[Can the antibiotic prescription practice in a hospital be influenced by in-house guidelines? An interventional study at the University Hospital Halle (Saale), Germany]

BACKGROUND

In-house guidelines are an essential tool of antibiotic stewardship (ABS) programs to guide antimicrobial therapy. We studied the effect of in-house guidelines adapted to the local pathogen and resistance epidemiology on prescribing behavior.

METHODS

At the University Hospital Halle (Saale) guidelines for the antimicrobial therapy and essential microbiological diagnostics were introduced. Main objectives were reducing the use of third generation cephalosporines and fluoroquinolones, decreasing selection pressure for enterococci and multidrug-resistant Gram-negative bacteria, minimizing Clostridium difficile infections (CDI), and improving microbiological diagnostics to enhance de-escalation strategies. 12 months thereafter a comparison of antibiotic consumption, pathogen and resistance statistics and use of blood cultures was performed.

RESULTS

There was a decrease of third-generation cephalosporines (-18.6%) and fluoroquinolones (-9.8%), while consumption of broad- and intermediate-spectrum penicillins (+23.8% and +37%) as well as carbapenems (+11.9%) increased. The total volume of prescribed anti-infectives remained unchanged. The number of enterococcal isolates (-18.3%) and CDI (-26.3%) decreased considerably. Gram-negatives, particulary ESBL-producing Enterobacteriaceae, were detected more frequently due to an expanded screening program. The rate of blood cultures/1000 patient-days was unaffected.

CONCLUSION

In-house guidelines for the empiric antiinfective therapy appear to be suitable to influence the prescribing behavior and the selection pressure on individual pathogen groups. The total volume of antibiotic prescriptions was not affected in this study.

Colonization and infection due to multi-resistant bacteria in neonates: a single center analysis

BACKGROUND

In the last years the prevalence of multi-resistant pathogens (MRPs) has increased. Systemic infections remain important for neonatal morbidity and mortality.

PATIENTS

Neonates born between January 2011 and December 2012 and admitted to the neonatology before their tenth day of life were included into this retrospective analysis. Vancomycin-resistant Enterococci, Methicillin-resistant Staphylococcus aureus, Gram-negative bacilli with Extend Spectrum Beta Lactamase or AMP-C resistance were defined as multi-resistant pathogens (MRPs). MRP positive and negative patients were analyzed regarding clinical risk factors and the incidence of systemic infections.

RESULTS

635 neonates were admitted during the analysis period. In 31 patients MRPs were detected. 2 patients developed MRP-associated infections. Both were discharged without long term health risks. Low gestational age and need for mechanical ventilation were risk factors for colonization with MRPs in the univariat analysis. The incidence density (per 1 000 patient days) for all MRE increased from 0.76 in 2011 to 3.51 in 2012. In contrast the sepsis rate remained stable (14.9% and 14.2%). 2 MRP colonization clusters were detected by routine microbiology swabs. Both could be controlled by appropriate hygienic measures.

CONCLUSIONS

The prevalence of Gram-negative MRPs increased in neonates. Microbiological screening seems to be helpful for early detection of colonization and thus prevention of nosocomial infections with MRPs. Despite the increased attention towards the problems associated with multiresistant bacteria, there are still major efforts needed for prevention and early treatment of sepsis with non-resistant bacteria.

[Immunosuppressive treatment as a risk factor for the occurrence of clostridium difficile infection (CDI)]

BACKGROUND

Toxigenic Clostridium difficile strains are known as the most common infectious cause of antibiotic-associated intestinal disease and nosocomial diarrhoea. The increased incidence of hypervirulent strains gives rise to worldwide concern. In particular, courses with multiple recurrences are observed in the presence of immunosuppression.

METHODS

In this retrospective controlled observational study we aimed to determine immunosuppression as an independent risk factor for symptomatic CDI and to identify characteristics and differences of immunocompromised patients with respect to disease severity, disease progression, intestinal manifestations, recurrence rates and other factors. We compared symptoms and clinical features of 55 immunosuppressed patients with confirmed CDI with those of 50 patients without immunosuppressive medication (mean age 59.3 years ± 16.2 vs. 69.2 years ± 15.0) who were treated at the Departments of Internal Medicine I and IV of the University Hospital Halle (Saale), Germany, between 2006 and 2009. Multivariate analysis using binary logistic regression was performed for a control group of 105 patients without CDI. In this group, there were 62 patients without evidence of immunosuppression and 43 immunosuppressed patients (mean age 66.9 years ± 12.4 vs. 56.0 years ± 13.7).

RESULTS

The clinical courses of the two groups differed considerably. Immunosuppressed patients were significantly more frequently colonised with Clostridium difficile without clinically detectable manifestation or only mild clinical symptoms not requiring therapy (22 vs. 2 %, p = 0.003), while there were similar numbers of moderate (46 vs. 52 %, p = 0.503) but less severe CDI cases (27 vs. 40 %, p = 0.167). Relapses were observed more frequently in the group of immunosuppressed patients (15 vs. 6 %, p = 0.153). Multivariate analysis using logistic regression identified immunosuppression as an independent risk factor for CDI (OR = 2.75), in addition to prior antibiotic therapy (OR = 10.15) and PPI intake (OR = 2.93).

CONCLUSION

We conclude that immunosuppression has to be regarded as an independent risk factor for CDI. Immunosuppressive treatment increases the risk of colonisation and infection with Clostridium difficile and leads to a higher relapse rate in patients with CDI.

Microbial diagnostics in patients with presumed severe infection in the emergency department

INTRODUCTION

Sepsis in the early stage is a common disease in emergency medicine, and rapid diagnosis is essential. Our aim was to compare pathogen diagnosis using blood cultures (BC) and the multiplex polymerase chain reaction (PCR) test.Methods. At total of 211 patients admitted to the multidisciplinary emergency department of our university hospital between 2006 and 2009 with suspected severe infection from any origin were studied. Blood samples for BC (aerobic and anaerobic) and multiplex PCR were taken for identification of infectious microorganisms immediately after hospital admission. Results of the BC and PCR correlated with procalcitonin concentration (PCT) and clinical diagnosis of sepsis (≥2 positive SIRS criteria) as well as with severity of disease at admission and with clinical outcome measures.

RESULTS

Results of the BC were available in 200 patients (94.8%) and PCR were available in 119 patients (56.3%), respectively. In total, 87 BC (43.5%) were positive and identified 94 pathogens. In 45 positive PCRs, 47 pathogens (37.8%) were found. Identical results were obtained in 81.4%. In addition, BC identified 9 Gram-positive and 3 Gram-negative bacteria, while PCR added 5 Gram-negative pathogens. Coagulase-negative staphylococci were detected in blood cultures only (n=20, 21.3%), whereas PCR identified significantly more Gram-negative bacteria than BC. In patients with positive PCR results, the PCT level was significantly higher than in patients with negative PCR (15.0±23.3 vs. 8.8±32.8 ng/ml, p<0.001). This difference was not observed for BC (10.6±25.7 vs. 11.6±44.9 ng/ml, p=0.075). The APACHE II score correlated with PCR (19.2±9.1 vs. 15.8±8.9, p<0.05) and was also higher in positive BC (18.7±8.7 vs. 14.4±8.0, p<0.01). Positive PCR and BC were correlated with negative clinical outcomes (e.g., transfer to ICU, mechanical ventilation, renal replacement therapy, death).

CONCLUSION

In patients admitted with suspected severe infection, a high percentage of positive BC and PCR were observed. Positive findings in the PCR correlate with elevated levels of PCT and high APACHE II scores.

[Unexplained fever and B-symptoms in a young male Black African]

An immunocompetent Nigerian developed a fulminant hemophagocytic lymphohistiocytosis due to Epstein-Barr virus reactivation. The patient initially presented with fever, hepatosplenomegaly and pancytopenia. The clinical status of our patient deteriorated quickly despite treatment with corticoids. Escalation of immunosuppressive treatment was not possible. He died of lung, liver and circulatory failure in our intensive care unit.Hemophagocytic lymphohistiocytosis is a rare disease characterized by inflammation due to prolonged and excessive activation of antigen-presenting cells. High plasma ferritin levels and phagocytosis of hematopoetic cells in bone marrow, spleen and liver lead to the diagnosis. Hemophagocytic lymphohistiocytosis should therefore be included in the differential diagnosis in patients with persistent fever, hepatosplenomegaly and cytopenia.

[37-year old patient with fever, diarrhea and lymphadenopathy]

A 37-year-old homosexual man was admitted because of oropharyngeal pain, fever, diarrhea, loss of weight and lymphadenopathy since one week. Acute retroviral syndrome (ARS) in primary HIV type 1 infection was diagnosed, associated with Giardia lamblia infection. Antiinfective and combined antiretroviral treatment was established, and the general condition of the patient rapidly improved. The presented report demonstrates that in case of acute HIV-infection with diarrhea other infections should be considered, particularly with regard to enteropathogens like Giardia lamblia.

In vitro activity of linezolid against clinical isolates of Fusobacterium spp

OBJECTIVES

Although most susceptibility studies for linezolid have investigated aerobic bacteria, only a few have investigated anaerobe isolates. The aim of the present study was to determine the antibacterial activity of linezolid against a larger sample of clinical isolates of Fusobacterium spp. and to report on the detailed susceptibility, stratified by species.

METHODS

The in vitro susceptibility of 80 clinical isolates of Fusobacterium (Fusobacterium necrophorum, n = 34; Fusobacterium nucleatum, n = 20; Fusobacterium varium, n = 18; Fusobacterium mortiferum; n = 8) was tested and compared with the activity of the older compounds amoxicillin and amoxicillin/clavulanic acid.

RESULTS

The MIC of linezolid ranged from 0.016 to 1.0 mg/L, with the MIC(90) being 0.5 mg/L. The highest MIC obtained for linezolid (1.0 mg/L) was measured for an F. varium isolate. The MIC(90) for both, amoxicillin (range: 0.016-0.75 mg/L) and amoxicillin/clavulanic acid (range: 0.047-0.75 mg/L), was 0.5 mg/L. Overall, no resistant strains were found in the study.

CONCLUSIONS

Compared with amoxicillin and amoxicillin/clavulanic acid, linezolid was less active against F. necrophorum (MIC(90) 0.25 mg/L) and F. nucleatum (MIC(90) 0.25 mg/L), equally active against F. varium (MIC(90) 0.75 mg/L) and slightly more active against F. mortiferum (MIC(90) 0.19 mg/L).

Identification of a novel sequence at the 3' end of the GB virus B genome

GB virus B (GBV-B) is a virus of the family Flaviviridae that infects small primates (Saguinus sp. [tamarins]) and shows similarities to hepatitis C virus (HCV) in genome organization, protein function, tissue tropism, and pathogenicity. This suggests the possibility of using tamarins infected by GBV-B or GBV-B/HCV chimeric viruses as a surrogate animal model of HCV infection. To achieve the construction of such chimeric viruses, it is essential to produce a complete and infectious GBV-B genomic RNA. We have identified a novel sequence at the 3' end of the GBV-B genome and show that it can be arranged in a secondary structure resembling that of the 3' end of the HCV genome, which is known to be essential for infectivity.

Quality control study on the performance of GB virus C/hepatitis G virus PCR

BACKGROUND/AIMS

A novel virus, GBV-C/HGV, with a genome RNA organization similar to that of the Flaviviridae family was identified in sera of patients with hepatitis. The presence of GBV-C/HGV RNA can only be determined by the amplification of genomic regions using the reverse transcriptase-polymerase chain reaction (RT-PCR).

METHODS

To assess the quality of the RT-PCR, 14 laboratories investigated a coded serum panel that comprised three GBV-C/HGV RNA-positive sera from three different patients, dilutions of these sera, and three GBV-C/HGV RNA-negative serum samples, two of which were collected from patients with hepatitis C but without GBV-C/HGV infection. In-house RT-PCR as well as commercially available GBV-C/HGV test kits were used in this study.

RESULTS

Only four laboratories (29%) reported the expected results, and four laboratories (29%) false-positive results; nine laboratories (64%) reported at least one false-negative result. Eleven laboratories (79%) detected the undiluted samples. The majority of false results were obtained with the dilutions of GBV-C/HGV RNA-positive samples. Negative results in the 10(-4) dilution were not considered to be false-negative, since during pre-screening GBV-C/HGV RNA had been detected in this dilution in only 50% of assays by the three laboratories involved in organizing the evaluation. Results obtained by commercial kits and by in-house assays were indiscriminate in quality of performance in this study.

CONCLUSION

To facilitate further quality assessment studies on the performance of GBV-C/HGV RNA detection, an international GBV-C/HGV RNA standard should be made available. Further efforts are required to optimize GBV-C/HGV RT-PCR.

Hepatoma-derived integrated HBV DNA causes multi-stage transformation in vitro

The hepatoma-derived hepatitis B virus (HBV) DNA insert HU-a has recently been shown to contain two viral transactivator genes, X and preS2 /S. We report here that HU-a induces malignant transformation after stable transfection of the fetal mouse hepatocyte line FMH202, as indicated by soft agar growth and nude mouse tumorigenicity. Transfections with HU-a subclones, containing the X gene of the preS2 /S gene alone or sequences without transactivator gene, respectively, suggested that the X gene is essential for transformation. Sequential stages of transformation and tumor progression were analysed by injection of the stably transfected FMH202 lines into nude mice, explanation of the resulting tumors and re-establishment of cell lines from the tumors. Comparison of two HU-a-transformed cell lines by HBV mRNA hybridization, Southern analysis and chromosomal in situ hybridization revealed that integrated HBV DNAs were involved in major chromosomal rearrangements in both cases. Interestingly, recombination of the HBV Dna insert during the nude mouse passage had completely abolished HBV-specific transcription in one case, indicating that expression of integrated HBV genes, while presumably involved in early transformation, is dispensable at later stages of tumor progression. The sequential transformation observed in this experimental system suggests that expression of the X gene by integrated viral DNA and subsequent hepatocyte genome mutations might both contribute to HBV-associated liver carcinogenesis.

The hepatitis B virus preS2/St transactivator utilizes AP-1 and other transcription factors for transactivation

Integrated hepatitis B virus DNA cloned from hepatitis B virus-associated hepatocellular carcinoma frequently contains 3'-truncated middle surface genes (preS2/St), which were recently found to have a transcriptional transactivator function. Because preS2/St, among others, is able to transactivate the promoters of the cellular oncogenes c-myc and c-fos, it has been speculated that integrated preS2/St genes might contribute to hepatitis B virus-associated liver carcinogenesis. In this study, we investigated the mechanism of target gene stimulation by preS2/St. It was found that deletion of a fragment containing the binding site for transcription factor AP-1 (Jun-Fos) substantially decreases inducibility of the human c-myc promoter by preS2/St. A subsequent investigation of AP-1 activation by preS2/St revealed the following: (a) insertion of multimeric AP-1 binding sites confers inducibility to an otherwise unstimulatable test promoter; (b) transactivation of AP-1 sites is dramatically increased when Jun and Fos are overexpressed by cotransfected expression plasmids; and (c) inhibitors of AP-1 activation also impair transactivation by preS2/St. Besides AP-1, preS2/St was also able to utilize the unrelated transcription factors NF-kappa B and AP-2 for transactivation, suggesting that the gene product of preS2/St acts indirectly through one or several general cellular pathways rather than as a bona fide transcription factor. Because AP-1 conveys induction of a large panel of tumor-relevant genes, its preS2/St-dependent activation implies a possible causative role in hepatitis B virus-associated hepatocarcinogenesis.

ER-localization and functional expression of the HBV transactivator MHBst

In two recently reported cases, integrated hepatitis B virus (HBV) DNAs cloned from hepatocellular carcinoma were found to express a transcriptional transactivator from 3'-terminally truncated HBV surface (preS/S) genes. In this study, we characterized the transactivator at the protein level. Expression of a 3'-truncated preS2/S gene in Spodoptera frugiperda (Sf9) insect cells resulted in a C-terminally truncated middle surface protein of 76 amino acids (MHBst76), which was found to be associated with membranes of the endoplasmic reticulum and retained from Golgi processing and secretion. Accordingly, the microsome fraction of MHBst76-expressing Sf9 cells displayed transactivator activity after electric field-mediated transfer into Chang liver cells. In contrast to full-length MHBs, MHBst76 is unglycosylated, and glycosylation is not required for transactivation as shown by mutation of the glycosylation site at asparagine-4. Since highly purified MHBst76 derived from an E. coli expression system also showed transactivator activity, it is concluded that unglycosylated MHBst76 protein is the authentic transactivating factor. As the transactivator protein derives from inactive MHbs by rearrangements of integrated HBV DNA, it may be important for HBV-associated liver carcinogenesis.

The hepatitis B virus transactivator HBx causes elevation of diacylglycerol and activation of protein kinase C

Chronic infection with hepatitis B virus (HBV) is accompanied by an increasing risk of developing hepatocellular carcinoma. There are indications that the HBx protein of HBV is involved in the process of tumour formation. HBx also transactivates several transcription factor binding sites. Recently, we reported that HBx can use a tumour promotor pathway for transactivation. In particular, we found that transactivation of the binding motif for transcription factor AP-1 (JUN/FOS) by HBx is dependent on functional protein kinase C (PKC), as indicated by abolition of the transcriptional stimulation following downregulation or inhibition of the enzyme. Moreover, HBx activates PKC, probably via increasing the endogenous PKC activator sn-1,2-diacylglycerol (DAG). Here we extend these data and report on the time course of PKC activation. We found that activation of PKC by HBx is transient and differs from activation of PKC by the ras oncogene product or phorbol ester in that it does not lead to rapid downregulation of the enzyme subsequent to the activation. Moreover, we provide evidence that an increase in cellular DAG is observable not only as an early event in response to HBx but also in cell lines transformed after transfection with HBV DNA and stably expressing HBx. Besides its important role in the regulation of cellular genes, PKC is also the intracellular receptor for tumour-promoting agents and an activator of proto-oncogenes, suggesting that our observations might provide an explanation for the oncogenic properties of HBx.

Hepatitis B virus transactivator HBx uses a tumour promoter signalling pathway

The hepatitis B virus (HBV) transactivator protein HBx is enigmatic in that it stimulates a striking variety of promoters which do not share a common cis-regulatory element. As it does not bind to DNA, it has been speculated that HBx acts indirectly through cellular pathways. Under certain conditions HBx can have an oncogenic potential, which may be relevant for HBV-associated liver carcinogenesis, but until now the mechanism for transactivation and cell transformation by HBx was unclear. We report here that HBx uses a complex signal transduction pathway for transactivation. An increase in the endogenous protein kinase C (PKC) activator sn-1,2-diacylglycerol and the subsequent activation of PKC give rise to activation of the transcription factor AP-1 (Jun-Fos). As a result, HBx transactivates through binding sites for AP-1 and other PKC-dependent transcription factors (AP-2, NF-kappa B), thereby explaining the as-yet incomprehensible variety of HBx-inducible genes. As the PKC signal cascade also mediates cell transformation by tumour-promoting agents, the mechanism presented here might account for the oncogenic potential of HBx.

The hepatitis B virus pre-S/S(t) transactivator is generated by 3' truncations within a defined region of the S gene

Recently, it was reported that 3' truncation of an integrated surface gene (pre-S2/S) cloned from a hepatitis B virus (HBV)-associated hepatoma gave rise to the generation of a C-terminally truncated middle surface protein (MHBst), which surprisingly exerted a transcriptional transactivator function. To define the molecular requirements for the generation of transactivating MHBs(t) proteins, a 3' deletion analysis of the HBV pre-S2/S gene was performed. In cotransfection experiments with reporter plasmid pSV2CAT, full-length pre-S2/S genes or pre-S2/S genes with minor 3'-terminal deletions did not exhibit transactivator activity. In contrast, deletion of C-terminal hydrophobic region III of the S domain generated the transactivator function. Further stepwise 3' deletions, removing hydrophobic region II and both hydrophilic regions of the S domain, did not interfere with the transactivator activity; it was completely abolished, however, after additional deletion of hydrophobic region I. The results of this study define a range within the S open reading frame (between HBV nucleotides 221 and 573), termed the trans-activity-on region, in which 3' deletions give rise to the generation of transactivating MHBs(t) proteins. Within this region, not only 3' deletions but also the introduction of a stop codon activated the transactivator function, indicating that point mutations of integrated HBV DNA also may give rise to the synthesis of transactivating MHBs(t) proteins in vivo.

Trans-activation by hepatitis B virus X protein is mediated via a tumour promoter pathway

We have studied the c-myc gene as a possible target of HBV X protein in liver carcinogenesis. Our results indicate that trans-activation by X protein occurs via PKC/AP1 signal transduction, suggesting a possible two-step mechanism in HBV related liver carcinogenesis.

A trans-activator function is generated by integration of hepatitis B virus preS/S sequences in human hepatocellular carcinoma DNA

The X gene of wild-type hepatitis B virus or integrated DNA has recently been shown to stimulate transcription of a variety of enhancers and promoters. To further delineate the viral sequences responsible for trans-activation in hepatomas, we cloned the single hepatitis B virus insert from human hepatocellular carcinoma DNA M1. The plasmid pM1 contains 2004 base pairs of hepatitis B virus DNA subtype adr, including truncated preS/S sequences and the enhancer element. The X promoter and 422 nucleotides of the X coding region are present. The entire preC/C gene is deleted. In transient cotransfection assays using Chang liver cells (CCL 13), pM1 DNA exerts a 6- to 10-fold trans-activating effect on the expression of the pSV2CAT reporter plasmid. The trans-activation occurs by stimulation of transcription and is dependent on the simian virus 40 enhancer in the reporter plasmid. Deletion analysis of pM1 subclones reveals that the trans-activator is encoded by preS/S and not by X sequences. A frameshift mutation within the preS2 open reading frame shows that this portion is indispensable for the trans-activating function. Initiation of transcription has been mapped to the S1 promoter. A comparable trans-activating effect is also observed with cloned wild-type hepatitis B virus sequences similarly truncated. These results show that a transcriptional trans-activator function not present in the intact gene is generated by 3' truncation of integrated hepatitis B virus DNA preS/S sequences.

The preS2/S region of integrated hepatitis B virus DNA encodes a transcriptional transactivator

Hepatitis B virus (HBV) is regarded as the main aetiologic factor in the development of human hepatocellular carcinoma (HCC), one of the most frequent fatal malignancies worldwide. Detection of integrated HBV sequences in the cellular DNA of almost all HCCs studied, and the recent finding that the integrated HBV open reading frame (orf) X encodes a transactivating activity, supports the notion that integrated HBV DNA could contribute to liver carcinogenesis by activation of cellular genes in trans. But not all HCCs seem to harbour a functional orf X. We report here that 3'-truncated preS2/S sequences in integrated HBV DNA of liver cell carcinomas encode a so far unidentified transcriptional trans-activation activity. This activity is also produced by an artificially 3'-truncated preS2/S gene of the wild-type HBV genome. Besides the simian virus 40 promoter of the reporter plasmid pSV2CAT, the promoter of the human c-myc oncogene can also be activated. These results, taken together with the fact that preS/S is the only HBV gene found to be integrated in almost every HBV-related HCC analysed so far, indicate that trans-activation by integrated preS2/S sequences is a possible mechanism for HBV-associated oncogenesis.