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Jiang S, Xu J, Ke C, Huang P. Impact of P2Y12 inhibitors on clinical outcomes in sepsis-3 patients receiving aspirin: a propensity score matched analysis. BMC Infect Dis 2024; 24:575. [PMID: 38862910 PMCID: PMC11167871 DOI: 10.1186/s12879-024-09421-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/21/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND Sepsis is a life-threatening disease accompanied by disorders of the coagulation and immune systems. P2Y12 inhibitors, widely used for arterial thrombosis prevention and treatment, possess recently discovered anti-inflammatory properties, raising potential for improved sepsis prognosis. METHOD We conducted a retrospective analysis using the data from Medical Information Mart for Intensive Care-IV database. Patients were divided into an aspirin-alone group versus a combination group based on the use of a P2Y12 inhibitor or not. Differences in 30-day mortality, length of stay (LOS) in intensive care unit (ICU), LOS in hospital, bleeding events and thrombotic events were compared between the two groups. RESULT A total of 1701 pairs of matched patients were obtained by propensity score matching. We found that no statistically significant difference in 30-day mortality in aspirin-alone group and combination group (15.3% vs. 13.7%, log-rank p = 0.154). In addition, patients received P2Y12 inhibitors had a higher incidence of gastrointestinal bleeding (0.5% vs. 1.6%, p = 0.004) and ischemic stroke (1.7% vs. 2.9%, p = 0.023), despite having a shorter LOS in hospital (11.1 vs. 10.3, days, p = 0.043). Cox regression showed that P2Y12 inhibitor was not associated with 30-day mortality (HR = 1.14, 95% CI 0.95-1.36, p = 0.154). CONCLUSION P2Y12 inhibitors did not provide a survival benefit for patients with sepsis 3 and even led to additional adverse clinical outcomes.
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Affiliation(s)
- Shaojun Jiang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Jianwen Xu
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Chengjie Ke
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pinfang Huang
- Department of Pharmacy, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China.
- Department of Pharmacy, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China.
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2
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Sakoulas G, Tsou EE, Geriak M, Vasina L. Contemporary Management of Staphylococcus aureus Bacteremia: Some Additional Considerations for Clinicians. Clin Infect Dis 2024:ciae080. [PMID: 38507229 DOI: 10.1093/cid/ciae080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/22/2024] Open
Affiliation(s)
- George Sakoulas
- Division of Infectious Diseases, Sharp Rees Stealy Medical Group, San Diego, California, USA
- Division of Host-Microbe Systems and Therapeutics, University of California-San Diego School of Medicine, La Jolla, California, USA
| | - Erin E Tsou
- Department of Pharmacy, Sharp Memorial Hospital, San Diego, California, USA
| | - Matthew Geriak
- Central Research Pharmacy, Sharp Healthcare, San Diego, California, USA
| | - Logan Vasina
- Department of Pharmacy, Sharp Memorial Hospital, San Diego, California, USA
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3
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Cacace E, Kim V, Varik V, Knopp M, Tietgen M, Brauer-Nikonow A, Inecik K, Mateus A, Milanese A, Mårli MT, Mitosch K, Selkrig J, Brochado AR, Kuipers OP, Kjos M, Zeller G, Savitski MM, Göttig S, Huber W, Typas A. Systematic analysis of drug combinations against Gram-positive bacteria. Nat Microbiol 2023; 8:2196-2212. [PMID: 37770760 PMCID: PMC10627819 DOI: 10.1038/s41564-023-01486-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Accepted: 08/30/2023] [Indexed: 09/30/2023]
Abstract
Drug combinations can expand options for antibacterial therapies but have not been systematically tested in Gram-positive species. We profiled ~8,000 combinations of 65 antibacterial drugs against the model species Bacillus subtilis and two prominent pathogens, Staphylococcus aureus and Streptococcus pneumoniae. Thereby, we recapitulated previously known drug interactions, but also identified ten times more novel interactions in the pathogen S. aureus, including 150 synergies. We showed that two synergies were equally effective against multidrug-resistant S. aureus clinical isolates in vitro and in vivo. Interactions were largely species-specific and synergies were distinct from those of Gram-negative species, owing to cell surface and drug uptake differences. We also tested 2,728 combinations of 44 commonly prescribed non-antibiotic drugs with 62 drugs with antibacterial activity against S. aureus and identified numerous antagonisms that might compromise the efficacy of antimicrobial therapies. We identified even more synergies and showed that the anti-aggregant ticagrelor synergized with cationic antibiotics by modifying the surface charge of S. aureus. All data can be browsed in an interactive interface ( https://apps.embl.de/combact/ ).
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Affiliation(s)
- Elisabetta Cacace
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - Vladislav Kim
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
- Collaboration for joint PhD degree between EMBL and Heidelberg University, Faculty of Biosciences, Heidelberg, Germany
| | - Vallo Varik
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - Michael Knopp
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - Manuela Tietgen
- Goethe University Frankfurt, University Hospital, Institute for Medical Microbiology and Infection Control, Frankfurt am Main, Germany
| | | | - Kemal Inecik
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - André Mateus
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - Alessio Milanese
- European Molecular Biology Laboratory, Structural and Computational Biology Unit, Heidelberg, Germany
- Department of Biology, Institute of Microbiology, and Swiss Institute of Bioinformatics, ETH Zurich, Zurich, Switzerland
| | - Marita Torrissen Mårli
- Faculty of Chemistry, Biotechnology and Food Science, Norwegian University of Life Sciences, Ås, Norway
| | - Karin Mitosch
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - Joel Selkrig
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
- Institute of Medical Microbiology, University Hospital of RWTH, Aachen, Germany
| | - Ana Rita Brochado
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
- Cluster of Excellence EXC 2124 Controlling Microbes to Fight Infections, University of Tübingen, Tübingen, Germany
- Interfaculty Institute of Microbiology and Infection Medicine, University of Tübingen, Tübingen, Germany
| | - Oscar P Kuipers
- Department of Molecular Genetics, Groningen Molecular Biology and Biotechnology Institute, University of Groningen, Groningen, the Netherlands
| | - Morten Kjos
- Faculty of Chemistry, Biotechnology and Food Science, Norwegian University of Life Sciences, Ås, Norway
| | - Georg Zeller
- European Molecular Biology Laboratory, Structural and Computational Biology Unit, Heidelberg, Germany
| | - Mikhail M Savitski
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - Stephan Göttig
- Goethe University Frankfurt, University Hospital, Institute for Medical Microbiology and Infection Control, Frankfurt am Main, Germany
| | - Wolfgang Huber
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany
| | - Athanasios Typas
- European Molecular Biology Laboratory, Genome Biology Unit, Heidelberg, Germany.
- European Molecular Biology Laboratory, Structural and Computational Biology Unit, Heidelberg, Germany.
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4
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Lancellotti P, Aqil A, Musumeci L, Jacques N, Ditkowski B, Debuisson M, Thiry M, Dupont J, Gougnard A, Sandersen C, Cheramy-Bien JP, Sakalihasan N, Nchimi A, Detrembleur C, Jérôme C, Oury C. Bioactive surface coating for preventing mechanical heart valve thrombosis. J Thromb Haemost 2023; 21:2485-2498. [PMID: 37196847 DOI: 10.1016/j.jtha.2023.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2023] [Revised: 04/13/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Prosthetic heart valves are the only treatment for most patients with severe valvular heart disease. Mechanical valves, made of metallic components, are the most long-lasting type of replacement valves. However, they are prone to thrombosis and require permanent anticoagulation and monitoring, which leads to higher risk of bleeding and impacts the patient's quality of life. OBJECTIVES To develop a bioactive coating for mechanical valves with the aim to prevent thrombosis and improve patient outcomes. METHODS We used a catechol-based approach to produce a drug-releasing multilayer coating adherent to mechanical valves. The hemodynamic performance of coated Open Pivot valves was verified in a heart model tester, and coating durability in the long term was assessed in a durability tester producing accelerated cardiac cycles. Coating antithrombotic activity was evaluated in vitro with human plasma or whole blood under static and flow conditions and in vivo after surgical valve implantation in a pig's thoracic aorta. RESULTS We developed an antithrombotic coating consisting of ticagrelor- and minocycline-releasing cross-linked nanogels covalently linked to polyethylene glycol. We demonstrated the hydrodynamic performance, durability, and hemocompatibility of coated valves. The coating did not increase the contact phase activation of coagulation, and it prevented plasma protein adsorption, platelet adhesion, and thrombus formation. Implantation of coated valves in nonanticoagulated pigs for 1 month efficiently reduced valve thrombosis compared with noncoated valves. CONCLUSION Our coating efficiently inhibited mechanical valve thrombosis, which might solve the issues of anticoagulant use in patients and the number of revision surgeries due to valve thrombosis despite anticoagulation.
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Affiliation(s)
- Patrizio Lancellotti
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Abdelhafid Aqil
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Lucia Musumeci
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Nicolas Jacques
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Bartosz Ditkowski
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Margaux Debuisson
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Marc Thiry
- Laboratory of Cellular and Tissular Biology, GIGA-Neurosciences, Cell Biology, University of Liège, Liège, Belgium
| | - Julien Dupont
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Alexandra Gougnard
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Charlotte Sandersen
- Department of Clinical Sciences, Faculty of Veterinary Medicine, University of Liège, Liège, Belgium
| | - Jean-Paul Cheramy-Bien
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire of Liège, University of Liège, Liège, Belgium; Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Natzi Sakalihasan
- Department of Cardiovascular and Thoracic Surgery, Centre Hospitalier Universitaire of Liège, University of Liège, Liège, Belgium; Surgical Research Center, GIGA-Cardiovascular Science Unit, University of Liège, Liège, Belgium
| | - Alain Nchimi
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium
| | - Christophe Detrembleur
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Christine Jérôme
- Center for Education and Research on Macromolecules, CESAM Research Unit, University of Liège, Liège, Belgium
| | - Cécile Oury
- Laboratory of Cardiology, GIGA Institute, and Department of Cardiology, Centre Hospitalier Universitaire of Liège, University of Liège Hospital, Liège, Belgium.
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5
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Beadell B, Nehra S, Gusenov E, Huse H, Wong-Beringer A. Machine Learning with Alpha Toxin Phenotype to Predict Clinical Outcome in Patients with Staphylococcus aureus Bloodstream Infection. Toxins (Basel) 2023; 15:417. [PMID: 37505686 PMCID: PMC10467129 DOI: 10.3390/toxins15070417] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 06/17/2023] [Accepted: 06/25/2023] [Indexed: 07/29/2023] Open
Abstract
Staphylococcus aureus bloodstream (SAB) infection remains a leading cause of sepsis-related mortality. Yet, current treatment does not account for variable virulence traits that mediate host dysregulated immune response, such as SA α-toxin (Hla)-mediated thrombocytopenia. Here, we applied machine learning (ML) to bacterial growth images combined with platelet count data to predict patient outcomes. We profiled Hla phenotypes of SA isolates collected from patients with bacteremia by taking smartphone images of beta-hemolytic growth on sheep blood agar (SBA). Electronic medical records were reviewed to extract relevant laboratory and clinical data. A convolutional neural network was applied to process the plate image data for input along with day 1 patient platelet count to generate ML-based models that predict thrombocytopenia on day 4 and mortality. A total of 229 patients infected with SA strains exhibiting varying zone sizes of beta-hemolysis on SBA were included. A total of 539 images of bacterial growth on SBA were generated as inputs for model development. One-third of patients developed thrombocytopenia at onset, with an overall mortality rate of 18.8%. The models developed from the ML algorithm showed strong performance (AUC 0.92) for predicting thrombocytopenia on day 4 of infection and modest performance (AUC 0.711) for mortality. Our findings support further development and validation of a proof-of-concept ML application in digital microbiology, with a measure of bacterial virulence factor production that carries prognostic significance and can help guide treatment selection.
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Affiliation(s)
- Brent Beadell
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA 90089, USA; (B.B.); (E.G.)
| | - Surya Nehra
- Viterbi School of Engineering, University of Southern California, Los Angeles, CA 90089, USA;
| | - Elizabeth Gusenov
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA 90089, USA; (B.B.); (E.G.)
| | - Holly Huse
- Department of Microbiology, Harbor-UCLA Medical Center, Torrance, CA 90502, USA;
| | - Annie Wong-Beringer
- Alfred E. Mann School of Pharmacy and Pharmaceutical Sciences, University of Southern California, Los Angeles, CA 90089, USA; (B.B.); (E.G.)
- Department of Pharmacy, Huntington Hospital, Pasadena, CA 91105, USA
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6
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Gatica S, Fuentes B, Rivera-Asín E, Ramírez-Céspedes P, Sepúlveda-Alfaro J, Catalán EA, Bueno SM, Kalergis AM, Simon F, Riedel CA, Melo-Gonzalez F. Novel evidence on sepsis-inducing pathogens: from laboratory to bedside. Front Microbiol 2023; 14:1198200. [PMID: 37426029 PMCID: PMC10327444 DOI: 10.3389/fmicb.2023.1198200] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Accepted: 06/05/2023] [Indexed: 07/11/2023] Open
Abstract
Sepsis is a life-threatening condition and a significant cause of preventable morbidity and mortality globally. Among the leading causative agents of sepsis are bacterial pathogens Escherichia coli, Klebsiella pneumoniae, Staphylococcus aureus, Pseudomonas aeruginosa, and Streptococcus pyogenes, along with fungal pathogens of the Candida species. Here, we focus on evidence from human studies but also include in vitro and in vivo cellular and molecular evidence, exploring how bacterial and fungal pathogens are associated with bloodstream infection and sepsis. This review presents a narrative update on pathogen epidemiology, virulence factors, host factors of susceptibility, mechanisms of immunomodulation, current therapies, antibiotic resistance, and opportunities for diagnosis, prognosis, and therapeutics, through the perspective of bloodstream infection and sepsis. A list of curated novel host and pathogen factors, diagnostic and prognostic markers, and potential therapeutical targets to tackle sepsis from the research laboratory is presented. Further, we discuss the complex nature of sepsis depending on the sepsis-inducing pathogen and host susceptibility, the more common strains associated with severe pathology and how these aspects may impact in the management of the clinical presentation of sepsis.
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Affiliation(s)
- Sebastian Gatica
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Brandon Fuentes
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Elizabeth Rivera-Asín
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Paula Ramírez-Céspedes
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Javiera Sepúlveda-Alfaro
- Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo A. Catalán
- Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Susan M. Bueno
- Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Alexis M. Kalergis
- Departamento de Genética Molecular y Microbiología, Facultad de Ciencias Biológicas, Millennium Institute on Immunology and Immunotherapy, Pontificia Universidad Católica de Chile, Santiago, Chile
- Departamento de Endocrinología, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Felipe Simon
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Claudia A. Riedel
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
| | - Felipe Melo-Gonzalez
- Facultad de Ciencias de la Vida, Universidad Andres Bello, Santiago, Chile
- Millennium Institute on Immunology and Immunotherapy, Santiago, Chile
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7
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Elbaz M, Stein E, Raykhshtat E, Weiss-Meilik A, Cohen R, Ben-Ami R. Exposure to Non-Antimicrobial Drugs and Risk of Infection with Antibiotic-Resistant Enterobacteriaceae. Antibiotics (Basel) 2023; 12:antibiotics12040789. [PMID: 37107151 PMCID: PMC10135367 DOI: 10.3390/antibiotics12040789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/11/2023] [Accepted: 04/15/2023] [Indexed: 04/29/2023] Open
Abstract
Antimicrobial resistance (AMR) has consistently been linked to antibiotic use. However, the roles of commonly prescribed non-antimicrobial drugs as drivers of AMR may be under-appreciated. Here, we studied a cohort of patients with community-acquired pyelonephritis and assessed the association of exposure to non-antimicrobial drugs at the time of hospital admission with infection with drug-resistant organisms (DRO). Associations identified on bivariate analyses were tested using a treatment effects estimator that models both outcome and treatment probability. Exposure to proton-pump inhibitors, beta-blockers, and antimetabolites was significantly associated with multiple resistance phenotypes. Clopidogrel, selective serotonin reuptake inhibitors, and anti-Xa agents were associated with single-drug resistance phenotypes. Antibiotic exposure and indwelling urinary catheters were covariates associated with AMR. Exposure to non-antimicrobial drugs significantly increased the probability of AMR in patients with no other risk factors for resistance. Non-antimicrobial drugs may affect the risk of infection with DRO through multiple mechanisms. If corroborated using additional datasets, these findings offer novel directions for predicting and mitigating AMR.
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Affiliation(s)
- Meital Elbaz
- Department of Infectious Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
| | - Esther Stein
- I-Medata AI Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Eli Raykhshtat
- I-Medata AI Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Ahuva Weiss-Meilik
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
- I-Medata AI Center, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
| | - Regev Cohen
- Hillel Yaffe Medical Center, Hadera 3820302, Israel
- Rappaport Faculty of Medicine, Technion, Haifa 3200003, Israel
| | - Ronen Ben-Ami
- Department of Infectious Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv 6423906, Israel
- Faculty of Medicine, Tel Aviv University, Tel Aviv 6997801, Israel
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8
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Gentry CA, Whitman CM, Kliewer BS, Williams RJ, Thind SK. Propensity-matched analysis of the protective effect of ticagrelor versus clopidogrel on the risk of developing Staphylococcus aureus bacteremia. Int J Antimicrob Agents 2023; 61:106752. [PMID: 36773940 DOI: 10.1016/j.ijantimicag.2023.106752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/24/2023] [Accepted: 02/04/2023] [Indexed: 02/12/2023]
Abstract
OBJECTIVE Recent data indicate that ticagrelor, used in acute coronary syndromes (ACS), has antibacterial effects against Staphylococcus sp. and other effects that may help management of infection. The primary objective of this study was to evaluate the protective effect of ticagrelor in patients who have had an ACS event and the risk of developing Staphylococcus aureus bacteremia (SAB) compared to a propensity-matched cohort receiving clopidogrel. METHODS This study was a retrospective, nationwide analysis of all patients presenting to any percutaneous coronary intervention-performing Veterans Affairs Medical Center with an ACS episode and resultant prescription for clopidogrel or ticagrelor. The primary outcome was the comparative rate of SAB in patients receiving ticagrelor vs. clopidogrel. RESULTS Analysis involved 24 456 patients on ticagrelor and 277 277 patients on clopidogrel. There was a statistically significant difference in the number of patients developing SAB between the propensity-matched groups (32 [0.13%] of 24 456 for ticagrelor vs. 71 [0.29%] of 24 456 for clopidogrel; odds ratio (OR), 0.43; 95% confidence interval (CI), 0.28-0.65; P<0.0001). Multivariate logistic regression showed that receipt of clopidogrel, comorbid dermatologic condition, comorbid hematologic condition, and baseline anemia were independently associated with the development of SAB. CONCLUSIONS The study findings align with recent reports that ticagrelor may have a beneficial role in the prevention of SAB.
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Affiliation(s)
- Chris A Gentry
- Pharmacy Service, Oklahoma City Veterans Affairs Health Care System, Oklahoma City, Oklahoma, USA.
| | - Charles M Whitman
- Pharmacy Service, Oklahoma City Veterans Affairs Health Care System, Oklahoma City, Oklahoma, USA
| | - Brian S Kliewer
- Section of Internal Medicine, Medical Service, Oklahoma City Veterans Affairs Health Care System, and Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
| | - Riley J Williams
- Pharmacy Service, Oklahoma City Veterans Affairs Health Care System, Oklahoma City, Oklahoma, USA
| | - Sharanjeet K Thind
- Section of Infectious Diseases, Medical Service, Oklahoma City Veterans Affairs Health Care System, and Department of Medicine, University of Oklahoma Health Sciences Center, Oklahoma City, Oklahoma, USA
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9
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Douglas-Louis R, Lou M, Lee B, Minejima E, Bubeck-Wardenburg J, Wong-Beringer A. Prognostic significance of early platelet dynamics in Staphylococcus aureus bacteremia. BMC Infect Dis 2023; 23:82. [PMID: 36750777 PMCID: PMC9906934 DOI: 10.1186/s12879-023-08046-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/30/2023] [Indexed: 02/09/2023] Open
Abstract
BACKGROUND Platelets are recognized as key immune effectors, but they are targets of bacterial virulence factors. In the present study, we aimed to examine the relationship between early platelet dynamics and the outcome of Staphylococcus aureus bacteremia (SAB). METHOD Electronic medical records of adult patients hospitalized for SAB between July 2012 and November 2020 were retrospectively reviewed for relevant demographic, laboratory, and clinical data. The outcome endpoints were mortality and microbial persistence. RESULTS Among the 811 patients evaluated, 29% experienced thrombocytopenia on Day 1. Platelet count nadir occurred on Days 2-3 following SAB onset, and Day 4 was a determining point of platelet count trajectory and mortality. Mortality risk was 6% or less for those with normal platelet count by Day 4 regardless of whether they experienced thrombocytopenia on Day 1, but the risk increased to 16-21% for those who experienced thrombocytopenia on Day 4 regardless of whether they had normal platelet count on Day 1 or sustained thrombocytopenia. The duration of bacteremia was prolonged by one day (median 3 d vs. 2 d) for those with sustained thrombocytopenia compared to those without. CONCLUSION Early platelet dynamics during SAB have prognostic significance and represent an early window for potential platelet-directed therapeutic interventions to improve outcome.
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Affiliation(s)
- Rachid Douglas-Louis
- grid.42505.360000 0001 2156 6853Department of Clinical Pharmacy, University of Southern California (USC) Alfred E. Mann School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90089 USA
| | - Mimi Lou
- grid.42505.360000 0001 2156 6853Department of Clinical Pharmacy, University of Southern California (USC) Alfred E. Mann School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90089 USA
| | - Brian Lee
- grid.42505.360000 0001 2156 6853Department of Clinical Pharmacy, University of Southern California (USC) Alfred E. Mann School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90089 USA
| | - Emi Minejima
- grid.42505.360000 0001 2156 6853Department of Clinical Pharmacy, University of Southern California (USC) Alfred E. Mann School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA 90089 USA ,grid.42505.360000 0001 2156 6853Los Angeles County and USC Medical Center, Los Angeles, CA USA
| | - Juliane Bubeck-Wardenburg
- grid.4367.60000 0001 2355 7002Department of Pediatrics and Division of Pediatric Critical Care Medicine, Washington University School of Medicine, St. Louis, MO USA
| | - Annie Wong-Beringer
- Department of Clinical Pharmacy, University of Southern California (USC) Alfred E. Mann School of Pharmacy, 1985 Zonal Ave, Los Angeles, CA, 90089, USA. .,Department of Pharmacy, Huntington Memorial Hospital, Pasadena, CA, USA.
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10
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Hinman KD, Laforce-Nesbitt SS, Cohen JT, Mundy M, Bliss JM, Horswill AR, Lefort CT. Bi-fluorescent Staphylococcus aureus infection enables single-cell analysis of intracellular killing in vivo. Front Immunol 2023; 14:1089111. [PMID: 36756129 PMCID: PMC9900177 DOI: 10.3389/fimmu.2023.1089111] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 01/03/2023] [Indexed: 01/24/2023] Open
Abstract
Techniques for studying the clearance of bacterial infections are critical for advances in understanding disease states, immune cell effector functions, and novel antimicrobial therapeutics. Intracellular killing of Staphylococcus aureus by neutrophils can be monitored using a S. aureus strain stably expressing GFP, a fluorophore that is quenched when exposed to the reactive oxygen species (ROS) present in the phagolysosome. Here, we expand upon this method by developing a bi-fluorescent S. aureus killing assay for use in vivo. Conjugating S. aureus with a stable secondary fluorescent marker enables the separation of infected cell samples into three populations: cells that have not engaged in phagocytosis, cells that have engulfed and killed S. aureus, and cells that have viable internalized S. aureus. We identified ATTO647N-NHS Ester as a favorable dye conjugate for generating bi-fluorescent S. aureus due to its stability over time and invariant signal within the neutrophil phagolysosome. To resolve the in vivo utility of ATTO647N/GFP bi-fluorescent S. aureus, we evaluated neutrophil function in a murine model of chronic granulomatous disease (CGD) known to have impaired clearance of S. aureus infection. Analysis of bronchoalveolar lavage (BAL) from animals subjected to pulmonary infection with bi-fluorescent S. aureus demonstrated differences in neutrophil antimicrobial function consistent with the established phenotype of CGD.
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Affiliation(s)
- Kristina D Hinman
- Division of Surgical Research, Department of Surgery, Rhode Island Hospital, Providence, RI, United States.,Warren Alpert Medical School, Brown University, Providence, RI, United States.,Graduate Program in Pathobiology, Brown University, Providence, RI, United States
| | | | - Joshua T Cohen
- Division of Surgical Research, Department of Surgery, Rhode Island Hospital, Providence, RI, United States
| | - Miles Mundy
- Graduate Program in Pathobiology, Brown University, Providence, RI, United States
| | - Joseph M Bliss
- Warren Alpert Medical School, Brown University, Providence, RI, United States.,Department of Pediatrics, Women and Infants Hospital, Providence, RI, United States
| | - Alexander R Horswill
- Department of Immunology and Microbiology, University of Colorado School of Medicine, Aurora, CO, United States
| | - Craig T Lefort
- Division of Surgical Research, Department of Surgery, Rhode Island Hospital, Providence, RI, United States.,Warren Alpert Medical School, Brown University, Providence, RI, United States
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11
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Lakbar I, Delamarre L, Einav S, Leone M. Endocarditis in the intensive care unit: an update. Curr Opin Crit Care 2022; 28:503-512. [PMID: 35942691 DOI: 10.1097/mcc.0000000000000973] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The incidence of infective endocarditis (IE) is increasing worldwide, resulting in a higher number of patients with IE being admitted to intensive care units (ICU). Nearly half of patients with IE develop a complication during their clinical course. However, few well conducted studies or reviews are devoted to critically ill IE patients. This review discusses the contemporary perioperative and intensive care literature. RECENT FINDINGS IE epidemiology is changing towards elderly and frail patients. ICU patients are at risk of risk of developing IE because they are often in a pro-inflammatory state and many also have several indwelling catheters, which favors infection. Increased performance and recent advances in cardiac imaging allow for easier diagnosis of EI, but the applicability of these techniques to ICU patients is still relatively limited. New developments in antibiotic treatment and adjunctive therapies are explored further in this review. SUMMARY The lack of evidence on ICU patients with IE highlights the critical importance of multidisciplinary decision-making and the need for further research.
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Affiliation(s)
- Ines Lakbar
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Louis Delamarre
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
| | - Sharon Einav
- General Intensive Care Unit of the Shaare Zedek Medical Centre and the Hebrew University Faculty of Medicine, Jerusalem, Israel
| | - Marc Leone
- Department of Anesthesiology and Intensive Care Unit, Aix Marseille University, Assistance Publique Hôpitaux Universitaires de Marseille, Nord Hospital, Marseille, France
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12
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Pant N, Miranda-Hernandez S, Rush C, Warner J, Eisen DP. Non-Antimicrobial Adjuvant Therapy Using Ticagrelor Reduced Biofilm-Related Staphylococcus aureus Prosthetic Joint Infection. Front Pharmacol 2022; 13:927783. [PMID: 35846990 PMCID: PMC9284533 DOI: 10.3389/fphar.2022.927783] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 05/16/2022] [Indexed: 11/13/2022] Open
Abstract
Background: Prosthetic joint infection (PJI), frequently caused by Staphylococcus aureus, leads to a significant arthroplasty failure rate. Biofilm is a crucial virulence factor of S. aureus that is intrinsic to the pathogenesis of PJI. Biofilm-related infections are recalcitrant to antibiotic treatment. Surgical and antibiotic therapy could be combined with non-antibacterial adjuvants to improve overall treatment success. Ticagrelor, a P2Y12 receptor inhibitor antiplatelet drug, is known to have anti-staphylococcal antibacterial and antibiofilm activity. However, the molecular mechanism for ticagrelor’s antibiofilm activity and its efficacy in the treatment of S. aureus PJI are unknown.Methods: To study the in vitro antibacterial and antibiofilm activity of ticagrelor, broth microdilution and crystal violet staining method were used. Ticagrelor’s effect on the expression of S. aureus biofilm genes (icaA, icaD, ebps, fib, eno, and agr) was studied using the relative quantification method. To test ticagrelor’s in vivo efficacy to treat S. aureus PJI, mice were randomized into five groups (n = 8/group): infected femoral implants treated with ticagrelor alone; infected implants treated with cefazolin alone; infected implants treated with ticagrelor and cefazolin; infected implants treated with phosphate buffer solution (PBS)-positive controls, and sterile implants-negative controls. Ticagrelor was administered orally from day 4 to day 7 post-surgery, while cefazolin was injected intravenously on day 7.Results: Ticagrelor, alone and with selected antibiotics, showed in vitro antibacterial and antibiofilm activity against S. aureus. Strain-specific downregulation of biofilm-related genes, fib, icaD, ebps, and eno, was shown. In an animal model of biofilm-related S. aureus PJI, ticagrelor alone and combined with cefazolin significantly reduced bacterial concentrations on the implants compared with the positive control group. Ticagrelor significantly reduced bacterial dissemination to periprosthetic tissue compared with the positive controls.Conclusion: Ticagrelor adjuvant therapy reduced S. aureus PJI in an animal model. However, this study is very preliminary to make a conclusion on the clinical implication of the findings. Based on the current results, more studies are recommended to better understand its implication.
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Affiliation(s)
- Narayan Pant
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Australian Institute of Tropical Health and Medicine, Townsville, QLD, Australia
- *Correspondence: Narayan Pant,
| | | | - Catherine Rush
- Australian Institute of Tropical Health and Medicine, Townsville, QLD, Australia
| | - Jeffrey Warner
- Australian Institute of Tropical Health and Medicine, Townsville, QLD, Australia
| | - Damon P. Eisen
- College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
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13
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Impact of Clopidogrel on Clinical Outcomes in Patients with Staphylococcus aureus Bacteremia: a National Retrospective Cohort Study. Antimicrob Agents Chemother 2022; 66:e0211721. [PMID: 35416712 PMCID: PMC9211425 DOI: 10.1128/aac.02117-21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
Activated platelets have known antimicrobial activity against Staphylococcus aureus. Accelerated clearance of platelets induced by S. aureus can result in thrombocytopenia and increased mortality in patients. Recent studies suggest that P2Y12 inhibition protects platelets from accelerated clearance. We therefore evaluated the effect of P2Y12 inhibition on clinical outcomes in patients with S. aureus bacteremia across a large national cohort. Our retrospective cohort (2010 to 2018) included patients admitted to Veterans Affairs (VA) hospitals with blood cultures positive for S. aureus and treated with standard-of-care antibiotics. Employing propensity score-matched Cox proportional hazards regression models, we compared clinical outcomes in patients treated with clopidogrel for at least the 30 days prior to admission and continuing for at least 5 days after admission to patients without any P2Y12 inhibitor use in the year preceding admission. Mortality was significantly lower among clopidogrel users than P2Y12 inhibitor nonusers (n = 147 propensity score-matched pairs): the inpatient mortality hazard ratio (HR) was 0.11 (95% confidence interval [CI], 0.01 to 0.86), and 30-day mortality HR was 0.43 (95% CI, 0.19 to 0.98). There were no differences in 30-day readmission, 30-day S. aureus reinfection, microbiological clearance, or thrombocytopenia. Clopidogrel use at the time of infection reduced in-hospital mortality by 89% and 30-day mortality by 57% among a cohort of patients with S. aureus bacteremia. These results support the need to further study the use of P2Y12 inhibitors as adjunctive therapy in S. aureus bloodstream infections.
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14
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Antiplatelet Therapy in Staphylococcus aureus Bacteremia: No Time Like the Past? Antimicrob Agents Chemother 2022; 66:e0036522. [PMID: 35535570 DOI: 10.1128/aac.00365-22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In this invited commentary, we reflect on the accompanying study by A. R. Caffrey, H. J. Appaneal, K. L. LaPlante, V. V. Lopes, et al. (Antimicrob Agents Chemother 66:e02117-21, 2022, https://doi.org/10.1128/aac.02117-21), which analyzed the impact of clopidogrel use on clinical outcomes in Staphylococcus aureus bacteremia.
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15
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Meyers S, Crescente M, Verhamme P, Martinod K. Staphylococcus aureus and Neutrophil Extracellular Traps: The Master Manipulator Meets Its Match in Immunothrombosis. Arterioscler Thromb Vasc Biol 2022; 42:261-276. [PMID: 35109674 PMCID: PMC8860219 DOI: 10.1161/atvbaha.121.316930] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Over the past 10 years, neutrophil extracellular traps (NETs) have become widely accepted as an integral player in immunothrombosis, due to their complex interplay with both pathogens and components of the coagulation system. While the release of NETs is an attempt by neutrophils to trap pathogens and constrain infections, NETs can have bystander effects on the host by inducing uncontrolled thrombosis, inflammation, and tissue damage. From an evolutionary perspective, pathogens have adapted to bypass the host innate immune response. Staphylococcus aureus (S. aureus), in particular, proficiently overcomes NET formation using several virulence factors. Here we review mechanisms of NET formation and how these are intertwined with platelet activation, the release of endothelial von Willebrand factor, and the activation of the coagulation system. We discuss the unique ability of S. aureus to modulate NET formation and alter released NETs, which helps S. aureus to escape from the host's defense mechanisms. We then discuss how platelets and the coagulation system could play a role in NET formation in S. aureus-induced infective endocarditis, and we explain how targeting these complex cellular interactions could reveal novel therapies to treat this disease and other immunothrombotic disorders.
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Affiliation(s)
- Severien Meyers
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Belgium (S.M., M.C., P.V., K.M.)
| | - Marilena Crescente
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Belgium (S.M., M.C., P.V., K.M.).,Department of Life Sciences, Manchester Metropolitan University, United Kingdom (M.C.)
| | - Peter Verhamme
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Belgium (S.M., M.C., P.V., K.M.)
| | - Kimberly Martinod
- Department of Cardiovascular Sciences, Center for Molecular and Vascular Biology, KU Leuven, Belgium (S.M., M.C., P.V., K.M.)
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16
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Tatara AM, Gandhi RG, Mooney DJ, Nelson SB. Antiplatelet therapy for Staphylococcus aureus bacteremia: Will it stick? PLoS Pathog 2022; 18:e1010240. [PMID: 35143595 PMCID: PMC8830658 DOI: 10.1371/journal.ppat.1010240] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Staphylococcus aureus bacteremia (SAB) remains a clinically challenging infection despite extensive investigation. Repurposing medications approved for other indications is appealing as clinical safety profiles have already been established. Ticagrelor, a reversible adenosine diphosphate receptor antagonist that prevents platelet aggregation, is indicated for patients suffering from acute coronary syndrome (ACS). However, some clinical data suggest that patients treated with ticagrelor are less likely to have poor outcomes due to S. aureus infection. There are several potential mechanisms by which ticagrelor may affect S. aureus virulence. These include direct antibacterial activity, up-regulation of the innate immune system through boosting platelet-mediated S. aureus killing, and prevention of S. aureus adhesion to host tissues. In this Pearl, we review the clinical data surrounding ticagrelor and infection as well as explore the evidence surrounding these proposed mechanisms of action. While more evidence is needed before antiplatelet medications formally become part of the arsenal against S. aureus infection, these potential mechanisms represent exciting pathways to target in the host/pathogen interface.
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Affiliation(s)
- Alexander M. Tatara
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts, United States of America
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, United States of America
| | - Ronak G. Gandhi
- Department of Pharmacy, Massachusetts General Hospital, Boston, Massachusetts, United States of America
| | - David J. Mooney
- Wyss Institute for Biologically Inspired Engineering, Harvard University, Boston, Massachusetts, United States of America
- Harvard John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, Massachusetts, United States of America
| | - Sandra B. Nelson
- Division of Infectious Diseases, Massachusetts General Hospital, Boston, Massachusetts, United States of America
- * E-mail:
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17
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Leeten K, Jacques N, Lancellotti P, Oury C. Aspirin or Ticagrelor in Staphylococcus aureus Infective Endocarditis: Where Do We Stand? Front Cell Dev Biol 2021; 9:716302. [PMID: 34692677 PMCID: PMC8529053 DOI: 10.3389/fcell.2021.716302] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 09/21/2021] [Indexed: 12/04/2022] Open
Abstract
Infective endocarditis is a challenging disease with a high mortality and morbidity rate. Antibiotic prophylaxis is currently recommended in high-risk infective endocarditis patients. However, the use of antibiotics faces the challenge of a low efficacy and contributes further to the emerging infection rate by antibiotic-resistant strains, emphasizing the need for new therapeutic strategies. Platelets are essential in the initial phase of infective endocarditis, acting as first-line immune responders. During the first phase of disease, bacteria can interact with platelets and counteract platelet antimicrobial activities. Mechanistic in vitro and animal studies on the effect of aspirin on bacteria-platelet interactions and the prevention of vegetation development showed promising results. However, data from clinical studies on the outcome of infective endocarditis patients who were receiving medically indicated aspirin therapy remain controversial. Therefore, the benefit of antiplatelet agents in infective endocarditis prevention has been questioned. Besides aspirin, it has been discovered that the platelet P2Y12 receptor antagonist ticagrelor has antibacterial properties in addition to its potent antiplatelet activity. Furthermore, a recent study in mice and a case report remarkably indicated the ability of this drug to eradicate Staphylococcus aureus bacteremia. This review will focus on current knowledge on antibacterial activity of ticagrelor, compared to aspirin, pointing out main unanswered questions. The goal is to provide food for thought as to whether a prior ticagrelor therapy might be beneficial for the prevention of infective endocarditis.
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Affiliation(s)
- Kirsten Leeten
- Laboratory of Cardiology, Department of Cardiology, GIGA Institute, University of Liège Hospital, Liège, Belgium
| | - Nicolas Jacques
- Laboratory of Cardiology, Department of Cardiology, GIGA Institute, University of Liège Hospital, Liège, Belgium
| | - Patrizio Lancellotti
- Laboratory of Cardiology, Department of Cardiology, GIGA Institute, University of Liège Hospital, Liège, Belgium.,Gruppo Villa Maria Care and Research, Maria Cecilia Hospital, Cotignola, and Anthea Hospital, Bari, Italy
| | - Cécile Oury
- Laboratory of Cardiology, Department of Cardiology, GIGA Institute, University of Liège Hospital, Liège, Belgium
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