INTRODUCTION
Even though vaccines and antiviral drugs are available, influenza still constitutes a serious health problem and a key economic issue. Although influenza virus infection generally causes mild-to-moderate disease, it can sometimes, depending on the strain’s virulence and the host’s health status, trigger severe disease. Seasonal influenza leads to ∼300,000 deaths a year worldwide (
1). Most of these influenza-related deaths are due to acute respiratory distress symptoms, compromised pulmonary functions, multiorgan dysfunction, and secondary bacterial infections (
2,
3). Along with lung disease
per se, influenza is frequently associated with extrapulmonary complications, including intestinal disorders (
4). Indeed, the results of preclinical and clinical studies indicate that influenza can lead to nausea, vomiting, and/or diarrhea (
4–8). The causes, nature, and consequences of these associated intestinal disorders have yet to be fully characterized.
We and others have shown that influenza alters the composition and function of the gut microbiota (
6–10). The consequences of this dysbiosis on the disease’s outcome remain to be fully defined (
11). Wang and colleagues (
6) were the first to report a link between gut dysbiosis and intestinal inflammation. An impact of gut dysbiosis on secondary bacterial infection in the intestine has also been suggested (
7,
8). Lastly, our recent findings indicate that by reducing the production of short-chain fatty acids (SCFAs; the main metabolites of the gut microbiota), influenza favors secondary bacterial infection of the lungs (
10). With regard to the role of SCFAs in gut homeostasis (
12–17), we hypothesize herein that the influenza virus infection’s impairment of SCFA production weakens the gut’s barrier function and thus favors secondary enteric infections.
Short-chain fatty acids represent the end products of dietary fiber fermentation (for reviews, see references
18 and
19). The SCFAs supply energy to colonocytes and are critical for intestinal homeostasis, gut functions, and gut metabolism. Although the SCFAs’ role in the control of gut inflammation appears to be a function of the disease state, these compounds tend to reinforce the gut barrier, a critical property for controlling the dissemination of gut commensals, opportunistic pathogens, and microbial components. Moreover, SCFAs display antimicrobial activity by favoring the synthesis of antimicrobial components (including antimicrobial peptides) in the intestine (
17–20). In the present study, we sought to specify the nature of gut disorders (including disruption of barrier functions) during an experimental influenza A virus (IAV) infection. We found that (i) decreased SCFA production is important for these effects and (ii) SCFA supplementation during IAV infection partially protects animals from secondary infection with the enteric pathogen
Salmonella enterica serovar Typhimurium. Taken as a whole, our data emphasize that viral respiratory infections can remotely impact gut homeostasis and intestinal barrier functions and thereby favor secondary bacterial infections. Reduced production of gut microbiota-derived fermentative products (SCFAs) might have a critical role in these alterations.
DISCUSSION
Our data support the hypothesis that viral respiratory infection can remotely trigger intestinal disorders (namely, mild inflammation and altered barrier functions) and thus have a major impact on secondary enteric infections. Furthermore, our data show that SCFA supplementation during an influenza virus infection ameliorated gut disorders and reduced secondary Salmonella infection. Given that gut dysfunction has been described in many critical illnesses, these relationships might have clinical relevance.
Several studies have highlighted the impact of influenza virus infection on gut homeostasis, with dysbiosis and inflammation (
6–10,
22). In line with other researchers (
7,
9), we did not observe major intestinal architecture remodeling at 7 dpi (i.e., when gut disorders peak). However, a shorter colon and altered intestinal metabolic functions (as revealed by systemic citrulline levels) indicated the presence of intestinal dysfunction in our mouse model. Furthermore, the present study is the first to have shown that influenza virus infection is associated with disruption of the intestine’s barrier functions. In line with the results of Deriu and colleagues (
7), our overall transcript analysis indicated that the expression of a large panel of inflammatory (NF-κB-dependent) genes and immune genes (in particular, ISGs) was modulated in the intestine during an IAV infection. ISG expression probably reflects the increased systemic interferon levels during infection, since a quantitative PCR did not detect any genomic IAV RNA in the intestine (
6,
10). Although speculative at this stage, a change in the enteric virome during influenza (exposure to virus-associated signals) might also influence local ISG expression (
24). Influenza virus infection is also associated with a low expression of genes involved in the maintenance of barrier functions and with elevated paracellular permeability, as assessed by enhanced passage of FITC-dextran into the blood. This alteration in barrier function was combined with enhanced inflammatory gene expression in the liver, perhaps as a result of the portal translocation of bacterial components from the gut. Pair-feeding experiments indicated that reduced food consumption during influenza is not involved in gut inflammation and barrier disruption (and secondary
Salmonella infection). There are probably many causes of intestinal barrier leakage. One can reasonably hypothesize that microbiota dysbiosis, altered microbiota-host interactions, and inflammation during influenza are causally linked to the alterations in barrier properties (
25,
26). Hence, the loss of beneficial members of the microbial community (
Lachnospiraceae and
Lactobacillus), the overgrowth of pathosymbionts (
Alphaproteobacteria,
Gammaproteobacteria, and the
Escherichia genus) and/or a shift in metabolism (such as altered fermentation) may accentuate the gut’s leakiness (
10). Enhanced production of toxic metabolites may also be involved in barrier disruption. For instance, the excessive production of phenolic and sulfur-containing compounds by dysbiotic microbiota can alter tight junctions between cells and disrupt barrier functions (
27,
28). Counts of mucin-degrading bacteria like
Ruminococcus increase during influenza (
10). These bacteria erode the colonic mucosa and favor interactions between luminal bacteria and the intestinal epithelium, which in turn may lead to inflammation and the impairment of barrier function (
29).
The question of the impact of gut dysbiosis and intestinal disorders on influenza outcomes then arises. Increased leakiness of the gut barrier and dissemination of commensal bacteria and/or their components might lead to extraintestinal complications, such as acute liver injury, acute respiratory distress syndrome, bacterial respiratory tract coinfections, and systemic symptoms (e.g., a cytokine storm, circulatory collapse, sepsis, and multiorgan dysfunction) (
11). These complications are observed in critically ill patients and constitute key causes of mortality (
30–32). However, the extent to which gut perturbations cause extraintestinal disorders remains to be determined. Gut barrier dysfunction is a well-known feature of aging and chronic metabolic diseases, like obesity (
25,
33–36). It would be interesting to look at whether these alterations amplify secondary extraintestinal complications in obese and older individuals, who are particularly at risk of developing critical illnesses during influenza (
31). The dissemination of microbial components through the gut wall might affect not only inflammation and organ functions but also host metabolism (such as glucose homeostasis) and other outcomes (
37–39). Our present data highlighted the altered expression of many inflammatory genes and metabolic genes (data not shown) in the liver. We also recently showed that the homeostasis of adipose tissue is dramatically altered during experimental influenza, with inflammation and metabolic perturbations (
40). The impact of compromised gut barrier function on hepatic and adipose inflammation and metabolism warrants investigation.
Influenza virus infection is associated with a drop in the production of SCFAs; this phenomenon is due, at least in part, to reduced food (fiber) consumption by the diseased host (
10). This drop may limit the energy supply to colonocytes, accentuate mucosal inflammation, and alter the intestine’s barrier functions. SCFAs are currently considered to be a promising adjunct treatment for active inflammatory bowel disease and diversion colitis (for a review, see reference
20). Various approaches (including enemas of butyrate and mixtures of acetate, propionate, and butyrate) have given differing clinical outcomes (
41–43). In the present study, we observed a beneficial effect of SCFA supplementation on gut barrier functions, as measured by greater gut impermeability and diminished inflammatory gene expression in the liver. This effect was not associated with major changes in the composition of the gut microbiota. In contrast, we did not find a marked effect on local inflammatory gene expression (data not shown), even though SCFA supplementation rescued the colon shortening typically observed in a setting of inflammation. This is in line with suggestions that the SCFAs’ functional activities depend on the disease context and severity. Recent research indicates that gut disorders during influenza virus infection may favor the local colonization and systemic dissemination of the intestinal pathogenic bacterium
Salmonella (
7,
8), a leading cause of acute gastroenteritis and inflammatory diarrhea. Our data confirm these findings, although the underlying mechanism has yet to be defined. However, we postulated that the influenza-associated drop in intestinal SCFA production might cause, at least in part, secondary enteric infections. Acetate can protect against
E. coli (
13), while propionate and butyrate can protect against
S. Typhimurium (
44) and
Citrobacter rodentium (
45,
46). In these settings, SCFAs inhibited pathogen growth directly or (through host signaling) indirectly, leading to the production of cytokines and antimicrobial compounds (
13,
45,
47,
48) and to increased bactericidal activity by macrophages (
46). SCFAs can also prevent the abnormal expansion of antibiotic-resistant strains of
Enterobacteriaceae, in part by increasing intracellular acidification (
49). SCFAs (including propionate) have also been shown to regulate (favor) the growth and virulence of enteric pathogens, such as enterohemorrhagic and adherent-invasive
E. coli (
50,
51). In our experimental model, mice fed SCFAs before an
S. Typhimurium infection did not show a lower degree of local bacterial colonization, indicating a lack of a direct effect on bacterial growth. In contrast, SCFA supplementation limited systemic bacterial dissemination, probably by reinforcing intestinal barrier properties, as our data show. Interestingly, SCFA supplementation tended to lower the degree of morbidity (i.e., improved weight loss recovery) and to increase the survival rate of doubly infected animals. Mechanisms through which SCFAs reduced
Salmonella dissemination in our setting are still elusive. They might include a direct role in virulence factors involved in bacterial invasion and translocation (
52) and/or an indirect role in host signaling pathways. Among them, activation of the G protein-coupled receptors free fatty acid receptor 3 and/or 2 (receptors for acetate and/or propionate) and/or inhibition of histone deacetylase (butyrate and, to a lower extent, propionate) are probable. Together with the fact that acetate protected against postinfluenza pneumococcal infection in the lungs (
10), our finding highlights the potential benefit of using SCFAs to lower secondary influenza outcomes. In this context, the restoration of mucosa homeostasis might be achieved by stimulating SCFA production via prebiotics (e.g., high-fiber diets) or probiotics (i.e., SCFA producers themselves). The clinical efficacy of this adjunct treatment remains to be determined.
ACKNOWLEDGMENTS
We acknowledge Richard Flavell (Howard Hughes Medical Institute, Princeton University, Princeton, NJ) for the gift of the NF-κB–luciferase transgenic B10.A mice and Hugues Lelouard (CIML, Marseille, France) for scientific discussions. We thank the animal facility (PLETHA) of the Pasteur Institute, Lille, France, for animal maintenance and the PICT platform (INRAE, Jouy-en-Josas, France) for microarray technical assistance.
This work was supported in part by the INSERM, CNRS, University of Lille, Pasteur Institute of Lille, Région des Hauts-de-France (FLUMICROBIOTE), and the Agence Nationale de la Recherche (AAP Générique 2017, ANR-17-CE15-0020-01, ACROBAT) (F.T.). V.S., M.G.M., and A.B. received salary support (Ph.D. fellowship) from Lille University and from the Fondation pour la Recherche Médicale (V.S.).