Delays in Appropriate Antibiotic Therapy for Gram-Negative Bloodstream Infections: A Multicenter,Community Hospital Study

Background

Gram-negative bacterial bloodstream infection (BSI) is a serious condition with estimated 30% mortality. Clinical outcomes for patients with severe infections improve when antibiotics are appropriately chosen and given early. The objective of this study was to estimate the association of prior healthcare exposure on time to appropriate antibiotic therapy in patients with gram-negative BSI.

Method

We performed a multicenter cohort study of adult, hospitalized patients with gram-negative BSI using time to event analysis in nine community hospitals from 2003-2006. Event time was defined as the first administration of an antibiotic with in vitro activity against the infecting organism. Healthcare exposure status was categorized as community-acquired, healthcare-associated, or hospital-acquired. Time to appropriate therapy among groups of patients with differing healthcare exposure status was assessed using Kaplan-Meier analyses and multivariate Cox proportional hazards models.

Results

The cohort included 578 patients with gram-negative BSI, including 320 (55%) healthcare-associated, 217 (38%) community-acquired, and 41 (7%) hospital-acquired infections. 529 (92%) patients received an appropriate antibiotic during their hospitalization. Time to appropriate therapy was significantly different among the groups of healthcare exposure status (log-rank p=0.02). Time to first antibiotic administration regardless of drug appropriateness was not different between groups (p=0.3). The unadjusted hazard ratios (HR) (95% confidence interval) were 0.80 (0.65-0.98) for healthcare-associated and 0.72 (0.63-0.82) for hospital-acquired, relative to patients with community-acquired BSI. In multivariable analysis, interaction was found between the main effect and baseline Charlson comorbidity index. When Charlson index was 3, adjusted HRs were 0.66 (0.48-0.92) for healthcare-associated and 0.57 (0.44-0.75) for hospital-acquired, relative to patients with community-acquired infections.

Conclusions

Patients with healthcare-associated or hospital-acquired BSI experienced delays in receipt of appropriate antibiotics for gram-negative BSI compared to patients with community-acquired BSI. This difference was not due to delayed initiation of antibiotic therapy, but due to the inappropriate choice of antibiotic.     

Interleukin-10 regulates the inflammasome-driven augmentation of inflammatory arthritis and joint destruction

Introduction

Activation of the inflammasome has been implicated in the pathology of various autoinflammatory and autoimmune diseases. While the NLRP3 inflammasome has been linked to arthritis progression, little is known about its synovial regulation or contribution to joint histopathology. Regulators of inflammation activation, such as interleukin (IL)-10, may have the potential to limit the inflammasome-driven arthritic disease course and associated structural damage. Hence, we used IL-10-deficient (IL-10KO) mice to assess NLRP3 inflammasome-driven arthritic pathology.

Methods

Antigen-induced arthritis (AIA) was established in IL-10KO mice and wild-type controls. Using histological and radiographic approaches together with quantitative real-time PCR of synovial mRNA studies, we explored the regulation of inflammasome components. These were combined with selective blocking agents and ex vivo investigative studies in osteoclast differentiation assays.

Results

In AIA, IL-10KO mice display severe disease with increased histological and radiographic joint scores. Here, focal bone erosions were associated with increased tartrate-resistant acid phosphatase (TRAP)-positive cells and a localized expression of IL-1β. When compared to controls, IL-10KO synovium showed increased expression of Il1b, Il33 and NLRP3 inflammasome components. Synovial Nlrp3 and Casp1 expression further correlated with Acp5 (encoding TRAP), while neutralization of IL-10 receptor signaling in control mice caused increased expression of Nlrp3 and Casp1. In ex vivo osteoclast differentiation assays, addition of exogenous IL-10 or selective blockade of the NLRP3 inflammasome inhibited osteoclastogenesis.

Conclusions

These data provide a link between IL-10, synovial regulation of the NLRP3 inflammasome and the degree of bone erosions observed in inflammatory arthritis.

Electronic supplementary material

The online version of this article (doi:10.1186/s13075-014-0419-y) contains supplementary material, which is available to authorized users.     

Molecular Differentiation of the African Yellow Fever Vector Aedes bromeliae (Diptera: Culicidae) from Its Sympatric Non-vector Sister Species,Aedes lilii

Introduction

Yellow fever continues to be a problem in sub-Saharan Africa with repeated epidemics occurring. The mosquito Aedes bromeliae is a major vector of yellow fever, but it cannot be readily differentiated from its non-vector zoophilic sister species Ae. lilii using morphological characters. Genetic differences have been reported between anthropophilic Ae. bromeliae and zoophilic Ae. lilii and between forest and domestic populations. However, due to the application of different molecular markers and non-overlapping populations employed in previous studies, interpretation of species delimitation is unclear.

Methodology/Principle Findings

DNA sequences were generated from specimens of Ae. simpsoni s.l. from the Republic of Benin, Tanzania and Uganda for two nuclear genes apolipophorin 2 (apoLp2) and cytochrome p450 (CYPJ92), the ribosomal internal transcribed spacer region (ITS) and the mitochondrial cytochrome c oxidase (COI) barcoding region. Nuclear genes apoLp2 and CYPJ92 were unable to differentiate between species Ae. bromeliae and Ae. lilii due to ancestral lineage sorting, while ITS sequence data provided clear topological separation on a phylogeny. The standard COI barcoding region was shown to be subject to species introgression and unable to clearly distinguish the two taxa. Here we present a reliable direct PCR-based method for differentiation of the vector species Ae. bromeliae from its isomorphic, sympatric and non-biomedically important sister taxon, Ae. lilii, based on the ITS region. Using molecular species verification, we describe novel immature habitats for Ae. lilii and report both sympatric and allopatric populations. Whereas only Ae. lilii is found in the Republic of Benin and only Ae. bromeliae in Tanzania, both species are sympatric in Uganda.

Conclusions/Significance

Our accurate identification method will allow informed distribution and detailed ecological studies that will facilitate assessment of arboviral disease risk and development of future targeted vector control.     

Rootstock-induced physiological and biochemical mechanisms of drought tolerance in sweet orange

The poorly understood physiological and biochemical drought responses induced in sweet orange by citrus rootstocks of contrasting drought tolerance were investigated during a drought/rewatering cycle under controlled conditions. Long-term exposure of the grafted trees to a gradually increasing water deficit and subsequent recovery revealed distinct strategies of drought acclimation that were induced by the different rootstocks. Trees grafted onto the drought-tolerant rootstock ‘Cravo’ rangpur lime were less water conservative, exhibiting an increased cell-wall elasticity that contributes to turgor maintenance and its related processes of growth and photosynthesis over a wider range of soil–water potentials. On the other hand, the drought-tolerant ‘Sunki Tropical’ mandarin and drought-sensitive ‘Flying Dragon’ trifoliate orange rootstocks induced a water conservation strategy by increasing tissue rigidity under drought. ‘Sunki Tropical’ was also able to induce osmotic adjustment, conferring thereby a more efficient water conservation strategy than ‘Flying Dragon’ by allowing for turgor maintenance at lower soil–water potentials while attenuating cell dehydration and shrinkage. In contrast to ‘Cravo’ and ‘Sunki Tropical’, trees grafted onto ‘Flying Dragon’ exhibited a significant photoinhibition of the photosystem II reaction centers, as well as an increased H₂O₂ production and lipid peroxidation under drought treatment. A significantly higher activity of the antioxidant enzyme GPX was also observed in drought stressed trees grafted onto ‘Flying Dragon’. Collectively, these results support the involvement of elastic and osmotic adjustments, as well as the control of oxidative stress, as functional leaf traits associated with the rootstock-induced drought tolerance in sweet orange.     

Increased hatching success as a direct benefit of polyandry in birds

Multiple mating by females is difficult to explain in primarily socially monogamous taxa such as birds because mating outside the pair bond often provides no obvious benefit to females. Although indirect selection is often invoked to explain the evolution of polyandry, current evidence suggests that selection on indirect benefits of mating is weak. Here, I consider a direct benefit of remating in birds: increased fertilization success. I test whether increased hatching success of a female's eggs is related to rates of extra-pair paternity (EPP), a proxy of polyandry, across 113 bird species. I use two statistical approaches, control for phylogenetic uncertainty, and assess the fit of competing evolutionary models. Results show there is indeed a positive relationship between rates of EPP and hatching success in birds. I propose that by mating with many males, females may increase their fertility. I end by discussing the biological rationale for this explanation, alternative interpretations of the results, and how this study furthers our understanding of polyandry and mating system evolution.     

Exploring the environmental diversity of kinetoplastid flagellates in the high-throughput DNA sequencing era

The class Kinetoplastea encompasses both free-living and parasitic species from awide range of hosts. Several representatives of this group are responsible for severehuman diseases and for economic losses in agriculture and livestock. While this groupencompasses over 30 genera, most of the available information has been derived fromthe vertebrate pathogenic genera LeishmaniaandTrypanosoma. Recent studies of the previously neglected groups ofKinetoplastea indicated that the actual diversity is much higher than previouslythought. This article discusses the known segment of kinetoplastid diversity and howgene-directed Sanger sequencing and next-generation sequencing methods can help todeepen our knowledge of these interesting protists.     

Determining a minimum detection threshold in terminal restriction fragment length polymorphism analysis

Terminal restriction fragment length polymorphism (T-RFLP) analysis is a common technique used to characterize soil microbial diversity. The fidelity of this technique in accurately reporting diversity has not been thoroughly evaluated. Here we determine if rare fungal species can be reliably detected by T-RFLP analysis. Spores from three arbuscular mycorrhizal fungal species were each mixed at a range of concentrations (1%, 10%, 50%, and 100%) with Glomus irregulare to establish a minimum detection threshold. T-RFLP analysis was capable of detecting diagnostic peaks of rare taxa at concentrations as low as 1%. The relative proportion of the target taxa in the sample and DNA concentration influenced peak detection reliability. However, low concentrations produced small, inconsistent electropherogram peaks contributing to difficulty in differentiating true peaks from signal noise. The results of this experiment suggest T-RFLP is a reproducible and high fidelity procedure, which requires careful data interpretation in order to accurately characterize sample diversity.