Akkermansia muciniphila identified as key strain to function in pathogen invasion and intestinal stem cell proliferation through Wnt signaling pathway

Reviewer #1 (Public Review):

Summary:
In this paper, the authors investigate the impact of fecal microbiota transfer (FMT) on intestinal recovery from enterotoxigenic E. coli infection following antibiotic treatment. Using a piglet model of intestinal infection, the authors demonstrate that FMT reduces weight loss and diarrhea and enhances the expression of tight junction proteins. Sequencing analysis of the intestinal microbiota following FMT showed significant increases in Akkermansia muciniphila and Bacteroides fragilis. Using additional mouse and organoid models, the authors examine the impact of these microbes on intestinal recovery and modulation of the Wnt signaling pathway. Overall, the data support the notion that FMT following ETEC infection is beneficial, however, additional investigation is required to fully elucidate the mechanisms involved.

Strengths:
Initial experiments used a piglet model of infection to test the value of FMT on recovery from E. coli. The FMT treatment was beneficial and the authors provide solid evidence that the treatment increased the diversity of the microbiota and enhanced the recovery of the intestinal epithelium. Sequencing data highlighted an increase in Akkermansia muciniphila and Bacteroides fragilis after FMT.

The mouse data are consistent with the observations in pigs, and reveal that daily gavage with A. muciniphila or B. fragilis enhances intestinal recovery based on histological analysis, expression of tight junction proteins, and analysis of intestinal barrier function.

The authors demonstrate the benefit of probiotic treatment following infection using a range of model systems.

Weaknesses:
Without sequencing the pre-infection pig microbiota or the FMT input material itself, it's challenging to firmly say that the observed bloom in Akkermansia muciniphila and Bacteroides fragilis stemmed from the FMT.

The lack of details for the murine infection model, such as weight loss and quantification of bacterial loads over time, make it challenging for a reader to fully appreciate how treatment with Akkermansia muciniphila and Bacteroides fragilis is altering the course of infection. Bacterial loads of E. coli were only quantified at one time point, and the mice that received A. muciniphila and B. fragilis had very low levels of E. coli. Therefore, it is not clear if all mice were subjected to the same level of infection in the first place. The reduced translocation of E. coli to the organs and enhanced barrier function may just reflect the low level of infection in these mice. Further, the authors' conclusion that the effect is specific to A. muciniphila or B. fragilis would be more convincing if the experiments included an inert control bacterium, to demonstrate that gavage with any commensal microbe would not elicit a similar effect.

Many of the conclusions in the study are drawn from the microscopy results. However, the methods describing both light microscopy and electron microscopy lack sufficient detail. For example, it is not clear how many sections and fields of view were imaged or how the SEM samples were prepared and dehydrated. The mucus layer does not appear to be well preserved, which would make it challenging to accurately measure the thickness of the mucus layer.

Gene expression data appears to vary across the different models, for example, Wnt3 expression in mice versus organoids. Additional experiments may be required to clarify the mechanisms involved. Considering that both of the bacteria tested elicited similar changes in Wnt signaling, this pathway might be broadly modulated by the microbiota.

The unconventional choice to not include references in the results section makes it challenging for the reader to put the results in context with what is known in the field. Similarly, there is a lack of discussion acknowledging that B. fragilis is a potential pathogen, associated with intestinal inflammation and cancer (Haghi et al. BMC Cancer 19, 879 (2019) ), and how this would impact its utility as a potential probiotic.

Reviewer #2 (Public Review):

Ma X. et al proposed that A. muciniphila was a key strain that promotes the proliferation and differentiation of intestinal stem cells by acting on the Wnt/b-catenin signaling pathway. They used various models, such as the piglet model, mouse model, and intestinal organoids to address how A. muciniphila and B. fragilis offer protection against ETEC infection. They showed that FMT with fecal samples, A. muciniphila or B. fragilis protected piglets and/or mice from ETEC infection, and this protection is manifested as reduced intestinal inflammation/bacterial colonization, increased tight junction/Muc2 proteins, as well as proper Treg/Th17 cells. Additionally, they demonstrated that A. muciniphila protected basal-out and/or apical-out intestinal organoids against ETEC infection via Wnt signaling. While a large body of work has been performed in this study, there are quite a few questions to be addressed.

Major comments:

- The similar protective effect of FMT with fecal samples, A. muciniphila or B. fragilis is perhaps not that surprising, considering that FMT likely restores microbiota-mediated colonization resistance against ETEC infection. While FMT with fecal samples increases SCFAs, it is unclear whether/how FMT with A. muciniphila or B. fragilis alter the microbiota composition/abundance as well as metabolites in the current models in a way that offers protection.

- Does ETEC infection in piglets/mice cause histological damage in the intestines? These data should be shown.

- Line 447, "ETEC adheres to intestinal epithelial cells". However, there is no data showing the adherence (or invasion) of ETEC to intestinal epithelial cells, irrespective of piglets/mouse/organoids.

- In both basal-out and apical-out intestinal organoid models, A. muciniphila protects organoids against ETEC infection. Did ETEC enter into intestinal epithelial cells at all after only one hour of infection? Is the protection through certain A. muciniphila metabolites?

Reviewer #3 (Public Review):

Summary:
The manuscript by Ma et al. describes a multi-model (pig, mouse, organoid) investigation into how fecal transplants protect against E. coli infection. The authors identify A. muciniphila and B. fragilis as two important strains and characterize how these organisms impact the epithelium by modulating host signaling pathways, namely the Wnt pathway in lgr5 intestinal stem cells.

Strengths:
The strengths of this manuscript include the use of multiple model systems and follow-up mechanistic investigations to understand how A. muciniphila and B. fragilis interacted with the host to impact epithelial physiology.

Weaknesses:
The major weakness is that, as presented, the manuscript is quite difficult to follow, even for someone familiar with the field. The lack of detail in figure legends, organization of the text, and frequent use of non-intuitive abbreviated group names without a clear key (ex. EP/EF, or C E A B) make comprehension challenging. The results section is perhaps too succinct and does not provide sufficient information to understand experimental design and interpretation without reading the methods section first or skipping to the discussion (as an example: WNT-c59 treatment). Extensive revisions could be encouraged to aid in communicating the potentially exciting findings.

The bioinformatics section of the methods requires revision and may indicate issues in the pipeline. Merging the forward and reverse reads may represent a problem for denoising. Also since these were sequenced on a NovaSeq, the error learning would have to be modified or the diversity estimates would be inappropriately multiplied. "Alpha diversity and beta diversity were calculated by normalized to the same sequence randomly." Not sure what this means, does this mean subsampled? "Blast was used for sequence alignment", does this mean the taxonomic alignment? This would need to be elaborated on and database versions should be included. The methods, including if any form of multiple testing was included, for LEFSE was also not included.