequencing only indicates relative proportions of stool bacteria. qPCR determination of 16S rRNA genome equivalents per gram stool showed for controls a significant 8-fold higher titer than cases (Fig. 2G). As intestinal Streptococci (enriched in cases) have 25% more rRNA gene copies than Bifidobacterium or Prevotella (both enriched in controls) [5 copies versus 4 and 4 copies (Stoddard et al, 2015)], the difference in bacterial counts is approximatively 10 fold. Although cases produce an estimated 2-3 fold higher daily stool output (S. Sarker, unpublished observations), an about four-fold higher bacterial output per day in controls than in AD cases remains, representing a potentially very significant biological difference. Stool metagenome sequencing


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Metagenome sequencing was conducted with 9 controls, 5 patients with EAEC as only pathogen, and 11 AD-p cases. Stool samples collected at the day of hospitalization were analyzed. The classification of the metagenome sequences showed a marked decrease (P= 0.0025) for Prevotella copri and Bifidobacterium (which affected more B. bifidum than B. breve and B. longum), for Megamonas, Megasphaera, and Lactobacillus ruminis in cases compared to controls (Fig. 4A), confirming and extending the 16S rRNA sequencing analysis. E. coli and Streptococcus belonging to the S. bovis complex (S. infantarius, S. lutetiensis, S. pasteurianus) and the S. salivarius complex (S. salivarius, S. vestibularis) were higher in cases than controls. Pathway analysis identified a higher mannan degradation capacity in controls attributed to Bacteroides (Table 3), which concurs with the observed decrease of Bacteroides in cases. Bacteroides is known to digest yeast mannan in the human gut (Cuskin et al., 2015). Controls are also enriched for methylerythritol phosphate pathway (contributed by B. longum in controls) and the biosynthesis of thiamin (contributed by Bacteroides in controls), two pathways which are prominent in the distal colon microbiome of healthy humans (Gill et al., 2006). Conversely, stool metagenomes from cases were enriched for a number of biosynthetic and degradation pathways without a common denominator (data not shown) including lactose and galactose degrading genes contributed by streptococci (Fig. 5A) and anaerobic and to a lesser extent aerobic respiration genes contributed by E. coli (Fig. 5B). Antibiotic resistance genes contributed by E. coli were increased in EAEC cases over controls, but not in AD-p (Fig. 5C). We also investigated bacterial genera for a higher ratio of origin-over-terminus DNA (OT ratio) suggesting actively replicating bacteria (Korem et al., 2015). Cases showed a significant higher OT ratio for Bifidobacterium over controls, but not for Streptococcus or Escherichia (Fig. 5D). 8 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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Virulence genes For the 11 AD-p and 5 EAEC cases and 9 controls, we screened the metagenome sequences for bacterial virulence genes with annotations of toxin, adherence or invasion characteristics (Chen et al., 2016) (Fig. 4C). Overall, cases showed a higher number of bacterial virulence genes than controls (P= 0.05) (except for Campylobacter jejuni). Virulence genes in cases were mainly associated with E. coli pathogens: fimbriae of uropathogenic CFT073, adhesins and toxins from enterohemorrhagic O157:H7 and EAEC O44:H18, pili from EPEC, followed by adherence and flagella genes from Salmonella, and Yersinia enterocolitica, respectively.

Virome analysis Elevated amounts of phage DNA sequences were detected in cases over controls (Fig. 4B, 6A). While significant, it is important to point out that there are very clearly only few patients that are skewing the data (Fig. 6A). Within the 5 EAEC patients, 2 showed high abundance of coliphage DNA, suggesting phage replication on the infecting E. coli strains (Fig. 4B, 6B). One EAEC patient contained large amounts of the rV5-like E. coli Myophage phAPEC8 (Tsonos et al., 2012), another EAEC patient showed large amounts of phiEco32-like E. coli Podophage (Savalia et al., 2008). Both phages are lytic and were found in patients with high fecal E. coli abundance (Fig. 6B) suggesting ongoing coliphage replication in two out of five EAEC patients. Within the 11 AD-p patients, four displayed phage sequences (Fig. 4B, 6B). One patient showed high amounts of a Sfi19-like Streptococcus Siphophage, another a moderately elevated amount of an Lj965-like Lactobacillus Siphophage. Both are temperate phages observed in presence of their host bacterium, suggesting the detection of prophages (no purification of virus-like particles was done). A third AD-p patient showed an pYD38-like vibriophage lacking genes for prophage integration, suggesting a lytic phage. A fourth AD-p patient displayed lytic T5-like phages. Within the 9 controls, 1 showed a lytic Bacillus and a 9 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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lytic Klebsiella phage. Small amounts of human viruses were found in 3 subjects (polyoma-, adeno- and bocavirus, the latter in a healthy control).

Discussion A survey of 71 Bangladeshi children hospitalized with acute watery diarrhea revealed a stool microbiota characterized by elevated levels of streptococci irrespective of etiology. Sequence analysis attributed the fecal streptococci to the S. bovis and S. salivarius species complexes. Similar observations were previously reported for adult and pediatric diarrhea patients from Bangladesh hospitalized with cholera (Hsiao et al., 2014) and E. coli infections (David et al., 2015; Sarker et al., 2016), Chinese children hospitalized with AD-p (Jin et al., 2013), as well as African children from Kenya, Mali and The Gambia hospitalized with AD and dysentery (Pop et al., 2015). The studies differed slightly in methods and resulting species annotation, Hsiao et al. (2014) annotated S. bovis and S. thermophilus, a subspecies of S. salivarius, and Pop et al. (2015) added S. mitis to these streptococci. Apparently, fecal abundance increase in streptococci represents a biomarker for AD independent of etiology and geography. Most groups observing fecal streptococci in diarrhea patients have not attributed a pathogenic role to these bacteria, except Jin et al. (2013), who suggested Streptococcus lutetiensis, a member of the S. bovis group, as potential new diarrhea pathogen based on the detection of purported virulence factors observed in genome sequencing of fecal isolates. This observation would fit with our observation that stool output in children with mostly ETEC diarrhea correlated with fecal Streptococcus, but not Escherichia abundance (Sarker et al., 2016). However, sequenced streptococcal isolates from these children did not show known bacterial virulence genes. While this does not exclude unknown virulence genes, one might search for alternative interpretations for the high streptococcal percentage in the stool of diarrhea patients. 10 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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Streptococci belonging to the S. bovis and S. salivarius species complexes were also found in control children albeit with lower proportion. Likewise, members of the S. bovis species complex were also described in healthy European adults as normal commensals of the small intestine (Booijink et al., 2010). S. bovis is also known as food microbe (Jans et al., 2016), while pathogenic isolates are rare (Danne et al., 2011). S. salivarius is a major oral commensal with low pathogenic potential, only associated with opportunistic infection (Chaffanel et al., 2015), but has also been reported as commensal of the small intestine (Mignolet et al., 2016). Recent studies have stressed the importance of getting from relative to absolute abundance estimates for the interpretation of the fecal microbiome (Stämmler et al., 2016; Vandeputte et al., 2017). In addition, intestinal transit time should also be taken into account. In diarrhea patients, transit times (as demonstrated by the increased stool frequency in the patients) are dramatically reduced and this should affect particularly the colon microbiota characterized by a slow transit. Diarrhea would thus not allow the outgrowth of colon bacteria to their normal population sizes (1011-1012 bacteria per gram of content) simply due to a lack of time and therefore skew the fecal microbiota to bacterial groups that are typically abundant in the small intestine. Some observations from this study speak for this interpretation: the stool of diarrhea patients showed a lower bacterial diversity typical for the small intestinal microbiota and a lower bacterial density than controls (although the difference was estimated to be about fourfold, while the ileal bacterial density is with 108 bacteria per gram of content much smaller than this 4-fold reduction). Therefore intestinal streptococci must have experienced a specific growth stimulation since other typical small intestinal bacteria like Veillonella and Bilophila did not show such an outgrowth. Glucose in ORS can stimulate rapid growth particularly of intestinal streptococci (van den Bogert et al., 2013) and might explain the high frequency of streptococci in diarrhea patients independent of etiology in this and the above-mentioned 11 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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studies since glucose-based ORS represents the WHO recommended treatment for acute diarrhea. One should, however, not rapidly reject the association of streptococci with diarrhea as reverse causation. Several classical diarrhea pathogens particularly some E. coli pathotypes have in epidemiological surveys low pathogenicity indices (Kotloff et al., 2013; Liu et al., 2014). Many diarrhea patients harbor several enteric pathogens and are thus candidates for polymicrobial infections. In addition, the pathobiont and the dysbiosis concept invokes that gut commensals can develop a pathogenic potential when increased in number (CerfBensussan et al., 2010; Kamada et al., 2013). Therefore there is the possibility that a marked frequency increase of gut commensals, being it streptococci or E. coli, could cause or contribute to diarrhea as seen in cases of antibiotic-associated diarrhea without Clostridium difficile diagnosis (Larcombe et al., 2016). There is another, clinical reason to ask about a potential role of intestinal streptococci increases in diarrhea. A recent Cochrane review concluded that glucose polymer (i.e. starch)based ORS resulted in a reduced first day diarrhea output and a reduced diarrhea duration compared to glucose-based ORS when diarrhea etiology was not considered (Gregorio et al., 2016). Furthermore, several (Alam et al., 1992; Molla et al., 1982, 1985; 1989), but not all (Hossain et al., 2003) clinical trials from Bangladesh showed a reduced stool output in patients with cholera treated with a starch- compared to a glucose-based ORS. Since intestinal streptococci cannot digest starch, polymer ORS might have its beneficial effect by suppressing the intestinal streptococcal outgrowth. Other effects might also explain the superior efficacy of polymer over glucose ORS (Kühn et al., 2014). To settle these points, microbiota studies in polymer ORS treated diarrhea patients are clearly warranted, as well as studies in patients treated with intravenous, but not oral rehydration.


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Virome analysis in the stool is increasingly complementing gut microbiota analyses (Lim et al., 2015; Manrique et al., 2016) and starts to be applied to pathological gut conditions (Norman et al., 2015). The metagenome analysis revealed that phage-related sequences are enriched in the AD case samples compared to controls. This is quite an intriguing finding since two of the 5 EAEC-infected AD patients showed high abundance of virulent (lytic) coliphages concomitantly with an elevated frequency of their potential bacterial hosts. The biological relevance of these findings remains unclear because of the small sample numbers analyzed by metagenome sequencing in this study. In a previous study with AD patients showing -despite a diagnosed ETEC infection- only low fecal E. coli titers, no substantial coliphage titers were seen (Sarker et al., 2016). However, in malnourished AD patients who showed high fecal E. coli titers, 7 of 19 patients showed elevated titers of fecal coliphages (Kieser et al, 2018) suggesting in vivo coliphage replication when the host cell crosses a threshold titer.

We should mention limitations of the study. The group sizes were uneven with 20 healthy controls versus 71 AD individuals. This unevenness may have skewed the conclusions. In a large diarrhea hospital like icddr,b, no healthy controls present to the clinicians, obtaining time- and place-matched controls represent therefore logistic challenges, which explain also that cases and controls were not matched for all epidemiological parameters. However, these differences are relatively small, and the consistency of the observation of fecal streptococcal increases in diarrhea patients over many published studies (David et al., 2015; Hsiao et al., 2014; Jin et al., 2013; Pop et al., 2015; Sarker et al., 2016) makes it unlikely that we report a sampling bias. Although the methodologies based on sequencing provide relative quantification only, we made an attempt to evaluate the difference of absolute output of fecal streptococci per day between cases and controls. Transforming relative frequencies of 13 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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bacterial groups into absolute titers is however difficult by the used method: qPCR estimates with universal primers represent numerous difficulties (distinct efficiency of DNA extraction, primer fit, different rRNA gene copy numbers for different bacterial groups) and more reliable methods like flow cytometry (Vandeputte et al., 2017) and stool quantification are needed to obtain reliable absolute titers.

Diarrhea patients without an identified pathogen (AD-P) by standard clinical microbiology remain a challenge for the understanding of diarrhea pathogenesis. Using molecular tests we could detect pathogens in a number of AD-P patients. However, signals were low, sometimes not much higher than the highest titers for these pathogens found in control patients. In the case of C. jejuni even higher titers were found in controls than in diarrhea cases. This is a repeated observation at icddr,b (S. Sarker, unpublished observations) and one might question the role of C. jejuni as an enteropathogen in pediatric diarrhea patients from Bangladesh.

Overall, one gets the impression that widely shared concepts in diarrhea pathogenesis are challenged by a wealth of recent observations from children living in developing countries. Here, we raised attention on the difficulty to assign etiology despite the progress in diagnostic tools, on the potential impact of the carbohydrates supplied in the ORS, and on the commensal microbiota and their hypothetical conversion into pathobiont (streptococci dysbiosis) that may contribute to the diarrhea. Further detailed microbiome including virome analyses are clearly needed to clarify the situation.


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Experimental Procedures Cohort recruitment Seventy-one boys and girls between 6 months and 2 years of age hospitalized at the Dhaka Hospital of the International Center for Diarrheal Diseases Research in Bangladesh (icddr,b) with a diagnosis of acute diarrhea were enrolled into an observational study during the winter season 2014/2015. Twenty healthy children were in the same time period recruited as controls from Nandipara, a peri-urban community of Dhaka (12 km from icddr,b hospital). The study was approved by the Ethical Review Committee of icddr,b as protocol #PR-14081 and a written informed consent was obtained from the parents or caregiver of the children. Assessments in the hospital All subjects underwent a physical examination and nutritional assessment (including past and present breastfeeding and supplementary food). Socioeconomic and medical data were collected at anamnesis as part of the standard process. Low income was defined as less than 8000 Takas per month. Home medication including antibiotics was documented for the month preceding hospitalization. AD patients received standard care consisting of reduced glucose ORS supplemented with zinc, but no antibiotics. Antibiotics are at icddr,b only used in dysentery and cholera patients or patients with other co morbidities e.g., acute respiratory tract infection, severe acute malnutrition (< -3WHZ) or sepsis. Two stool samples were obtained for each AD patient at day 1 and day 2 of hospitalization. Pathogen detection Fresh stool samples obtained on day 1 of hospitalization were used for pathogen detection. Rotavirus (RV) was detected by ELISA, Vibrio, Salmonella, Shigella, Aeromonas, and Campylobacter by culture and Vibrio cholerae was confirmed by dark field microscopy;


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ETEC, EPEC, EAEC, enterohemorrhagic (EHEC) and Shiga-toxin producing E. coli (STEC) were diagnosed by multiplex PCR after culture (Harris et al., 2008). Total nucleic acids from stool samples of AD patients without identified pathogen (QIAamp MinElute Virus Spin Kit, Qiagen) was investigated by TaqMan Array Card for 19 different enteropathogens (Liu et al., 2016) : Rota-, Adeno-, Astro-, Noro- and Sapovirus; Vibrio, Salmonella, Shigella, Aeromonas, Campylobacter, Clostridium difficile, ETEC, EPEC, EAEC; Cryptosporidium, Giardia, Entamoeba histolytica, Ascaris, Trichuris. The results are expressed as semi-quantitative cycle threshold (CT) values for each pathogen. We normalized the pathogen PCR signal to the signal for total bacterial count based on 16S rRNA gene CT.

Fecal DNA extraction, sequencing of 16S rRNA genes, and 16S rRNA quantification by qPCR Total DNA was extracted using the QIAamp DNA Stool Mini Kit (QIAGEN), following the manufacturer's instructions, except for the addition of a series of mechanical disruption steps (4 × 60 s) using a FastPrep apparatus and Lysing Matrix B tubes (MP Biochemicals). Then, the 16S rRNA gene variable regions V3 to V4 were PCR amplified using universal primers (Klindworth et al., 2013) with dual indexing (Kozich et al., 2013) and sequenced with Miseq reagent kit V3 (Illumina Inc., San Diego, California) as previously described (Caporaso et al., 2012). Total bacterial load (expressed as average genome equivalent) in the stool samples was determined by real-time PCR as described by Nadkarni et al. (2002) using E.coli K12 strain for the standard curve and an average bacterial genome weight of 3.34 x 10-15 g to calculate the average genome equivalent. 16S rRNA gene data analysis


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Raw sequence data were analyzed using Mothur V.1.33.0 21 (Schloss et al., 2009) and QIIME V.1.8 22 (Caporaso et al., 2010) software packages. Paired-end sequences were demultiplexed and joined as described (Kozich et al., 2013). Then, sequences were split in separated fasta files for each sample using Mothur commands [deunique.seqs(), degap.seqs(), and split.groups()]. Conversion to QIIME format using add_qiime_labels.py and subsequent analytical steps were performed in QIIME. Chimera were identified de novo and against Greengenes V13.8 with usearch61. Using a new approach (see below), sequences of the genera Bifidobacterium, Lactobacillus and Streptococcus were annotated to the species level and enumerated. Standard OTUs picking at 97% identity was performed on the remaining sequences using pick_otus.py, with options usearch_ref (Edgar et al., 2011), optimal uclust, and without additional chimera detection. Taxonomy assignment was performed on representative sequences using RDP Classifier (Wang et al., 2007). After merging the results of both picking approaches, OTU and species representative sequences were aligned using PyNast method (Caporaso et al. 2010) and Uclust as pairwise alignment method. The resulting multiple alignments was then filtered and used to build a phylogenetic tree with the FastTree method (Price et al., 2009). After quality filtering of the OTUs (Bokulich et al., 2013) diversity analyses were performed in QIIME. Species level analysis of the 16S rRNA gene belonging to the genera Bifidobacterium, Lactobacillus, and Streptococcus We first defined species and subspecies-level reference signatures on the 16S rRNA gene sequences. Sequences from isolates assigned to species from Bifidobacterium, Lactobacillus, and Streptococcus genera were retrieved from the RDP v10 and Silva v119 databases. Subsequent steps were performed separately for each genus. Using Mothur, all good quality sequences of >1200 bp corresponding to isolates of the species of interest and to all other type strains of the genus were aligned on the Silva reference v119. To increase the quality of our 17 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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reference dataset, clear outlier sequences within each species were removed based on phylogenic trees analyses. The signatures were determined as minimal combinations of nucleotides at defined positions on the alignment which were conserved within species, but variable among species. In some instances, closely related species could not be distinguished based on the V3 to V4 16S rRNA gene region targeted by primers for Illumina sequencing. In these cases, they were pooled as groups of species identified by common signatures. Signatures are reported in Suppl. Table 1 for Bifidobacterium species, Suppl. Table 2 for Lactobacillus species, and Suppl. Table 3 for Streptococcus species. The accuracy of the approach was assessed with annotated sequences from RDP and Silva databases, and from well-characterized sequences from isolates of the Nestlé Culture Collection. To analyze the Illumina sequencing datasets using our species-level reference signatures, chimera checked 16S rRNA sequences were classified at genus level with the RDP Classifier v10 (Wang et al., 2007) implementation in Mothur. Sequences annotated as Bifidobacterium, Lactobacillus, or Streptococcus, were then aligned on the Silva reference v119. Based on the combinations of nucleotides searched in our species-level reference signatures, each assembled Illumina sequence was annotated. Sequences unassigned at species level kept their genus-level annotation (with sp. suffix). Metagenomics Twenty five stool samples were investigated with shotgun metagenomics. We randomly selected 11 of the 15 AD-p patients for metagenome sequencing because we were particularly interested to identify potential pathogens in AD patients without enteropathogens diagnosed by standard procedures of the clinical microbiology laboratory (AD-p). Nine samples were randomly selected among the 20 healthy controls. As a comparator, we used five samples from AD patients with EAEC as the only detected pathogen.


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Stool DNA was extracted using MoBio PowerMag Microbiome DNA Isolation Kit on an epMotion M5073 (Vaudaux-Eppendorf AG, Basel) followed by Zymo DNA Clean & Concentrator Kit. Library preparation was done according to the Nextera XT protocol from Illumina. The quality and quantity check was based on LabChip GX Touch HT (Perkin Elmer) results. Sequencing was performed on HiSeq 2500 using chemistry HighOutput v4 PE125. The paired-end reads were filtered using KneadData v0.5.1 (https://bitbucket.org/biobakery/kneaddata), which included quality filtering based on Trimmomatic and excluded reads mapping to the human genome. Taxonomic profiles were generated with MetaPhlAn2 2.5.0 (Truong et al., 2015). Functional annotation was performed with HUMANn2 v0.7.1 (Abubucker et al., 2012) and integrated into pathways from the MetaCyc database (Caspi et al., 2014). The mapped reads are normalized first by gene length, then by million reads (counts per million). Antibiotic resistance genes were retrieved from CARD database (McArthur et al., 2013). Virulence factors were retrieved from VFDB database (Chen et al., 2016) using ShortBRED (Kaminski et al., 2015). The mapped reads were normalized (first by million mapped reads and then by kilobase of reference database, RPKM). Growth rate estimates of origin-toterminus-ratio were produced according to the pipeline described by Korem et al. (2015). Data availability. 16S rDNA and metagenome reads are available under the Bio Project accessions SRP100410, SRP100895, SRP119744, and SRP120020. Statistics As microbiota abundance have a non-normal distribution, non-parametric test were used. If not mentioned otherwise, the two-sided Mann-Whitney-test was used for continuous variables and a χ2- test for categorical variables. 19 Wiley-Blackwell and Society for Applied Microbiology This article is protected by copyright. All rights reserved.

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Table 1 Clinical comparison of acute diarrhea patients (AD) with healthy controls (HC)

Weight(kg) Height(cm) Mid upper arm circumference(cm) Weight for age Z score Height for age Z score Body mass index Weight for height Z score BMI Z score MUAC_Z Temperature/°C Pulse/min Respiration Rate /min Vomiting/ day Diarrhea at home(days) Stool frequency/ day Systolic Blood Pressure(mmHg) Diastolic Blood Pressure(mmHg) Exclusive breastfeeding(months) Diarrhea in hospital( days)

AD (N=71) Mean std median

HC (N=20) mean std median

P value

8.2 71.3 14.1

1.4 5.7 1.2

7.8 70.2 14.0

8.7 73.5 13.6

1.3 5.1 0.7

8.4 73.5 13.3

NS 0.09 0.02

-1.0 -0.9 16.0 -0.6

1.0 1.3 1.7 1.2

-1.1 -0.9 15.7 -0.9

-0.9 -1.1 16.1 -0.4

1.1 1.3 1.5 1.0

-1.2 -1.4 16.0 -0.5

NS NS NS NS

-0.6 -0.3 37.0 136.5 35.6 1.9 2.2

1.2 1.1 0.7 4.9 2.0 2.8 1.3

-1.0 -0.4 37.0 138.0 36.0 1.0 2.0

-0.3 -0.8 36.3 109.0 30.4

1.0 0.6 0.5 9.1 1.5

-0.3 -0.9 36.5 110.0 30.0

NS 0.01