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Callaby H, McGuire E, Rajwal S, Stahlschmidt J, Hartley J, Brown RM, Deheragoda M, Quaglia A, Rampling T, Houlihan CF, Claire Gordon N, Brown CS, Simmons R, Samson A, Mandal S, Grammatikopoulos T, Demirjian A. Histopathological findings from the investigation of paediatric acute hepatitis of unknown aetiology, United Kingdom 2022. J Pediatr Gastroenterol Nutr 2024; 78:534-538. [PMID: 38327256 DOI: 10.1002/jpn3.12133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2023] [Revised: 12/14/2023] [Accepted: 12/18/2023] [Indexed: 02/09/2024]
Abstract
In 2022, there were global reports of increased numbers of acute hepatitis not explained by hepatitis A-E virus infection in children. This manuscript summarises histopathology results from 20 patients in the United Kingdom who underwent liver transplant or had a liver biopsy as part of aetiological investigations. All available histopathological samples were reviewed centrally as part of the outbreak investigation. A working group comprised of infection specialists, hepatologists and histopathologists met virtually to review the cases, presentation, investigations and histopathology. All 20 liver samples had evidence of inflammation without significant interface activity, and submassive confluent pan-lobular or multilobular hepatocellular necrosis. Overall, the predominant histopathological findings were of acute nonspecific hepatitis with submassive hepatic necrosis and central vein perivenulitis and endothelitis. Histopathological findings were a poor indicator of aetiology.
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Affiliation(s)
- Helen Callaby
- UKHSA Rare and Imported Pathogen Laboratory, Porton Down, London, UK
- Institute of Medical Sciences, University of Aberdeen, Aberdeen, UK
| | - Emma McGuire
- HCAI, Fungal, AMR, AMU & Sepsis Division, UKHSA, London, UK
| | | | - Jens Stahlschmidt
- Department of Histopathology and Molecular Pathology, St James's University Hospital, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jane Hartley
- Liver Unit, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Rachel M Brown
- Department of Histopathology Birmingham Children's Hospital, Birmingham, UK
| | | | - Alberto Quaglia
- Department of Cellular Pathology, Royal Free London, London, UK
| | - Tommy Rampling
- UKHSA Rare and Imported Pathogen Laboratory, Porton Down, London, UK
| | | | - N Claire Gordon
- UKHSA Rare and Imported Pathogen Laboratory, Porton Down, London, UK
| | - Colin S Brown
- HCAI, Fungal, AMR, AMU & Sepsis Division, UKHSA, London, UK
- NIHR Health Protection Research Unit in Healthcare Associated Infections and Antimicrobial Resistance, London, UK
| | - Ruth Simmons
- Blood Safety, Hepatitis, STI & HIV Division, UK Health Security Agency, London, UK
| | - Anda Samson
- HCAI, Fungal, AMR, AMU & Sepsis Division, UKHSA, London, UK
| | - Sema Mandal
- Blood Safety, Hepatitis, STI & HIV Division, UK Health Security Agency, London, UK
| | - Tassos Grammatikopoulos
- Paediatric Liver, GI & Nutrition Centre and Mowat Labs, King's College Hospital, London, UK
- Institute of Liver Studies, King's College London, London, UK
| | - Alicia Demirjian
- HCAI, Fungal, AMR, AMU & Sepsis Division, UKHSA, London, UK
- Department of Paediatric Infectious Diseases & Immunology, Evelina London Children's Hospital, London, UK
- Faculty of Life Sciences & Medicine, King's College London, London, UK
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Leslie T, Parry C, Ondoa P, Walsh T, Moore C, Poudyal N, Marks F, Gordon NC. The Reality of Antimicrobial Resistance and Antibiotic Usage Data in Asia: The CAPTURA Experience. Clin Infect Dis 2023; 77:S497-S499. [PMID: 38118008 PMCID: PMC10732558 DOI: 10.1093/cid/ciad580] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023] Open
Abstract
Antimicrobial resistance (AMR), particularly in low- and middle-income countries, is threatening to undermine advances in health and development. Scarce technical and human resources in these countries limit the collection of quality AMR data for evidence-based decision-making. The CAPTURA consortium, funded by the Fleming Fund, was implemented across 7 countries in the South and Southeast Asian region. The program focused on collating historical bacteriological data for qualitative and quantitative analyses. The team gathered standard data on the quality of laboratories and clinics and the quality and quantity of retrospective historical AMR data. In addition, retrospective data on antimicrobial use and consumption were analyzed. While standard protocols guided the project, a tailored approach for stakeholder engagement was implemented to work with countries and secure data-sharing agreements. The program also had to navigate the challenges of the COVID-19 pandemic, making some innovative adaptations to overcome logistical barriers. From 2018 through 2022, a large body of data was collected that was used to base a series of recommended key measures for strengthening the development of standardized national surveillance programs and to support alignment with international efforts.
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Affiliation(s)
- Toby Leslie
- Fleming Fund Management Agent, Mott MacDonald, London, United Kingdom
| | - Claudia Parry
- Fleming Fund Management Agent, Mott MacDonald, London, United Kingdom
| | - Pascale Ondoa
- African Society for Laboratory Medicine, Addis Ababa, Ethiopia
- Department of Global Health, University of Amsterdam, Amsterdam Institute for Global Health and Development, Amsterdam, The Netherlands
| | - Timothy Walsh
- Department of Biology, University of Oxford/Ineos Oxford Institute for Antimicrobial Research, Oxford, United Kingdom
| | - Catrin Moore
- Institute of Infection and Immunity at St George's, University of London, London, United Kingdom
| | - Nimesh Poudyal
- International Vaccine Institute, Seoul, Republic of Korea
| | - Florian Marks
- International Vaccine Institute, Seoul, Republic of Korea
- Cambridge Institute of Therapeutic Immunology and Infectious Disease, University of Cambridge School of Clinical Medicine, Cambridge, United Kingdom
- Heidelberg Institute of Global Health, University of Heidelberg, Heidelberg, Germany
- Madagascar Institute for Vaccine Research, University of Antananarivo, Antananarivo, Madagascar
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Callaby H, Gordon NC. Mpox: evidence for strengthening and sustaining global surveillance. Lancet Glob Health 2023; 11:e983-e984. [PMID: 37349040 DOI: 10.1016/s2214-109x(23)00241-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Accepted: 05/12/2023] [Indexed: 06/24/2023]
Affiliation(s)
- Helen Callaby
- NHS Grampian, Aberdeen Royal Infirmary, Aberdeen, UK; UK Health Security Agency Rare and Imported Pathogens Laboratory, Porton Down SP4 0JG, UK
| | - N Claire Gordon
- UK Health Security Agency Rare and Imported Pathogens Laboratory, Porton Down SP4 0JG, UK.
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Cole J, Choudry S, Kular S, Payne T, Akili S, Callaby H, Gordon NC, Ankcorn M, Martin A, Hobson E, Tunbridge AJ. Monkeypox encephalitis with transverse myelitis in a female patient. Lancet Infect Dis 2023; 23:e115-e120. [PMID: 36470282 PMCID: PMC9718539 DOI: 10.1016/s1473-3099(22)00741-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 10/26/2022] [Accepted: 10/29/2022] [Indexed: 12/05/2022]
Abstract
The 2022 monkeypox outbreak has affected 110 countries worldwide, outside of classic endemic areas (ie, west Africa and central Africa). On July 23, 2022, the outbreak was classified by WHO as a public health emergency of international concern. Clinical presentation varies from mild to life-changing symptoms; neurological complications are relatively uncommon and there are few therapeutic interventions for monkeypox disease. In this Grand Round, we present a case of monkeypox with encephalitis complicated by transverse myelitis in a previously healthy woman aged 35 years who made an almost complete recovery from her neurological symptoms after treatment with tecovirimat, cidofovir, steroids, and plasma exchange. We describe neurological complications associated with orthopoxvirus infections and laboratory diagnosis, the radiological features in this case, and discuss treatment options.
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Affiliation(s)
- Joby Cole
- Department of Infectious Diseases and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Infection, Immunity, and Cardiovascular Diseases, University of Sheffield, Sheffield, UK.
| | - Saher Choudry
- Department of Infectious Diseases and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Saminderjit Kular
- Department of Neuroradiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Thomas Payne
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Suha Akili
- Department of Infectious Diseases and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Virology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Helen Callaby
- Rare and Imported Pathogens Laboratory, UK Health Security Agency, Porton Down, UK
| | - N Claire Gordon
- Rare and Imported Pathogens Laboratory, UK Health Security Agency, Porton Down, UK
| | - Michael Ankcorn
- Department of Infectious Diseases and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Virology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Andrew Martin
- Department of Neuroradiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Esther Hobson
- Academic Department of Neurology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Anne J Tunbridge
- Department of Infectious Diseases and Tropical Medicine, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
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Gordon NC, Rampling T. The 2022 monkeypox outbreak: the need for clinical curiosity. Lancet Infect Dis 2023; 23:133-134. [PMID: 36216017 PMCID: PMC9546521 DOI: 10.1016/s1473-3099(22)00669-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 10/03/2022] [Indexed: 11/06/2022]
Affiliation(s)
- N Claire Gordon
- Rare and Imported Pathogens Laboratory, UK Health Security Agency, Porton Down SP4 0JG, UK.
| | - Tommy Rampling
- Rare and Imported Pathogens Laboratory, UK Health Security Agency, Porton Down SP4 0JG, UK
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Young BC, Wu CH, Charlesworth J, Earle S, Price JR, Gordon NC, Cole K, Dunn L, Liu E, Oakley S, Godwin H, Fung R, Miller R, Knox K, Votintseva A, Quan TP, Tilley R, Scarborough M, Crook DW, Peto TE, Walker AS, Llewelyn MJ, Wilson DJ. Antimicrobial resistance determinants are associated with Staphylococcus aureus bacteraemia and adaptation to the healthcare environment: a bacterial genome-wide association study. Microb Genom 2021; 7:000700. [PMID: 34812717 PMCID: PMC8743558 DOI: 10.1099/mgen.0.000700] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 09/30/2021] [Indexed: 12/30/2022] Open
Abstract
Staphylococcus aureus is a major bacterial pathogen in humans, and a dominant cause of severe bloodstream infections. Globally, antimicrobial resistance (AMR) in S. aureus remains challenging. While human risk factors for infection have been defined, contradictory evidence exists for the role of bacterial genomic variation in S. aureus disease. To investigate the contribution of bacterial lineage and genomic variation to the development of bloodstream infection, we undertook a genome-wide association study comparing bacteria from 1017 individuals with bacteraemia to 984 adults with asymptomatic S. aureus nasal carriage. Within 984 carriage isolates, we also compared healthcare-associated (HA) carriage with community-associated (CA) carriage. All major global lineages were represented in both bacteraemia and carriage, with no evidence for different infection rates. However, kmers tagging trimethoprim resistance-conferring mutation F99Y in dfrB were significantly associated with bacteraemia-vs-carriage (P=10-8.9-10-9.3). Pooling variation within genes, bacteraemia-vs-carriage was associated with the presence of mecA (HMP=10-5.3) as well as the presence of SCCmec (HMP=10-4.4). Among S. aureus carriers, no lineages were associated with HA-vs-CA carriage. However, we found a novel signal of HA-vs-CA carriage in the foldase protein prsA, where kmers representing conserved sequence allele were associated with CA carriage (P=10-7.1-10-19.4), while in gyrA, a ciprofloxacin resistance-conferring mutation, L84S, was associated with HA carriage (P=10-7.2). In an extensive study of S. aureus bacteraemia and nasal carriage in the UK, we found strong evidence that all S. aureus lineages are equally capable of causing bloodstream infection, and of being carried in the healthcare environment. Genomic variation in the foldase protein prsA is a novel genomic marker of healthcare origin in S. aureus but was not associated with bacteraemia. AMR determinants were associated with both bacteraemia and healthcare-associated carriage, suggesting that AMR increases the propensity not only to survive in healthcare environments, but also to cause invasive disease.
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Affiliation(s)
- Bernadette C. Young
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Chieh-Hsi Wu
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Jane Charlesworth
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sarah Earle
- Big Data Institute, Nuffield Department of Population Health, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
| | - James R. Price
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton BN2 5BE, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - N. Claire Gordon
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Kevin Cole
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton BN2 5BE, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - Laura Dunn
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Elian Liu
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Sarah Oakley
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Heather Godwin
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Rowena Fung
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Ruth Miller
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Kyle Knox
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Antonina Votintseva
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - T. Phuong Quan
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Robert Tilley
- Department of Microbiology, University Hospitals Plymouth NHS Trust, Derriford Hospital, Plymouth PL6 8DH, UK
| | - Matthew Scarborough
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
| | - Derrick W. Crook
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Timothy E. Peto
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - A. Sarah Walker
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, John Radcliffe Hospital, Oxford OX3 9DU, UK
- National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, UK
- NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, UK
| | - Martin J. Llewelyn
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton BN2 5BE, UK
- Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Falmer BN1 9PS, UK
| | - Daniel J. Wilson
- Big Data Institute, Nuffield Department of Population Health, Li Ka Shing Centre for Health Information and Discovery, University of Oxford, Old Road Campus, Oxford, OX3 7LF, UK
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Williams PCM, Waichungo J, Gordon NC, Sharland M, Murunga S, Kamau A, Berkley JA. The potential of fosfomycin for multi-drug resistant sepsis: an analysis of in vitro activity against invasive paediatric Gram-negative bacteria. J Med Microbiol 2019; 68:711-719. [PMID: 30994430 PMCID: PMC7116424 DOI: 10.1099/jmm.0.000973] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
PURPOSE Antimicrobial resistance (AMR) is of increasing global concern, threatening to undermine recent progress in reducing child and neonatal mortality. Repurposing older antimicrobials is a prominent strategy to combat multidrug-resistant sepsis. A potential agent is fosfomycin, however, there is scarce data regarding its in vitro activity and pharmacokinetics in the paediatric population. METHODOLOGY We analysed a contemporary, systematically collected archive of community-acquired (CA) and hospital-acquired (HA) paediatric Gram-negative bacteraemia isolates for their susceptibility to fosfomcyin. MICs were determined using agar serial dilution methods and validated by disk diffusion testing where breakpoints are available. Disk diffusion antimicrobial susceptibility testing was also conducted for current empirical therapies (ampicillin, gentamicin, ceftriaxone) and amikacin (proposed in the literature as a new combination empirical therapeutic option). RESULTS Fosfomycin was highly active against invasive Gram-negative isolates, including 90 % (202/224) of Enterobacteriaceae and 96 % (22/23) of Pseudomonas spp. Fosfomycin showed high sensitivity against both CA isolates (94 %, 142/151) and HA isolates (81 %, 78/96; P =0.0015). CA isolates were significantly more likely to be susceptible to fosfomycin than the current first-line empirical therapy (96 % vs 59 %, P <0.0001). Extended spectrum β-lactamases (ESBL) production was detected in 34 % (85/247) of isolates with no significant difference in fosfomycin susceptibility between ESBL-positive or -negative isolates [73/85 (86 %) vs 147/162 (91 %) respectively, P =0.245]. All isolates were susceptible to a fosfomycin-amikacin combination. CONCLUSION Gram-negative paediatric bacteraemia isolates are highly susceptible to fosfomycin, which could be combined with aminoglycosides as a new, carbapenem-sparing regimen to achieve excellent coverage to treat antimicrobial-resistant neonatal and paediatric sepsis.
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Affiliation(s)
| | - Joseph Waichungo
- The University of Oxford, Nuffield Department of Clinical Medicine, Oxford, UK
| | - N. Claire Gordon
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- London School of Hygiene and Tropical Medicine, London, UK
| | - Mike Sharland
- St Georges University Hospital, London, United Kingdom
| | | | - Alice Kamau
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
| | - James A. Berkley
- The University of Oxford, Nuffield Department of Clinical Medicine, Oxford, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
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Thwaites GE, Scarborough M, Szubert A, Saramago Goncalves P, Soares M, Bostock J, Nsutebu E, Tilley R, Cunningham R, Greig J, Wyllie SA, Wilson P, Auckland C, Cairns J, Ward D, Lal P, Guleri A, Jenkins N, Sutton J, Wiselka M, Armando GR, Graham C, Chadwick PR, Barlow G, Gordon NC, Young B, Meisner S, McWhinney P, Price DA, Harvey D, Nayar D, Jeyaratnam D, Planche T, Minton J, Hudson F, Hopkins S, Williams J, Török ME, Llewelyn MJ, Edgeworth JD, Walker AS. Adjunctive rifampicin to reduce early mortality from Staphylococcus aureus bacteraemia: the ARREST RCT. Health Technol Assess 2019; 22:1-148. [PMID: 30382016 DOI: 10.3310/hta22590] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Staphylococcus aureus bacteraemia is a common and frequently fatal infection. Adjunctive rifampicin may enhance early S. aureus killing, sterilise infected foci and blood faster, and thereby reduce the risk of dissemination, metastatic infection and death. OBJECTIVES To determine whether or not adjunctive rifampicin reduces bacteriological (microbiologically confirmed) failure/recurrence or death through 12 weeks from randomisation. Secondary objectives included evaluating the impact of rifampicin on all-cause mortality, clinically defined failure/recurrence or death, toxicity, resistance emergence, and duration of bacteraemia; and assessing the cost-effectiveness of rifampicin. DESIGN Parallel-group, randomised (1 : 1), blinded, placebo-controlled multicentre trial. SETTING UK NHS trust hospitals. PARTICIPANTS Adult inpatients (≥ 18 years) with meticillin-resistant or susceptible S. aureus grown from one or more blood cultures, who had received < 96 hours of antibiotic therapy for the current infection, and without contraindications to rifampicin. INTERVENTIONS Adjunctive rifampicin (600-900 mg/day, oral or intravenous) or placebo for 14 days in addition to standard antibiotic therapy. Investigators and patients were blinded to trial treatment. Follow-up was for 12 weeks (assessments at 3, 7, 10 and 14 days, weekly until discharge and final assessment at 12 weeks post randomisation). MAIN OUTCOME MEASURES The primary outcome was all-cause bacteriological (microbiologically confirmed) failure/recurrence or death through 12 weeks from randomisation. RESULTS Between December 2012 and October 2016, 758 eligible participants from 29 UK hospitals were randomised: 370 to rifampicin and 388 to placebo. The median age was 65 years [interquartile range (IQR) 50-76 years]. A total of 485 (64.0%) infections were community acquired and 132 (17.4%) were nosocomial; 47 (6.2%) were caused by meticillin-resistant S. aureus. A total of 301 (39.7%) participants had an initial deep infection focus. Standard antibiotics were given for a median of 29 days (IQR 18-45 days) and 619 (81.7%) participants received flucloxacillin. By 12 weeks, 62 out of 370 (16.8%) patients taking rifampicin versus 71 out of 388 (18.3%) participants taking the placebo experienced bacteriological (microbiologically confirmed) failure/recurrence or died [absolute risk difference -1.4%, 95% confidence interval (CI) -7.0% to 4.3%; hazard ratio 0.96, 95% CI 0.68 to 1.35; p = 0.81]. There were 4 (1.1%) and 5 (1.3%) bacteriological failures (p = 0.82) in the rifampicin and placebo groups, respectively. There were 3 (0.8%) versus 16 (4.1%) bacteriological recurrences (p = 0.01), and 55 (14.9%) versus 50 (12.9%) deaths without bacteriological failure/recurrence (p = 0.30) in the rifampicin and placebo groups, respectively. Over 12 weeks, there was no evidence of differences in clinically defined failure/recurrence/death (p = 0.84), all-cause mortality (p = 0.60), serious (p = 0.17) or grade 3/4 (p = 0.36) adverse events (AEs). However, 63 (17.0%) participants in the rifampicin group versus 39 (10.1%) participants in the placebo group experienced antibiotic or trial drug-modifying AEs (p = 0.004), and 24 (6.5%) participants in the rifampicin group versus 6 (1.5%) participants in the placebo group experienced drug-interactions (p = 0.0005). Evaluation of the costs and health-related quality-of-life impacts revealed that an episode of S. aureus bacteraemia costs an average of £12,197 over 12 weeks. Rifampicin was estimated to save 10% of episode costs (p = 0.14). After adjustment, the effect of rifampicin on total quality-adjusted life-years (QALYs) was positive (0.004 QALYs), but not statistically significant (standard error 0.004 QALYs). CONCLUSIONS Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S. aureus bacteraemia. FUTURE WORK Given the substantial mortality, other antibiotic combinations or improved source management should be investigated. TRIAL REGISTRATIONS Current Controlled Trials ISRCTN37666216, EudraCT 2012-000344-10 and Clinical Trials Authorisation 00316/0243/001. FUNDING This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 59. See the NIHR Journals Library website for further project information.
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Affiliation(s)
- Guy E Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam
| | | | - Alexander Szubert
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Marta Soares
- Centre for Health Economics, University of York, York, UK
| | - Jennifer Bostock
- Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
| | - Emmanuel Nsutebu
- Tropical and Infectious Diseases Unit, Royal Liverpool University Hospital, Liverpool, UK
| | - Robert Tilley
- Department of Microbiology, Plymouth Hospitals NHS Trust, Plymouth, UK
| | | | - Julia Greig
- Department of Infectious Diseases, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | - Sarah A Wyllie
- Microbiology Department, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Peter Wilson
- Centre for Clinical Microbiology, University College London Hospital NHS Foundation Trust, London, UK
| | - Cressida Auckland
- Microbiology Department, Royal Devon and Exeter NHS Foundation Trust, Exeter, UK
| | - Janet Cairns
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Denise Ward
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Pankaj Lal
- Microbiology Department, Aintree University Hospital NHS Foundation Trust, Liverpool, UK
| | - Achyut Guleri
- Microbiology Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Neil Jenkins
- Department of Infectious Diseases and Tropical Medicine, Heart of England NHS Foundation Trust, Birmingham, UK
| | - Julian Sutton
- Department of Microbiology and Virology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martin Wiselka
- Department of Infection and Tropical Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Clive Graham
- Microbiology Department, North Cumbria University Hospitals NHS Trust, Cumbria, UK
| | - Paul R Chadwick
- Microbiology Department, Salford Royal NHS Foundation Trust, Salford, UK
| | - Gavin Barlow
- Department of Infection, Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - N Claire Gordon
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Bernadette Young
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Meisner
- Microbiology Department, Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Paul McWhinney
- Microbiology Department, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - David A Price
- Department of Infectious Diseases, Newcastle Upon Tyne Hospital NHS Foundation Trust, Newcastle, UK
| | - David Harvey
- Microbiology Department, Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - Deepa Nayar
- Microbiology Department, County Durham and Darlington NHS Foundation Trust, Durham, UK
| | - Dakshika Jeyaratnam
- Department of Microbiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Timothy Planche
- Department of Infectious Diseases and Tropical Medicine, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Jane Minton
- Department of Infectious Diseases, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Fleur Hudson
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Susan Hopkins
- Infectious Diseases Unit, Royal Free London NHS Foundation Trust, London, UK
| | - John Williams
- Department of Infectious Diseases, South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - M Estee Török
- Department of Medicine, University of Cambridge, Cambridge, UK
| | - Martin J Llewelyn
- Department of Infectious Diseases, Brighton and Sussex Medical School, Brighton, UK
| | - Jonathan D Edgeworth
- Department of Immunology, Infectious and Inflammatory diseases, King's College London, London, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK.,Medical Research Council Clinical Trials Unit, University College London, London, UK
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9
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Nambiar K, Seifert H, Rieg S, Kern WV, Scarborough M, Gordon NC, Kim HB, Song KH, Tilley R, Gott H, Liao CH, Edgeworth J, Nsutebu E, López-Cortés LE, Morata L, Walker AS, Thwaites G, Llewelyn MJ, Kaasch AJ. Survival following Staphylococcus aureus bloodstream infection: A prospective multinational cohort study assessing the impact of place of care. J Infect 2018; 77:516-525. [PMID: 30179645 DOI: 10.1016/j.jinf.2018.08.015] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2018] [Accepted: 08/25/2018] [Indexed: 11/19/2022]
Abstract
BACKGROUND Staphylococcus aureus bloodstream infection (SAB) is a common, life-threatening infection with a high mortality. Survival can be improved by implementing quality of care bundles in hospitals. We previously observed marked differences in mortality between hospitals and now assessed whether mortality could serve as a valid and easy to implement quality of care outcome measure. METHODS We conducted a prospective observational study between January 2013 and April 2015 on consecutive, adult patients with SAB from 11 tertiary care centers in Germany, South Korea, Spain, Taiwan, and the United Kingdom. Factors associated with mortality at 90 days were analyzed by Cox proportional hazards regression and flexible parametric models. RESULTS 1851 patients with a median age of 66 years (64% male) were analyzed. Crude 90-day mortality differed significantly between hospitals (range 23-39%). Significant variation between centers was observed for methicillin-resistant S. aureus, community-acquisition, infective foci, as well as measures of comorbidities, and severity of disease. In multivariable analysis, factors independently associated with mortality at 90 days were age, nosocomial acquisition, unknown infective focus, pneumonia, Charlson comorbidity index, SOFA score, and study center. The risk of death varied over time differently for each infective focus. Crude mortality differed markedly from adjusted mortality. DISCUSSION We observed significant differences in adjusted mortality between hospitals, suggesting differences in quality of care. However, mortality is strongly influenced by patient mix and thus, crude mortality is not a suitable quality indicator.
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Affiliation(s)
- Kate Nambiar
- Department of Microbiology and Infectious Diseases, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Harald Seifert
- Institute for Medical Microbiology, Immunology and Hygiene, Faculty of Medicine, University of Cologne, Goldenfelsstr. 19, 50935 Cologne, Germany; German Center for Infection Research (DZIF), partner site Bonn-Cologne, Germany
| | - Siegbert Rieg
- Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg 79106, Freiburg, Germany
| | - Winfried V Kern
- Division of Infectious Diseases, Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg 79106, Freiburg, Germany
| | - Matt Scarborough
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Headington, Oxford, OX3 9DU, United Kingdom
| | - N Claire Gordon
- Nuffield Department of Medicine, Oxford University Hospitals NHS Foundation, Headington, Oxford, OX3 9DU, United Kingdom
| | - Hong Bin Kim
- Department of Internal Medicine, Seoul National University College of Medicine and Division of Infectious Diseases, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Republic of Korea
| | - Kyoung-Ho Song
- Department of Internal Medicine, Seoul National University College of Medicine and Division of Infectious Diseases, Seoul National University Bundang Hospital, 173-82 Gumi-ro, Bundang-gu, Seongnam, Gyeonggi-do, 13620, Republic of Korea
| | - Robert Tilley
- Department of Microbiology, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Crownhill, Plymouth, PL6 8DH, United Kingdom
| | - Hannah Gott
- Department of Research and Development, Plymouth Hospitals NHS Trust, Derriford Hospital, Derriford Road, Crownhill, Plymouth, PL6 8DH, United Kingdom
| | - Chun-Hsing Liao
- Infectious Diseases, Department of Internal Medicine, Far Eastern Memorial Hospital, No. 21, Section 2, Nanya South Road, Banchio District, New Taipei City 220, Taiwan; Department of Medicine, Yang-Ming University, No. 155, Section 2, Linong Street, Taipei 112, Taiwan
| | - Jonathan Edgeworth
- Centre for Clinical Infection and Diagnostics Research, Department of Infectious Diseases, Kings College London, Guy's and St. Thomas' Hospitals NHS Foundation Trust, St Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom
| | - Emmanuel Nsutebu
- Tropical & Infectious Disease Unit, Royal Liverpool and Broadgreen University Teaching Hospital, Prescot Street, Liverpool, L7 8XP, United Kingdom
| | - Luis Eduardo López-Cortés
- Unidad Clínica de Enfermedades Infecciosas, Microbiología y Medicina Preventiva, Hospital Universitario Virgen Macarena /CSIC / Instituto de Biomedicina de Sevilla (IBiS), Avda Dr Fedriani, s/n. 41003 Seville, Spain
| | - Laura Morata
- Service of Infectious Diseases, Hospital Clínic of Barcelona, Barcelona, Spain
| | - A Sarah Walker
- Medical Research Council Clinical Trials Unit at University College London, University College London, United Kingdom; Nuffield Department of Medicine, University of Oxford, Level 7 Microbiology, John Radcliffe Hospital, Headley Way, Oxford, OX3 9DU, United Kingdom
| | - Guy Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, United Kingdom
| | - Martin J Llewelyn
- Department of Microbiology and Infectious Diseases, Brighton and Sussex University Hospitals NHS Trust, Royal Sussex County Hospital, Eastern Road, Brighton, BN2 5BE, United Kingdom
| | - Achim J Kaasch
- Institute of Medical Microbiology and Hospital Hygiene, Faculty of Medicine, Heinrich-Heine-University Düsseldorf, Universitätsstraße 1, 40225 Düsseldorf, Germany.
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10
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Thwaites GE, Scarborough M, Szubert A, Nsutebu E, Tilley R, Greig J, Wyllie SA, Wilson P, Auckland C, Cairns J, Ward D, Lal P, Guleri A, Jenkins N, Sutton J, Wiselka M, Armando GR, Graham C, Chadwick PR, Barlow G, Gordon NC, Young B, Meisner S, McWhinney P, Price DA, Harvey D, Nayar D, Jeyaratnam D, Planche T, Minton J, Hudson F, Hopkins S, Williams J, Török ME, Llewelyn MJ, Edgeworth JD, Walker AS. Adjunctive rifampicin for Staphylococcus aureus bacteraemia (ARREST): a multicentre, randomised, double-blind, placebo-controlled trial. Lancet 2018; 391:668-678. [PMID: 29249276 PMCID: PMC5820409 DOI: 10.1016/s0140-6736(17)32456-x] [Citation(s) in RCA: 114] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 08/27/2017] [Accepted: 08/30/2017] [Indexed: 02/05/2023]
Abstract
BACKGROUND Staphylococcus aureus bacteraemia is a common cause of severe community-acquired and hospital-acquired infection worldwide. We tested the hypothesis that adjunctive rifampicin would reduce bacteriologically confirmed treatment failure or disease recurrence, or death, by enhancing early S aureus killing, sterilising infected foci and blood faster, and reducing risks of dissemination and metastatic infection. METHODS In this multicentre, randomised, double-blind, placebo-controlled trial, adults (≥18 years) with S aureus bacteraemia who had received ≤96 h of active antibiotic therapy were recruited from 29 UK hospitals. Patients were randomly assigned (1:1) via a computer-generated sequential randomisation list to receive 2 weeks of adjunctive rifampicin (600 mg or 900 mg per day according to weight, oral or intravenous) versus identical placebo, together with standard antibiotic therapy. Randomisation was stratified by centre. Patients, investigators, and those caring for the patients were masked to group allocation. The primary outcome was time to bacteriologically confirmed treatment failure or disease recurrence, or death (all-cause), from randomisation to 12 weeks, adjudicated by an independent review committee masked to the treatment. Analysis was intention to treat. This trial was registered, number ISRCTN37666216, and is closed to new participants. FINDINGS Between Dec 10, 2012, and Oct 25, 2016, 758 eligible participants were randomly assigned: 370 to rifampicin and 388 to placebo. 485 (64%) participants had community-acquired S aureus infections, and 132 (17%) had nosocomial S aureus infections. 47 (6%) had meticillin-resistant infections. 301 (40%) participants had an initial deep infection focus. Standard antibiotics were given for 29 (IQR 18-45) days; 619 (82%) participants received flucloxacillin. By week 12, 62 (17%) of participants who received rifampicin versus 71 (18%) who received placebo experienced treatment failure or disease recurrence, or died (absolute risk difference -1·4%, 95% CI -7·0 to 4·3; hazard ratio 0·96, 0·68-1·35, p=0·81). From randomisation to 12 weeks, no evidence of differences in serious (p=0·17) or grade 3-4 (p=0·36) adverse events were observed; however, 63 (17%) participants in the rifampicin group versus 39 (10%) in the placebo group had antibiotic or trial drug-modifying adverse events (p=0·004), and 24 (6%) versus six (2%) had drug interactions (p=0·0005). INTERPRETATION Adjunctive rifampicin provided no overall benefit over standard antibiotic therapy in adults with S aureus bacteraemia. FUNDING UK National Institute for Health Research Health Technology Assessment.
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Affiliation(s)
- Guy E Thwaites
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Oxford University Clinical Research Unit, Ho Chi Minh City, Vietnam.
| | | | - Alexander Szubert
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - Robert Tilley
- Plymouth Hospitals National Health Service (NHS) Trust, Plymouth, UK
| | - Julia Greig
- Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
| | | | - Peter Wilson
- University College London Hospital National Health Service Foundation Trust, London, UK
| | | | - Janet Cairns
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Denise Ward
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | - Pankaj Lal
- Aintree University Hospital NHS Foundation Trust, Aintree, UK
| | - Achyut Guleri
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Neil Jenkins
- Heart of England NHS Foundation Trust, Birmingham, UK
| | - Julian Sutton
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Martin Wiselka
- Department of Infection and Tropical Medicine, University Hospitals of Leicester NHS Trust, Leicester, UK
| | | | - Clive Graham
- North Cumbria University Hospitals NHS Trust, Carlisle, UK
| | | | - Gavin Barlow
- Hull and East Yorkshire Hospitals NHS Trust, Hull, UK
| | - N Claire Gordon
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Bernadette Young
- Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Sarah Meisner
- Royal United Hospitals Bath NHS Foundation Trust, Bath, UK
| | - Paul McWhinney
- Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - David A Price
- Newcastle upon Tyne Hospital NHS Foundation Trust, Newcastle, UK
| | - David Harvey
- Wirral University Teaching Hospital NHS Foundation Trust, Birkenhead, UK
| | - Deepa Nayar
- County Durham and Darlington NHS Foundation Trust, Durham, UK
| | | | - Tim Planche
- St Georges University Hospitals NHS Foundation Trust, London, UK
| | - Jane Minton
- Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Fleur Hudson
- Medical Research Council Clinical Trials Unit, University College London, London, UK
| | | | - John Williams
- South Tees Hospitals NHS Foundation Trust, Middlesbrough, UK
| | - M Estee Török
- University of Cambridge, Department of Medicine, Cambridge, UK
| | | | | | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford, UK; Medical Research Council Clinical Trials Unit, University College London, London, UK
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11
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Fowler PW, Cole K, Gordon NC, Kearns AM, Llewelyn MJ, Peto TEA, Crook DW, Walker AS. Robust Prediction of Resistance to Trimethoprim in Staphylococcus aureus. Cell Chem Biol 2018; 25:339-349.e4. [PMID: 29307840 DOI: 10.1016/j.chembiol.2017.12.009] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2017] [Revised: 10/24/2017] [Accepted: 12/08/2017] [Indexed: 01/28/2023]
Abstract
The rise of antibiotic resistance threatens modern medicine; to combat it new diagnostic methods are required. Sequencing the whole genome of a pathogen offers the potential to accurately determine which antibiotics will be effective to treat a patient. A key limitation of this approach is that it cannot classify rare or previously unseen mutations. Here we demonstrate that alchemical free energy methods, a well-established class of methods from computational chemistry, can successfully predict whether mutations in Staphylococcus aureus dihydrofolate reductase confer resistance to trimethoprim. We also show that the method is quantitatively accurate by calculating how much the most common resistance-conferring mutation, F99Y, reduces the binding free energy of trimethoprim and comparing predicted and experimentally measured minimum inhibitory concentrations for seven different mutations. Finally, by considering up to 32 free energy calculations for each mutation, we estimate its specificity and sensitivity.
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Affiliation(s)
- Philip W Fowler
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Headley Way, Oxford OX3 9DU, UK.
| | - Kevin Cole
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, Brighton and Sussex Medical School, Brighton BN1 9PS, UK
| | - N Claire Gordon
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Headley Way, Oxford OX3 9DU, UK
| | - Angela M Kearns
- Antimicrobial Resistance and Healthcare Associated Infections Reference Unit, Public Health England, Colindale NW9 5EQ, UK
| | - Martin J Llewelyn
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, Brighton and Sussex Medical School, Brighton BN1 9PS, UK
| | - Tim E A Peto
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Headley Way, Oxford OX3 9DU, UK
| | - Derrick W Crook
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Headley Way, Oxford OX3 9DU, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, John Radcliffe Hospital, University of Oxford, Headley Way, Oxford OX3 9DU, UK
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12
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Young BC, Wu CH, Gordon NC, Cole K, Price JR, Liu E, Sheppard AE, Perera S, Charlesworth J, Golubchik T, Iqbal Z, Bowden R, Massey RC, Paul J, Crook DW, Peto TE, Walker AS, Llewelyn MJ, Wyllie DH, Wilson DJ. Severe infections emerge from commensal bacteria by adaptive evolution. eLife 2017; 6. [PMID: 29256859 PMCID: PMC5736351 DOI: 10.7554/elife.30637] [Citation(s) in RCA: 71] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2017] [Accepted: 12/02/2017] [Indexed: 12/23/2022] Open
Abstract
Bacteria responsible for the greatest global mortality colonize the human microbiota far more frequently than they cause severe infections. Whether mutation and selection among commensal bacteria are associated with infection is unknown. We investigated de novo mutation in 1163 Staphylococcus aureus genomes from 105 infected patients with nose colonization. We report that 72% of infections emerged from the nose, with infecting and nose-colonizing bacteria showing parallel adaptive differences. We found 2.8-to-3.6-fold adaptive enrichments of protein-altering variants in genes responding to rsp, which regulates surface antigens and toxin production; agr, which regulates quorum-sensing, toxin production and abscess formation; and host-derived antimicrobial peptides. Adaptive mutations in pathogenesis-associated genes were 3.1-fold enriched in infecting but not nose-colonizing bacteria. None of these signatures were observed in healthy carriers nor at the species-level, suggesting infection-associated, short-term, within-host selection pressures. Our results show that signatures of spontaneous adaptive evolution are specifically associated with infection, raising new possibilities for diagnosis and treatment.
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Affiliation(s)
- Bernadette C Young
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Chieh-Hsi Wu
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom
| | - N Claire Gordon
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom
| | - Kevin Cole
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, United Kingdom
| | - James R Price
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, United Kingdom.,Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - Elian Liu
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Anna E Sheppard
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,NIHR Health Protection Unit in Healthcare Associated Infections and Antimicrobial Resistance at University of Oxford in partnership with Public Health England, Oxford, United Kingdom
| | - Sanuki Perera
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,Microbiology and Infectious Diseases Department, Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Jane Charlesworth
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom
| | - Tanya Golubchik
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom
| | - Zamin Iqbal
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Rory Bowden
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom
| | - Ruth C Massey
- School of Cellular and Molecular Medicine, University of Bristol, Bristol, United Kingdom
| | - John Paul
- National Infection Service, Public Health England, London, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Derrick W Crook
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,National Infection Service, Public Health England, London, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Timothy E Peto
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - A Sarah Walker
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,National Institute for Health Research, Oxford Biomedical Research Centre, Oxford, United Kingdom
| | - Martin J Llewelyn
- Department of Infectious Diseases and Microbiology, Royal Sussex County Hospital, Brighton, United Kingdom.,Department of Global Health and Infection, Brighton and Sussex Medical School, University of Sussex, Brighton, United Kingdom
| | - David H Wyllie
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,Centre for Molecular and Cellular Physiology, Jenner Institute, Oxford, United Kingdom
| | - Daniel J Wilson
- Nuffield Department of Medicine, Experimental Medicine Division, University of Oxford, Oxford, United Kingdom.,Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford, United Kingdom.,Institute for Emerging Infections, Oxford Martin School, University of Oxford, Oxford, United Kingdom
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13
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Seale AC, Gordon NC, Islam J, Peacock SJ, Scott JAG. AMR Surveillance in low and middle-income settings - A roadmap for participation in the Global Antimicrobial Surveillance System (GLASS). Wellcome Open Res 2017; 2:92. [PMID: 29062918 PMCID: PMC5645727 DOI: 10.12688/wellcomeopenres.12527.1] [Citation(s) in RCA: 91] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/17/2017] [Indexed: 11/20/2022] Open
Abstract
Drug-resistant infections caused by bacteria with increasing antimicrobial resistance (AMR) threaten our ability to treat life-threatening conditions. Tackling AMR requires international collaboration and partnership. An early and leading priority to do this is to strengthen AMR surveillance, particularly in low-income countries where the burden of infectious diseases is highest and where data are most limited. The World Health Organization (WHO) has developed the Global AMR Surveillance System (GLASS) as one of a number of measures designed to tackle the problem of AMR, and WHO member states have been encouraged to produce National Action Plans for AMR by 2017. However, low-income countries are unlikely to have the resources or capacity to implement all the components in the GLASS manual. To facilitate their efforts, we developed a guideline that is aligned to the GLASS procedures, but written specifically for implementation in low-income countries. The guideline allows for flexibility across different systems, but has sufficient standardisation of core protocols to ensure that, if followed, data will be valid and comparable. This will ensure that the surveillance programme can provide health intelligence data to inform evidence-based interventions at local, national and international levels.
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Affiliation(s)
- Anna C. Seale
- College of Health and Medical Sciences, Haramaya University, Harar, Ethiopia
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - N. Claire Gordon
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
| | - Jasmin Islam
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Sharon J. Peacock
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- Department of Medicine, University of Cambridge, Cambridge, CB2 0QQ, UK
- Wellcome Trust Sanger Institute, Cambridge, CB10 1SA, UK
| | - J. Anthony G. Scott
- London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
- KEMRI-Wellcome Trust Research Programme, Kilifi, Kenya
- Nuffield Department of Medicine, University of Oxford, Oxford, OX3 7BN, UK
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14
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Bradley P, Gordon NC, Walker TM, Dunn L, Heys S, Huang B, Earle S, Pankhurst LJ, Anson L, de Cesare M, Piazza P, Votintseva AA, Golubchik T, Wilson DJ, Wyllie DH, Diel R, Niemann S, Feuerriegel S, Kohl TA, Ismail N, Omar SV, Smith EG, Buck D, McVean G, Walker AS, Peto TEA, Crook DW, Iqbal Z. Corrigendum: Rapid antibiotic-resistance predictions from genome sequence data for Staphylococcus aureus and Mycobacterium tuberculosis. Nat Commun 2016; 7:11465. [PMID: 27095245 PMCID: PMC4843104 DOI: 10.1038/ncomms11465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
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15
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Bradley P, Gordon NC, Walker TM, Dunn L, Heys S, Huang B, Earle S, Pankhurst LJ, Anson L, de Cesare M, Piazza P, Votintseva AA, Golubchik T, Wilson DJ, Wyllie DH, Diel R, Niemann S, Feuerriegel S, Kohl TA, Ismail N, Omar SV, Smith EG, Buck D, McVean G, Walker AS, Peto TEA, Crook DW, Iqbal Z. Rapid antibiotic-resistance predictions from genome sequence data for Staphylococcus aureus and Mycobacterium tuberculosis. Nat Commun 2015; 6:10063. [PMID: 26686880 PMCID: PMC4703848 DOI: 10.1038/ncomms10063] [Citation(s) in RCA: 353] [Impact Index Per Article: 39.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2015] [Accepted: 10/28/2015] [Indexed: 01/14/2023] Open
Abstract
The rise of antibiotic-resistant bacteria has led to an urgent need for rapid detection of drug resistance in clinical samples, and improvements in global surveillance. Here we show how de Bruijn graph representation of bacterial diversity can be used to identify species and resistance profiles of clinical isolates. We implement this method for Staphylococcus aureus and Mycobacterium tuberculosis in a software package ('Mykrobe predictor') that takes raw sequence data as input, and generates a clinician-friendly report within 3 minutes on a laptop. For S. aureus, the error rates of our method are comparable to gold-standard phenotypic methods, with sensitivity/specificity of 99.1%/99.6% across 12 antibiotics (using an independent validation set, n=470). For M. tuberculosis, our method predicts resistance with sensitivity/specificity of 82.6%/98.5% (independent validation set, n=1,609); sensitivity is lower here, probably because of limited understanding of the underlying genetic mechanisms. We give evidence that minor alleles improve detection of extremely drug-resistant strains, and demonstrate feasibility of the use of emerging single-molecule nanopore sequencing techniques for these purposes.
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Affiliation(s)
- Phelim Bradley
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - N Claire Gordon
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - Timothy M Walker
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - Laura Dunn
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - Simon Heys
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Bill Huang
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Sarah Earle
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - Louise J Pankhurst
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - Luke Anson
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | | | - Paolo Piazza
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | | | - Tanya Golubchik
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - Daniel J Wilson
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK.,Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - David H Wyllie
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK
| | - Roland Diel
- Institute for Epidemiology, University Medical Hospital Schleswig-Holstein, Niemannsweg 11, 24105 Kiel, Germany
| | - Stefan Niemann
- Molecular and Experimental Mycobacteriology, Research Centre Borstel, Parkallee 1, 23845 Borstel, Germany.,German Centre for Infection Research, Partner Site Borstel, Parkallee 1, 23845 Borstel, Germany
| | - Silke Feuerriegel
- Molecular and Experimental Mycobacteriology, Research Centre Borstel, Parkallee 1, 23845 Borstel, Germany.,German Centre for Infection Research, Partner Site Borstel, Parkallee 1, 23845 Borstel, Germany
| | - Thomas A Kohl
- Molecular and Experimental Mycobacteriology, Research Centre Borstel, Parkallee 1, 23845 Borstel, Germany
| | - Nazir Ismail
- Centre for Tuberculosis, National Institute for Communicable Diseases, Private Bag X4 Sandringham, Johannesburg 2131, South Africa.,Department of Medical Microbiology, University of Pretoria, PO Box 667, Pretoria 0001, South Africa
| | - Shaheed V Omar
- Centre for Tuberculosis, National Institute for Communicable Diseases, Private Bag X4 Sandringham, Johannesburg 2131, South Africa
| | - E Grace Smith
- Regional Centre for Mycobacteriology, PHE Public Health Laboratory Birmingham. Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK
| | - David Buck
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - Gil McVean
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
| | - A Sarah Walker
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK.,Biomedical Research Centre, NIHR (National Institutes of Health Research) Oxford Biomedical Research Centre, Oxford OX3 7LE, UK
| | - Tim E A Peto
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK.,Biomedical Research Centre, NIHR (National Institutes of Health Research) Oxford Biomedical Research Centre, Oxford OX3 7LE, UK
| | - Derrick W Crook
- Nuffield Department of Medicine, University of Oxford, Oxford OX1 1NF, UK.,Biomedical Research Centre, NIHR (National Institutes of Health Research) Oxford Biomedical Research Centre, Oxford OX3 7LE, UK.,National Infection Service, Public Health England, Wellington House, 133-155 Waterloo Road, London SE1 8UG, UK
| | - Zamin Iqbal
- Wellcome Trust Centre for Human Genetics, University of Oxford, Oxford OX3 7BN, UK
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Moore G, Cookson B, Gordon NC, Jackson R, Kearns A, Singleton J, Smyth D, Wilson APR. Whole-genome sequencing in hierarchy with pulsed-field gel electrophoresis: the utility of this approach to establish possible sources of MRSA cross-transmission. J Hosp Infect 2015; 90:38-45. [PMID: 25648940 DOI: 10.1016/j.jhin.2014.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2014] [Accepted: 12/18/2014] [Indexed: 10/24/2022]
Abstract
BACKGROUND In order to study the micro-epidemiology of meticillin-resistant Staphylococcus aureus (MRSA) effectively, the molecular typing method used must be able to distinguish between different MRSA strains. Pulsed-field gel electrophoresis (PFGE) can detect small genetic differences but is limited in its potential to distinguish isolates within a major lineage. Whole-genome sequencing (WGS) provides sufficient resolution to support or exclude links between otherwise indistinguishable isolates, but lacks the practical utility of conventional typing methods. AIM To explore the utility of WGS in a hierarchical approach with PFGE to help establish possible sources of MRSA cross-transmission in the intensive care setting. METHODS Possible transmission routes from donor to recipient via the hands of staff, the air or environmental surfaces were identified. Focused molecular typing used PFGE to explore these transmission hypotheses. WGS was applied when an acquisition event involved a common PFGE pulsotype. FINDINGS Thirty-eight of the 78 acquisition events could not be explored as clinical isolates were not available. PFGE excluded all potential donors from 26 of the remaining 40 acquisition events, but did identify a probable source in 14 new colonizations. Within the hypotheses tested, PFGE supported links between patients occupying the same bay, the same bed space, adjacent isolation rooms and different wards. When a patient source was not identified, PFGE implicated the ward environment and the hands of staff. However, WGS disproved three of these transmission pathways. CONCLUSION WGS can complement conventional typing methods by confirming or refuting possible MRSA transmission hypotheses. Epidemiological data are crucial in this process.
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Affiliation(s)
- G Moore
- Clinical Microbiology and Virology, University College London Hospitals NHS Foundation Trust, London, UK; Biosafety Investigation Unit, Public Health England, Porton Down, Salisbury, UK.
| | - B Cookson
- Staphylococcus Reference Unit, Antimicrobial Resistance and Healthcare Associated Infections, Public Health England Colindale, London, UK; Division of Infection and Immunity, University College London, London, UK
| | - N C Gordon
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - R Jackson
- Clinical Microbiology and Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - A Kearns
- Staphylococcus Reference Unit, Antimicrobial Resistance and Healthcare Associated Infections, Public Health England Colindale, London, UK
| | - J Singleton
- Department of Intensive Care, Royal Free Hampstead NHS Trust, London, UK
| | - D Smyth
- Clinical Microbiology and Virology, University College London Hospitals NHS Foundation Trust, London, UK
| | - A P R Wilson
- Clinical Microbiology and Virology, University College London Hospitals NHS Foundation Trust, London, UK
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17
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Price J, Claire Gordon N, Crook D, Llewelyn M, Paul J. The usefulness of whole genome sequencing in the management of Staphylococcus aureus infections. Clin Microbiol Infect 2013; 19:784-9. [DOI: 10.1111/1469-0691.12109] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Revised: 11/14/2012] [Accepted: 11/18/2012] [Indexed: 01/23/2023]
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Eyre DW, Golubchik T, Gordon NC, Bowden R, Piazza P, Batty EM, Ip CLC, Wilson DJ, Didelot X, O'Connor L, Lay R, Buck D, Kearns AM, Shaw A, Paul J, Wilcox MH, Donnelly PJ, Peto TEA, Walker AS, Crook DW. A pilot study of rapid benchtop sequencing of Staphylococcus aureus and Clostridium difficile for outbreak detection and surveillance. BMJ Open 2012; 2:e001124. [PMID: 22674929 PMCID: PMC3378946 DOI: 10.1136/bmjopen-2012-001124] [Citation(s) in RCA: 196] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2012] [Accepted: 05/09/2012] [Indexed: 01/22/2023] Open
Abstract
OBJECTIVES To investigate the prospects of newly available benchtop sequencers to provide rapid whole-genome data in routine clinical practice. Next-generation sequencing has the potential to resolve uncertainties surrounding the route and timing of person-to-person transmission of healthcare-associated infection, which has been a major impediment to optimal management. DESIGN The authors used Illumina MiSeq benchtop sequencing to undertake case studies investigating potential outbreaks of methicillin-resistant Staphylococcus aureus (MRSA) and Clostridium difficile. SETTING Isolates were obtained from potential outbreaks associated with three UK hospitals. PARTICIPANTS Isolates were sequenced from a cluster of eight MRSA carriers and an associated bacteraemia case in an intensive care unit, another MRSA cluster of six cases and two clusters of C difficile. Additionally, all C difficile isolates from cases over 6 weeks in a single hospital were rapidly sequenced and compared with local strain sequences obtained in the preceding 3 years. MAIN OUTCOME MEASURE Whole-genome genetic relatedness of the isolates within each epidemiological cluster. RESULTS Twenty-six MRSA and 15 C difficile isolates were successfully sequenced and analysed within 5 days of culture. Both MRSA clusters were identified as outbreaks, with most sequences in each cluster indistinguishable and all within three single nucleotide variants (SNVs). Epidemiologically unrelated isolates of the same spa-type were genetically distinct (≥21 SNVs). In both C difficile clusters, closely epidemiologically linked cases (in one case sharing the same strain type) were shown to be genetically distinct (≥144 SNVs). A reconstruction applying rapid sequencing in C difficile surveillance provided early outbreak detection and identified previously undetected probable community transmission. CONCLUSIONS This benchtop sequencing technology is widely generalisable to human bacterial pathogens. The findings provide several good examples of how rapid and precise sequencing could transform identification of transmission of healthcare-associated infection and therefore improve hospital infection control and patient outcomes in routine clinical practice.
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Affiliation(s)
- David W Eyre
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Tanya Golubchik
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Statistics, University of Oxford, Oxford, UK
| | - N Claire Gordon
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
| | - Rory Bowden
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Statistics, University of Oxford, Oxford, UK
- Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Paolo Piazza
- Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Elizabeth M Batty
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Statistics, University of Oxford, Oxford, UK
| | - Camilla L C Ip
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Statistics, University of Oxford, Oxford, UK
| | - Daniel J Wilson
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Xavier Didelot
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Statistics, University of Oxford, Oxford, UK
| | - Lily O'Connor
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Trust, Oxford, UK
| | - Rochelle Lay
- Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Trust, Oxford, UK
| | - David Buck
- Wellcome Trust Centre for Human Genetics, Oxford, UK
| | - Angela M Kearns
- Staphylococcus Reference Unit, Centre for Infections, Health Protection Agency, London, UK
| | - Angela Shaw
- Department of Microbiology, Ashford and St. Peter's Hospitals, NHS Foundation Trust, Surrey, UK
| | - John Paul
- Health Protection Agency, Royal Sussex County Hospital, Brighton, UK
| | - Mark H Wilcox
- Department of Microbiology, Leeds General Infirmary Old Medical School, Leeds Teaching Hospitals and University of Leeds, Leeds, UK
| | | | - Tim E A Peto
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Trust, Oxford, UK
| | - A Sarah Walker
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Medical Research Council, Clinical Trials Unit, London, UK
| | - Derrick W Crook
- Nuffield Department of Clinical Medicine, University of Oxford, John Radcliffe Hospital, Oxford, UK
- NIHR Oxford Biomedical Research Centre, John Radcliffe Hospital, Oxford, UK
- Department of Microbiology and Infectious Diseases, Oxford University Hospitals NHS Trust, Oxford, UK
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Wareham DW, Gordon NC, Hornsey M. In vitro activity of teicoplanin combined with colistin versus multidrug-resistant strains of Acinetobacter baumannii. J Antimicrob Chemother 2011; 66:1047-51. [PMID: 21393131 DOI: 10.1093/jac/dkr069] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Antimicrobial treatment of multidrug-resistant Acinetobacter baumannii (MDRAB) remains an important therapeutic challenge. With isolates resistant to all conventional agents now reported, clinicians are increasingly forced to turn to unorthodox combination treatments in the hope that these may be efficacious. Although a potent interaction between vancomycin and colistin has been demonstrated, there are concerns regarding the inherent toxicity of combining these agents in clinical practice. As teicoplanin has less nephrotoxic potential than vancomycin, we assessed whether a colistin/teicoplanin combination would have similar antimicrobial activities in vitro. METHODS The antimicrobial activity of colistin alone and in combination with teicoplanin was assessed versus a collection of MDRAB belonging to a number of epidemic lineages present in the UK. Synergy studies were undertaken using microtitre plate chequerboard assays, an Etest agar dilution method and standard time-kill methodology. RESULTS The combination of teicoplanin and colistin was bactericidal versus all of the strains tested. In chequerboard assays, fractional inhibitory concentration indices of <0.5 were obtained, consistent with significant in vitro synergy. Using the Etest method the MIC of teicoplanin fell from >256 mg/L to ≤2 mg/L in the presence of subinhibitory concentrations of colistin. CONCLUSIONS Significant synergy was observed when colistin was combined with teicoplanin versus MDRAB in vitro. This may represent a useful therapeutic combination for the treatment of A. baumannii infections, especially when renal toxicity is a significant concern.
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Affiliation(s)
- D W Wareham
- Centre for Immunology and Infectious Disease, Blizard Institute, Barts and The London, Queen Mary's School of Medicine and Dentistry, London, UK.
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20
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Gordon NC, Wareham DW. Novel variants of the Smqnr family of quinolone resistance genes in clinical isolates of Stenotrophomonas maltophilia. J Antimicrob Chemother 2010; 65:483-9. [PMID: 20071366 DOI: 10.1093/jac/dkp476] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Recent analysis of Stenotrophomonas maltophilia has identified a novel family of resistance genes (Smqnr) encoding pentapeptide repeat proteins, which confer low-level resistance to quinolones. This study describes further novel variants present in clinical isolates of S. maltophilia and investigates their effect on resistance to a number of quinolones in an Escherichia coli host. METHODS PCR for Smqnr alleles was carried out on a selection of S. maltophilia from clinical specimens, and amplicons were cloned and transformed in E. coli TOP10 cells. Transformed colonies carrying the plasmid were tested for susceptibility to a range of quinolones by MIC determination. DNA sequences were determined and translated peptide sequences compared with known SmQnr sequences. RESULTS Thirteen isolates were found to contain Smqnr alleles, of which six corresponded to previously identified Smqnr sequences, while seven were novel variants. Increases in quinolone MICs compared with wild-type E. coli TOP10 were seen for all strains transformed with Smqnr alleles. CONCLUSIONS There is considerable diversity within Smqnr alleles. S. maltophilia may be a significant reservoir for the dissemination of quinolone resistance elements to Enterobacteriaceae.
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Affiliation(s)
- N C Gordon
- Division of Infection, Barts & The London NHS Trust, Newark Street, Whitechapel, London E1 2ES, UK
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21
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Gordon NC, Wareham DW. A review of clinical and microbiological outcomes following treatment of infections involving multidrug-resistant Acinetobacter baumannii with tigecycline. J Antimicrob Chemother 2009; 63:775-80. [PMID: 19158109 DOI: 10.1093/jac/dkn555] [Citation(s) in RCA: 111] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
OBJECTIVES Multidrug-resistant Acinetobacter baumannii (MRAB) is an increasing problem in UK hospitals, with many strains now resistant to all available antibiotics except polymyxins. Tigecycline has been used for the treatment of MRAB as it demonstrates activity in vitro, but there are limited data on its clinical efficacy in Gram-negative infections, especially those involving the lower respiratory tract or bacteraemia. PATIENTS AND METHODS A retrospective study of the clinical and microbiological outcomes of all patients treated with tigecycline for MRAB over an 18 month period was undertaken. RESULTS Thirty-four patients received tigecycline for MRAB or polymicrobial infection involving MRAB. Twenty-three (68%) had a positive clinical outcome: microbiological clearance was demonstrated in 10 of these. The overall mortality was 41% (n = 14), with nine deaths directly attributable to sepsis. Three patients had episodes of Gram-negative bacteraemia while receiving treatment with tigecycline, with documented resistance occurring in one patient. Overall, the correlation between microbiological and clinical outcomes was poor. CONCLUSIONS While tigecycline retains excellent in vitro activity against MRAB, its clinical efficacy remains uncertain. A prospective study, including the use of tigecycline in combination with other antimicrobial agents, should be undertaken to define its role in the treatment of MRAB.
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Affiliation(s)
- N C Gordon
- Division of Infection, Barts and The London NHS Trust, London, UK
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22
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Shah A, Gordon NC, Pheel L, Wareham DW. Comparison of microscopic, phenotypic and molecular techniques for the rapid identification and susceptibility testing of Staphylococci from positive blood culture bottles. Crit Care 2009. [PMCID: PMC2776217 DOI: 10.1186/cc8100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/03/2023] Open
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Abstract
PYRIN domains were identified recently as putative protein-protein interaction domains at the N-termini of several proteins thought to function in apoptotic and inflammatory signaling pathways. The approximately 95 residue PYRIN domains have no statistically significant sequence homology to proteins with known three-dimensional structure. Using secondary structure prediction and potential-based fold recognition methods, however, the PYRIN domain is predicted to be a member of the six-helix bundle death domain-fold superfamily that includes death domains (DDs), death effector domains (DEDs), and caspase recruitment domains (CARDs). Members of the death domain-fold superfamily are well established mediators of protein-protein interactions found in many proteins involved in apoptosis and inflammation, indicating further that the PYRIN domains serve a similar function. An homology model of the PYRIN domain of CARD7/DEFCAP/NAC/NALP1, a member of the Apaf-1/Ced-4 family of proteins, was constructed using the three-dimensional structures of the FADD and p75 neurotrophin receptor DDs, and of the Apaf-1 and caspase-9 CARDs, as templates. Validation of the model using a variety of computational techniques indicates that the fold prediction is consistent with the sequence. Comparison of a circular dichroism spectrum of the PYRIN domain of CARD7/DEFCAP/NAC/NALP1 with spectra of several proteins known to adopt the death domain-fold provides experimental support for the structure prediction.
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Affiliation(s)
- W J Fairbrother
- Department of Protein Engineering, Genentech, Inc., South San Francisco, California 94080, USA.
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Peterson FC, Gordon NC, Gettins PG. High-level bacterial expression and 15N-alanine-labeling of bovine trypsin. Application to the study of trypsin-inhibitor complexes and trypsinogen activation by NMR spectroscopy. Biochemistry 2001; 40:6275-83. [PMID: 11371189 DOI: 10.1021/bi0100992] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
We describe here the high-level expression of bovine trypsinogen in E. coli, its refolding and activation to beta-trypsin, and the selective incorporation of (15)N-labeled alanine through supplementation of the growth medium. Using this procedure, we expressed (15)N-labeled S195A trypsinogens, both on a wild-type and on a D189S background, in amounts suitable for NMR spectroscopy. 2D [(1)H-(15)N]-HSQC NMR was used to follow conformational changes upon activation of trypsinogen and formation of noncovalent complexes between S195A or S195A/D189S trypsin and protein proteinase inhibitors of different structural families and different sizes, as well as to examine the effects of introduction of the D189S mutation. Spectra of good quality were obtained for both trypsins alone and in complexes of increasing size with the proteinase inhibitors BPTI (total molecular mass 31 kDa), SBTI (total molecular mass 44 kDa), and the serpin alpha(1)-proteinase inhibitor Pittsburgh (alpha(1)PI Pittsburgh) (total molecular mass 69 kDa). Assignments of alanines 55 and 56, close to the active site histidine, and of alanine 195, present in the S195A variant used for most of the studies, were made by mutagenesis. These three alanines, together with two others, probably close to the S1 specificity pocket, were very sensitive to complex formation. In contrast, the remaining 10 alanines were invariant in chemical shift in all 3 of the noncovalent complexes formed, reflecting the conservation of structure in complexes with BPTI and SBTI known from X-ray crystal structures, but also indicating that there is no change in backbone conformation for the noncovalent complex with alpha(1)PI, for which there is no crystal structure. This was true both for S195A and for S195A/D189S trypsins. This high-level expression and labeling approach will be of great use for solution NMR studies on trypsin-serpin complexes, as well as for structural and mechanistic studies on trypsin variants.
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Affiliation(s)
- F C Peterson
- Department of Biochemistry and Molecular Biology, M/C 536, College of Medicine, University of Illinois at Chicago, 60612, USA
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Peterson FC, Gordon NC, Gettins PG. Formation of a noncovalent serpin-proteinase complex involves no conformational change in the serpin. Use of 1H-15N HSQC NMR as a sensitive nonperturbing monitor of conformation. Biochemistry 2000; 39:11884-92. [PMID: 11009600 DOI: 10.1021/bi001152+] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
A structural understanding of the nature and scope of serpin inhibition mechanisms has been limited by the inability so far to crystallize any serpin-proteinase complex. We describe here the application of [(1)H-(15)N]-HSQC NMR on uniformly and residue-selectively (15)N-labeled serpin alpha(1)-proteinase inhibitor (Pittsburgh variant with stabilizing mutations) to provide a nonperturbing and exquisitely sensitive means of probing the conformation of the serpin alone and in a noncovalent complex with inactive, serine 195-modified, bovine trypsin. The latter should be a good model both for the few examples of reversible serpin-proteinase complexes and for the initial Michaelis-like complex formed en route to irreversible covalent inhibition. Cleavage of the reactive center loop, with subsequent insertion into beta-sheet A, caused dramatic perturbation of most of the NMR cross-peaks. This was true for both the uniformly labeled and alanine-specifically labeled samples. The spectra of uniformly or leucine- or alanine-specifically labeled alpha(1)-proteinase inhibitor in noncovalent complex with unlabeled inactive trypsin gave almost no detectable chemical shift changes of cross-peaks, but some general increase in line width. Residue-specific assignments of the four alanines in the reactive center loop, at P12, P11, P9, and P4, allowed specific examination of the behavior of the reactive center loop. All four alanines showed higher mobility than the body of the serpin, consistent with a flexible reactive center loop, which remained flexible even in the noncovalent complex with proteinase. The three alanines near the hinge point for insertion showed almost no chemical shift perturbation upon noncovalent complex formation, while the alanine at P4 was perturbed, presumably by interaction with the active site of bound trypsin. Reporters from both the body of the serpin and the reactive center loop therefore indicate that noncovalent complex formation involves no conformational change in the body of the serpin and only minor perturbation of the reactive center loop in the region which contacts proteinase. Thus, despite the large size of serpin and serpin-proteinase complex, 45 and 69 kDa respectively, NMR provides a very sensitive means of probing serpin conformation and mobility, which should be applicable both to noncovalent and to covalent complexes with a range of different proteinases, and probably to other serpins.
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Affiliation(s)
- F C Peterson
- Department of Biochemistry and Molecular Biology, M/C 536,College of Medicine, University of Illinois at Chicago, 1853 West Polk Street, Chicago, Illinois 60612, USA
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Smith RA, Karas N, Pogrel MA, Gordon NC, Goldman K, Silva R, Whalen M. Soft tissue surgery in the oral and maxillofacial region. J Calif Dent Assoc 2000; 28:668-80. [PMID: 11324048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 02/19/2023]
Abstract
The practice of dentistry is most often perceived as the treatment of the hard tissues of the oral region, specifically the teeth and jaws. However, there are many disorders and conditions involving surgical treatment of the soft tissues that extend to the adjacent and associated structures of the oral and maxillofacial surgery region.
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Affiliation(s)
- R A Smith
- Department of Oral and Maxillofacial Surgery, University of California, San Francisco, School of Dentistry, USA.
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Gear RW, Miaskowski C, Gordon NC, Paul SM, Heller PH, Levine JD. The kappa opioid nalbuphine produces gender- and dose-dependent analgesia and antianalgesia in patients with postoperative pain. Pain 1999; 83:339-45. [PMID: 10534607 DOI: 10.1016/s0304-3959(99)00119-0] [Citation(s) in RCA: 193] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Nalbuphine, pentazocine, and butorphanol, mixed agonist/antagonist opioids that induce analgesia by acting predominantly at kappa opioid receptors, have recently been shown in single-dose studies to have greater analgesic efficacy in women than in men. In the current experiments, the first placebo controlled dose response study of opioid analgesic efficacy that examines for gender differences, nalbuphine (5, 10, or 20 mg) and placebo were evaluated in 62 men and 69 women for the treatment of moderate to severe postoperative pain following extraction of impacted wisdom teeth. In a randomized, open injection, double blind experimental design, pain intensity was recorded on a 10 cm visual analog scale (VAS) immediately prior to drug administration (baseline) and at 20 min intervals thereafter. Although responses to placebo were similar in men and women, for all doses of nalbuphine women exhibited significantly greater analgesic response than men, compatible with our previous results. Unexpectedly, men receiving the 5 mg dose of nalbuphine experienced significantly greater pain than those receiving placebo; only the 20 mg dose of nalbuphine in men produced significant analgesia compared to placebo. While a similar antianalgesic effect was not observed in women, only the 10 mg dose of nalbuphine produced significant analgesia compared to placebo. These results suggest that the optimal analgesic dose of nalbuphine for women is lower than the highest dose that can be safely administered. In contrast, the antianalgesic effect of nalbuphine suggests avoidance of its routine use for postoperative analgesia in men until further studies clarify this issue. Because gender differences in other mixed kappa agonists/antagonists (i.e. pentazocine and butorphanol) have previously been shown, these results may generally apply to this class of opioid analgesics.
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Affiliation(s)
- R W Gear
- Center for Orofacial Pain, University of California, San Francisco 94143, USA
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Abstract
Activation of supraspinal gamma-aminobutyric acid-A (GABAA) receptors is known to result in antagonism of opioid analgesia. Since benzodiazepines enhance the action of GABA at GABAA receptors, we hypothesized that administration of these agents for preoperative sedation might antagonize the analgesic effects of opioids administered postoperatively. If so, then administration of the benzodiazepine antagonist flumazenil should enhance postoperative morphine analgesia. In a double-blind, placebo-controlled study of patients who received a preoperatively administered benzodiazepine (diazepam) for sedation and a postoperatively administered opioid (morphine) for analgesia, we investigated opioid-benzodiazepine interactions affecting postoperative dental pain. We found that flumazenil significantly enhanced morphine analgesia consistent with the hypothesis that the preoperatively administered benzodiazepine exerts an ongoing antianalgesic effect. In addition, we followed these patients over the first and second postoperative days to determine if there were differences between the drug groups in post-discharge pain, analgesic consumption, or side-effects. Participants receiving flumazenil reported significantly less post-discharge nausea and used significantly less ibuprofen. Since post-discharge pain levels were not significantly different, these results suggest that the patients receiving flumazenil required less analgesic medication to achieve a comparable level of pain control. In summary, our results indicate that the benzodiazepine antagonist flumazenil enhances morphine analgesia and decreases post-discharge side-effects as well as post-discharge need for analgesic medication.
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Affiliation(s)
- R W Gear
- Department of Restorative Dentistry, University of California, San Francisco 94143, USA
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Abstract
Sex differences in human responses to nociceptive stimuli and painful pathological conditions have generally indicated that women report higher pain levels or exhibit less tolerance than men for given stimulus intensities (reviewed in ref. 1 and 2). However, studies have not evaluated sex differences in analgesic responses. We recently reported that the opioid agonist-antagonist pentazocine, which acts predominantly at kappa-receptors, produced significantly better postoperative analgesia in females than in males in patients who underwent surgery for the removal of their third molars (wisdom teeth). In the current study, we evaluated the hypothesis that this sex difference is a characteristic of kappa-opioid agonism. In order to determine whether there are sex differences associated with kappa-opioid agonism, the analgesic efficacy of two other predominantly kappa-opioid analgesics, nalbuphine and butorphanol; was compared in males and females who underwent surgery for the removal of third molar teeth. We found that both nalbuphine and butorphanol produced significantly greater analgesia in females as compared with males. Considering our earlier findings, we conclude that kappa-opioid analgesia is greater in females than in males, probably reflecting a difference in kappa-opioid-activated endogenous pain modulating circuits.
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Affiliation(s)
- R W Gear
- Department of Restorative Dentistry, University of California-San Francisco, 94143-0452, USA
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Abstract
Gender difference in analgesia produced by the kappa-opiate pentazocine was investigated in a model of post-operative dental pain. In a recent study [Gordon et al., Neuroscience, 69 (1995) 345-349.] evaluating interaction between the GABAB agonist baclofen and opiates with respect to postoperative analgesia we found that females receiving pentazocine for the treatment of postoperative pain showed better analgesia than did males receiving similar treatment. To follow-up this result, we evaluated for the effect of gender on analgesia produced by pentazocine administered to participants not receiving another experimental medication. The analgesic response to pentazocine in ten females was compared to that in eight males. All participants were administered pentazocine after undergoing surgery for the removal of impacted third molars. We confirm our previous finding that pentazocine produces significantly greater analgesia in females than in males; no significant difference was observed in analgesia among females in different phases of the menstrual cycle.
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Affiliation(s)
- R W Gear
- Department of Restorative Dentistry, University of California, San Francisco 94143, USA.
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31
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Abstract
Opioid-GABAergic interactions for the treatment of post-operative pain were investigated in two double-blind, placebo-controlled experiments. We first studied the effect of pre-operatively administered baclofen, a GABAB receptor agonist, on the analgesia produced by intravenously administered morphine, a predominantly mu-opioid analgesic. In a separate trial, we studied the effect of baclofen on the analgesia produced by pentazocine, a predominantly kappa-opioid analgesic. While baclofen alone did not affect the level of post-operative pain, morphine analgesia was significantly enhanced by baclofen compared to placebo. In contrast, baclofen did not affect the level of pentazocine analgesia: however, females receiving pentazocine showed significantly greater analgesia than males.
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Affiliation(s)
- N C Gordon
- Department of Oral and Maxillofacial Surgery, University of California, San Francisco 94143, USA
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32
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Abstract
Although interactions between opioids and adrenergic agonists in the treatment of pain have been demonstrated in humans, the contribution of specific adrenergic receptors in this interaction remains to be clarified. In a double-blind, placebo-controlled study in male patients with postoperative dental pain, we investigated the effect of preoperative administration of the alpha 2-adrenergic antagonist, yohimbine, on analgesia produced by postoperative intravenous morphine. Although yohimbine by itself did not affect the pain, the overall analgesic effect of morphine was significantly enhanced in the presence of yohimbine. This report is the first to demonstrate that an alpha 2-adrenergic antagonist enhances opiate analgesia in humans.
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Affiliation(s)
- R W Gear
- Graduate Program in Oral Biology, University of California, San Francisco 94143, USA
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33
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Gordon NC, Tolstunov L. Submental approach to oroendotracheal intubation in patients with midfacial fractures. Oral Surg Oral Med Oral Pathol Oral Radiol Endod 1995; 79:269-72. [PMID: 7621002 DOI: 10.1016/s1079-2104(05)80218-5] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
A submental endotracheal intubation technique is an alternative to nasoendotracheal intubation and tracheostomy in the management of patients with severe midfacial fractures. The procedure is simple to do and has a low morbidity.
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Affiliation(s)
- N C Gordon
- University of California San Francisco, USA
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34
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Gordon NC. An aura of enlightenment. J Oral Maxillofac Surg 1994; 52:657. [PMID: 8189310 DOI: 10.1016/0278-2391(94)90161-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
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35
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Dodson TB, Perrott DH, Kaban LB, Gordon NC. Fixation of mandibular fractures: a comparative analysis of rigid internal fixation and standard fixation techniques. J Oral Maxillofac Surg 1990; 48:362-6. [PMID: 2313443 DOI: 10.1016/0278-2391(90)90431-z] [Citation(s) in RCA: 85] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
This study used a prospective design to compare standard therapy (closed or open reduction with 4 weeks of maxillomandibular fixation) to rigid internal fixation (RIF) for the treatment of mandibular fractures. Ninety-two patients with 143 fractures were evaluated and treated. There was no statistically significant difference in the treatment results between the two groups, despite a bias in the distribution of study variables that favored the standard therapy.
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Affiliation(s)
- T B Dodson
- Department of Oral and Maxillofacial Surgery, University of California-San Francisco 94143
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36
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Abstract
The analgesia produced by combinations of low-dose naloxone with pentazocine or morphine was studied in 105 patients with moderately severe postoperative pain after standardized surgery for removal of impacted third molars. Pain intensity was quantified using a visual-analogue scale. To eliminate the release of endogenous opioids produced by the placebo component of open drug administration, all injections were made by a preprogrammed infusion pump. The analgesia produced by pentazocine, an agonist-antagonist opiate-analgesic acting predominantly at the kappa opiate receptor, was potentiated by low-dose naloxone, whereas the analgesia produced by morphine, a mu-agonist, was attenuated by low-dose naloxone. To evaluate whether similar potentiation would be present in an animal model, and specifically, in the absence of diazepam, which patients receive, we performed an analogous experiment in rats in which nociceptive threshold was determined using the Randall-Selitto paw-withdrawal test. The results were completely analogous to the clinical results: pentazocine analgesia was potentiated by low-dose naloxone, whereas morphine analgesia was attenuated by low-dose naloxone. These data demonstrate a novel interaction between opiates, and suggest a rationale for opiate combinations to produce potent analgesia with fewer autonomic side effects and less abuse potential than presently available analgesics.
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Affiliation(s)
- J D Levine
- Department of Medicine, School of Medicine and Dentistry, University of California, San Francisco 94143
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37
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Abstract
The opiate antagonist, naloxone, produces dose-dependent biphasic changes in clinical pain. The mechanism of the analgesia produced by low dose naloxone is unknown. To study the analgesic effect of naloxone, we have used a programmable infusion pump, which eliminates placebo-induced endorphin-mediated analgesia, to administer different doses of naloxone. We report that use of machine infusion of naloxone exclusively produces analgesia. The implications of this finding to the mechanism of naloxone-induced analgesia are discussed.
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38
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Abstract
The appropriate control group in studies of placebo-induced analgesia has not been established. A traditional control has been a 'no treatment' or natural-history group. In some studies, the natural-history group receives a hidden infusion of vehicle, a physiologically inactive substance such as saline solution, to eliminate differences in expectation of the outcome on the part of the experimenter. To evaluate whether 'hidden' as well as open infusion of vehicle can elicit a placebo response, we have now tested a different natural-history group, one which received an infusion of vehicle from a syringe pump controlled by a programmable timer. A comparison of these two control groups provides evidence that hidden infusion of vehicle can elicit a placebo response. Use of this new control group also permitted a clear distinction between a naloxone-antagonizable component of placebo analgesia and naloxone antagonism of endorphin-mediated analgesia induced by surgical stress. Our study underscores the power of the placebo and emphasizes that even the most subtle cues can elicit a placebo response.
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Abstract
Rats exposed to a Pavlovian conditioning paradigm developed naloxone-reversible analgesia only when the intensity of a noxious unconditioned stimulus was suprathreshold and the level of stress was augmented. The time course of the onset of this conditioned analgesia was reproduced by systemic administration of morphine. These findings suggest that both a minimal level of stimulus intensity and stress are necessary for the activation of endogenous opioid-mediated analgesia.
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40
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Abstract
Vocalization was induced in rats by electrical stimulation of the tail (pain-induced vocalization), and its components were characterized in terms of latency, duration, frequency spectrum and energy. Noxious stimuli at threshold elicit a single vocalization component (V1). Increases in stimulus intensity produce additional discrete vocalization components (V2-Vn) with successively longer latencies, termed the vocalization afterdischarge (AD). The AD components are acoustically similar to each other but differ significantly from the V1 component. The duration, the specific acoustic measures and the sound energy of both V1 and AD components are positively correlated with intensity of the stimulus. The dependence of the V1 and AD components on the affective state of the rat was evaluated by comparing the acoustic characteristics of both components to those of stress-induced vocalizations, and by studying the effects of the anxiolytic drug diazepam and physical restraint on the threshold of V1 and AD. The AD components were markedly more dependent on the affective state of the rat then was the V1 component. A moderately low dose of morphine (3.0 mg/kg) also preferentially affected the AD component, suggesting that a significant portion of the action of morphine on pain-induced vocalization is mediated through its action on the affective state of the rat.
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41
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Abstract
That physiological effects are directly related to concentration at the site of action has been validated for only a few classes of drugs. For opiates, a direct correlation is known to exist between concentration and magnitude of analgesia, but has not been shown for duration of analgesia. These experiments in rats, using opiates whose elimination half-lives differ by a factor of 2 1/2, in a range of doses that produce 10-90% of maximal analgesic effect, show that duration is not dependent on dose or rate of elimination of opiate analgesics. The data suggest that analgesic duration is not determined by the pharmacokinetics of opiates at the receptors where these drugs act to elicit analgesia.
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Levine JD, Lane SR, Gordon NC, Fields HL. A spinal opioid synapse mediates the interaction of spinal and brain stem sites in morphine analgesia. Brain Res 1982; 236:85-91. [PMID: 6279239 DOI: 10.1016/0006-8993(82)90036-1] [Citation(s) in RCA: 49] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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43
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Abstract
The relationship to pain level of extent of injury (as measured by number of teeth extracted) and attention paid to the injury (as measured by frequency of pain ratings) was studied in patients with dental postoperative pain. Patients had either 2 or 4 impacted wisdom teeth removed and rated their pain either 2 or 5 times during the experiment. A positive correlation was found between extent of injury and reported pain level as well as between frequency of pain rating and pain level. The correlation between frequency of pain rating and pain level was found only in patients with 4 teeth extracted. To our knowledge, this is the first study which quantitatively evaluates the relationship between amount of injury and level of pain. This study also suggests that the degree to which manipulations of psychological variables alter an individual's pain perception may depend on the extent of injury.
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Smith RA, Gordon NC, Beirne OW. Self-instruction guides in the undergraduate oral surgery curriculum. Oral Surg Oral Med Oral Pathol 1981; 52:28-30. [PMID: 6944674 DOI: 10.1016/0030-4220(81)90168-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A study was undertaken to evaluate the self-instruction guides in oral surgery developed at the University of Washington School of Dentistry. The third-year dental class enrolled in the basic oral surgery course was divided into four groups. Group I received the traditional lecture series and textbook. Group II attended the lectures series, used the standard textbook, and were given the guides to study at their own convenience. Students in Group III received only the self-instruction guides and were assigned to review them in a study hall during the usual lecture hours. Members of Group IV were given only the guides to be studied at their own convenience. Scores on the midterm and final examinations and on the oral surgery section of the National Dental Board examination showed no significant differences in performance among the four groups, indicating that students can learn oral surgery from these self-instruction guides.
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45
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Gordon NC, Levine JD. Physiological substrates of placebo analgesia. Psychopharmacol Bull 1981; 17:76-7. [PMID: 7244065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
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46
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Gordon NC, Chan WC, Khosla VM, Lim RC. Soft tissue injuries. J Can Dent Assoc 1980; 46:776-80. [PMID: 7006752] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
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47
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Gordon NC, Brown SL. Closure of oronasoantral defects: report of case. J Oral Surg 1980; 38:600-5. [PMID: 6930462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A brief review of the techniques for closure of defects of the palate is presented. A case is reported in which an oronasoantral defect was successfully closed using the Fickling's inkwell technique. The importance of delayed closure and careful planning and preparation of the flap is emphasized.
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48
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Gordon NC, Swann NP, Hansen LS. Medical palatine cyst and maxillary antral osteoma: report of an unusal case. J Oral Surg 1980; 38:361-5. [PMID: 6928935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
A case is presented of a patient with the coincidental occurrence of two unusual lesions, median palatine cyst and osteoma of the maxillary antrum. There was no atypia of either lesion, but this combination led to the impression that the median palatine cyst had eroded into the maxillary antrum. Both lesions are usually asymptomatic and were incidental findings in this case. An occlusal radiograph is best for showing the palatal radiolucent area and is usually diagnostic. The preferred treatment for median palatine cyst is enucleation; a palatal splint is an excellent aid for reapproximation of the mucoperiosteal flap. The maxillary antrum was explored to obtain a biopsy specimen for a microscopic diagnosis of the radiopaque lesion; this proved to be an osteoma. The diagnosis of an osteoma is an indication for a radiographic survey to rule out Gardner syndrome, which has serious implications.
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49
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Gordon NC, Swann N, Khosla VM, Lim RC. Delayed rupture of the spleen in a patient with mandibular fracture. J Oral Surg 1979; 37:597-9. [PMID: 286780] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
A case of blunt abdominal trauma with subsequent damage to and rupture of the spleen is presented. Clinical manifestations, diagnosis, and sequelae and complications of injury are discussed. This case report demonstrates the insidious nature of trauma to the spleen and the ultimate dangers of delayed rupture. Treatment and disposition of the case are discussed and recommendations for physical examination of the patient who has suffered trauma to the abdomen are outlined.
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50
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Abstract
The hypothesis that perceived pain intensity can influence placebo analgesia was tested. One hundred and seven subjects rated their pain from from 0 to 10 on a visual analog scale after a standard wisdom tooth extraction. The expected course of such postoperative pain in the absence of therapy or placebo is a steady increase; this was confirmed by blind administration of the placebo. When placebos were given intravenously in view of the patients, some (placebo nonresponders) reported that their pain increased, whereas others (placebo responders) reported that their pain either decreased or remained the same over the next 60 min. A placebo response was more likely to occur if the pain rating 5 min prior to placebo administration (initial pain) was greater than 2.6. Furthermore, placebo responders with initial pain above this 2.6 level reported significantly greater mean analgesia than those with lower initial pain. Indeed, responders with initial pain less than 2.6 reported no change in pain during the 60 min after administration of a placebo. When their initial pain level was greater than 2.6, they reported a steady decline in pain over this period. However, above the 2.6 level there was no obvious relationship between the magnitude of the placebo analgesia and the initial pain.
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