Abstract
Escherichia coli is a leading cause of neonatal sepsis, with infection occurring in approximately one in every 1,000 live births(1,2). However, with E. coli colonization beginning soon after birth(3-5) and defects in neonatal host defence maturation(6-9), an alternative consideration is why infection does not occur even more frequently. Here we show that newborn babies with E. coli sepsis have selectively reduced vertically transferred natural antibodies that recognize E. coli, mechanistically explaining their susceptibility to infection. Complementary preclinical studies show that preconceptual intestinal colonization with probiotic E. coli Nissle 1917 (EcN)(10) primes anti-E. coli immunoglobulin G (IgG) antibodies with broad cross-reactivity to clinical isolates responsible for neonatal sepsis that override the inherent susceptibility of neonatal mice. Outer membrane protein A (OmpA) is a target of maternal IgG and is also essential for EcN colonization-induced serological immunogenicity. Upon vertical transfer to neonates, colonization-primed anti-E. coli IgG uniquely protects against infection via opsonization, requiring both complement and IgG Fc receptors. Compared with specimens from sex and gestational age-matched healthy control babies without infection, dried blood spot specimens collected one day after birth from 100 babies with E. coli sepsis show consistently reduced IgG titres to pooled E. coli clinical isolates and OmpA, along with impaired IgG-dependent antibacterial opsonization. Together, these results demonstrate that natural infection susceptibility of neonates is efficiently rescued by anti-E. coli IgG and identify defects in pathogen-targeted vertically transferred immunity as a primary risk factor for severe invasive infection in newborn babies.