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Diep BA, Le VTM, Badiou C, Le HN, Pinheiro MG, Duong AH, Wang X, Dip EC, Aguiar-Alves F, Basuino L, Marbach H, Mai TT, Sarda MN, Kajikawa O, Matute-Bello G, Tkaczyk C, Rasigade JP, Sellman BR, Chambers HF, Lina G. IVIG-mediated protection against necrotizing pneumonia caused by MRSA. Sci Transl Med 2017; 8:357ra124. [PMID: 27655850 DOI: 10.1126/scitranslmed.aag1153] [Citation(s) in RCA: 58] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Accepted: 09/02/2016] [Indexed: 12/12/2022]
Abstract
New therapeutic approaches are urgently needed to improve survival outcomes for patients with necrotizing pneumonia caused by Staphylococcus aureus One such approach is adjunctive treatment with intravenous immunoglobulin (IVIG), but clinical practice guidelines offer conflicting recommendations. In a preclinical rabbit model, prophylaxis with IVIG conferred protection against necrotizing pneumonia caused by five different epidemic strains of community-associated methicillin-resistant S. aureus (MRSA) as well as a widespread strain of hospital-associated MRSA. Treatment with IVIG, either alone or in combination with vancomycin or linezolid, improved survival outcomes in this rabbit model. Two specific IVIG antibodies that neutralized the toxic effects of α-hemolysin (Hla) and Panton-Valentine leukocidin (PVL) conferred protection against necrotizing pneumonia in the rabbit model. This mechanism of action of IVIG was uncovered by analyzing loss-of-function mutant bacterial strains containing deletions in 17 genes encoding staphylococcal exotoxins, which revealed only Hla and PVL as having an impact on necrotizing pneumonia. These results demonstrate the potential clinical utility of IVIG in the treatment of severe pneumonia induced by S. aureus.
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Affiliation(s)
- Binh An Diep
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA.
| | - Vien T M Le
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Cedric Badiou
- INSERM U1111, Université Lyon 1, CNRS UMR5308, ENS Lyon, Lyon, France. Centre National de Référence des Staphylocoques, Hospices Civils de Lyon, Bron, France
| | - Hoan N Le
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Marcos Gabriel Pinheiro
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA. Pathology Program, Fluminense Federal University, Niterói, RJ, Brazil
| | - Au H Duong
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Xing Wang
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Etyene Castro Dip
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Fábio Aguiar-Alves
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA. Pathology Program, Fluminense Federal University, Niterói, RJ, Brazil
| | - Li Basuino
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Helene Marbach
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Thuy T Mai
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Marie N Sarda
- Laboratory of Immunology, Centre Hospitalier Lyon Sud, Hospices Civils de Lyon, Lyon, France
| | - Osamu Kajikawa
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98109, USA
| | - Gustavo Matute-Bello
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, University of Washington School of Medicine, Seattle, WA 98109, USA
| | - Christine Tkaczyk
- Department of Infectious Diseases, MedImmune, LLC, Gaithersburg, MD 20878, USA
| | - Jean-Philippe Rasigade
- INSERM U1111, Université Lyon 1, CNRS UMR5308, ENS Lyon, Lyon, France. Centre National de Référence des Staphylocoques, Hospices Civils de Lyon, Bron, France
| | - Bret R Sellman
- Department of Infectious Diseases, MedImmune, LLC, Gaithersburg, MD 20878, USA
| | - Henry F Chambers
- Division of HIV, Infectious Diseases, and Global Medicine, Department of Medicine, University of California, San Francisco, San Francisco, CA 94110, USA
| | - Gerard Lina
- INSERM U1111, Université Lyon 1, CNRS UMR5308, ENS Lyon, Lyon, France. Centre National de Référence des Staphylocoques, Hospices Civils de Lyon, Bron, France.
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Löffler B, Niemann S, Ehrhardt C, Horn D, Lanckohr C, Lina G, Ludwig S, Peters G. Pathogenesis of Staphylococcus aureus necrotizing pneumonia: the role of PVL and an influenza coinfection. Expert Rev Anti Infect Ther 2013; 11:1041-51. [PMID: 24073746 DOI: 10.1586/14787210.2013.827891] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Only recently necrotizing pneumonia was defined as a specific disease entity that is caused by a Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus strain and is frequently preceded by an influenza infection. Necrotizing pneumonia is characterized by a sudden onset and rapid worsening of symptoms, leukopenia, airway hemorrhages, severe respiratory failure and a high mortality rate. Despite clear epidemiological data, the function of PVL in necrotizing pneumonia has been controversially discussed due to conflicting results from different disease models. Furthermore, there are many proposed mechanisms how a viral infection could facilitate and interact with a bacterial superinfection. In this review, we summarize current data from 43 clinical cases and results from various infection models on necrotizing pneumonia. We discuss the contribution of S. aureus PVL and a preceding influenza infection and present a concept of the pathogenesis of necrotizing pneumonia.
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Affiliation(s)
- Bettina Löffler
- Institute of Medical Microbiology, University Hospital of Münster, Domagkstraße 10, D-48149 Münster, Germany
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Gillet Y, Dumitrescu O, Tristan A, Dauwalder O, Javouhey E, Floret D, Vandenesch F, Etienne J, Lina G. Pragmatic management of Panton-Valentine leukocidin-associated staphylococcal diseases. Int J Antimicrob Agents 2011; 38:457-64. [PMID: 21733661 DOI: 10.1016/j.ijantimicag.2011.05.003] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2011] [Accepted: 05/29/2011] [Indexed: 01/22/2023]
Abstract
Panton-Valentine leukocidin (PVL)-producing Staphylococcus aureus is associated with a broad spectrum of diseases, ranging from common uncomplicated soft tissue infections to severe diseases such as complicated soft tissue infections, extensive bone and joint infections, and necrotising pneumonia. Specialised management of infection based on the presence of PVL may not be required for mild infections, whereas it could be lifesaving in other settings. Moreover, most severe PVL diseases are recently identified entities and a 'gold standard' treatment from comparatives studies of different therapeutic options is lacking. Thus, recommendations are based on expert opinions, which are elaborated based on theory, in vitro data and analogies with other toxin-mediated diseases. In this review, we consider the potential need for specialised PVL-based management and, if required, which tools should be used to achieve optimal management.
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Affiliation(s)
- Y Gillet
- Division of Pediatric Intensive Care, Hôpital Femme Mère Enfant, Bron, France
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9
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Li HT, Zhang TT, Huang J, Zhou YQ, Zhu JX, Wu BQ. Factors associated with the outcome of life-threatening necrotizing pneumonia due to community-acquired Staphylococcus aureus in adult and adolescent patients. Respiration 2010; 81:448-60. [PMID: 21051855 DOI: 10.1159/000319557] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2010] [Accepted: 07/07/2010] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Although community-acquired Staphylococcus aureus pneumonia with highly virulent Panton-Valentine leukocidin (PVL)-positive strains, a severe disease with significant lethality, is rare, especially in adult and adolescent patients, recent reports highlight that these infections are on the rise. OBJECTIVES To describe the demographic and clinical features of reported cases of life-threatening community-acquired S. aureus pneumonia with usually PVL-positive strains in adult and adolescent patients, to evaluate the variables related to death, and to select a more appropriate antimicrobial treatment for this potentially deadly disease. METHODS We summarized all of the 92 reported cases and our case. The effect of 5 variables on mortality was measured using logistic regression. RESULTS S. aureus community-acquired pneumonia (CAP) with usually PVL-positive strains is a severe disease with significant lethality, i.e. 42.9%; a short duration of the time from the onset of symptoms to death, i.e. 5.5 ± 10.1 days, and prolonged hospital admissions, i.e. 33.2 ± 29.5 days. Seventy-three cases have been tested for the gene for PVL, and 71 strains have been found to carry the PVL gene. Logistic regression analysis showed that leucopenia (p = 0.002), influenza-like symptoms or laboratory-confirmed influenza (p = 0.011), and hemoptysis (p = 0.024) were the factors associated with death. Antibiotic therapies inhibiting toxin production were associated with an improved outcome in these cases (p = 0.007). CONCLUSIONS Physicians should pay special attention to those patients who acquired severe CAP during influenza season and have flu-like symptoms, hemoptysis, and leucopenia, and they should consider S. aureus more frequently among the possible pathogens of severe CAP. Empiric therapy for severe CAP with this distinct clinical picture should include coverage for S. aureus. Targeted treatment with antimicrobials inhibiting toxin production appears to be a more appropriate selection.
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Affiliation(s)
- Hong-Tao Li
- Department of Respiratory Medicine, Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
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Secondary hemophagocytic lymphohistiocytosis and severe sepsis/ systemic inflammatory response syndrome/multiorgan dysfunction syndrome/macrophage activation syndrome share common intermediate phenotypes on a spectrum of inflammation. Pediatr Crit Care Med 2009; 10:387-92. [PMID: 19325510 DOI: 10.1097/pcc.0b013e3181a1ae08] [Citation(s) in RCA: 192] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
In an effort to attain earlier diagnoses in children with hemophagocytic lymphohistiocytosis (HLH), the International Histiocyte Society has now broadened their diagnostic criteria to no longer differentiate primary (HLH) and secondary hemophagocytic lymphohistiocytosis (SHLH). Five of the following eight diagnostic criteria needed to be met: 1) fever, 2) cytopenia of two lines, 3) hypertriglyceridemia and/or hypofibrinogenemia, 4) hyperferritinemia (>500 microg/L), 5) hemophagocytosis, 6) elevated soluble interleukin-2 receptor (CD25), 7) decreased natural killer-cell activity, and 8) splenomegaly can also commonly be found in patients with sepsis, systemic inflammatory response syndrome (SIRS), multiorgan dysfunction syndrome (MODS), and macrophage activation syndrome (MAS). Nevertheless, the therapeutic options for these are radically different. Chemotherapy and bone marrow transplant have been used for treatment of HLH/SHLH, whereas antibiotics and supportive treatment are used in severe sepsis/SIRS and MODS. MAS is treated with limited immune suppression. Outcomes are also different, SHLH has a mortality rate around 50%, whereas pediatric septic shock and MODS have a mortality of 10.3% and 18%, respectively, and severe sepsis in previously healthy children has a mortality rate of 2%. MAS has a mortality rate between 8% and 22%. Because SHLH and severe sepsis/SIRS/MODS/MAS share clinical and laboratory inflammatory phenotypes, we recommend extreme caution when considering applying HLH therapies to children with sepsis/SIRS/MODS/MAS. HLH therapies are clearly warranted for children with HLH; however, a quantitative functional estimate of cytotoxic lymphocyte function may be a more precise approach to define the overlap of these conditions, better identify these processes, and develop novel therapeutic protocols that may lead to improved treatments and outcomes.
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