Diabetic foot ulcers (DFUs) are the most common complications of diabetes resulting from hyperglycemia leading to ischemic hypoxic tissue and nerve damage.
Staphylococcus aureus
is the most frequently isolated bacteria from DFUs and causes severe necrotic infections leading to amputations with a poor 5-year survival rate. However, very little is known about the mechanisms by which
S. aureus
dominantly colonizes and causes severe disease in DFUs. Herein, we utilized a pressure wound model in diabetic TALLYHO/JngJ mice to reproduce ischemic hypoxic tissue damage seen in DFUs and demonstrated that anaerobic fermentative growth of
S. aureus
significantly increased the virulence and the severity of disease by activating two-component regulatory systems leading to expression of virulence factors. Our
in vitro
studies showed that supplementation of nitrate as a terminal electron acceptor promotes anaerobic respiration and suppresses the expression of
S. aureus
virulence factors through inactivation of two-component regulatory systems, suggesting potential therapeutic benefits by promoting anaerobic nitrate respiration. Our
in vivo
studies revealed that dietary supplementation of L-arginine (L-Arg) significantly attenuated the severity of disease caused by
S. aureus
in the pressure wound model by providing nitrate. Collectively, these findings highlight the importance of anaerobic fermentative growth in
S. aureus
pathogenesis and the potential of dietary L-Arg supplementation as a therapeutic to prevent severe
S. aureus
infection in DFUs.
IMPORTANCE
S. aureus
is the most common cause of infection in DFUs, often resulting in lower-extremity amputation with a distressingly poor 5-year survival rate. Treatment for
S. aureus
infections has largely remained unchanged for decades and involves tissue debridement with antibiotic therapy. With high levels of conservative treatment failure, recurrence of ulcers, and antibiotic resistance, a new approach is necessary to prevent lower-extremity amputations. Nutritional aspects of DFU treatment have largely been overlooked as there has been contradictory clinical trial evidence, but very few
in vitro
and
in vivo
modelings of nutritional treatment studies have been performed. Here we demonstrate that dietary supplementation of L-Arg in a diabetic mouse model significantly reduced duration and severity of disease caused by
S. aureus
. These findings suggest that L-Arg supplementation could be useful as a potential preventive measure against severe
S. aureus
infections in DFUs.