Enhanced antimicrobial stewardship based on rapid phenotypic antimicrobial susceptibility testing for bacteraemia in patients with haematological malignancies: a randomized controlled trial

OBJECTIVES

Recently, rapid phenotypic antimicrobial susceptibility testing (AST) based on microscopic imaging analysis has been developed. The aim of this study was to determine whether implementation of antimicrobial stewardship programmes (ASP) based on rapid phenotypic AST can increase the proportion of patients with haematological malignancies who receive optimal targeted antibiotics during early periods of bacteraemia.

METHODS

This randomized controlled trial enrolled patients with haematological malignancies and at least one positive blood culture. Patients were randomly assigned 1:1 to conventional (n = 60) or rapid phenotypic (n = 56) AST. The primary outcome was the proportion of patients receiving optimal targeted antibiotics 72 hr after blood collection for culture.

RESULTS

The percentage receiving optimal targeted antibiotics at 72 hr was significantly higher in the rapid phenotypic AST group (45/56, 80.4%) than in conventional AST group (34/60, 56.7%) (relative risk (RR) 1.42, 95% confidence interval (CI) 1.09-1.83). The percentage receiving unnecessary broad-spectrum antibiotics at 72 hr was significantly lower (7/26, 12.5% vs 18/60, 30.0%; RR 0.42, 95% CI 0.19-0.92) and the mean time to optimal targeted antibiotic treatment was significantly shorter (38.1, standard deviation (SD) 38.2 vs 72.8, SD 93.0 hr; p < 0.001) in the rapid phenotypic AST group. The mean time from blood collection to the AST result was significantly shorter in the rapid phenotypic AST group (48.3, SD 17.6 vs 83.1, SD 22.2 hr).

DISCUSSION

ASP based on rapid phenotypic AST can rapidly optimize antibiotic treatment for bacteraemia in patients with haematological malignancy. Rapid phenotypic AST can improve antimicrobial stewardship in immunocompromised patients.

Complete mitochondrial genome of the spotted lanternfly, Lycorma delicatula White, 1845 (Hemiptera: Fulgoridae)

The spotted lanternfly, Lycorma delicatula White, 1845 (Hemiptera: Fulgoridae), is an invasive pest that attacks forest as well as agricultural trees. We sequenced the 15,798-bp long complete mitochondrial genome (mitogenome) of this species; it consists of a typical set of genes (13 protein-coding genes, 2 rRNA genes, and 22 tRNA genes) and one major non-coding A + T-rich region. The orientation and gene order of the L. delicatula mitogenome are identical to that of the ancestral type found in majority of the insects. Bayesian inference (BI) and maximum-likelihood (ML) phylogeny placed the L. delicatula examined in our study, together with other geographical samples of the species in a group with the highest nodal support, forming the subfamily Aphaeninae to which L. delicatula belongs.

Complete mitochondrial genome of Acropteris iphiata (Lepidoptera: Uraniidae)

Acropteris iphiata belongs to the family Uraniidae in the superfamily Geometroidea (Lepidoptera). We sequenced 15,346-bp long complete mitochondrial genome (mitogenome) of the species, which consists of a typical set of genes (13 protein-coding genes, 2 rRNA genes, and 22 tRNA genes) and one major non-coding A + T-rich region. The A. iphiata mitogenome harbored the gene order tRNA^Met, tRNA^Ile, and tRNA^Gln between the A + T-rich region and ND2 that is found in most lepidopteran mitogenomes. Bayesian inference (BI) and maximum likelihood (ML) phylogeny, using 13 protein-coding genes (PCGs) and 2 rRNAs showed that A. iphiata was placed as a sister to Geometridae with the highest nodal support (Bayesian posterior probabilities for BI = 1.00 and Bootstrap support for ML = 100).

Comparison of the difference between income quintiles with the slope index of inequality

Background

The difference between income quintiles in health is relatively well accepted by the general public as a measure of health inequality. However, the slope index of inequality (SII) in health reflects the patterns of all social groups, including the middle 60%, and it could therefore be considered more academically desirable. If these two measures are closely correlated, the widespread use of the difference between income quintiles in health would be better supported. This study was conducted to compare differences between income quintiles in life expectancy (LE) and healthy life expectancy (HLE) with the SII.

Methods

Data on LE and HLE by income quintile from all 252 subnational districts of Korea were obtained using the National Health Information Database of the National Health Insurance Service and the Korea Community Health Survey. The SII was estimated with linear regression analysis, and Pearson correlation coefficients between differences between income quintiles and the SII were computed.

Results

The correlation coefficients between differences between income quintiles and the SII were generally high: 0.97 (95% CI: 0.96-0.98) for LE in men and women combined and 0.96 (95% CI: 0.94-0.97) for HLE in men and women combined. In most districts, the SII was greater than the difference between income quintiles.

Conclusions

Differences between income quintiles were closely correlated with the SII. The widespread use of differences between income quintiles in health as a measure of health inequality may be preferable for communicating results of health inequality measurements to the public.

Key messages

Differences in life expectancy and health life expectancy between income quintiles were closely correlated with the slope index of inequality in life expectancy and healthy life expectancy. The widespread use of differences between income quintiles in health as a measure of health inequality may be preferable for communicating results of health inequality measurements to the public.

Complete mitochondrial genome of the silver stripped skipper, Leptalina unicolor (Lepidoptera: Hesperiidae)

The silver stripped skipper, Leptalina unicolor Bremer and Grey, 1853 (Lepidoptera: Hesperiidae), is listed as endangered insect in South Korea. We sequenced the whole genome (15,854 bp) of L. unicolor species using Next-Generation Sequencing method and the subsequent gap-filling method. This genome included a set of typical genes and one major non-coding A + T-rich region, with an arrangement identical to that observed in most lepidopteran genomes. Twelve protein-coding genes (PCGs) had the typical ATN start codon, whereas COI had the atypical CGA codon that is frequently found in the start region of the lepidopteran COI. The 757-bp long A + T-rich region was the second largest among completely sequenced Hesperiidae, which ranged from 234 to 793 bp. Phylogenetic reconstruction was performed by maximum-likelihood method using the concatenated sequences of 13 PCGs and two rRNAs of available species of Hesperiidae, including that of L. unicolor (a total of 28 species). The resulting phylogeny provided strong support for monophyletic Heteropterinae in which L. unicolor belongs, with the highest nodal support and a sister relationship between current L. unicolor and co-subfamilial species Carterocephalus silvicola with a bootstrap value of 91%.

Complete mitochondrial genome of the silkworm strain, Chilseongjam Bombyx mori (Lepidoptera: Bombycidae), with a unique larval body marking

Recently, a new silkworm strain with a peculiar larval marking and rare cocoon colour was bred in Korea for educational learning and exhibition. In order to obtain the genetic information of the newly bred strain, Chilseongjam Bombyx mori (Lepidoptera: Bombycidae), its complete mitochondrial genome (mitogenome) was sequenced. The mitogenome is 15,660 bp in length, contains a typical set of genes, and has gene arrangement and composition typical of Lepidoptera. However, the Chilseongjam strain mitogenome is 4-36 bp longer than 19 other strains originating from other countries and 16 bp shorter than the whole genome of a Korean Hukpyobeom strain. In particular, the Chilseongjam strain has an intergenic spacer sequence that is shorter than that of the Hukpyobeom strain at the tRNAHis and ND4 junction as it has fewer microsatellite-like AT repeats. Phylogenetic analyses conducted using a total of 21 silkworm strains originating from nine countries revealed a few subgroups with moderate-to-high nodal support (80-94%). The Korean Chilseongjam strain formed a relatively strong subgroup (85%) with a Japanese strain (J106) instead of the Korean Hukpyobeom strain.

Evaluation of an antibody to α4β7 in the control of SIVmac239-nef-stop infection

Treatment of SIV-infected rhesus macaques with short-term antiretroviral therapy (ART) and partially overlapping infusions of antibody to integrin α4β7 was reported to induce durable posttreatment viral suppression. In an attempt to replicate those observations, we treated macaques infected with the same virus and with the same ART and monoclonal antibody (mAb) regimens (anti-α4β7 versus control mAb). Sequencing demonstrated that the virus used was actually SIVmac239-nef-stop, not wild-type SIVmac239. A positive correlation was found at 2 weeks after infection between the frequency of repair of attenuated Nef-STOP virus to pathogenic Nef-OPEN and plasma SIV RNA levels. Levels of plasma viremia before the first antibody infusion and preinfection levels of α4β7hi CD4+ T cells, but not treatment with antibody to α4β7 , correlated with levels of viral replication upon discontinuation of all treatments. Follow-up plasma viremia, peripheral blood CD4+ T cell counts, and lymph node and rectal tissue viral load were not significantly different between anti-α4β7 and control mAb groups.

Global genetic diversity, lineage distribution, and Wolbachia infection of the alfalfa weevil Hypera postica (Coleoptera: Curculionidae)

The alfalfa weevil (Hypera postica) is a well-known example of a worldwide-distributed pest with high genetic variation. Based on the mitochondrial genes, the alfalfa weevil clusters into two main mitochondrial lineages. However, there is no clear picture of the global diversity and distribution of these lineages; neither the drivers of its diversification are known. However, it appears likely that historic demographic events including founder effects played a role. In addition, Wolbachia, a widespread intracellular parasite/symbiont, likely played an important role in the evolution of the species. Wolbachia infection so far was only detected in the Western lineage of H. postica with no information on the infecting strain, its frequency, and its consequences on the genetic diversity of the host. We here used a combination of mitochondrial and nuclear sequences of the host and sequence information on Wolbachia to document the distribution of strains and the degree of infection. The Eastern lineage has a higher genetic diversity and is found in the Mediterranean, the Middle East, Eastern Europe, and eastern America, whereas the less diverse Western lineage is found in Central Europe and the western America. Both lineages are infected with the same common strain of Wolbachia belonging to Supergroup B. Based on neutrality tests, selection tests, and the current distribution and diversification of Wolbachia in H. postica, we suggested the Wolbachia infection did not shape genetic diversity of the host. The introduced populations in the United States are generally genetically less diverse, which is in line with founder effects.

Histone deacetylase inhibition has cardiac and vascular protective effects in rats with pressure overload cardiac hypertrophy

Histone deacetylase (HDAC) inhibitors have shown beneficial effects in animal models of cardiovascular diseases. We hypothesized that HDAC inhibitor, sodium valproate (VPA), has cardiac and vascular protective effects in rats with pressure overload cardiac hypertrophy induced by transverse aortic constriction (TAC). Sections of the heart were visualized after hematoxylin and eosin staining, picrosirius red staining and immunohistochemistry. The expression of genes related to cardiac hypertrophy, fibrosis, and oxidative stress was determined by quantitative real-time polymerase chain reaction. The aortic ring tension analysis was conducted using both the ascending aorta and descending thoracic aorta. TAC increased the expression of hypertrophic, fibrotic, and oxidative stress genes, which was attenuated by VPA. In the ascending aorta with intact endothelium, there was a significant decrease in the relaxation response, which was recovered by VPA treatment. These results indicate that VPA has cardiac and vascular protective effects in rats with pressure overload cardiac hypertrophy.

Complete mitochondrial genome sequence of Bekko Tombo Libellula angelina Selys, 1883 (Odonata: Libellulidae)

The dragonfly Libellula angelina Selys, 1883 (Odonata: Libellulidae) has been listed as a critically endangered species by the International Union for Conservation of Nature (IUCN) and is also an endangered insect in South Korea. We sequenced the whole genome (15,233 bp) of L. angelina species, which included a set of typical genes and one major non-coding AT-rich region with an arrangement identical to that observed in most insect genomes. The A + T-rich region harbored one identical repeat composed of 65 bp and two tRNA-like structures (trnF and trnK-like sequences) with proper anticodon and clover-leaf structures. Phylogenetic reconstruction using the concatenated sequences of 13 protein-coding genes (PCGs) and two rRNAs of the representative odonate mitogenomes utilizing both Bayesian inference and maximum-likelihood methods revealed a strong support for the monophyletic Zygoptera and a moderate to high support for the monophyletic Anisoptera suborders. Unlike that in conventional phylogenetic analysis, a relatively strong sister relationship was revealed between the suborders of Anisozygoptera and Zygoptera.

Abstract P2-08-52: A predictive model for distant metastasis in breast cancer patients using machine learning

Introduction

Tumor metastasis is a major clinical challenge accounting for the vast majority of cancer related deaths.In previous studies, prediction of distant metastasis was based on subtypes,clinical status and sometimes gene expression were used however clinical application was difficult.

In this study, we develop the easy to use prediction tool for distant metastasis using clinical characteristics and gene profiles which came from CancerSCANTM, Next Generation Sequencing based targeted-sequencing platform designed at Samsung Medical Center(SMC).

Methods

We performed a retrospective chart review of 326 breast cancer patients who underwent surgery and CancerSCAN TM between Jan 2001 and Dec 2014 at SMC. Median follow up period was 83 months (Range 1˜190). Cancer scanTM cover 381 genes but 27 genes and 34 occasions (loss of function, mutation or copy number variation) were selected for analysis through gradient boosting and Wilcoxon Signed rank test. Azure Machine Learning is a cloud service that enables the execution of machine learning processes.This was accomplished using the steps of (1) edit the data, (2) split the data, (3) train the model, (4) score the model, and (5) evaluate the model. We split the modeling data into training and testing sets using a randomized 50–50 split. Two-class Decision Forest method was used. After deploying the Azure ML predictive model as a web service, we used a Representational State Transfer application programming interface to send data and obtained predictions in real-time.

Results

No distant metastasis group and distant metastasis group consisted of 267 and 59 patients, respectively. HR-/HER2+ and 50 years old and over patients were higher in metastasis group (p-value = 0.003 and p-value = 0.000). Nuclear grade 3 and N2,3 were higher in metastasis group (p-value = 0.010 and p-value = 0.000, p-value = 0.001 respectively). Stage III was also higher in metastasis group (p-value = 0.000). Among 59 patients with distantmetastasis, multiple sites metastasis was 21 cases (35.6%) and then lung metastasis was 19 cases (32.2%). In the 21 cases of multiple sites metastasis, triple sites was 6 cases (28.6%) and double sites was 15 cases (71.4%). PIK3CA mutation was the most frequent gene variation in all patients (34.5% of no metastasis group and 27.1% of metastasis group) but there was no difference between two groups(p-value = 0.278). BRCA 1 loss of function and BRCA2 loss of function were more frequent in metastasis group than no metastasis group(p-value = 0.033 and p-value = 0.024, respectively) but total counts was too small. We assessed the area under the curve (AUC) of the receiver operating characteristic (ROC) curve for predictive value. The AUC of ROC curve was 1.000 and also accuracy, precision, recall were 1.000. In addition, we conducted internal validation using 83 patients during 2015. When we applied a 0.5 threshold value with our predictive model, true negative was 81 and true positive was 2 among 83 patients. Finally, the accuracy of validation was 1.000.

Conclusion

Our predicted model could represent a useful and easy-to-access tool for the selection of patients with distant metastasis. After additional evaluation with large data and external validation, worldwide use of our model could be expected.

Citation Format: Kim I, Choi HJ, Ryu JM, Lee SK, Yu JH, Kim SW, Nam SJ, Seo SW, Lee JE. A predictive model for distant metastasis in breast cancer patients using machine learning [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-52.

Abstract P1-15-18: Not presented

This abstract was not presented at the conference.

Citation Format: Choi HJ, Kim SW, Ryu JM, Kim I, Nam SJ, Yu J, Lee SK, Lee JE. Not presented [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P1-15-18.

Abstract P2-08-29: The impact of time interval between diagnosis and surgery in each type and stage of breast cancer

Background: There are many factors that might contribute to the delay of surgery in patients with breast cancer. Previous studies investigate the influence of delay of surgery, but they reported inconsistent results. The purpose of this study was to evaluate the impact of time of surgery on prognosis of breast cancer.

Methods: We performed a retrospective review of the patients with breast cancer, who received surgery between 1992 and 2009, by using data from Korea Breast Cancer Society Registry. Kaplan-Meier survival analysis and Cox regression model were used to evaluate the impact of time to surgery in breast cancer and subgroup analyses were performed for each disease stage and molecular subtype.

Result: A total 14727 patients were included for analysis. Delay of surgery more than 31 days was associated with worse survival for breast cancer [hazard ratio (HR) = 2.16; 95% confidence interval (CI), 1.936-2.408, p&lt;0.001]. Subgroup analyses revealed that over 31 days of surgical delay were significantly associated with worse survival in hormone receptor positive and HER-2 negative (p&lt;0.001), hormone receptor positive and HER-2 positive (p&lt;0.001), hormone receptor negative and HER-2 positive (p&lt;0.001), triple negative (p&lt;0.001) and stage II, III breast cancer patients (p&lt;0.001).

Conclusion: Surgical delay of more than 31 days were independent risk factors for worse outcome of breast cancer in each molecular subtype and breast cancer group except stage 0 and I. Although preoperative evaluation is required, surgical delay should be shortened to enhance survival of breast cancer, especially in patients with tumor size more than 2cm or presence of lymph node metastasis.

Citation Format: Kim J-M, Choi HJ, Kim I, Ryu JM, Yu J, Lee JE, Kim SW, Nam SJ, Lee SK. The impact of time interval between diagnosis and surgery in each type and stage of breast cancer [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-08-29.

Abstract P2-09-03: Updated efficacy of first or second-line pembrolizumab (pembro) plus capecitabine (cape) in metastatic triple negative breast cancer (mTNBC) and correlations with baseline lymphocyte and naïve CD4+ T-cell count

Background: In mTNBC, anti-PD-1/L1 monotherapy is most effective when administered early in the course of disease, with recent trials demonstrating overall response rates (ORR) of 23-26% in the first-line setting and 5-6% in later lines. This may reflect iatrogenic lymphopenia from preceding cytotoxic chemotherapy. Furthermore, curative-intent chemotherapy is associated with prolonged suppression of naïve CD4+ cells, a T-cell subset that may play a critical role in the generation of de novo anti-tumor immune responses. We present the final clinical results of a pilot study evaluating the safety and efficacy of combining pembrolizumab plus standard-of-care capecitabine in the first/second-line mTNBC setting. We also explore potential associations between clinical benefit and lymphopenia, preceding chemotherapy, and absolute naïve CD4+ counts.

Methods: In a pilot study, we evaluated the tolerability and preliminary efficacy of concurrent pembro (200mg IV q21 day) plus investigator-selected 1st/2nd line paclitaxel (80mg/m2 IV weekly) or oral cape (2,000mg BID, weekly 1 on/1 off). The primary endpoint was tolerability, defined as the proportion of subjects receiving &gt;6 weeks concurrent therapy without dose discontinuation with toxicities reported per CTCAE v4.0. The secondary endpoint was 12-week objective response rate (ORR) by RECIST1.1. Exploratory endpoints included peripheral blood cell enumeration by real-time flow cytometry and routine clinical laboratory. Naïve CD4+ cells were defined as CD45+ CD3+ TCRab+ CD4+ CD45RA+ CCR7+. Here, we report the results of the pilot phase of the cape cohort (NCT02734290).

Results: Twelve of 14 subjects were treated in the first-line setting. All subjects (14/14, 100%) tolerated cape+pembro for &gt;6 weeks, with toxicities consistent with monotherapy cape experience (diarrhea: grade I-II 50%, grade III 7%; hand-foot: grade I-II 71%) that improved with dose-reduction as needed. At 12 weeks, the ORR was 6/14 (42.9%), and the clinical benefit rate (ORR + stable disease) was 8/14 (57.1%). Depressed absolute lymphocyte count at baseline (ALC&lt;1.0/uL: 33% CBR; ALC≥1.0/uL: 75% CBR) and recent exposure to cytotoxic chemotherapy (&lt;6 months: 33% CBR; &gt;6 months: 75% CBR) were associated with reduced clinical benefit. By flow cytometry, subjects experiencing clinical benefit had higher baseline absolute naïve CD4+ counts (average 283 cells/uL v. 93 cells/uL, p=.069).

Conclusions: This study met the primary endpoint of safety for cape plus pembro in mTNBC, with encouraging clinical activity. These data are supportive of further studies evaluating combination chemotherapy plus anti-PD-1/L1 mTNBC. We observed greater clinical benefit in subjects with non-suppressed ALC, less exposure to recent chemo, and higher baseline naïve CD4+ counts, suggesting that iatrogenic immunosuppression can impair response to immune checkpoint therapy in mTNBC. These findings should be confirmed in ongoing randomized trials of immune checkpoint +/- chemotherapy in mTNBC, and should be considered in the design of future clinical trials.

Citation Format: Page DB, Pucilowska J, Bennetts L, Kim I, Sanchez K, Martel M, Conlin A, Moxon N, Mellinger S, Acheson A, Kemmer K, Mitri Z, Vuky J, Ahn J, Abaya C, Manigault T, Basho R, Urba WJ, McArthur HL. Updated efficacy of first or second-line pembrolizumab (pembro) plus capecitabine (cape) in metastatic triple negative breast cancer (mTNBC) and correlations with baseline lymphocyte and naïve CD4+ T-cell count [abstract]. In: Proceedings of the 2018 San Antonio Breast Cancer Symposium; 2018 Dec 4-8; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2019;79(4 Suppl):Abstract nr P2-09-03.