Actinobacillus sp. Bacteremia in Foals: Clinical Signs and Prognosis

Clinical predictive models in equine medicine: A systematic review

Clinical predictive models use a patient's baseline demographic and clinical data to make predictions about patient outcomes and have the potential to aid clinical decision making. The extent of equine clinical predictive models is unknown in the literature. Using PubMed and Google Scholar, we systematically reviewed the predictive models currently described for use in equine patients. Models were eligible for inclusion if they were published in a peer-reviewed article as a multivariable model used to predict a clinical/laboratory/imaging outcome in an individual horse or herd. The agreement of at least two authors was required for model inclusion. We summarised the patient populations, model development methods, performance metric reporting, validation efforts, and, using the Predictive model Risk of Bias Assessment Tool (PROBAST), assessed the risk of bias and applicability concerns for these models. In addition, we summarised the index conditions for which models were developed and provided detailed information on included models. A total of 90 predictive models and 9 external validation studies were included in the final systematic review. A plurality of models (41%) was developed to predict outcomes associated with colic, for example, need for surgery or survival to discharge. All included models were at high risk of bias, defined as failing one or more PROBAST signalling questions, primarily for analysis-related reasons. Importantly, a high risk of bias does not necessarily mean that models are unusable, but that they require more careful consideration prior to clinical use. Concerns about applicability were low for the majority of models. Systematic reviews such as this can serve to increase veterinarians' awareness of predictive models, including evaluation of their performance and their use in different patient populations.

Pathological Features and Genomic Characterization of an Actinobacillus equuli subsp. equuli Bearing Unique Virulence-Associated Genes from an Adult Horse with Pleuropneumonia

Actinobacillus equuli subsp. equuli is the etiological agent of sleepy foal disease, an acute form of fatal septicemia in newborn foals. A. equuli is commonly found in the mucous membranes of healthy horses' respiratory and alimentary tracts and rarely causes disease in adult horses. In this study, we report a case of a 22-year-old American Paint gelding presenting clinical signs associated with an atypical pattern of pleuropneumonia subjected to necropsy. The gross and histopathological examinations revealed a unilateral fibrinosuppurative and hemorrhagic pleuropneumonia with an infrequent parenchymal distribution and heavy isolation of A. equuli. The whole genome sequence analysis indicated that the isolate shared 95.9% homology with the only other complete genome of A. equuli subsp. equuli available in GenBank. Seven virulence-associated genes specific to the isolate were identified and categorized as iron acquisition proteins, lipopolysaccharides (LPS), and capsule polysaccharides. Moreover, four genes (glf, wbaP, glycosyltransferase family 2 protein, and apxIB) shared higher amino acid similarity with the invasive Actinobacillus spp. than the reference A. equuli subsp. equuli genome. Availability of the whole genome sequence will allow a better characterization of virulence determinants of A. equuli subsp. equuli, which remain largely elusive.

The fecal bacterial microbiota of healthy and sick newborn foals

BACKGROUND

The fecal bacterial microbiota of normal foals and foals with enterocolitis has been characterized using next-generation sequencing technology; however, there are no reports investigating the gut microbiota in foals hospitalized for other perinatal diseases.

OBJECTIVE

To describe and compare the fecal bacterial microbiota in healthy and sick foals using next-generation sequencing techniques.

ANIMALS

Hospitalized (17) and healthy foals (21).

METHODS

Case-control study. Fecal samples were collected from healthy and sick foals on admission. Sick foals were further divided into sick nonseptic (SNS, n = 9) and septic (n = 8) foals. After extraction of DNA, the V4 region of the 16 S rRNA gene was amplified using a PCR assay, and the final product was sequenced with an Illumina MiSeq.

RESULTS

Diversity was significantly lower in healthy than sick foals (P < .05). The bacterial membership (Jaccard index) and structure (Yue & Clayton index) of the fecal microbiota of healthy, septic, and SNS foals were similar (AMOVA, P > .05). Bacterial membership (AMOVA, P = .06) and structure (AMOVA, P = .33) were not different between healthy and sick foals. Enterobacteriaceae, Enterococcus, and Streptococcus were among the 5 more abundant taxa identified in both groups.

CONCLUSION AND CLINICAL IMPORTANCE

Higher fecal microbiota diversity in sick than healthy foals might suggest a high exposure to environmental microorganisms or an unstable colonic microbiota. The presence of microorganisms causing bacteremia in foals in a high relative abundance in the feces of foals suggests the intestine might play an essential role in the causation of bacteremia in foals.

Serum amyloid A as a marker to detect sepsis and predict outcome in hospitalized neonatal foals

BACKGROUND

Serum amyloid A (SAA) has been reported to hold promise as diagnostic and prognostic marker in foals. This has not been investigated thoroughly.

OBJECTIVES

Evaluate admission SAA concentrations as predictor of sepsis and outcome.

ANIMALS

Five hundred and ninety hospitalized foals <14 days old.

METHODS

Retrospective multicenter study. Foals were scored with sepsis and survival scores, grouped according to health category (septic, sick but nonseptic, uncertain sepsis status) and outcome; septic foals were further categorized according to severity (normal sepsis, severe sepsis, and septic shock). SAA was compared between groups using Mann-Whitney test and Kruskal-Wallis test. Receiver operating characteristic curves identified optimal SAA cut off values for detecting sepsis and predicting outcome.

RESULTS

Admission SAA concentrations differed significantly between sick nonseptic foals (312.1 ± 685.4 mg/L) and septic foals (1079.7 ± 1254.5 mg/L) and increased with increasing sepsis score. SAA did not differ between sepsis severity groups. The optimal cut off for sepsis detection was 1050 mg/L (sensitivity 30.2%, specificity 90.7%). Admission SAA concentrations were lower in surviving (435.0 ± 723.6 mg/L) compared to nonsurviving foals (1062.7 ± 1440.1 mg/L) and decreased with increasing survival score. The optimal cut off for nonsurvival prediction was 1250 mg/L (sensitivity 22.1%, specificity 90.8%).

CONCLUSIONS AND CLINICAL IMPORTANCE

SAA concentration was higher in septic foals and nonsurviving foals. Even though optimal cut offs for SAA to detect sepsis and predict outcome had low sensitivity, they had good specificity. SAA can therefore be used as a marker to rule out sepsis and nonsurvival.

Actinobacillus species isolated from Japanese Thoroughbred racehorses in the last two decades

Actinobacillus species are known to be pathogenic to horses. To clarify etiological agents of actinobacillosis in Japanese adult horses, 27 isolates from Japanese Thoroughbred racehorses putatively identified by matrix-assisted laser desorption ionization time-of-flight mass spectrometry as Actinobacillus were further identified by PCR of the A. equuli toxin gene, by CAMP test, and by 16S rRNA sequencing analysis. Actinobacillus equuli subsp. haemolyticus was isolated most frequently (16/27) and was related to respiratory infections. Actinobacillus equuli subsp. equuli (4/27) was isolated from chronic cases or concomitant with other bacterial infections. The remainder were A. pleuropneumoniae, unclassified Actinobacillus species and Pasteurella caballi. Actinobacillus equuli including subsp. haemolyticus and subsp. equuli were the species most frequently isolated from equine actinobacillosis in Japan.

Retrospective evaluation of blood culture isolates and sepsis survival rate in foals in the Czech Republic: 50 cases (2011-2013)

OBJECTIVE

To identify the specific pathogens causing sepsis in hospitalized foals in the Czech Republic and identify important factors associated with their survival.

DESIGN

A retrospective study from 2011 to 2013.

SETTING

University veterinary teaching hospital.

ANIMALS

Fifty compromised foals.

INTERVENTIONS

None.

MEASUREMENT AND MAIN RESULTS

Blood was aseptically collected for bacterial culture from compromised foals. The foals were classified as septic according to a positive blood culture result or sepsis score ≥11. Blood cultures were positive in 44% of the foals. In these positive cultures, 27.3% had only Gram-positive (G+) bacteria and 54.5% had only Gram-negative (G-) bacteria. A mixed bacterial population was presented in 18.2% of the positive cultures. Thirty-six foals were classified as septic on the basis of positive blood culture or a sepsis score ≥11. In the group of foals that did not survive, there were significantly more foals with low levels of immunoglobulin G (IgG) than foals with normal levels of IgG (P < 0.0001). We also found a significant difference in the proportion of foals with low levels of IgG and positive blood cultures when compared to negative blood cultures. Twenty-six of the 50 foals were discharged from the hospital. Survival was significantly lower in foals with a diagnosis of sepsis than in foals without sepsis. There was no statistically significant difference between foals that died as a result of infection caused by G- or G+ pathogens. There was no difference in the proportion of survivors that did or did not receive antimicrobials prior to admission.

CONCLUSIONS

In our study, we confirmed the increasing trend for G+ bacteria in blood cultures but G- still predominate. The percentage of nonsurviving septic foals was high.

A review of equine sepsis

Sepsis is defined as an exaggerated, systemic inflammatory response to infection and is a common condition in horses. Systemic inflammatory response syndrome (SIRS) associated with bacterial infection is a hallmark of sepsis. Sepsis in neonatal foals is a common sequela of failure of passive transfer and, in addition to development of SIRS, may be characterised by bacteraemia, pneumonia, enterocolitis, omphalophlebitis, meningoencephalitis or arthritis. Sepsis in mature horses is most commonly observed secondary to gastrointestinal lesions that result in disrupted mucosa and bacterial translocation into circulation (endotoxaemia). Pleuropneumonia and metritis may also cause sepsis in mature horses. Diagnosis of sepsis is based on SIRS criteria as well as suspected or confirmed infection. Due to the relatively low sensitivity of microbial culture and the subjectivity of sepsis scoring, many sepsis biomarkers are being studied for their usefulness in diagnosis and prognostication of sepsis in horses. Treatment of sepsis requires an intensive care approach that includes antimicrobial drug administration, fluid resuscitation and pressure support, and treatment for inflammation, endotoxaemia and coagulopathy. Early recognition of sepsis and prompt antimicrobial drug treatment are critical for a successful outcome. Multiple organ dysfunction syndrome may occur in severe cases of sepsis, with common manifestations including laminitis and coagulopathies. Although prognosis for septic mature horses depends highly on the primary disease process, the overall survival rate in septic neonatal foals ranges from 26 to 86%, with most studies indicating a survival rate of 45-60%.

Plasma adrenomedullin concentrations in critically ill neonatal foals

Background

Bacterial sepsis remains a leading cause of morbidity and mortality in neonatal foals, but accurate diagnostic and prognostic markers are lacking. Adrenomedullin (AM) is a polypeptide with diverse biologic effects on the cardiovascular system that increases in septic humans and laboratory animals.

Hypotheses

Plasma AM concentration (p[AM]) is increased in septic neonatal foals compared to sick nonseptic and healthy control foals, and p[AM] is predictive of survival in septic neonatal foals.

Animals

Ninety critically ill (42 septic, 48 sick nonseptic) and 61 healthy foals <1 week of age.

Methods

A prospective observational clinical study was performed. Venous blood was collected from critically ill foals at admission and from healthy foals at 24 hours of age. Critically ill foals were categorized as septic or sick nonseptic based on blood culture results and sepsis score. Plasma [AM] was measured by using a commercially available ELISA for horses. Data were analyzed by using the Mann‐Whitney U‐test and P < .05 was considered significant.

Results

Plasma [AM] was not significantly different between septic and sick nonseptic foals (P = .71), but critically ill foals had significantly increased p[AM] compared to healthy controls (P < .0001). In critically ill foals, p[AM] was not predictive of survival (P = .051). A p[AM] cutoff concentration of 0.041 ng/mL provided a test sensitivity of 91% and specificity of 54% to predict illness.

Conclusions and Clinical Relevance

Plasma [AM] shows promise as a marker of health in neonatal foals, but p[AM] increases nonspecifically during perinatal illnesses and is not necessarily associated with sepsis.

A retrospective study of equine actinobacillosis cases: 1999-2011

Several Actinobacillus spp. are common commensal bacteria of the oral cavity, gastrointestinal tract, and reproductive tract of horses and can cause disease in both foals and adults. The current retrospective study was designed to review Actinobacillus spp. isolated from clinical samples or necropsies of 99 horses during 1999-2011. The cases consisted of 43 foals (<6 months of age), 4 young adults (6 months-2 years), 39 adults (>2 years of age), 2 aborted fetuses, and 11 with unspecified ages. Clinical history, signs, bacterial species isolated, and associated lesions were documented. Actinobacillus spp. were isolated 111 times. The most common isolates were Actinobacillus equuli subsp. equuli (38.7%) and hemolytic Actinobacillus spp. (24.3%). Other isolates were Actinobacillus lignieresii (5.4%), Actinobacillus pleuropneumoniae (1.8%), and unclassified Actinobacillus spp. (28.8%). Actinobacillus equuli subsp. equuli was most commonly isolated from clinical and necropsy cases of septicemia and respiratory disease in both foals and adults. Embolic nephritis, the classical septicemic lesion of equine neonatal actinobacillosis, was also present in several adult septicemic actinobacillosis cases. Predisposing factors such as failure of passive transfer of colostral antibodies as well as concurrent pathogenic bacterial or viral infections were present in numerous actinobacillosis cases. There were many cases, however, for which a predisposing factor or concurrent infection was not documented or apparent, suggesting that Actinobacillus spp. can be primary pathogens under the right circumstances and in the right location.

Weissella confusa septicemia in a foal

Weissella confusa is a Gram-positive bacterium that has been identified in environmental and food samples from around the world. Rare cases of bacteremia in immunocompromised people have been reported. A 2-day-old foal was presented for weakness and suspected sepsis. Blood culture yielded pure growth of a Gram-positive coccobacillus, which was identified as W. confusa through sequencing of the 16S ribosomal DNA. Although the foal initially responded to antimicrobial therapy with ceftiofur and metronidazole, it later developed septic complications of the right tarsocrural joint and right digital flexor tendon sheath and was euthanized. Postmortem examination and histology revealed subcutaneous icterus, severe diffuse interstitial pneumonia, septic synovitis, necrotizing vasculitis with marked thrombosis and hemorrhage in the medial digital vessels of the right hind limb, and ischemic necrosis of the right hind hoof laminae. Gram-positive, coccobacilli were observed in the vascular lesion.

Renin-Angiotensin-aldosterone system and hypothalamic-pituitary-adrenal axis in hospitalized newborn foals

BACKGROUND

The renin-angiotensin-aldosterone system (RAAS) and hypothalamic-pituitary-adrenal axis (HPAA) and their interactions during illness and hypoperfusion are important to maintain organ function. HPAA dysfunction and relative adrenal insufficiency (RAI) are common in septic foals. Information is lacking on the RAAS and mineralocorticoid response in the context of RAI in newborn sick foals.

OBJECTIVES/HYPOTHESIS

To investigate the RAAS, as well as HPAA factors that interact with the RAAS, in hospitalized foals, and to determine their association with clinical findings. We hypothesized that critical illness in newborn foals results in RAAS activation, and that inappropriately low aldosterone concentrations are part of the RAI syndrome of critically ill foals.

ANIMALS

A total of 167 foals ≤3 days of age: 133 hospitalized (74 septic, 59 sick nonseptic) and 34 healthy foals.

METHODS

Prospective, multicenter, cross-sectional study. Blood samples were collected on admission. Plasma renin activity (PRA) and angiotensin-II (ANG-II), aldosterone, ACTH, and cortisol concentrations were measured in all foals.

RESULTS

ANG-II, aldosterone, ACTH, and cortisol concentrations as well as ACTH/aldosterone and ACTH/cortisol ratios were higher in septic foals compared with healthy foals (P < .05). No difference in PRA between groups was found. High serum potassium and low serum chloride concentrations were associated with hyperaldosteronemia in septic foals.

CONCLUSIONS AND CLINICAL IMPORTANCE

RAAS activation in critically ill foals is characterized by increased ANG-II and aldosterone concentrations. Inappropriately low cortisol and aldosterone concentrations defined as high ACTH/cortisol and ACTH/aldosterone ratios in septic foals suggest that RAI is not restricted to the zona fasciculata in critically ill newborn foals.

Serum antibody responses in horses and mice following immunization with Actinobacillus equuli outer membrane proteins and recombinant Aqx toxin

The immune responsiveness of mice (without prior natural exposure) and mares (with naturally acquired antibodies) was determined following vaccination with Actinobacillus equuli outer membrane proteins (OMPs) and/or recombinant A. equuli toxin (rAqx). Mice were vaccinated subcutaneously on days 0 and 21 with one of three doses (5, 25 or 50μg) of A. equuli OMPs, rAqx or both, together with Freund's incomplete adjuvant (FIA). Antibodies against formalin-killed whole bacterial cells (WBCs), OMPs and Aqx were determined on days 0, 21 and 42. Mares were vaccinated subcutaneously on days 0 and 21 with 100μg OMPs, 100μg rAqx or a combination of 50μg of each antigen, together with FIA. Antibodies against WBCs, OMPs and Aqx were determined at 7day intervals for the first 42days, as well as on days 56, 70, 154 and 238. Vaccination of mice stimulated an apparent dose response to OMPs and Aqx. Antibodies against OMPs and Aqx were enhanced following vaccination of mares that had naturally acquired pre-existing antibodies. There was no evidence of interference with antibody responses to the individual antigens when OMPs and rAqx were combined prior to vaccination.

Horse species symposium: a novel approach to monitoring pathogen progression during uterine and placental infection in the mare using bioluminescence imaging technology and lux-modified bacteria

Uterine and placental infections are the leading cause of abortion, stillbirth, and preterm delivery in the mare. Whereas uterine and placental infections in women have been studied extensively, a comprehensive examination of the pathogenic processes leading to this unsatisfactory pregnancy outcome in the mare has yet to be completed. Most information in the literature relating to late-term pregnancy loss in mares is based on retrospective studies of clinical cases submitted for necropsy. Here we report the development and application of a novel approach, whereby transgenically modified bacteria transformed with lux genes of Xenorhabdus luminescens or Photorhabdus luminescens origin and biophotonic imaging are utilized to better understand pathogen-induced preterm birth in late-term pregnant mares. This technology uses highly sensitive bioluminescence imaging camera systems to localize and monitor pathogen progression during tissue invasion by measuring the bioluminescent signatures emitted by the lux-modified pathogens. This method has an important advantage in that it allows for the potential tracking of pathogens in vivo in real time and over time, which was hitherto impossible. Although the application of this technology in domestic animals is in its infancy, investigators were successful in identifying the fetal lungs, sinuses, nares, urinary, and gastrointestinal systems as primary tissues for pathogen invasion after experimental infection of pregnant mares with lux-modified Escherichia coli. It is important that pathogens were not detected in other vital organs, such as the liver, brain, and cardiac system. Such precision in localizing sites of pathogen invasion provides potential application for this novel approach in the development of more targeted therapeutic interventions for pathogen-related diseases in the equine and other domestic species.

Bacteraemia in neonatal foals: clinicopathological differences between Gram-positive and Gram-negative infections, and single organism and mixed infections

REASONS FOR PERFORMING STUDY

Treatment for bacteraemia in foals must be started before the identity of the causative organism is known. Information aiding selection of effective antimicrobials should improve outcome.

OBJECTIVES

To describe differences in clinical and clinicopathological data and outcome in foals with bacteraemia due to different classes of bacteria.

METHODS

Records of foals with a positive blood culture, age < 10 days and presenting to a university hospital 1995-2004, were reviewed. Bacterial culture results, subject details, historical information, physical examination findings at admission and clinicopathological data generated during the first 48 h of hospitalisation were analysed. Results from foals with Gram-positive or Gram-negative organisms, single or mixed organism bacteraemias, and with bacteraemia due to 3 commonly isolated organisms were compared.

RESULTS

Eighty-five foals met the inclusion criteria. Gram-negative organisms (n = 59) Gram-positive organisms (n = 13) or multiple organisms (n = 19) were cultured from individual foals. Foals with Gram-negative bacteraemia had lower total white blood cell and lymphocyte counts at admission than did those from which only Gram-positive bacteria were cultured. Mixed organism bacteraemia was associated with tachycardia, increased serum concentrations of sodium, chloride and urea nitrogen, acidosis, respiratory distress, recumbency on admission and nonsurvival. Actinobacillus spp. infections were associated with leucopenia, neutropenia, lymphopenia and depression on hospital admission.

CONCLUSIONS AND POTENTIAL RELEVANCE

Recognising particular patterns of clinical and clinicopathological findings associated with infection with specific groups of bacteria may, in the future, aid antimicrobial selection and influence prognosis in bacteraemic foals.

Infectious agents detected in the feces of diarrheic foals: a retrospective study of 233 cases (2003-2008)

Background: Diarrhea is common in foals but there are no studies investigating the relative prevalence of common infectious agents in a population of hospitalized diarrheic foals.

Objectives: To determine the frequency of detection of infectious agents in a population of hospitalized foals with diarrhea and to determine if detection of specific pathogens is associated with age, outcome, or clinicopathologic data.

Animals: Two hundred and thirty‐three foals ≤ 10 months of age with diarrhea examined at a referral institution.

Methods: Retrospective case series. Each foal was examined for Salmonella spp., viruses, Clostridium difficile toxins, Clostridium perfringens culture, C. perfringens enterotoxin, Cryptosporidium spp., and metazoan parasites in feces collected at admission or at the onset of diarrhea.

Results: At least 1 infectious agent was detected in 122 foals (55%). Rotavirus was most frequently detected (20%) followed by C. perfringens (18%), Salmonella spp. (12%), and C. difficile (5%). Foals < 1 month of age were significantly more likely to be positive for C. perfringens (odds ratio [OR] = 15, 95% confidence interval [CI] = 3.5–66) or to have negative fecal diagnostic results (OR = 3.0, 95% CI = 1.7–5.2) than older foals. Foals > 1 month of age were significantly more likely to have Salmonella spp. (OR = 2.6, 95% CI = 1.2–6.0), rotavirus (OR = 13.3, 95% CI = 5.3–33), and parasites (OR = 23, 95% CI = 3.1–185) detected compared with younger foals. Overall 191 of the 223 foals (87%) survived. The type of infectious agent identified in the feces or bacteremia was not significantly associated with survival.

Conclusions and Clinical Importance: In the population studied, foals with diarrhea had a good prognosis regardless of which infectious agent was identified in the feces.

Blood culture status in mature horses with diarrhoea: a possible association with survival

REASONS FOR PERFORMING STUDY

The incidence and implications of positive blood cultures in mature horses with diarrhoea is unknown. The diagnosis of bacteraemia may alter treatment and prognosis.

HYPOTHESIS

The proportion of horses with diarrhoea that are blood culture positive is higher than previously assumed and a positive blood culture has a negative impact on survival.

METHODS

Blood cultures were taken at admission and 24 h after admission from 31 mature horses with diarrhoea.

RESULTS

Nine (29%) horses were blood culture positive within 24 h of admission. Organisms isolated included Corynebacterium spp. (n = 6), Streptococcus spp. (n = 2), Pantoea agglomerans (n = 1), Gram-negative rod (n = 1), Bacillus spp. (n = 1) and yeast (n = 1). Horses with positive blood cultures were significantly less likely to survive. Prior treatment with antimicrobial drugs had no significant effect on blood culture status. Horses with positive blood cultures had a significantly higher heart rate, packed cell volume (PCV) and plasma potassium concentration at admission, and a higher PCV and lower total plasma protein concentration 24 h after admission.

CONCLUSIONS

Positive blood cultures occur more frequently than previously reported, and may have a negative impact on survival in horses with diarrhoea.

POTENTIAL RELEVANCE

Results of blood cultures may be useful in formulating a prognosis for horses with diarrhoea. Further research is required to determine the effect of antimicrobial treatment on outcome.

Equine neonatal sepsis

Neonatal infection remains a leading cause of morbidity and mortality in the equine industry, despite advances in prevention and treatment. Many factors can influence a foal's risk for the development of sepsis in the peripartum period. This article discusses those factors, causative organisms, and therapeutic options. Factors that influence prognosis and potential preventative strategies also are addressed.

Neonatal foal diarrhea

Diarrhea is a significant cause of morbidity and mortality in the neonatal foal. Numerous noninfectious and infectious agents are responsible for enterocolitis and enteritis. This article provides an overview of the differential diagnoses for neonatal diarrhea and general and specific guidelines for therapy.