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Berska J, Bugajska J, Sztefko K. A Liquid Chromatography-Tandem Mass Spectrometry Method for Simultaneously Determining Meropenem and Linezolid in Blood and Cerebrospinal Fluid. Ann Lab Med 2024; 44:174-178. [PMID: 37869779 PMCID: PMC10628749 DOI: 10.3343/alm.2023.0250] [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: 06/21/2023] [Revised: 08/03/2023] [Accepted: 09/14/2023] [Indexed: 10/24/2023] Open
Abstract
Antibiotic therapy requires appropriate dosage of drugs for effective treatment. Too low antibiotic concentrations may lead to treatment failure and the development of resistant pathogens, whereas overdosing may cause neurological side effects or hemolytic diseases. Meropenem and linezolid are used only in the treatment of serious infections or when other antibiotics are no longer effective as well as for treating central nervous system infections. It is difficult or sometimes even impossible to predict the relation between dosing of antibiotics and its cerebrospinal fluid (CSF) concentration; thus, a method of determining antibiotics not only in the blood but also in the CSF is needed. Analytical method validation is an integral part of good laboratory practice and ensures high accuracy of the results. We performed complete validation process according to the Food and Drug Administration and European Medicine Agency, covering the aspects precision, specificity, accuracy, recovery, limit of detection, limit of quantification, stability, carry-over, and matrix effects. Our liquid chromatography-tandem mass spectrometry method for the simultaneous measurement of meropenem and linezolid in different matrix meets all the acceptance criteria. The method was successfully applied to determine meropenem and linezolid concentrations in serum and CSF samples obtained from children treated with these antibiotics.
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Affiliation(s)
- Joanna Berska
- Department of Clinical Biochemistry, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Jolanta Bugajska
- Department of Clinical Biochemistry, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
| | - Krystyna Sztefko
- Department of Clinical Biochemistry, Institute of Pediatrics, Jagiellonian University Medical College, Krakow, Poland
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Cheng J, Dang C, Li X, Wang J, Huang X, Li Y, Cui X. The participation of clinical pharmacists in the treatment of patients with central nervous system infection can improve the effectiveness and appropriateness of anti-infective treatments: a retrospective cohort study. Front Pharmacol 2023; 14:1226333. [PMID: 37745082 PMCID: PMC10512419 DOI: 10.3389/fphar.2023.1226333] [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: 05/21/2023] [Accepted: 08/28/2023] [Indexed: 09/26/2023] Open
Abstract
Background: Central nervous system infection (CNSI) treatment in hospital neurosurgery emphasizes the importance of optimizing antimicrobial therapy. Timely and appropriate empiric antibiotic treatment is critical for managing patients with bacterial meningitis. Objectives: To evaluate the activities of clinical pharmacists in the anti-infective treatment of patients with CNSI in neurosurgery. Method: A single-center retrospective cohort study was carried out from January 2021 to March 2023 at a tertiary teaching hospital in China. The study sample included a group that received pharmacy services and a group that did not. In the pharmacy services group, the anti-infective treatment plan was led and developed by pharmacists. Pharmaceutical care, including medication therapy and all CNSI treatment regimens, was administered in daily unit rounds by pharmacists. Baseline demographics, treatment outcomes, and rational use of antibiotics were compared between the two groups, and the impact of a antimicrobial stewardship (AMS) program was evaluated. Results: Of the 306 patients assessed according to the inclusion and exclusion criteria, 151 patients were included, and 155 patients were excluded due to abnormal data and missing information on antibiotic costs or antimicrobial use. Eventually, 73 were included in the pharmacy services group and 78 in the group without pharmacist participation. The antibiotic use density (AUD) of the pharmacy services group decreased from 167.68 to 127.63 compared to the group without pharmacist participation. After the pharmacist services, the AUD for linezolid decreased from 9.15% to 5.23% and that for miscellaneous agents decreased from 17.91% to 6.72%. The pharmacy services group had better improvement (p < 0.05) and a significantly higher score for the rational use of antibiotics (p < 0.05) than the group without pharmacist participation. Conclusion: The clinical pharmacist services evaluation results demonstrated an essential role of clinical pharmacist-led AMS programs in the effective and appropriate use of anti-infective treatments in neurosurgery with patients with CNSI.
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Affiliation(s)
- Jie Cheng
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
- Department of Clinical Pharmacy, The First Affiliated Hospital of Baotou Medical College, Baotou, China
| | - ChuanDong Dang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Xiao Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - JianJun Wang
- Department of Neurosurgery, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Neurosurgery, Jinan, China
| | - Xin Huang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - Yan Li
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
| | - XueYan Cui
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University and Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, China
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Marzaman ANF, Roska TP, Sartini S, Utami RN, Sulistiawati S, Enggi CK, Manggau MA, Rahman L, Shastri VP, Permana AD. Recent Advances in Pharmaceutical Approaches of Antimicrobial Agents for Selective Delivery in Various Administration Routes. Antibiotics (Basel) 2023; 12:antibiotics12050822. [PMID: 37237725 DOI: 10.3390/antibiotics12050822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 04/15/2023] [Accepted: 04/24/2023] [Indexed: 05/28/2023] Open
Abstract
Globally, the increase of pathogenic bacteria with antibiotic-resistant characteristics has become a critical challenge in medical treatment. The misuse of conventional antibiotics to treat an infectious disease often results in increased resistance and a scarcity of effective antimicrobials to be used in the future against the organisms. Here, we discuss the rise of antimicrobial resistance (AMR) and the need to combat it through the discovery of new synthetic or naturally occurring antibacterial compounds, as well as insights into the application of various drug delivery approaches delivered via various routes compared to conventional delivery systems. AMR-related infectious diseases are also discussed, as is the efficiency of various delivery systems. Future considerations in developing highly effective antimicrobial delivery devices to address antibiotic resistance are also presented here, especially on the smart delivery system of antibiotics.
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Affiliation(s)
| | - Tri Puspita Roska
- Faculty of Pharmacy, Hasanuddin University, Makassar 90245, Indonesia
| | - Sartini Sartini
- Faculty of Pharmacy, Hasanuddin University, Makassar 90245, Indonesia
| | - Rifka Nurul Utami
- Faculty of Pharmacy, Hasanuddin University, Makassar 90245, Indonesia
| | | | | | | | - Latifah Rahman
- Faculty of Pharmacy, Hasanuddin University, Makassar 90245, Indonesia
| | - Venkatram Prasad Shastri
- Institute for Macromolecular Chemistry, Albert Ludwigs Universitat Freiburg, 79085 Freiburg, Germany
| | - Andi Dian Permana
- Faculty of Pharmacy, Hasanuddin University, Makassar 90245, Indonesia
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Sigurdardottir AH, Knudtzen FC, Nymark A, Bang M. Fatigue and cognitive impairment in neuroborreliosis patients posttreatment-A neuropsychological retrospective cohort study. Brain Behav 2022; 12:e2719. [PMID: 36017773 PMCID: PMC9480899 DOI: 10.1002/brb3.2719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Revised: 06/21/2022] [Accepted: 07/07/2022] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND The aim of this study was to determine the prevalence of fatigue and cognitive impairment in patients with neuroborreliosis (NB) posttreatment and to determine whether delayed treatment initiation led to higher levels of fatigue and cognitive impairment. METHODS The study population consisted of 88 patients with NB included between October 10, 2014, and August 21, 2020, at the Clinical Center for Emerging and Vector-borne Infections at Odense University Hospital, Denmark. The Symbol Digit Modalities Test (SDMT) was used as a cognitive screening test, and the Modified Fatigue Impact Scale (MFIS) was used to assess the patients' level of fatigue over the course of a year. RESULTS Overall, 14.3% of patients had an SDMT score indicative of cognitive impairment, and 38.8% of patients reported experiencing fatigue 12 months posttreatment. We found no statistically significant differences in fatigue or cognitive impairment when comparing the patients who had a treatment delay of ≤14 days and those with a treatment delay of >14 days (p > .05) 12 months posttreatment. A random effects regression model showed a significant positive correlation between longer treatment delay and higher MFIS scores, indicating higher levels of fatigue. CONCLUSIONS The results of this study show that both the early and late treatment groups improved significantly over a 12-month period in terms of both cognitive symptoms and fatigue. However, it also showed that a substantial subgroup of patients with NB still suffer from fatigue and cognitive impairment 12 months posttreatment.
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Affiliation(s)
- Anna Helena Sigurdardottir
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Fredrikke Christie Knudtzen
- Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark.,Department of Infectious Diseases, Odense University Hospital, Odense, Denmark
| | - Anita Nymark
- Clinical Center of Emerging and Vector-borne Infections, Odense University Hospital, Odense, Denmark
| | - Malcolm Bang
- Department of Psychology, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
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Schneider F, Gessner A, El-Najjar N. Efficacy of Vancomycin and Meropenem in Central Nervous System Infections in Children and Adults: Current Update. Antibiotics (Basel) 2022; 11:antibiotics11020173. [PMID: 35203776 PMCID: PMC8868565 DOI: 10.3390/antibiotics11020173] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Revised: 01/23/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022] Open
Abstract
The current antimicrobial therapy of bacterial infections of the central nervous system (CNS) in adults and pediatric patients is faced with many pitfalls as the drugs have to reach necessary levels in serum and cross the blood-brain barrier. Furthermore, several studies report that different factors such as the structure of the antimicrobial agent, the severity of disease, or the degree of inflammation play a significant role. Despite the available attempts to establish pharmacokinetic (PK) modeling to improve the required dosing regimen for adults and pediatric patients, conclusive recommendations for the best therapeutic strategies are still lacking. For instance, bacterial meningitis, the most common CNS infections, and ventriculitis, a severe complication of meningitis, are still associated with 10% and 30% mortality, respectively. Several studies report on the use of vancomycin and meropenem to manage meningitis and ventriculitis; therefore, this review aims to shed light on the current knowledge about their use in adults and pediatric patients. Consequently, studies published from 2015 until mid-July 2021 are included, and data about the study population, levels of drugs in serum and cerebrospinal fluid (CSF), and measured PK data in serum and CSF are provided. The overall aim is to provide the readers a recent reference that summarizes the pitfalls and success of the current therapy and emphasizes the importance of performing more studies to improve the clinical outcome of the current therapeutical approach.
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Li N, Huang XJ, Wang Y, Suo P, Xu LP, Liu KY, Zhang XH, Yan CH, Wang FR, Kong J, Cheng YF. [BK virus encephalitis in children with hematopoietic stem cell transplantation]. ZHONGHUA XUE YE XUE ZA ZHI = ZHONGHUA XUEYEXUE ZAZHI 2021; 42:823-827. [PMID: 34788921 PMCID: PMC8607018 DOI: 10.3760/cma.j.issn.0253-2727.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
目的 探讨异基因造血干细胞移植患儿中BK病毒(BKV)脑炎的发病率、病死率、中位发病时间、临床表现、诊治及转归等,以提高临床医师对本病的认识。 方法 回顾性分析2015年1月1日至2020年12月31日在北京大学人民医院接受单倍型造血干细胞移植治疗的709例儿童患者,其中14例诊断为BKV脑炎,分析其临床特征、治疗过程及转归。 结果 BKV脑炎发生率为1.97%(14例)。患儿多为男性(12例),中位年龄为11岁,中位发病时间为移植后第55天。最常见的临床表现为意识障碍、抽搐发作(7例)。14例患儿予阿昔洛韦、更昔洛韦单用,或联合丙种球蛋白治疗,9例患儿痊愈,1例患儿死于病毒性脑炎,4例患儿死于其他疾病,病死率为35.7%。 结论 BKV脑炎主要表现为脑炎或脑膜炎。虽然确诊BKV脑炎后积极予药物治疗,但许多患者仍死于多器官衰竭或其他并发症。当异基因造血干细胞移植患者出现神经系统症状、出血性膀胱炎时,必须高度警惕BKV脑炎,尽早施救,从而改善患者的生存率及生活质量。
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Affiliation(s)
- N Li
- Peking University People's Hospital,Beijing 100044,China Xingtai People's Hospital, Xingtai 054000, China
| | - X J Huang
- Peking University People's Hospital,Beijing 100044,China
| | - Y Wang
- Peking University People's Hospital,Beijing 100044,China
| | - P Suo
- Peking University People's Hospital,Beijing 100044,China
| | - L P Xu
- Peking University People's Hospital,Beijing 100044,China
| | - K Y Liu
- Peking University People's Hospital,Beijing 100044,China
| | - X H Zhang
- Peking University People's Hospital,Beijing 100044,China
| | - C H Yan
- Peking University People's Hospital,Beijing 100044,China
| | - F R Wang
- Peking University People's Hospital,Beijing 100044,China
| | - J Kong
- Peking University People's Hospital,Beijing 100044,China
| | - Y F Cheng
- Peking University People's Hospital,Beijing 100044,China
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Antimicrobial use in central nervous system infections. Curr Opin Infect Dis 2021; 34:255-263. [PMID: 33741793 DOI: 10.1097/qco.0000000000000721] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
PURPOSE OF REVIEW Central nervous system (CNS) infections are associated with high rates of morbidity and mortality. The purpose of this review is to summarize current antimicrobial therapies, as well as, updates in the management of community-acquired meningitis and healthcare-associated meningitis and ventriculitis. RECENT FINDINGS Due to the increasing rates of multidrug resistant and extensively-drug resistant organisms, available antimicrobials are limited. Novel treatment options include newer systemic antimicrobials and antimicrobials that have previously limited data in the management of CNS infections. Although limited by retrospective data, intrathecal (IT) and intraventricular (IVT) routes of administration offer the opportunity for antimicrobials that conventionally have minimal cerebrospinal fluid (CSF) penetration to achieve high CSF concentrations while minimizing systemic exposure. SUMMARY Updates in the use of systemic, IT, and IVT antimicrobials offer promise as therapeutic options for CNS infections. Additional pharmacokinetic and prospective data are needed to confirm these findings.
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Predictive value of repeated cerebrospinal fluid parameters in the outcomes of bacterial meningitis in infants <90 days of age. PLoS One 2020; 15:e0238056. [PMID: 32857801 PMCID: PMC7454955 DOI: 10.1371/journal.pone.0238056] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 08/08/2020] [Indexed: 11/27/2022] Open
Abstract
Background There are variations in recommendations from different guidelines regarding the indications for repeat lumbar puncture (LP) in young infants with the diagnosis of bacterial meningitis. Objective To evaluate the frequency of repeat LPs and the characteristics of cerebrospinal fluid (CSF) parameters in repeated sampling and their predictive values for adverse outcomes in a national cohort. Methods This cohort study included infants born January 1, 2013 through December 31, 2014, who had proven or suspected bacterial meningitis within the first 90 days of life at seven paediatric tertiary care hospitals across Canada, and who underwent a repeat LP at the discretion of the treating physicians. Results Forty-nine of 111 infants (44%) underwent repeat LP at a median of 5 (IQR: 3, 13) days after the LP that led to the diagnosis of bacterial meningitis. Those who had meningitis caused by gram negative bacilli were more likely to have repeat LP than those with gram positive bacteria (77% versus 57%; p = 0.012). White blood cell (WBC) count on the second spinal tap yielded an area under the curve of 0.88 for predicting sequelae of meningitis at discharge from the hospital, with a cut-off value of 366 × 106/L, providing a sensitivity of 91% and specificity of 88%. Conclusion In this multi-centre retrospective cohort study, infants with gram negative meningitis were more likely to have repeated LP. A high WBC on the second CSF sample was predictive of adverse outcome at the time of discharge from the hospital.
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Xu X, Zhang L, Cai Y, Liu D, Shang Z, Ren Q, Li Q, Zhao W, Chen Y. Inhibitor discovery for the E. coli meningitis virulence factor IbeA from homology modeling and virtual screening. J Comput Aided Mol Des 2019; 34:11-25. [PMID: 31792885 DOI: 10.1007/s10822-019-00250-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2019] [Accepted: 11/08/2019] [Indexed: 11/28/2022]
Abstract
Escherichia coli (E. coli) K1 is the most common Gram-negative bacteria cause of neonatal meningitis. The penetration of E. coli through the blood-brain barrier is a key step of the meningitis pathogenesis. A host receptor protein, Caspr1, interacts with the E. coli virulence factor IbeA and thus facilitates bacterial penetration through the blood-brain barrier. Based on this result, we have now predicted the binding pattern between Caspr1 and IbeA by an integrated computational protocol. Based on the predicted model, we have identified a putative molecular binding pocket in IbeA, that directly bind with Caspr1. This evidence indicates that the IbeA (229-343aa) region might play a key role in mediating the bacteria invasion. Virtual screening with the molecular model was conducted to search for potential inhibitors from 213,279 commercially available chemical compounds. From the top 50 identified compounds, 9 demonstrated a direct binding ability to the residues within the Caspr1 binding site on IbeA. By using human brain microvascular endothelial cells (hBMEC) with E. coli strain RS218, four molecules were characterized that significantly attenuated the bacteria invasions at concentrations devoid of cell toxicity. Our study provides useful structural information for understanding the pathogenesis of neonatal meningitis, and have identified drug-like compounds that could be used to develop effective anti-meningitis agents.
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Affiliation(s)
- Xiaoqian Xu
- Department of Developmental Biology, Key Laboratory of Cell Biology, Ministry of Public Health and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China.
| | - Li Zhang
- Department of Life Science, Liaoning University, Shenyang, China
| | - Ying Cai
- Department of Developmental Biology, Key Laboratory of Cell Biology, Ministry of Public Health and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
| | - Dongxin Liu
- Department of Developmental Biology, Key Laboratory of Cell Biology, Ministry of Public Health and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
| | - Zhengwen Shang
- Department of Developmental Biology, Key Laboratory of Cell Biology, Ministry of Public Health and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
| | - Qiuhong Ren
- Department of Developmental Biology, Key Laboratory of Cell Biology, Ministry of Public Health and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
| | - Qiong Li
- Department of Life Science, University of Science and Technology of China, Hefei, China
| | - Weidong Zhao
- Department of Developmental Biology, Key Laboratory of Cell Biology, Ministry of Public Health and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China
| | - Yuhua Chen
- Department of Developmental Biology, Key Laboratory of Cell Biology, Ministry of Public Health and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, Shenyang, China.
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Principi N, Esposito S. Bacterial meningitis: new treatment options to reduce the risk of brain damage. Expert Opin Pharmacother 2019; 21:97-105. [PMID: 31675255 DOI: 10.1080/14656566.2019.1685497] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Introduction: Bacterial meningitis (BM) is a medical emergency and its etiology varies according to the age group and geographic area. Studies have shown that brain damage, sequelae and neuropsychological deficits depend not only on the direct deleterious action of the pathogens, but also on the host defenses themselves.Areas covered: Corticosteroids (CS) were the first drugs used with the intent to limit the exaggerated host response. However, as steroid addition to antibiotics is frequently unsatisfactory, other measures have been suggested. In this study, the most important adjuvant therapies that are potentially useful to limit the neuropsychological damage of BM are discussed.Expert opinion: The pathophysiological mechanisms leading to the development of brain damage are not completely defined. Moreover, the efficacy of adjuvant therapies can vary according to the aetiologic cause of BM, and differences in immune system function of the host can play a relevant role in the expression of inflammation and related problems. It is likely that none of the measures with demonstrated efficacy in animal models can be translated into clinical practice in the next few years, suggesting that to reduce the total burden of BM, the increased use of vaccines seems to be the best solution.
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Affiliation(s)
- Nicola Principi
- Emeritus of Pediatrics, Università degli Studi di Milano, Milan, Italy
| | - Susanna Esposito
- Pietro Barilla Children's Hospital, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Singhi S, Angurana SK. Principles of Management of Central Nervous System Infections. Indian J Pediatr 2019; 86:52-59. [PMID: 29333566 DOI: 10.1007/s12098-017-2583-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2017] [Accepted: 12/15/2017] [Indexed: 12/30/2022]
Abstract
CNS infections in children are medical emergency and are associated with high mortality and morbidity. For diagnosis, a high index of suspicion is required. Clinical assessment should be supplemented by laboratory investigations including CSF Gram stain and cultures, blood culture, PCR on CSF, serological tests, and imaging. Commonly associated life threatening complications include coma, seizure, raised intracranial pressure (ICP), focal deficits, shock, respiratory failure, and fluid and electrolyte abnormalities. Immediate management should first address control of airway, breathing and circulation; protocolized management of raised ICP and status epilepticus; maintaining adequate intravascular volume; and close monitoring for early detection of complications. Appropriate antimicrobial agents should be administered promptly according to the suspected pathogen. Clinical evaluation, laboratory workup, specific antimicrobial therapy, supportive treatment, and management of associated complications should go hand in hand in a protocolized way for better outcome.
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Affiliation(s)
- Sunit Singhi
- Division of Pediatrics, Medanta- The Medicity, Sector 38, Gurugram, Haryana, 122001, India.
| | - Suresh Kumar Angurana
- Department of Pediatrics, Government Medical College and Hospital, Sector 32, Chandigarh, India
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Zhao WD, Liu DX, Wei JY, Miao ZW, Zhang K, Su ZK, Zhang XW, Li Q, Fang WG, Qin XX, Shang DS, Li B, Li QC, Cao L, Kim KS, Chen YH. Caspr1 is a host receptor for meningitis-causing Escherichia coli. Nat Commun 2018; 9:2296. [PMID: 29895952 PMCID: PMC5997682 DOI: 10.1038/s41467-018-04637-3] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Accepted: 05/03/2018] [Indexed: 12/17/2022] Open
Abstract
Escherichia coli is the leading cause of neonatal Gram-negative bacterial meningitis, but the pathogenesis of E. coli meningitis remains elusive. E. coli penetration of the blood–brain barrier (BBB) is the critical step for development of meningitis. Here, we identify Caspr1, a single-pass transmembrane protein, as a host receptor for E. coli virulence factor IbeA to facilitate BBB penetration. Genetic ablation of endothelial Caspr1 and blocking IbeA–Caspr1 interaction effectively prevent E. coli penetration into the brain during meningitis in rodents. IbeA interacts with extracellular domain of Caspr1 to activate focal adhesion kinase signaling causing E. coli internalization into the brain endothelial cells of BBB. E. coli can invade hippocampal neurons causing apoptosis dependent on IbeA–Caspr1 interaction. Our results indicate that E. coli exploits Caspr1 as a host receptor for penetration of BBB resulting in meningitis, and that Caspr1 might be a useful target for prevention or therapy of E. coli meningitis. Penetration of the blood–brain barrier (BBB) is crucial for development of E. coli-caused meningitis. Here, the authors show that a host membrane protein, Caspr1, acts as a receptor for a bacterial virulence factor to facilitate BBB penetration and entry of E. coli into brain neurons.
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Affiliation(s)
- Wei-Dong Zhao
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China.
| | - Dong-Xin Liu
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Jia-Yi Wei
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Zi-Wei Miao
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Ke Zhang
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Zheng-Kang Su
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Xue-Wei Zhang
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Qiang Li
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Wen-Gang Fang
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Xiao-Xue Qin
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - De-Shu Shang
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Bo Li
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Qing-Chang Li
- Department of Pathology, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Liu Cao
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China
| | - Kwang Sik Kim
- Division of Pediatric Infectious Diseases, Johns Hopkins University School of Medicine, 200 North Wolfe St, Room 3157, Baltimore, MD, 21287, USA
| | - Yu-Hua Chen
- Department of Developmental Cell Biology, Key Laboratory of Cell Biology, Ministry of Public Health, and Key Laboratory of Medical Cell Biology, Ministry of Education, China Medical University, 77 Puhe Road, Shenbei New District, 110122, Shenyang, China.
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Lien CY, Huang CR, Tsai WC, Hsu CW, Tsai NW, Chang CC, Lu CH, Chien CC, Chang WN. Epidemiologic trend of adult bacterial meningitis in southern Taiwan (2006–2015). J Clin Neurosci 2017; 42:59-65. [DOI: 10.1016/j.jocn.2017.03.017] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2016] [Accepted: 03/06/2017] [Indexed: 12/28/2022]
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14
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Zhang XH, Zhang JM, Han W, Chen H, Chen YH, Wang FR, Wang JZ, Zhang YY, Mo XD, Chen Y, Wang Y, Chang YJ, Xu LP, Liu KY, Huang XJ. Viral encephalitis after haplo-identical hematopoietic stem cell transplantation: Causative viral spectrum, characteristics, and risk factors. Eur J Haematol 2017; 98:450-458. [PMID: 28129450 DOI: 10.1111/ejh.12855] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/22/2017] [Indexed: 12/25/2022]
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15
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Zhou L, Wu R, Shi X, Feng D, Feng G, Yang Y, Dai W, Bian T, Liu T, He Y, Shi M, Zhao G. Simultaneous Detection of Five Pathogens from Cerebrospinal Fluid Specimens Using Luminex Technology. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2016; 13:193. [PMID: 26861363 PMCID: PMC4772213 DOI: 10.3390/ijerph13020193] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/05/2015] [Revised: 01/25/2016] [Accepted: 01/29/2016] [Indexed: 12/13/2022]
Abstract
Early diagnosis and treatment are crucial for the outcome of central nervous system (CNS) infections. In this study, we developed a multiplex PCR-Luminex assay for the simultaneous detection of five major pathogens, including Mycobacterium tuberculosis, Cryptococcus neoformans, Streptococcus pneumoniae, and herpes simplex virus types 1 and 2, which frequently cause CNS infections. Through the hybridization reaction between multiplex PCR-amplified targets and oligonucleotide “anti-TAG” sequences, we found that the PCR-Luminex assay could detect as low as 101–102 copies of synthetic pathogen DNAs. Furthermore, 163 cerebrospinal fluid (CSF) specimens from patients with suspected CNS infections were used to evaluate the efficiency of this multiplex PCR-Luminex method. Compared with Ziehl-Neelsen stain, this assay showed a high diagnostic accuracy for tuberculosis meningitis (sensitivity, 90.7% and specificity, 99.1%). For cryptococcal meningitis, the sensitivity and specificity were 92% and 97.1%, respectively, compared with the May Grunwald Giemsa (MGG) stain. For herpes simplex virus types 1 and 2 encephalitis, the sensitivities were 80.8% and 100%, and the specificities were 94.2% and 99%, respectively, compared with Enzyme Linked Immunosorbent Assay (ELISA) assays. Taken together, this multiplex PCR-Luminex assay showed potential efficiency for the simultaneous detection of five pathogens and may be a promising supplement to conventional methods for diagnosing CNS infections.
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Affiliation(s)
- Linfu Zhou
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
- Department of Neurology, Third Hospital of People's Liberation Army, Baoji 721004, China.
| | - Rui Wu
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Xiaodan Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Dongyun Feng
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Guodong Feng
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Yining Yang
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Wen Dai
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Ting Bian
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Tingting Liu
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Ying He
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Ming Shi
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
| | - Gang Zhao
- Department of Neurology, Xijing Hospital, Fourth Military Medical University, Xi'an 710032, China.
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A Case Report on the Successful Treatment of Streptococcus pneumoniae-Induced Infectious Abdominal Aortic Aneurysm Initially Presenting with Meningitis. Case Rep Surg 2016; 2015:825069. [PMID: 26779361 PMCID: PMC4686708 DOI: 10.1155/2015/825069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Revised: 11/19/2015] [Accepted: 11/22/2015] [Indexed: 11/29/2022] Open
Abstract
Infectious abdominal aortic aneurysms often present with abdominal and lower back pain, but prolonged fever may be the only symptom. Infectious abdominal aortic aneurysms initially presenting with meningitis are extremely rare; there are no reports of their successful treatment. Cases with Streptococcus pneumoniae as the causative bacteria are even rarer with a higher mortality rate than those caused by other bacteria. We present the case of a 65-year-old man with lower limb weakness and back pain. Examination revealed fever and neck stiffness. Cerebrospinal fluid showed leukocytosis and low glucose levels. The patient was diagnosed with meningitis and bacteremia caused by Streptococcus pneumoniae and treated with antibiotics. Fever, inflammatory response, and neurologic findings showed improvement. However, abdominal computed tomography revealed an aneurysm not present on admission. Antibiotics were continued, and a rifampicin soaked artificial vascular graft was implanted. Tissue cultures showed no bacteria, and histological findings indicated inflammation with high leukocyte levels. There were no postoperative complications or neurologic abnormalities. Physical examination, blood tests, and computed tomography confirmed there was no relapse over the following 13 months. This is the first reported case of survival of a patient with an infectious abdominal aortic aneurysm initially presenting with meningitis caused by Streptococcus pneumoniae.
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Bertrand L, Nair M, Toborek M. Solving the Blood-Brain Barrier Challenge for the Effective Treatment of HIV Replication in the Central Nervous System. Curr Pharm Des 2016; 22:5477-5486. [PMID: 27464720 PMCID: PMC7219022 DOI: 10.2174/1381612822666160726113001] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Accepted: 07/27/2016] [Indexed: 12/21/2022]
Abstract
Recent decades mark a great progress in the treatment of HIV infection. What was once a deadly disease is now a chronic infection. However, HIV-infected patients are prone to develop comorbidities, which severely affect their daily functions. For example, a large population of patients develop a variety of neurological and cognitive complications, called HIV associated neurological disorders (HAND). Despite efficient repression of viral replication in the periphery, evidence shows that the virus can remain active in the central nervous system (CNS). This low level of replication is believed to result in a progression of neurocognitive dysfunction in infected individuals. Insufficient viral inhibition in the brain results from the inability of several treatment drugs in crossing the blood-brain barrier (BBB) and reaching therapeutic concentrations in the CNS. The current manuscript discusses several strategies that are being developed to enable therapeutics to cross the BBB, including bypassing BBB, inhibition of efflux transporters, the use of active transporters present at the BBB, and nanotechnology. The increased concentration of therapeutics in the CNS is desirable to prevent viral replication; however, potential side effects of anti-retroviral drugs need also to be taken into consideration.
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Affiliation(s)
| | | | - Michal Toborek
- University of Miami. Miller School of Medicine, Department of Biochemistry and Molecular Biology, 1011 NW 15th Street, Miami, FL 33136, USA.
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Pettini E, Fiorino F, Cuppone AM, Iannelli F, Medaglini D, Pozzi G. Interferon-γ from Brain Leukocytes Enhances Meningitis by Type 4 Streptococcus pneumoniae. Front Microbiol 2015; 6:1340. [PMID: 26648922 PMCID: PMC4664635 DOI: 10.3389/fmicb.2015.01340] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2015] [Accepted: 11/16/2015] [Indexed: 11/29/2022] Open
Abstract
Streptococcus pneumoniae is the leading cause of bacterial meningitis. Pneumococcal meningitis is a life-threatening disease with high rates of mortality and neurological sequelae. Immune targeting of S. pneumoniae is essential for clearance of infection; however, within the brain, the induced inflammatory response contributes to pathogenesis. In this study we investigate the local inflammatory response and the role of IFN-γ in a murine model of pneumococcal meningitis induced by intracranial injection of type 4 S. pneumoniae. Lymphoid and myeloid cell populations involved in meningitis, as well as cytokine gene expression, were investigated after infection. Animals were treated with a monoclonal antibody specific for murine IFN-γ to evaluate its role in animal survival. Intracranial inoculation of 3 × 104 colony-forming units of type 4 strain TIGR4 caused 75% of mice to develop meningitis within 4 days. The amount of lymphocytes, NK cells, neutrophils, monocytes and macrophages in the brain increased 48 h post infection. IFN-γ mRNA levels were about 240-fold higher in brains of infected mice compared to controls. Pro-inflammatory cytokines such as IL-1β and TNF-α, and TLR2 were also upregulated. In vivo treatment with anti-IFN-γ antibody increased survival of infected mice. This study shows that IFN-γ produced during meningitis by type 4 S. pneumoniae enhances bacterial pathogenesis exerting a negative effect on the disease outcome.
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Affiliation(s)
- Elena Pettini
- Laboratorio di Microbiologia Molecolare e Biotecnologia, Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena Siena, Italy
| | - Fabio Fiorino
- Laboratorio di Microbiologia Molecolare e Biotecnologia, Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena Siena, Italy
| | - Anna Maria Cuppone
- Laboratorio di Microbiologia Molecolare e Biotecnologia, Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena Siena, Italy
| | - Francesco Iannelli
- Laboratorio di Microbiologia Molecolare e Biotecnologia, Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena Siena, Italy
| | - Donata Medaglini
- Laboratorio di Microbiologia Molecolare e Biotecnologia, Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena Siena, Italy
| | - Gianni Pozzi
- Laboratorio di Microbiologia Molecolare e Biotecnologia, Dipartimento di Biotecnologie Mediche, Università degli Studi di Siena Siena, Italy
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Pratt AJ, DiDonato M, Shin DS, Cabelli DE, Bruns CK, Belzer CA, Gorringe AR, Langford PR, Tabatabai LB, Kroll JS, Tainer JA, Getzoff ED. Structural, Functional, and Immunogenic Insights on Cu,Zn Superoxide Dismutase Pathogenic Virulence Factors from Neisseria meningitidis and Brucella abortus. J Bacteriol 2015; 197:3834-47. [PMID: 26459556 PMCID: PMC4652047 DOI: 10.1128/jb.00343-15] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2015] [Accepted: 09/29/2015] [Indexed: 12/17/2022] Open
Abstract
UNLABELLED Bacterial pathogens Neisseria meningitidis and Brucella abortus pose threats to human and animal health worldwide, causing meningococcal disease and brucellosis, respectively. Mortality from acute N. meningitidis infections remains high despite antibiotics, and brucellosis presents alimentary and health consequences. Superoxide dismutases are master regulators of reactive oxygen and general pathogenicity factors and are therefore therapeutic targets. Cu,Zn superoxide dismutases (SODs) localized to the periplasm promote survival by detoxifying superoxide radicals generated by major host antimicrobial immune responses. We discovered that passive immunization with an antibody directed at N. meningitidis SOD (NmSOD) was protective in a mouse infection model. To define the relevant atomic details and solution assembly states of this important virulence factor, we report high-resolution and X-ray scattering analyses of NmSOD and of SOD from B. abortus (BaSOD). The NmSOD structures revealed an auxiliary tetrahedral Cu-binding site bridging the dimer interface; mutational analyses suggested that this metal site contributes to protein stability, with implications for bacterial defense mechanisms. Biochemical and structural analyses informed us about electrostatic substrate guidance, dimer assembly, and an exposed C-terminal epitope in the NmSOD dimer. In contrast, the monomeric BaSOD structure provided insights for extending immunogenic peptide epitopes derived from the protein. These collective results reveal unique contributions of SOD to pathogenic virulence, refine predictive motifs for distinguishing SOD classes, and suggest general targets for antibacterial immune responses. The identified functional contributions, motifs, and targets distinguishing bacterial and eukaryotic SOD assemblies presented here provide a foundation for efforts to develop SOD-specific inhibitors of or vaccines against these harmful pathogens. IMPORTANCE By protecting microbes against reactive oxygen insults, SODs aid survival of many bacteria within their hosts. Despite the ubiquity and conservation of these key enzymes, notable species-specific differences relevant to pathogenesis remain undefined. To probe mechanisms that govern the functioning of Neisseria meningitidis and Brucella abortus SODs, we used X-ray structures, enzymology, modeling, and murine infection experiments. We identified virulence determinants common to the two homologs, assembly differences, and a unique metal reservoir within meningococcal SOD that stabilizes the enzyme and may provide a safeguard against copper toxicity. The insights reported here provide a rationale and a basis for SOD-specific drug design and an extension of immunogen design to target two important pathogens that continue to pose global health threats.
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Affiliation(s)
- Ashley J Pratt
- Department of Integrative Structural and Computational Biology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, California, USA Molecular Biophysics and Integrated Bioimaging Division, Lawrence Berkeley National Laboratory, Berkeley, California, USA
| | - Michael DiDonato
- Department of Integrative Structural and Computational Biology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, California, USA
| | - David S Shin
- Department of Integrative Structural and Computational Biology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, California, USA Molecular Biophysics and Integrated Bioimaging Division, Lawrence Berkeley National Laboratory, Berkeley, California, USA
| | - Diane E Cabelli
- Chemistry Department, Brookhaven National Laboratory, Upton, New York, USA
| | - Cami K Bruns
- Department of Integrative Structural and Computational Biology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, California, USA
| | - Carol A Belzer
- National Animal Disease Center, Ruminant Diseases and Immunology, Ames, Iowa, USA
| | | | - Paul R Langford
- Section of Paediatrics, Department of Medicine, Imperial College London, St. Mary's Campus, London, England, United Kingdom
| | - Louisa B Tabatabai
- National Animal Disease Center, Ruminant Diseases and Immunology, Ames, Iowa, USA
| | - J Simon Kroll
- Section of Paediatrics, Department of Medicine, Imperial College London, St. Mary's Campus, London, England, United Kingdom
| | - John A Tainer
- Molecular Biophysics and Integrated Bioimaging Division, Lawrence Berkeley National Laboratory, Berkeley, California, USA Department of Molecular and Cellular Oncology, The University of Texas M. D. Anderson Cancer Center, Houston, Texas, USA
| | - Elizabeth D Getzoff
- Department of Integrative Structural and Computational Biology and The Skaggs Institute for Chemical Biology, The Scripps Research Institute, La Jolla, California, USA
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Nau R, Djukic M, Spreer A, Ribes S, Eiffert H. Bacterial meningitis: an update of new treatment options. Expert Rev Anti Infect Ther 2015; 13:1401-23. [DOI: 10.1586/14787210.2015.1077700] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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