A Simulation Study to Assess Indicators of Antimicrobial Use as Predictors of Resistance: Does It Matter Which Indicator Is Used?

Objective

Indicators of antimicrobial use have been described previously, but few studies have compared their accuracy in prediction of antimicrobial resistance in hospital settings. This study aimed to identify conditions under which significant differences would be observed in the predictive accuracy of indicators in the context of surveillance of intensive care units (ICUs).

Methods

Ten resistance / antimicrobial use combinations were studied. We used simulation to determine if Québec’s network of 81 ICUs or the National Healthcare Safety Network (NHSN) of 2952 ICUs are large enough to allow the detection of predetermined differences between the most accurate and 1) the second most accurate indicator, and 2) the least accurate indicator, in more than 80% of simulations. For each indicator, we simulated absolute errors in prediction for each ICU and each 4-week period, for surveillance lasting up to 5 years. Absolute errors were generated following a binomial distribution, using mean absolute errors (MAEs) observed in 9 ICUs as the average proportion; simulated MAEs were compared using t-tests. This was repeated 1000 times per scenario.

Results

When comparing the two most accurate indicators, 80% power was reached less often with the Québec network versus the NHSN (0/20 versus 2/20 scenarios, with 5 years of surveillance data), a finding reinforced when comparing the most and least accurate indicators (3/20 versus 20/20 scenarios). When simulating 1 year of data, scenarios reaching an 80% power dropped to 0/20, comparing the two most accurate indicators with the larger network, and to 1/20, comparing the most and least accurate indicators with the smaller network.

Conclusion

Most of the time (72%), identifying an indicator of antimicrobial use predicting antimicrobial resistance with a better accuracy was not possible. The choice of an indicator for an eventual surveillance system should rely on criteria other that predictive accuracy.     

Resistance of M. leprae to Quinolones: A Question of Relativity?

Multidrug resistant leprosy, defined as resistance to rifampin, dapsone and fluoroquinolones (FQ), has been described in Mycobacterium leprae. However, the in vivo impact of fluoroquinolone resistance, mainly mediated by mutations in DNA gyrase (GyrA₂GyrB₂), has not been precisely assessed. Our objective was to measure the impact of a DNA gyrase mutation whose implication in fluoroquinolone resistance has been previously demonstrated through biochemical studies, on the in vivo activity of 3 fluoroquinolones: ofloxacin, moxifloxacin and garenoxacin.

Methodology/Principal Findings

We used the proportional bactericidal method. 210 four-week-old immunodeficient female Nude mice (NMRI-Foxn1^nu/Foxn1^nu) were inoculated in the left hind footpad with 0.03 ml of bacterial suspension containing 5×10³, 5×10², 5×10¹, and 5×10⁰ M. leprae AFB organisms of strain Hoshizuka-4 which is a multidrug resistant strain harboring a GyrA A91V substitution. An additional subgroup of 10 mice was inoculated with 5×10⁻¹ bacilli in the untreated control group. The day after inoculation, subgroups of mice were treated with a single dose of ofloxacin, moxifloxacin, garenoxacin or clarithromycin at 150 mg/kg dosing. 12 months later mice were sacrificed and M. leprae bacilli were numbered in the footpad. The results from the untreated control group indicated that the infective inoculum contained 23% of viable M. leprae. The results from the moxifloxacin and garenoxacin groups indicated that a single dose of these drugs reduced the percentage of viable M. leprae by 90%, similarly to the reduction observed after a single dose of the positive control drug clarithromycin. Conversely, ofloxacin was less active than clarithromycin.

Conclusion/Significance

DNA gyrase mutation is not always synonymous of lack of in vivo fluoroquinolone activity in M. leprae. As for M. tuberculosis, in vivo studies allow to measure residual antibiotic activity in case of target mutations in M. leprae.     

Resistance of Clostridium perfringens Type A Spores to γ-Radiation

The radiation resistance of the spores of a classical strain and of an atypical, heat-resistant strain of Clostridium perfringens was determined. Spores were produced in Ellner's and in a Trypticase broth medium. Approximately 10⁶ viable spores per milliliter were suspended in 0.06 m phosphate buffer and irradiated with γ rays from cobalt-60; the survivors were counted in Tryptone-yeast extract-agar by the Prickett-tube technique. Radiation D values for spores of the atypical strain in phosphate buffer and in cooked-meat broth were 0.23 and 0.30 Mrad, respectively, and the D value of the classical strain was 0.25 Mrad in phosphate buffer. Spores of the classical and atypical strains of C. perfringens type A are characterized by differences in heat resistance; yet, all strains tested demonstrated similar radiation resistance. Also, the spores were more resistant to ionizing radiation in cooked-meat broth than in phosphate buffer.     

Which cervical sampler? A comparison of four methods

Four cytology sampling methods were compared in 1063 patients referred for colposcopy with a recent abnormal smear. A dyskaryotic smear of any grade was considered a positive result, though comparisons were limited to cases with a subsequent biopsy confirming CINII or III. There were no differences between the abilities of any of the four methods to detect higher grades of CIN (χ²₃=4.603, P >0.20). the presence or absence of endocervical cells in a smear was not significantly associated with any variation in success rate (χ²₁=0.959, P >0.30). the joint analysis of the four methods and the presence/absence of endocervical cells also showed no significant effects (χ²₇=12.768, 0.1 > P >0.05). In the latter analysis the trend towards a conventional level of significance was accounted for by the Aylesbury spatula giving a relatively high success rate when endocervical cells were present. the suggestion of advantage for the Aylesbury spatula merits further investigation.     

Which Stage of ADPKD Is More Appropriate for Decortication? A Retrospective Study of 137 Patients from a Single Clinic

ObjectiveTo study retrospectively the efficacy of decortication in patients with different stages of ADPKD and to determine which stage for decortication is more appropriate.ResultsIn 70 patients who underwent decortication, significant differences were observed in operative duration and bleeding volume between patients with stage I and II ADPKD (P<0.05), but no significant differences were observed in intestinal recovery time, pain medication dose, and the days of postoperative hospitalization (P > 0.05). The total complication occurrence rate was significantly different between them (P < 0.05). The serum creatinine (Scr) levels in patients with stage I ADPKD were within normal limits 1 and 3 years postoperatively and did not differ significantly (P > 0.05). Scr levels were significantly decreased in patients with stage II ADPKD in the 1st postoperative year (P < 0.05), but these were not significant differences in the 3rd postoperative year (P > 0.05). In the 1st postoperative year, VAS value, blood pressure and renal volume significantly differed (P < 0.05). However, no significant differences were observed 3 years later (P > 0.05).ConclusionsDecortication in patients with stage I ADPKD can alleviate back pain symptoms and decrease blood pressure within 1 year, but the long-term efficacy is not ideal. Scr levels can be maintained within normal limits, suggesting that decortication does not lead to deterioration of renal function. For patients with stage II ADPKD, decortication can significantly improve renal function over the short term. However, after 3 years, renal function returns to the preoperative level, and surgical difficulties and complications also increase.     

Is the In?Vitro Ejection of Bacteriophage DNA Quasistatic? A Bulk to Single Virus Study

Bacteriophage T5 DNA ejection is a complex process that occurs on several timescales in vitro. By using a combination of bulk and single phage measurements, we quantitatively study the three steps of the ejection—binding to the host receptor, channel-opening, and DNA release. Each step is separately addressed and its kinetics parameters evaluated. We reconstruct the bulk kinetics from the distribution of single phage events by following individual DNA molecules with unprecedented time resolution. We show that, at the single phage level, the ejection kinetics of the DNA happens by rapid transient bursts that are not correlated to any genome sequence defects. We speculate that these transient pauses are due to local phase transitions of the DNA inside the capsid. We predict that such pauses should be seen for other phages with similar DNA packing ratios.     

Resistance is useless?—Extensions to the game theory of kleptoparasitism

We extend the game theoretic model of kleptoparasitism introduced by Broom and Ruxton (1998, Behav. Ecol. 9, 397–403) in two ways: we allow for asymmetric contests, where the probability α of the challenger winning can take any value from 0 to 1; and we allow the handler to choose not to resist the challenge, but to immediately concede and relinquish its food to the challenger. We find, in general, three possible evolutionarily stable strategies—challenge-and-resist (Hawk), challenge-but-do-not-resist (Marauder) and do-not-challenge-but-resist (Retaliator). When α = 1/2, we find that Hawk and Marauder are the only ESS’s, in contrast to the result of the original model; we also find an overlap region, in parameter space, where two different ESS’s are possible, depending on initial conditions. For general α, we see that all three ESS are possible, depending on different values of the environmental parameters; however, as the average time of a contest over food becomes long, then the Marauder strategy becomes more and more prevalent. The model makes a potentially significant prediction about animal behaviour in the area of kleptoparasitism, that a searcher, when it meets a handler, will only decline to attack that handler when α < 1/2 i.e.when the defender is more likely to win. One possible converse of this statement, that a handler whose probability of success is greater than 1/2 should always resist a challenge, is not true.     

Why Have Small Multidrug Resistance Proteins Not Evolved into Fused,Internally Duplicated Structures?

The increasing number of solved membrane protein structures has led to the recognition of a common feature in a large fraction of the small-molecule transporters: inverted repeat structures, formed by two fused homologous membrane domains with opposite orientation in the membrane. An evolutionary pathway in which the ancestral state is a single gene encoding a dual-topology membrane protein capable of forming antiparallel homodimers has been posited. A gene duplication event enables the evolution of two oppositely orientated proteins that form antiparallel heterodimers. Finally, fusion of the two genes generates an internally duplicated transporter with two oppositely orientated membrane domains. Strikingly, however, in the small multidrug resistance (SMR) family of transporters, no fused, internally duplicated proteins have been found to date. Here, we have analyzed fused versions of the dual-topology transporter EmrE, a member of the SMR family, by blue-native PAGE and in vivo activity measurements. We find that fused constructs give rise to both intramolecular inverted repeat structures and competing intermolecular dimers of varying activity. The formation of several intramolecularly and intermolecularly paired species indicates that a gene fusion event may lower the overall amount of active protein, possibly explaining the apparent absence of fused SMR proteins in nature.     

Which Obesity Indicators Are Better Predictors of Metabolic Risk?: Healthy Twin Study

No consensus exists as to the most sensitive and specific obesity indicator associated with metabolic risk factors. We aimed to validate anthropometry as the predictor for obesity-related metabolic risk factors through comparison with direct body composition measures in Korean adults. A total of 995 Korean women and 577 Korean men who participated in the Healthy Twin study were the subjects. Anthropometric measurements included BMI, waist circumference (WC), waist-to-hip ratio (WHR), and waist-to-height ratio (WHTR). Direct body composition measures included the percentage of body fat (%BF) measured using dual-energy X-ray absorptiometry scanners and bioelectrical impedance analyzer (BIA). The following criteria were used to define abnormal metabolic risk factors: blood pressure > or = 130/85 mm Hg, fasting glucose (> or = 100 mg/dl), insulin (> or = 25 microU/ml), homeostasis model assessment (HOMA) (> or = 2.61), high-density lipoprotein (HDL) (<40 mg/dl for men or <50 mg/dl for women), triacylglycerol (> or = 150 mg/dl), uric acid (>7 mg/dl for men or >6 mg/dl for women), high-sensitivity C-reactive protein (hs-CRP) (> or = 2.11 mg/l). In multiple regression analyses (adjusted for age, education, smoking, alcohol, exercise and past/current medical history, and treated families as a random effect), WC, WHTR, and BMI were consistently associated with all metabolic risk factors regardless of the subject's gender. Some of the areas under the receiver-operating characteristic curves regarding abnormal metabolic risk factors were significantly higher for the three indicators of central obesity than for %BF. Our study validates the usefulness of anthropometry over direct body fat measures to predict metabolic risks.     

��-Amyloid Causes Depletion of Synaptic Vesicles Leading to Neurotransmission Failure

Alzheimer disease is a progressive neurodegenerative brain disorder that leads to major debilitating cognitive deficits. It is believed that the alterations capable of causing brain circuitry dysfunctions have a slow onset and that the full blown disease may take several years to develop. Therefore, it is important to understand the early, asymptomatic, and possible reversible states of the disease with the aim of proposing preventive and disease-modifying therapeutic strategies. It is largely unknown how amyloid β-peptide (Aβ), a principal agent in Alzheimer disease, affects synapses in brain neurons. In this study, we found that similar to other pore-forming neurotoxins, Aβ induced a rapid increase in intracellular calcium and miniature currents, indicating an enhancement in vesicular transmitter release. Significantly, blockade of these effects by low extracellular calcium and a peptide known to act as an inhibitor of the Aβ-induced pore prevented the delayed failure, indicating that Aβ blocks neurotransmission by causing vesicular depletion. This new mechanism for Aβ synaptic toxicity should provide an alternative pathway to search for small molecules that can antagonize these effects of Aβ.     

Multidrug resistant to extensively drug resistant tuberculosis: What is next?

Drug resistant tuberculosis is a man made problem. While tuberculosis is hundred percent curable, multidrug resistant tuberculosis (MDR-TB) is difficult to treat. Inadequate and incomplete treatment and poor treatment adherence has led to a newer form of drug resistance known as extensively drug resistant tuberculosis (XDR-TB). XDR-TB is defined as tuberculosis caused by Mycobacterium tuberculosis strain, which is resistant to at least rifampicin and isoniazid among the first line anti tubercular drugs (MDR-TB) in addition to resistance to any fluroquinolones and at least one of three injectable second line anti tubercular drugs i.e. amikacin, kanamycin and/or capreomycin. Mismanagement of tuberculosis paves the way to drug resistant tuberculosis. Emergence of XDR-TB is reported world wide. Reported prevalence rates of XDR-TB of total MDR cases are; 6.6% overall worldwide, 6.5% in industrialized countries, 13.6% in Russia and Eastern Europe, 1.5% in Asia, 0.6% in Africa and Middle East and 15.4% in Republic of Korea. Better management and control of tuberculosis specially drug resistant TB by experienced and qualified doctors, access to standard microbiology laboratory, co-morbitidy of HIV and tuberculosis, new anti-TB drug regimens, better diagnostic tests, international standards for second line drugs (SLD)-susceptibility testing, invention of newer antitubercular molecules and vaccines and knowing the real magnitude of XDR-TB are some of the important issues to be addressed for effective prevention and management of XDR-TB.     

The Primary Resistance of Helicobacter pylori in Taiwan after the National Policy to Restrict Antibiotic Consumption and Its Relation to Virulence Factors—A Nationwide Study

Objective

The Taiwan Government issued a policy to restrict antimicrobial usage since 2001. We aimed to assess the changes in the antibiotic consumption and the primary resistance of H. pylori after this policy and the impact of virulence factors on resistance.

Methods

The defined daily dose (DDD) of antibiotics was analyzed using the Taiwan National Health Insurance (NHI) research database. H. pylori strains isolated from treatment naïve (N=1395) and failure from prior eradication therapies (N=360) from 9 hospitals between 2000 and 2012 were used for analysis. The minimum inhibitory concentration was determined by agar dilution test. Genotyping for CagA and VacA was determined by PCR method.

Results

The DDD per 1000 persons per day of macrolides reduced from 1.12 in 1997 to 0.19 in 2008, whereas that of fluoroquinolones increased from 0.12 in 1997 to 0.35 in 2008. The primary resistance of amoxicillin, clarithromycin, metronidazole, and tetracycline remained as low as 2.2%, 7.9%, 23.7%, and 1.9% respectively. However, the primary levofloxacin resistance rose from 4.9% in 2000–2007 to 8.3% in 2008–2010 and 13.4% in 2011–2012 (p=0.001). The primary resistance of metronidazole was higher in females than males (33.1% vs. 18.8%, p<0.001), which was probably attributed to the higher consumption of nitroimidazole. Neither CagA nor VacA was associated with antibiotic resistance.

Conclusions

The low primary clarithromycin and metronidazole resistance of H. pylori in Taiwan might be attributed to the reduced consumption of macrolides and nitroimidazole after the national policy to restrict antimicrobial usage. Yet, further strategies are needed to restrict the consumption of fluoroquinolones in the face of rising levofloxacin resistance.     

Extracellular Vesicles: A Prevalent Tool for Microbial Gene Delivery?

Genetic plasticity of prokaryotic microbial communities is largely dependent on the ongoing exchange of genetic determinants by Horizontal Gene Transfer (HGT). HGT events allow beneficial genetic transitions to occur throughout microbial life, thus promoting adaptation to changing environmental conditions. Here, the significance of secreted vesicles in mediating HGT between microorganisms is discussed, while focusing on the benefits gained by vesicle‐mediated gene delivery and its occurrence under different environmental cues. The potential use of secreted DNA‐harboring vesicles as a mechanism of currently unresolved HGT events in eukaryotic microbes is further discussed.     

Do We Need to Detect Isoniazid Resistance in Addition to Rifampicin Resistance in Diagnostic Tests for Tuberculosis?

Background

Multidrug-resistant tuberculosis (MDR-TB) is resistant to both rifampicin (RIF) and isoniazid (INH). Whereas many TB diagnostics detect RIF-resistance, few detect INH-monoresistance, which is common and may increase risk of acquired MDR-TB. Whether inclusion of INH-resistance in a first-line rapid test for TB would have an important impact on MDR-TB rates remains uncertain.

Methods

We developed a transmission model to evaluate three tests in a population similar to that of India: a rapid molecular test for TB, the same test plus RIF-resistance detection (“TB+RIF”), and detection of RIF and INH-resistance (“TB+RIF/INH”). Our primary outcome was the prevalence of INH-resistant and MDR-TB at ten years.

Results

Compared to the TB test alone and assuming treatment of all diagnosed MDR cases, the TB+RIF test reduced the prevalence of MDR-TB among all TB cases from 5.5% to 3.8% (30.6% reduction, 95% uncertainty range, UR: 17–54%). Despite using liberal assumptions about the impact of INH-monoresistance on treatment outcomes and MDR-TB acquisition, expansion from TB+RIF to TB+RIF/INH lowered this prevalence only from 3.8% to 3.6% further (4% reduction, 95% UR: 3–7%) and INH-monoresistant TB from 15.8% to 15.1% (4% reduction, 95% UR: (-8)-19%).

Conclusion

When added to a rapid test for TB plus RIF-resistance, detection of INH-resistance has minimal impact on transmission of TB, MDR-TB, and INH-monoresistant TB.