Immunomodulatory effect of vancomycin on Treg in pediatric inflammatory bowel disease and primary sclerosing cholangitis

Abstract

Vancomycin has been shown to affect tumor necrosis factor-alpha (TNF-α) pathways as an immunomodulator; this is thought to be separate from its function as an antibiotic [1]. Previous studies have shown that oral vancomycin (OV) is an effective treatment for concomitant primary sclerosing cholangitis (PSC) and inflammatory bowel disease (IBD) in children [2, 3]. Since both diseases are associated with immune dysfunction, we hypothesized that vancomycin's therapeutic effect in IBD and PSC occurs through immunomodulation. Therefore, we examined the in vivo immunological changes that occur during OV treatment of 14 children with PSC and IBD. Within 3 months of OV administration, peripheral gamma-glutamyl transpeptidase (GGT) and alanine aminotransferase (ALT) concentrations, white blood cell (WBC) counts, and neutrophil counts normalized from elevated levels before treatment. Patients also demonstrated improved biliary imaging studies, liver biopsies and IBD symptoms and biopsies. Additionally, plasma transforming growth factor beta (TGF-β) levels were increased without concurrent shifts in Th1-or Th2-associated cytokine production. Peripheral levels of CD4 + CD25hiCD127lo and CD4 + FoxP3+ regulatory T (Treg) cells also increased in OV-treated PSC + IBD patients compared to pretreatment levels. A unique case study shows that the therapeutic effects of OV in the treatment of PSC + IBD do not always endure after OV discontinuation, with relapse of PSC associated with a decrease in blood Treg levels; subsequent OV retreatment was then associated with a rise in blood Treg levels and normalization of liver function tests (LFTs). Taken together, these studies support immune-related pathophysiology of PSC with IBD, which is responsive to OV.

Trial registration: ClinicalTrials.gov NCT01322386.

Conflict of interest statement

DISCLOSURES

The authors declare that they have no conflict of interest.

Figures

Fig. 1

Longitudinal analysis of liver and immune function in PSC + IBD patients during OV treatment. Serum (a) gamma-glutamyl transpeptidase (GGT) and (b) alanine aminotransferase levels (IU/L) over 12 months of OV (n=8). (c) Peripheral count (K/uL) of WBC, neutrophils, and lymphocytes over 12 months of OV (n=6). (d) Longitudinal changes in cytokine production patterns from Th1 (TNFα), Th2 (IL-4, IL-13), and Treg (TGF-β) subtype cells before and 3 months post OV administration in a separate cohort of children with PSC+IBD (n=6) initially reported on in the original Cox et al study [2]

Fig. 1

Longitudinal analysis of liver and immune function in PSC + IBD patients during OV treatment. Serum (a) gamma-glutamyl transpeptidase (GGT) and (b) alanine aminotransferase levels (IU/L) over 12 months of OV (n=8). (c) Peripheral count (K/uL) of WBC, neutrophils, and lymphocytes over 12 months of OV (n=6). (d) Longitudinal changes in cytokine production patterns from Th1 (TNFα), Th2 (IL-4, IL-13), and Treg (TGF-β) subtype cells before and 3 months post OV administration in a separate cohort of children with PSC+IBD (n=6) initially reported on in the original Cox et al study [2]

Fig. 1

Longitudinal analysis of liver and immune function in PSC + IBD patients during OV treatment. Serum (a) gamma-glutamyl transpeptidase (GGT) and (b) alanine aminotransferase levels (IU/L) over 12 months of OV (n=8). (c) Peripheral count (K/uL) of WBC, neutrophils, and lymphocytes over 12 months of OV (n=6). (d) Longitudinal changes in cytokine production patterns from Th1 (TNFα), Th2 (IL-4, IL-13), and Treg (TGF-β) subtype cells before and 3 months post OV administration in a separate cohort of children with PSC+IBD (n=6) initially reported on in the original Cox et al study [2]

Fig. 1

Longitudinal analysis of liver and immune function in PSC + IBD patients during OV treatment. Serum (a) gamma-glutamyl transpeptidase (GGT) and (b) alanine aminotransferase levels (IU/L) over 12 months of OV (n=8). (c) Peripheral count (K/uL) of WBC, neutrophils, and lymphocytes over 12 months of OV (n=6). (d) Longitudinal changes in cytokine production patterns from Th1 (TNFα), Th2 (IL-4, IL-13), and Treg (TGF-β) subtype cells before and 3 months post OV administration in a separate cohort of children with PSC+IBD (n=6) initially reported on in the original Cox et al study [2]

Fig. 2

(a) Flow cytometric data from human PBMCs isolated from untreated PSC+IBD subjects and PSC+IBD+OV treated subjects assessing CD4+CD25hiCD127lo and CD4+FoxP3+IL-10+ Treg levels. Data shown for untreated and treated subjects is longitudinal and representative. Comparison of (b) CD4+CD25hiCD127lo and (c) CD4+FoxP3+ Treg levels in peripheral blood of healthy age and gender matched controls with PSC+IBD patients ± OV treatment. (d) IL-10 reservoirs in peripheral CD4+FoxP3- T cells

Fig. 2

(a) Flow cytometric data from human PBMCs isolated from untreated PSC+IBD subjects and PSC+IBD+OV treated subjects assessing CD4+CD25hiCD127lo and CD4+FoxP3+IL-10+ Treg levels. Data shown for untreated and treated subjects is longitudinal and representative. Comparison of (b) CD4+CD25hiCD127lo and (c) CD4+FoxP3+ Treg levels in peripheral blood of healthy age and gender matched controls with PSC+IBD patients ± OV treatment. (d) IL-10 reservoirs in peripheral CD4+FoxP3- T cells

Fig. 2

(a) Flow cytometric data from human PBMCs isolated from untreated PSC+IBD subjects and PSC+IBD+OV treated subjects assessing CD4+CD25hiCD127lo and CD4+FoxP3+IL-10+ Treg levels. Data shown for untreated and treated subjects is longitudinal and representative. Comparison of (b) CD4+CD25hiCD127lo and (c) CD4+FoxP3+ Treg levels in peripheral blood of healthy age and gender matched controls with PSC+IBD patients ± OV treatment. (d) IL-10 reservoirs in peripheral CD4+FoxP3- T cells

Fig. 2

(a) Flow cytometric data from human PBMCs isolated from untreated PSC+IBD subjects and PSC+IBD+OV treated subjects assessing CD4+CD25hiCD127lo and CD4+FoxP3+IL-10+ Treg levels. Data shown for untreated and treated subjects is longitudinal and representative. Comparison of (b) CD4+CD25hiCD127lo and (c) CD4+FoxP3+ Treg levels in peripheral blood of healthy age and gender matched controls with PSC+IBD patients ± OV treatment. (d) IL-10 reservoirs in peripheral CD4+FoxP3- T cells

Fig. 3

Correlative analysis of CD4+CD25hiCD127lo and CD4+FoxP3+ Treg responses throughout OV in PSC+IBD patients to assess their similarity

Fig. 4

Treg levels in a PSC+IBD patient with a unique OV experience (patient 01). Control CD4+CD25hiCD127lo Treg levels are indicated by a solid horizontal line while CD4+FoxP3+ control levels are indicated by a dashed horizontal line. This case study presents variation in Treg populations during recurrence of PSC+IBD after removal from OV that is successfully resolved with OV-readministration