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Kvalvik SA, Zakariassen SB, Overrein S, Rasmussen S, Skrede S, Baghestan E. Obstetric infections and clinical characteristics of maternal sepsis: a hospital-based retrospective cohort study. Sci Rep 2024; 14:6067. [PMID: 38480912 PMCID: PMC10937963 DOI: 10.1038/s41598-024-56486-4] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 03/07/2024] [Indexed: 03/17/2024] Open
Abstract
Sepsis is responsible for 50% of intrahospital maternal deaths worldwide. Incidence is increasing in both low and middle-, and high-income countries. There is little data on incidence and clinical outcomes of obstetric infections including maternal sepsis in the Nordic countries. The aims of this study are to give estimates of the occurrence of obstetric infections and maternal sepsis in a Norwegian hospital cohort, assess the quality of management of maternal sepsis cases, and evaluate the usefulness of diagnostic codes to identify maternal sepsis retrospectively. We conducted a retrospective cohort study of pregnant, labouring, post-abortion, and postpartum women. We assessed the accuracy of the diagnostic code most frequently applied for maternal sepsis, O85. We found 7.8% (95% confidence interval 7.1-8.5) infection amongst pregnant, labouring, and postpartum women. The incidence of maternal sepsis was 0.3% (95% confidence interval 0.2-0.5), and the majority of sepsis cases were recorded in the postpartum period. Two thirds of women were given broad-spectrum antibiotics at the time sepsis was diagnosed, but only 15.4% of women with puerperal sepsis were given antimicrobials in accordance with national guidelines. When used retrospectively, obstetric infection codes are insufficient in identifying both maternal and puerperal sepsis, with only 20.3% positive predictive value for both conditions. In conclusion, obstetric infections contribute significantly to maternal morbidity in Norway's second largest maternity hospital. This study provides incidences of maternal infections for hospitalised patients in temporal relation to pregnancy, labour, abortion and the postpartum period, knowledge which is valuable for planning of health care services and allocation of resources. In addition, the study highlights areas where improvement is needed in clinical handling of maternal sepsis. There is need for studies on the management quality and use of correct diagnostic codes in this patient category.
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Affiliation(s)
- Sedina Atic Kvalvik
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Pb 1400, 5021, Bergen, Norway.
- Department of Clinical Science, University of Bergen, Pb 7804, 5020, Bergen, Norway.
| | | | - Sofie Overrein
- Department of Clinical Science, University of Bergen, Pb 7804, 5020, Bergen, Norway
| | - Svein Rasmussen
- Department of Clinical Science, University of Bergen, Pb 7804, 5020, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Pb 7804, 5020, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Pb 1400, 5021, Bergen, Norway
| | - Elham Baghestan
- Department of Obstetrics and Gynaecology, Haukeland University Hospital, Pb 1400, 5021, Bergen, Norway
- Department of Clinical Science, University of Bergen, Pb 7804, 5020, Bergen, Norway
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Gundersen IM, Bruun T, Almeland SK, Skutlaberg DH, Nedrebø T, Rath E, Oppegaard O, Guttormsen AB, Norrby-Teglund A, Mosevoll KA, Skrede S. Necrotising soft tissue infections. Tidsskr Nor Laegeforen 2024; 144:23-0720. [PMID: 38415568 DOI: 10.4045/tidsskr.23.0720] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/29/2024] Open
Abstract
Necrotising soft tissue infections can affect the skin, subcutaneous tissue, superficial fascia, deep fascia and musculature. The infections are severe, they spread quickly and can result in extensive tissue loss. Although rare, morbidity and mortality rates are high. Early clinical identification is crucial for the outcome, and rapid infection control through surgery and targeted antibiotic treatment is needed to save lives. Few prospective clinical trials have been conducted for the treatment of this type of infection. Specific challenges include rapid identification of the condition and the uncertain efficacy of the various treatment options. In this clinical review article, we describe clinical characteristics, diagnostics and treatment.
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Affiliation(s)
- Ingunn Margareetta Gundersen
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Trond Bruun
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Stian Kreken Almeland
- Avdeling for plastikk-, hand- og rekonstruktiv kirurgi, og, Brannskadeavdelinga, Haukeland universitetssjukehus, og, Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen
| | | | - Torbjørn Nedrebø
- Seksjon for hyperbarmedisin, Yrkesmedisinsk avdeling, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Eivind Rath
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, og, Mottaksklinikken, Haukeland universitetssjukehus
| | - Oddvar Oppegaard
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Anne Berit Guttormsen
- Klinisk institutt 1, Det medisinske fakultet, Universitetet i Bergen, og, Kirurgisk serviceklinikk, Haukeland universitetssjukehus
| | - Anna Norrby-Teglund
- Center for infektionsmedicin, Karolinska Institutet, Karolinska Universitetssjukhuset
| | - Knut Anders Mosevoll
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
| | - Steinar Skrede
- Seksjon for infeksjonssjukdommar, Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Det medisinske fakultet, Universitetet i Bergen
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Shumba P, Sura T, Moll K, Chakrakodi B, Tölken LA, Hoßmann J, Hoff KJ, Hyldegaard O, Nekludov M, Svensson M, Arnell P, Skrede S, Norrby-Teglund A, Siemens N. Neutrophil-derived reactive agents induce a transient SpeB negative phenotype in Streptococcus pyogenes. J Biomed Sci 2023; 30:52. [PMID: 37430325 DOI: 10.1186/s12929-023-00947-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 07/03/2023] [Indexed: 07/12/2023] Open
Abstract
BACKGROUND Streptococcus pyogenes (group A streptococci; GAS) is the main causative pathogen of monomicrobial necrotizing soft tissue infections (NSTIs). To resist immuno-clearance, GAS adapt their genetic information and/or phenotype to the surrounding environment. Hyper-virulent streptococcal pyrogenic exotoxin B (SpeB) negative variants caused by covRS mutations are enriched during infection. A key driving force for this process is the bacterial Sda1 DNase. METHODS Bacterial infiltration, immune cell influx, tissue necrosis and inflammation in patient´s biopsies were determined using immunohistochemistry. SpeB secretion and activity by GAS post infections or challenges with reactive agents were determined via Western blot or casein agar and proteolytic activity assays, respectively. Proteome of GAS single colonies and neutrophil secretome were profiled, using mass spectrometry. RESULTS Here, we identify another strategy resulting in SpeB-negative variants, namely reversible abrogation of SpeB secretion triggered by neutrophil effector molecules. Analysis of NSTI patient tissue biopsies revealed that tissue inflammation, neutrophil influx, and degranulation positively correlate with increasing frequency of SpeB-negative GAS clones. Using single colony proteomics, we show that GAS isolated directly from tissue express but do not secrete SpeB. Once the tissue pressure is lifted, GAS regain SpeB secreting function. Neutrophils were identified as the main immune cells responsible for the observed phenotype. Subsequent analyses identified hydrogen peroxide and hypochlorous acid as reactive agents driving this phenotypic GAS adaptation to the tissue environment. SpeB-negative GAS show improved survival within neutrophils and induce increased degranulation. CONCLUSIONS Our findings provide new information about GAS fitness and heterogeneity in the soft tissue milieu and provide new potential targets for therapeutic intervention in NSTIs.
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Affiliation(s)
- Patience Shumba
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Thomas Sura
- Department of Microbial Proteomics, Institute of Microbiology, University of Greifswald, Greifswald, Germany
| | - Kirsten Moll
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Bhavya Chakrakodi
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Lea A Tölken
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Jörn Hoßmann
- Helmholtz Center for Infection Research, Brunswick, Germany
| | - Katharina J Hoff
- Institute of Mathematics and Computer Science, University of Greifswald, Greifswald, Germany
| | - Ole Hyldegaard
- Department of Anaesthesia, Head and Orthopedic Center, University Hospital Copenhagen, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Mattias Svensson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Stockholm, Sweden
| | - Nikolai Siemens
- Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany.
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Movert E, Bolarin JS, Valfridsson C, Velarde J, Skrede S, Nekludov M, Hyldegaard O, Arnell P, Svensson M, Norrby-Teglund A, Cho KH, Elhaik E, Wessels MR, Råberg L, Carlsson F. Interplay between human STING genotype and bacterial NADase activity regulates inter-individual disease variability. Nat Commun 2023; 14:4008. [PMID: 37414832 PMCID: PMC10326033 DOI: 10.1038/s41467-023-39771-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [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: 08/16/2022] [Accepted: 06/28/2023] [Indexed: 07/08/2023] Open
Abstract
Variability in disease severity caused by a microbial pathogen is impacted by each infection representing a unique combination of host and pathogen genomes. Here, we show that the outcome of invasive Streptococcus pyogenes infection is regulated by an interplay between human STING genotype and bacterial NADase activity. S. pyogenes-derived c-di-AMP diffuses via streptolysin O pores into macrophages where it activates STING and the ensuing type I IFN response. However, the enzymatic activity of the NADase variants expressed by invasive strains suppresses STING-mediated type I IFN production. Analysis of patients with necrotizing S. pyogenes soft tissue infection indicates that a STING genotype associated with reduced c-di-AMP-binding capacity combined with high bacterial NADase activity promotes a 'perfect storm' manifested in poor outcome, whereas proficient and uninhibited STING-mediated type I IFN production correlates with protection against host-detrimental inflammation. These results reveal an immune-regulating function for bacterial NADase and provide insight regarding the host-pathogen genotype interplay underlying invasive infection and interindividual disease variability.
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Affiliation(s)
- Elin Movert
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | | | | | - Jorge Velarde
- Division of Infectious Diseases, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Anaesthesia, Head and Orthopedic Center, Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Per Arnell
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mattias Svensson
- Centre for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Centre for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Kyu Hong Cho
- Department of Biology, Indiana State University, Terre Haute, USA
| | - Eran Elhaik
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | - Michael R Wessels
- Division of Infectious Diseases, Boston Children's Hospital, and Department of Pediatrics, Harvard Medical School, Boston, USA
| | - Lars Råberg
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden
| | - Fredric Carlsson
- Department of Biology, Lund University, Sölvegatan 35, 223 62, Lund, Sweden.
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5
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Kaci A, Jonassen CM, Skrede S, Sivertsen A, Steinbakk M, Oppegaard O. Genomic epidemiology of Streptococcus dysgalactiae subsp. equisimilis strains causing invasive disease in Norway during 2018. Front Microbiol 2023; 14:1171913. [PMID: 37485526 PMCID: PMC10361778 DOI: 10.3389/fmicb.2023.1171913] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 03/31/2023] [Indexed: 07/25/2023] Open
Abstract
Background Streptococcus dysgalactiae subspecies equisimilis (SDSE) is an emerging global pathogen, yet the epidemiology and population genetics of SDSE species have not been extensively characterized. Methods We carried out whole genome sequencing to characterize 274 SDSE isolates causing bloodstream infections obtained through national surveillance program in 2018. We conducted multilocus sequence typing (MLST), emm-typing, core genome phylogeny, as well as investigated key features associated with virulence. Moreover, comparison to SDSE from other geographic regions were performed in order to gain more insight in the evolutionary dynamics in SDSE. Results The phylogenetic analysis indicated a substantial diversity of emm-types and sequence types (STs). Briefly, 17 emm-types and 58 STs were identified that formed 10 clonal complexes (CCs). The predominant ST-types were ST20 (20%), ST17 (17%), and ST29 (11%). While CC17 and CC29 clades showed a substantial heterogeneity with well-separated emm-associated subclades, the CC20 clade harboring the stG62647 emm-type was more homogenous and the most prevalent in the present study. Moreover, we observed notable differences in the distribution of clades within Norway, as well as several disseminated CCs and also distinct geographic variations when compared to data from other countries. We also revealed extensive intra-species recombination events involving surface exposed virulence factors, including the emm gene important for phylogenetic profiling. Conclusion Recombination events involving the emm as well as other virulence genes in SDSE, are important mechanisms in shaping the genetic variability in the SDSE population, potentially offering selective advantages to certain lineages. The enhanced phylogenetic resolution offered by whole genome sequencing is necessary to identify and delimitate outbreaks, monitor and properly characterize emerging strains, as well as elucidate bacterial population dynamics.
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Affiliation(s)
- Alba Kaci
- Center for Laboratory Medicine, Østfold Hospital Trust, Grålum, Norway
| | - Christine M. Jonassen
- Center for Laboratory Medicine, Østfold Hospital Trust, Grålum, Norway
- Department of Virology, Norwegian Institute of Public Health, Oslo, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Audun Sivertsen
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | | | - Martin Steinbakk
- Center for Laboratory Medicine, Østfold Hospital Trust, Grålum, Norway
| | - Oddvar Oppegaard
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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6
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Rath E, Palma Medina LM, Jahagirdar S, Mosevoll KA, Damås JK, Madsen MB, Svensson M, Hyldegaard O, Martins Dos Santos VAP, Saccenti E, Norrby-Teglund A, Skrede S, Bruun T. Systemic immune activation profiles in streptococcal necrotizing soft tissue infections: A prospective multicenter study. Clin Immunol 2023; 249:109276. [PMID: 36871764 DOI: 10.1016/j.clim.2023.109276] [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] [Received: 12/07/2022] [Revised: 02/05/2023] [Accepted: 02/28/2023] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Early stages with streptococcal necrotizing soft tissue infections (NSTIs) are often difficult to discern from cellulitis. Increased insight into inflammatory responses in streptococcal disease may guide correct interventions and discovery of novel diagnostic targets. METHODS Plasma levels of 37 mediators, leucocytes and CRP from 102 patients with β-hemolytic streptococcal NSTI derived from a prospective Scandinavian multicentre study were compared to those of 23 cases of streptococcal cellulitis. Hierarchical cluster analyses were also performed. RESULTS Differences in mediator levels between NSTI and cellulitis cases were revealed, in particular for IL-1β, TNFα and CXCL8 (AUC >0.90). Across streptococcal NSTI etiologies, eight biomarkers separated cases with septic shock from those without, and four mediators predicted a severe outcome. CONCLUSION Several inflammatory mediators and wider profiles were identified as potential biomarkers of NSTI. Associations of biomarker levels to type of infection and outcomes may be utilized to improve patient care and outcomes.
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Affiliation(s)
- Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Laura M Palma Medina
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands
| | - Knut A Mosevoll
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
| | - Jan K Damås
- Department of Infectious Diseases, St. Olav's Hospital, Trondheim University Hospital, Trondheim, Norway; Centre of Molecular Inflammation Research, Department of Clinical and Molecular Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Martin B Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Denmark
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Ole Hyldegaard
- Department of Anaesthesia- and Surgery, Head and Orthopaedic centre, Hyperbaric Unit, Copenhagen University Hospital, Rigshospitalet, Denmark; Department of Clinical Medicine, University of Copenhagen, Denmark
| | - Vitor A P Martins Dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands; LifeGlimmer GmbH, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, the Netherlands
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Huddinge, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Norway
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Oppegaard O, Glambek M, Skutlaberg DH, Skrede S, Sivertsen A, Kittang BR. Streptococcus dysgalactiae Bloodstream Infections, Norway, 1999-2021. Emerg Infect Dis 2023; 29:260-267. [PMID: 36692331 PMCID: PMC9881787 DOI: 10.3201/eid2902.221218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Streptococcus dysgalactiae increasingly is recognized as a pathogen of concern for human health. However, longitudinal surveillance data describing temporal trends of S. dysgalactiae are scarce. We retrospectively identified all β-hemolytic streptococcal bloodstream infections reported in Bergen, in western Norway, during 1999-2021. To explore S. dysgalactiae disease burden in a broader context, we mapped the incidence of all microbial species causing bloodstream infections during 2012-2021. We found S. dysgalactiae incidence rates substantially increased during the study period; by 2021, S. dysgalactiae was the fifth most common pathogen causing bloodstream infections in our region. We noted genotypic shifts and found that the rising trend was related in part to the introduction and expansion of the stG62647 emm-type. S. dysgalactiae is among the most common causes of bloodstream infections in western Norway, and increased surveillance and unambiguous species identification are needed to monitor the disease burden attributable to this pathogen.
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Holten AR, Skrede S. Tidlig antibiotikabehandling til de rette pasientene. Tidsskr Nor Laegeforen 2023; 143:22-0702. [PMID: 36718892 DOI: 10.4045/tidsskr.22.0702] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023] Open
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Abstract
BACKGROUND Sepsis is one of the most common causes of death in Norwegian hospitals. The condition is often overlooked with treatment being delayed. Scoring systems to detect patients with sepsis have mostly been studied in emergency departments and more rarely on wards. The objective of this study was to investigate the ability of various clinical scoring systems to identify sepsis in patients on wards. MATERIAL AND METHOD The ability of the scoring systems SIRS (Systemic Inflammatory Response Syndrome), qSOFA (quick Sequential Organ Failure Assessment) and NEWS2 (National Early Warning Score 2) to identify patients with sepsis was compared in a study of adult patients with clinically suspected severe infection on wards at Haukeland University Hospital in the period March-December 2019. The diagnosis of sepsis was made based on an increase in SOFA (Sequential Organ Failure Assessment) score of 2 or more in the first 24 hours after inclusion. RESULTS 89 patients with suspected new onset of severe infection were identified. Sepsis was diagnosed in 55 of these patients. SIRS had a sensitivity of 82 % and a specificity of 6 % in diagnosing sepsis, qSOFA had a sensitivity of 20 % and a specificity of 97 %, while NEWS2 with a threshold of an aggregate score ≥ 5 and/or 3 in a single parameter had a sensitivity of 96 % and a specificity of 59 %. Oxygen saturation with a threshold of 95 % was the most sensitive measurement for sepsis. INTERPRETATION NEWS2 was better suited than qSOFA and SIRS for early detection of sepsis on wards.
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Affiliation(s)
- Elisabet Ethun Karlsen
- Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Universitetet i Bergen
| | - Nora Almlid Rønsåsbjørg
- Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Universitetet i Bergen
| | - Steinar Skrede
- Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Universitetet i Bergen
| | - Knut Anders Mosevoll
- Medisinsk klinikk, Haukeland universitetssjukehus, og, Klinisk institutt 2, Universitetet i Bergen
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Gundersen IM, Berget E, Haugland HK, Bruun T, Almeland SK, Assmus J, Rath E, Norrby-Teglund A, Skrede S, Mosevoll KA. Clinical characteristics and histopathology in suspected necrotizing soft tissue infections. Open Forum Infect Dis 2022; 9:ofac571. [DOI: 10.1093/ofid/ofac571] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Indexed: 11/06/2022] Open
Abstract
Abstract
Background
Necrotizing soft tissue infections (NSTIs) are severe diseases with high morbidity and mortality. The diagnosis is challenging. Several guidelines recommend tissue biopsies as an adjunct diagnostic in routine management, but neither biopsy sampling nor classification are standardized or validated. We studied the quality of tissue biopsy examination as part of routine diagnostics in NSTIs.
Method
A retrospective cohort study of adult patients undergoing surgery due to suspected NSTIs in which tissue biopsy was taken as part of routine management. Clinical data were reviewed. The biopsies were evaluated according to a proposed histopathologic classification system and independently assessed by two pathologists. Interrater reliability and diagnostic accuracy were determined.
Results
Tissue biopsies from 75 patients were examined, 55 NSTIs and 20 non-NSTIs cases. The cohorts were similar in clinical characteristics. Interrater reliability for histopathologic staging was moderate (0.53) and fair (0.37) for diagnosis. The sensitivity of histologic diagnosis was 75% and the specificity 80%. The positive predictive value was 91% and the negative predictive value 53%. Necrotizing Infection Clinical Composite Endpoint (NICCE) success was associated with a more severe histological stage, achieved by 42% and 71% of the cases in stage 1 and 2, respectively (p = 0.046).
Conclusion
Our findings suggest that tissue biopsies have low clinical accuracy. The interrater reliability among experienced pathologists is only fair to moderate. A histopathological more severe stage was associated with favorable outcome. These findings discourage the use of histopathologic evaluation as part of contemporary management of patients with suspected NSTI.
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Affiliation(s)
- Ingunn M Gundersen
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Ellen Berget
- Department of Pathology, Haukeland University Hospital , Bergen , Norway
| | | | - Trond Bruun
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Stian Kreken Almeland
- Department of Plastic, Hand, and Reconstructive Surgery, Norwegian National Burn Center, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Medicine, University of Bergen , Norway
| | - Jürg Assmus
- Centre of Competence on Clinical Research, Haukeland University Hospital , Bergen , Norway
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital , Huddinge , Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
| | - Knut Anders Mosevoll
- Department of Medicine, Haukeland University Hospital , Bergen , Norway
- Department of Clinical Science, University of Bergen , Norway
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Jahagirdar S, Morris L, Benis N, Oppegaard O, Svenson M, Hyldegaard O, Skrede S, Norrby-Teglund A, Martins Dos Santos VAP, Saccenti E. Analysis of host-pathogen gene association networks reveals patient-specific response to streptococcal and polymicrobial necrotising soft tissue infections. BMC Med 2022; 20:173. [PMID: 35505341 PMCID: PMC9066942 DOI: 10.1186/s12916-022-02355-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 03/28/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Necrotising soft tissue infections (NSTIs) are rapidly progressing bacterial infections usually caused by either several pathogens in unison (polymicrobial infections) or Streptococcus pyogenes (mono-microbial infection). These infections are rare and are associated with high mortality rates. However, the underlying pathogenic mechanisms in this heterogeneous group remain elusive. METHODS In this study, we built interactomes at both the population and individual levels consisting of host-pathogen interactions inferred from dual RNA-Seq gene transcriptomic profiles of the biopsies from NSTI patients. RESULTS NSTI type-specific responses in the host were uncovered. The S. pyogenes mono-microbial subnetwork was enriched with host genes annotated with involved in cytokine production and regulation of response to stress. The polymicrobial network consisted of several significant associations between different species (S. pyogenes, Porphyromonas asaccharolytica and Escherichia coli) and host genes. The host genes associated with S. pyogenes in this subnetwork were characterised by cellular response to cytokines. We further found several virulence factors including hyaluronan synthase, Sic1, Isp, SagF, SagG, ScfAB-operon, Fba and genes upstream and downstream of EndoS along with bacterial housekeeping genes interacting with the human stress and immune response in various subnetworks between host and pathogen. CONCLUSIONS At the population level, we found aetiology-dependent responses showing the potential modes of entry and immune evasion strategies employed by S. pyogenes, congruent with general cellular processes such as differentiation and proliferation. After stratifying the patients based on the subject-specific networks to study the patient-specific response, we observed different patient groups with different collagens, cytoskeleton and actin monomers in association with virulence factors, immunogenic proteins and housekeeping genes which we utilised to postulate differing modes of entry and immune evasion for different bacteria in relationship to the patients' phenotype.
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Affiliation(s)
- Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands
| | - Lorna Morris
- Lifeglimmer GmbH, Markelstraße 38, 12163, Berlin, Germany
| | - Nirupama Benis
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands.,Present affiliation: Department of Medical Informatics, Amsterdam Public Health Research Institute, Amsterdam UMC, University of Amsterdam, Meibergdreef 9, Amsterdam, Netherlands
| | - Oddvar Oppegaard
- Department of Medicine, Division for infectious diseases, Haukeland University Hospital, Bergen, Norway
| | - Mattias Svenson
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Ole Hyldegaard
- Department of Anesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Steinar Skrede
- Department of Medicine, Division for infectious diseases, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | | | - Vitor A P Martins Dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands.,Lifeglimmer GmbH, Markelstraße 38, 12163, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Stippeneng 4, 6708, WE, Wageningen, the Netherlands.
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12
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Skutlaberg DH, Wiker HG, Mylvaganam H, Norrby-Teglund A, Skrede S. Consistent Biofilm Formation by Streptococcus pyogenes emm 1 Isolated From Patients With Necrotizing Soft Tissue Infections. Front Microbiol 2022; 13:822243. [PMID: 35250938 PMCID: PMC8895234 DOI: 10.3389/fmicb.2022.822243] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 01/27/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesBiofilm formation has been demonstrated in muscle and soft tissue samples from patients with necrotizing soft tissue infection (NSTI) caused by Streptococcus pyogenes, but the clinical importance of this observation is not clear. Although M-protein has been shown to be important for in vitro biofilm formation in S. pyogenes, the evidence for an association between emm type and biofilm forming capacity is conflicting. Here we characterize the biofilm forming capacity in a collection of S. pyogenes isolates causing NSTI, and relate this to emm type of the isolates and clinical characteristics of the patients.MethodsBacterial isolates and clinical data were obtained from NSTI patients enrolled in a multicenter prospective observational study. Biofilm forming capacity was determined using a microtiter plate assay.ResultsAmong 57 cases, the three most frequently encountered emm types were emm1 (n = 22), emm3 (n = 13), and emm28 (n = 7). The distribution of biofilm forming capacity in emm1 was qualitatively (narrow-ranged normal distribution) and quantitatively (21/22 isolates in the intermediate range) different from other emm types (wide ranged, multimodal distribution with 5/35 isolates in the same range as emm1). There were no significant associations between biofilm forming capacity and clinical characteristics of the patients.ConclusionsThe biofilm forming capacity of emm1 isolates was uniform and differed significantly from other emm types. The impact of biofilm formation in NSTI caused by S. pyogenes on clinical outcomes remains uncertain.
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Affiliation(s)
- Dag Harald Skutlaberg
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
- *Correspondence: Dag Harald Skutlaberg,
| | - Harald G. Wiker
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Haima Mylvaganam
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | | | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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13
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Palma Medina LM, Rath E, Jahagirdar S, Bruun T, Madsen MB, Strålin K, Unge C, Hansen MB, Arnell P, Nekludov M, Hyldegaard O, Lourda M, dos Santos VAM, Saccenti E, Skrede S, Svensson M, Norrby-Teglund A. Discriminatory plasma biomarkers predict specific clinical phenotypes of necrotizing soft-tissue infections. J Clin Invest 2021; 131:149523. [PMID: 34263738 PMCID: PMC8279592 DOI: 10.1172/jci149523] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 05/25/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUNDNecrotizing soft-tissue infections (NSTIs) are rapidly progressing infections frequently complicated by septic shock and associated with high mortality. Early diagnosis is critical for patient outcome, but challenging due to vague initial symptoms. Here, we identified predictive biomarkers for NSTI clinical phenotypes and outcomes using a prospective multicenter NSTI patient cohort.METHODSLuminex multiplex assays were used to assess 36 soluble factors in plasma from NSTI patients with positive microbiological cultures (n = 251 and n = 60 in the discovery and validation cohorts, respectively). Control groups for comparative analyses included surgical controls (n = 20), non-NSTI controls (i.e., suspected NSTI with no necrosis detected upon exploratory surgery, n = 20), and sepsis patients (n = 24).RESULTSThrombomodulin was identified as a unique biomarker for detection of NSTI (AUC, 0.95). A distinct profile discriminating mono- (type II) versus polymicrobial (type I) NSTI types was identified based on differential expression of IL-2, IL-10, IL-22, CXCL10, Fas-ligand, and MMP9 (AUC >0.7). While each NSTI type displayed a distinct array of biomarkers predicting septic shock, granulocyte CSF (G-CSF), S100A8, and IL-6 were shared by both types (AUC >0.78). Finally, differential connectivity analysis revealed distinctive networks associated with specific clinical phenotypes.CONCLUSIONSThis study identifies predictive biomarkers for NSTI clinical phenotypes of potential value for diagnostic, prognostic, and therapeutic approaches in NSTIs.TRIAL REGISTRATIONClinicalTrials.gov NCT01790698.FUNDINGCenter for Innovative Medicine (CIMED); Region Stockholm; Swedish Research Council; European Union; Vinnova; Innovation Fund Denmark; Research Council of Norway; Netherlands Organisation for Health Research and Development; DLR Federal Ministry of Education and Research; and Swedish Children's Cancer Foundation.
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Affiliation(s)
- Laura M. Palma Medina
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Eivind Rath
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Sanjeevan Jahagirdar
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Trond Bruun
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Martin B. Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kristoffer Strålin
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Department of Infectious Diseases and
| | - Christian Unge
- Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Functional Area of Emergency Medicine, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Bo Hansen
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Per Arnell
- Department of Anaesthesia and Intensive Care, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Michael Nekludov
- Department of Anaesthesia, Surgical Services and Intensive Care, Karolinska Institute, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Magda Lourda
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
- Childhood Cancer Research Unit, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Vitor A.P. Martins dos Santos
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
- LifeGlimmer GmbH, Berlin, Germany
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University and Research, Wageningen, Netherlands
| | - Steinar Skrede
- Department of Medicine, Division for Infectious Diseases, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institute, Stockholm, Sweden
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14
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Bruun T, Rath E, Madsen MB, Oppegaard O, Nekludov M, Arnell P, Karlsson Y, Babbar A, Bergey F, Itzek A, Hyldegaard O, Norrby-Teglund A, Skrede S. Risk Factors and Predictors of Mortality in Streptococcal Necrotizing Soft-tissue Infections: A Multicenter Prospective Study. Clin Infect Dis 2021; 72:293-300. [PMID: 31923305 PMCID: PMC7840107 DOI: 10.1093/cid/ciaa027] [Citation(s) in RCA: 45] [Impact Index Per Article: 15.0] [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: 09/11/2019] [Accepted: 01/09/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Necrotizing soft-tissue infections (NSTI) are life-threatening conditions often caused by β-hemolytic streptococci, group A Streptococcus (GAS) in particular. Optimal treatment is contentious. The INFECT cohort includes the largest set of prospectively enrolled streptococcal NSTI cases to date. METHODS From the INFECT cohort of 409 adults admitted with NSTI to 5 clinical centers in Scandinavia, patients culture-positive for GAS or Streptococcus dysgalactiae (SD) were selected. Risk factors were identified by comparison with a cohort of nonnecrotizing streptococcal cellulitis. The impact of baseline factors and treatment on 90-day mortality was explored using Lasso regression. Whole-genome sequencing of bacterial isolates was used for emm typing and virulence gene profiling. RESULTS The 126 GAS NSTI cases and 27 cases caused by SD constituted 31% and 7% of the whole NSTI cohort, respectively. When comparing to nonnecrotizing streptococcal cellulitis, streptococcal NSTI was associated to blunt trauma, absence of preexisting skin lesions, and a lower body mass index. Septic shock was significantly more frequent in GAS (65%) compared to SD (41%) and polymicrobial, nonstreptococcal NSTI (46%). Age, male sex, septic shock, and no administration of intravenous immunoglobulin (IVIG) were among factors associated with 90-day mortality. Predominant emm types were emm1, emm3, and emm28 in GAS and stG62647 in SD. CONCLUSIONS Streptococcal NSTI was associated with several risk factors, including blunt trauma. Septic shock was more frequent in NSTI caused by GAS than in cases due to SD. Factors associated with mortality in GAS NSTI included age, septic shock, and no administration of IVIG.
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Affiliation(s)
- Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Martin Bruun Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Michael Nekludov
- Perioperative Medicine and Intensive Care Function, Karolinska University Hospital, Stockholm, Sweden
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Ylva Karlsson
- Department of Anesthesiology and Intensive Care, Blekinge County Council Hospital, Karlskrona, Sweden
| | - Anshu Babbar
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | | | - Andreas Itzek
- Helmholtz-Zentrum für Infektionsforschung GmbH, Braunschweig, Germany
| | - Ole Hyldegaard
- Hyperbaric Medicine Center, Department of Anesthesiology and Surgery, Head and Orthopedic Center, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Norway
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15
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Oppegaard O, Skrede S, Mylvaganam H, Kittang BR. Emerging Threat of Antimicrobial Resistance in β-Hemolytic Streptococci. Front Microbiol 2020; 11:797. [PMID: 32477287 PMCID: PMC7242567 DOI: 10.3389/fmicb.2020.00797] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 01/29/2020] [Accepted: 04/03/2020] [Indexed: 11/13/2022] Open
Abstract
Highly variable resistance rates to erythromycin and clindamycin have been reported in the β-hemolytic streptococcal species Streptococcus pyogenes, Streptococcus agalactiae, and Streptococcus dysgalactiae, depending on geographic and temporal context. In the present study we aimed to examine the longitudinal trends of antimicrobial resistance in these three species in a northern European setting. Furthermore, we used whole genome sequencing to identify resistance determinants and the mobile genetic elements involved in their dissemination, as well as elucidate phylogenetic relationships. All cases of invasive β-hemolytic streptococcal diseases in Health Region Bergen, western Norway, in the period 2004 to 2018 were retrospectively identified, comprising 271, 358, and 280 cases of S. pyogenes, S. agalactiae, and S. dysgalactiae, respectively. Antimicrobial susceptibility testing revealed a gradual but significant increase in erythromycin and clindamycin resistance for S. agalactiae and S. dysgalactiae during the study period. Whole genome sequencing of the erythromycin and clindamycin resistant bacterial population revealed a substantial phylogenetic diversity in S. agalactiae and S. dysgalactiae. However, the mobile genetic elements harboring the resistance determinants showed remarkable intra- and interspecies similarities, suggesting a dissemination of antimicrobial resistance predominantly through conjugative transfer rather than clonal expansion of resistant strains in these two species. Conversely, antimicrobial resistance in S. pyogenes remained low, apart from a transient outbreak of a clindamycin and erythromycin resistant emm11/ST403-clone in 2010–2012. Increased epidemiological attentiveness is warranted to monitor the emerging threat of antimicrobial resistance in β-hemolytic streptococci, particularly in S. agalactiae and S. dysgalactiae.
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Affiliation(s)
- Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Bergen, Norway
| | - Haima Mylvaganam
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
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16
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Trieu MC, Jul-Larsen Å, Sævik M, Madsen A, Nøstbakken JK, Zhou F, Skrede S, Cox RJ. Antibody Responses to Influenza A/H1N1pdm09 Virus After Pandemic and Seasonal Influenza Vaccination in Healthcare Workers: A 5-Year Follow-up Study. Clin Infect Dis 2020; 68:382-392. [PMID: 29893797 PMCID: PMC6336911 DOI: 10.1093/cid/ciy487] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [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: 03/25/2018] [Accepted: 06/05/2018] [Indexed: 11/12/2022] Open
Abstract
Background The 2009 influenza pandemic was caused by the A/H1N1pdm09 virus, which was subsequently included in the seasonal vaccine, up to 2016/2017, as the A/H1N1 strain. This provided a unique opportunity to investigate the antibody response to H1N1pdm09 over time. Methods Healthcare workers (HCWs) were immunized with the AS03-adjuvanted H1N1pdm09 vaccine in 2009 (N = 250), and subsequently vaccinated with seasonal vaccines containing H1N1pdm09 for 4 seasons (repeated group), <4 seasons (occasional group), or no seasons (single group). Blood samples were collected pre and at 21 days and 3, 6, and 12 months after each vaccination, or annually (pre-season) from 2010 in the single group. The H1N1pdm09-specific antibodies were measured by the hemagglutination inhibition (HI) assay. Results Pandemic vaccination robustly induced HI antibodies that persisted above the 50% protective threshold (HI titers ≥ 40) over 12 months post-vaccination. Previous seasonal vaccination and the duration of adverse events after the pandemic vaccination influenced the decision to vaccinate in subsequent seasons. During 2010/2011-2013/2014, antibodies were boosted after each seasonal vaccination, although no significant difference was observed between the repeated and occasional groups. In the single group without seasonal vaccination, 32% of HCWs seroconverted (≥4-fold increase in HI titers) during the 4 subsequent years, most of whom had HI titers <40 prior to seroconversion. When excluding these seroconverted HCWs, HI titers gradually declined from 12 to 60 months post-pandemic vaccination. Conclusions Pandemic vaccination elicited durable antibodies, supporting the incorporation of adjuvant. Our findings support the current recommendation of annual influenza vaccination in HCWs. Clinical Trials Registration NCT01003288.
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Affiliation(s)
- Mai-Chi Trieu
- Influenza Centre, Department of Clinical Science, University of Bergen.,K. G. Jebsen Centre for Influenza Vaccine Research, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Åsne Jul-Larsen
- Influenza Centre, Department of Clinical Science, University of Bergen.,K. G. Jebsen Centre for Influenza Vaccine Research, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Marianne Sævik
- Division for Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Anders Madsen
- Influenza Centre, Department of Clinical Science, University of Bergen
| | | | - Fan Zhou
- Influenza Centre, Department of Clinical Science, University of Bergen.,K. G. Jebsen Centre for Influenza Vaccine Research, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Steinar Skrede
- Division for Infectious Diseases, Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Rebecca Jane Cox
- Influenza Centre, Department of Clinical Science, University of Bergen.,K. G. Jebsen Centre for Influenza Vaccine Research, Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Research and Development, Haukeland University Hospital, Bergen, Norway
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17
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Rath E, Skrede S, Oppegaard O, Bruun T. Non-purulent skin and soft tissue infections: predictive power of a severity score and the appropriateness of treatment in a prospective cohort. Infect Dis (Lond) 2020; 52:361-371. [DOI: 10.1080/23744235.2020.1726447] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022] Open
Affiliation(s)
- Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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18
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Afzal M, Saccenti E, Madsen MB, Hansen MB, Hyldegaard O, Skrede S, Martins Dos Santos VAP, Norrby-Teglund A, Svensson M. Integrated Univariate, Multivariate, and Correlation-Based Network Analyses Reveal Metabolite-Specific Effects on Bacterial Growth and Biofilm Formation in Necrotizing Soft Tissue Infections. J Proteome Res 2020; 19:688-698. [PMID: 31833369 DOI: 10.1021/acs.jproteome.9b00565] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Necrotizing soft-tissue infections (NSTIs) have multiple causes, risk factors, anatomical locations, and pathogenic mechanisms. In patients with NSTI, circulating metabolites may serve as a substrate having impact on bacterial adaptation at the site of infection. Metabolic signatures associated with NSTI may reveal the potential to be useful as diagnostic and prognostic markers and novel targets for therapy. This study used untargeted metabolomics analyses of plasma from NSTI patients (n = 34) and healthy (noninfected) controls (n = 24) to identify the metabolic signatures and connectivity patterns among metabolites associated with NSTI. Metabolite-metabolite association networks were employed to compare the metabolic profiles of NSTI patients and noninfected surgical controls. Out of 97 metabolites detected, the abundance of 33 was significantly altered in NSTI patients. Analysis of metabolite-metabolite association networks showed a more densely connected network: specifically, 20 metabolites differentially connected between NSTI and controls. A selected set of significantly altered metabolites was tested in vitro to investigate potential influence on NSTI group A streptococcal strain growth and biofilm formation. Using chemically defined media supplemented with the selected metabolites, ornithine, ribose, urea, and glucuronic acid, revealed metabolite-specific effects on both bacterial growth and biofilm formation. This study identifies for the first time an NSTI-specific metabolic signature with implications for optimized diagnostics and therapies.
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Affiliation(s)
- Muhammad Afzal
- Center for Infectious Medicine, Department of Medicine, ANA Futura, Karolinska Institutet , Karolinska University Hospital , Alfred Nobels Allé 8 , 141 52 Huddinge , Sweden
| | - Edoardo Saccenti
- Laboratory of Systems and Synthetic Biology , Wageningen University & Research , Stippeneng 4 , Wageningen 6708 WE , The Netherlands
| | - Martin Bruun Madsen
- Department of Intensive Care , Copenhagen University Hospital, Rigshospitalet , Copenhagen 2100 , Denmark
| | - Marco Bo Hansen
- Hyperbaric Unit, Department of Anesthesia, Center of Head and Orthopedics , Rigshospitalet, University of Copenhagen , Blegdamsvej 9 , Copenhagen DK-2100 , Denmark
| | - Ole Hyldegaard
- Department of Intensive Care , Copenhagen University Hospital, Rigshospitalet , Copenhagen 2100 , Denmark
| | - Steinar Skrede
- Department of Medicine , Haukeland University Hospital , Bergen N-5021 , Norway.,Department of Clinical Science , University of Bergen , Bergen N-5020 , Norway
| | - Vitor A P Martins Dos Santos
- Laboratory of Systems and Synthetic Biology , Wageningen University & Research , Stippeneng 4 , Wageningen 6708 WE , The Netherlands
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine, ANA Futura, Karolinska Institutet , Karolinska University Hospital , Alfred Nobels Allé 8 , 141 52 Huddinge , Sweden
| | - Mattias Svensson
- Center for Infectious Medicine, Department of Medicine, ANA Futura, Karolinska Institutet , Karolinska University Hospital , Alfred Nobels Allé 8 , 141 52 Huddinge , Sweden
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19
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Bergsten H, Madsen MB, Bergey F, Hyldegaard O, Skrede S, Arnell P, Oppegaard O, Itzek A, Perner A, Svensson M, Norrby-Teglund A, Nekludov M, Kjellberg A, Bruun T, Nedrebø T, Skutlaberg DH, Babbar A, Rosén A, Martins dos Santos VAP, Nekludov M, Kjellberg A, Bruun T, Nedrebø T, Skutlaberg DH, Babbar A, Rosén A, Martins dos Santos VAP. Correlation Between Immunoglobulin Dose Administered and Plasma Neutralization of Streptococcal Superantigens in Patients With Necrotizing Soft Tissue Infections. Clin Infect Dis 2020; 71:1772-1775. [DOI: 10.1093/cid/ciaa022] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Accepted: 01/08/2020] [Indexed: 12/18/2022] Open
Abstract
Abstract
Analyses of plasma collected pre- and postadministration of intravenous immunoglobulin (IVIG) from patients with group A Streptococcus necrotizing soft tissue infections demonstrated a negative correlation between IVIG dose and toxin-triggered T-cell proliferation (r = −.67, P < .0001). One 25-g IVIG dose was sufficient to yield plasma-neutralizing activity against streptococcal superantigens.
Clinical Trials Registration. NCT 01790698 and NCT02111161.
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Affiliation(s)
- Helena Bergsten
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Huddinge, Stockholm, Sweden
| | - Martin Bruun Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | | | - Ole Hyldegaard
- Department of Anesthesia and Surgery, Hyperbaric Unit, Head and Orthopedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
- Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Per Arnell
- Department of Anesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Andreas Itzek
- Helmholtz Centre for Infection Research, Braunschweig, Germany
| | - Anders Perner
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Mattias Svensson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Huddinge, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital Huddinge, Huddinge, Stockholm, Sweden
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20
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Abstract
β-hemolytic streptococci are major causes of necrotizing soft tissue infections (NSTIs), Streptococcus pyogenes (group A streptococcus; GAS) in particular. NSTIs caused by Streptococcus dysgalactiae (SD) have also been reported. In the INFECT cohort of 409 NSTIs patients, more than a third of the cases were caused by GAS (31%) or SD (7%). Risk factors of streptococcal NSTIs compared to streptococcal cellulitis have previously been largely unknown. The INFECT study confirmed blunt trauma as an important risk factor. In addition, absence of pre-existing skin lesions and a lower BMI were associated with NSTIs. The study also confirmed that septic shock is more frequent in GAS cases than in other types of NSTIs. Septic shock was also among several predictors of mortality. The role of intravenous immunoglobulin (IVIG) in streptococcal NSTIs has been unclear. In the INFECT cohort, IVIG treatment was associated with increased survival. As in other studies, a significant microbial diversity was observed, but with predominance of a few emm types. Overall, the INFECT study gives a comprehensive and contemporary picture of the clinical characteristics and the microbes involved in streptococcal NSTIs. The reported severity of disease underscores the need for new efforts aimed at identifying novel diagnostic measures and improved treatment.
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Affiliation(s)
- Trond Bruun
- Department of Clinical Science, University of Bergen, Bergen, Norway.
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Eivind Rath
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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21
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Siemens N, Oehmcke-Hecht S, Hoßmann J, Skorka SB, Nijhuis RHT, Ruppen C, Skrede S, Rohde M, Schultz D, Lalk M, Itzek A, Pieper DH, van den Bout CJ, Claas ECJ, Kuijper EJ, Mauritz R, Sendi P, Wunderink HF, Norrby-Teglund A. Prothrombotic and Proinflammatory Activities of the β-Hemolytic Group B Streptococcal Pigment. J Innate Immun 2019; 12:291-303. [PMID: 31743913 DOI: 10.1159/000504002] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2019] [Accepted: 10/06/2019] [Indexed: 12/29/2022] Open
Abstract
A prominent feature of severe streptococcal infections is the profound inflammatory response that contributes to systemic toxicity. In sepsis the dysregulated host response involves both immunological and nonimmunological pathways. Here, we report a fatal case of an immunocompetent healthy female presenting with toxic shock and purpura fulminans caused by group B streptococcus (GBS; serotype III, CC19). The strain (LUMC16) was pigmented and hyperhemolytic. Stimulation of human primary cells with hyperhemolytic LUMC16 and STSS/NF-HH strains and pigment toxin resulted in a release of proinflammatory mediators, including tumor necrosis factor, interleukin (IL)-1β, and IL-6. In addition, LUMC16 induced blood clotting and showed factor XII activity on its surface, which was linked to the presence of the pigment. The expression of pigment was not linked to a mutation within the CovR/S region. In conclusion, our study shows that the hemolytic lipid toxin contributes to the ability of GBS to cause systemic hyperinflammation and interferes with the coagulation system.
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Affiliation(s)
- Nikolai Siemens
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden, .,Center for Functional Genomics of Microbes, Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany,
| | - Sonja Oehmcke-Hecht
- Institute of Medical Microbiology, Virology, and Hygiene, University Medicine Rostock, Rostock, Germany
| | - Jörn Hoßmann
- Microbial Interactions and Processes, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | - Sebastian B Skorka
- Center for Functional Genomics of Microbes, Department of Molecular Genetics and Infection Biology, University of Greifswald, Greifswald, Germany
| | - Roel H T Nijhuis
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Microbiology and Medical Immunology, Meander Medical Center, Amersfoort, The Netherlands
| | - Corinne Ruppen
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Manfred Rohde
- Central Facility for Microscopy, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | - Daniel Schultz
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Michael Lalk
- Institute of Biochemistry, University of Greifswald, Greifswald, Germany
| | - Andreas Itzek
- Microbial Interactions and Processes, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | - Dietmar H Pieper
- Microbial Interactions and Processes, Helmholtz Centre for Infection Research - HZI, Braunschweig, Germany
| | | | - Eric C J Claas
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Ed J Kuijper
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Robert Mauritz
- Department of Intensive Care Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Parham Sendi
- Institute for Infectious Diseases, University of Bern, Bern, Switzerland
| | - Herman F Wunderink
- Department of Medical Microbiology, Leiden University Medical Center, Leiden, The Netherlands.,Department of Medical Microbiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Department of Medicine Huddinge, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
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22
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Thänert R, Itzek A, Hoßmann J, Hamisch D, Madsen MB, Hyldegaard O, Skrede S, Bruun T, Norrby-Teglund A, Medina E, Pieper DH. Molecular profiling of tissue biopsies reveals unique signatures associated with streptococcal necrotizing soft tissue infections. Nat Commun 2019; 10:3846. [PMID: 31451691 PMCID: PMC6710258 DOI: 10.1038/s41467-019-11722-8] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 12/02/2018] [Accepted: 07/25/2019] [Indexed: 12/21/2022] Open
Abstract
Necrotizing soft tissue infections (NSTIs) are devastating infections caused by either a single pathogen, predominantly Streptococcus pyogenes, or by multiple bacterial species. A better understanding of the pathogenic mechanisms underlying these different NSTI types could facilitate faster diagnostic and more effective therapeutic strategies. Here, we integrate microbial community profiling with host and pathogen(s) transcriptional analysis in patient biopsies to dissect the pathophysiology of streptococcal and polymicrobial NSTIs. We observe that the pathogenicity of polymicrobial communities is mediated by synergistic interactions between community members, fueling a cycle of bacterial colonization and inflammatory tissue destruction. In S. pyogenes NSTIs, expression of specialized virulence factors underlies infection pathophysiology. Furthermore, we identify a strong interferon-related response specific to S. pyogenes NSTIs that could be exploited as a potential diagnostic biomarker. Our study provides insights into the pathophysiology of mono- and polymicrobial NSTIs and highlights the potential of host-derived signatures for microbial diagnosis of NSTIs.
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Affiliation(s)
- Robert Thänert
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Andreas Itzek
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Jörn Hoßmann
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Domenica Hamisch
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Martin Bruun Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Ole Hyldegaard
- Department of Anaesthesia, Centre of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Trond Bruun
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | | | - Eva Medina
- Infection Immunity Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany
| | - Dietmar H Pieper
- Microbial Interactions and Processes Research Group, Helmholtz Center for Infection Research, Braunschweig, Germany.
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23
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Madsen MB, Skrede S, Perner A, Arnell P, Nekludov M, Bruun T, Karlsson Y, Hansen MB, Polzik P, Hedetoft M, Rosén A, Saccenti E, Bergey F, Martins dos Santos VAP, Norrby-Teglund A, Hyldegaard O. Patient’s characteristics and outcomes in necrotising soft-tissue infections: results from a Scandinavian, multicentre, prospective cohort study. Intensive Care Med 2019; 45:1241-1251. [DOI: 10.1007/s00134-019-05730-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 08/02/2019] [Indexed: 12/19/2022]
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24
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Peetermans M, de Prost N, Eckmann C, Norrby-Teglund A, Skrede S, De Waele JJ. Necrotizing skin and soft-tissue infections in the intensive care unit. Clin Microbiol Infect 2019; 26:8-17. [PMID: 31284035 DOI: 10.1016/j.cmi.2019.06.031] [Citation(s) in RCA: 62] [Impact Index Per Article: 12.4] [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: 03/23/2019] [Revised: 06/19/2019] [Accepted: 06/22/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND Necrotizing skin and soft-tissue infections (NSTI) are rare but potentially life-threatening and disabling infections that often require intensive care unit admission. OBJECTIVES To review all aspects of care for a critically ill individual with NSTI. SOURCES Literature search using Medline and Cochrane library, multidisciplinary panel of experts. CONTENT The initial presentation of a patient with NSTI can be misleading, as features of severe systemic toxicity can obscure sometimes less impressive skin findings. The infection can spread rapidly, and delayed surgery worsens prognosis, hence there is a limited role for additional imaging in the critically ill patient. Also, the utility of clinical scores is contested. Prompt surgery with aggressive debridement of necrotic tissue is required for source control and allows for microbiological sampling. Also, prompt administration of broad-spectrum antimicrobial therapy is warranted, with the addition of clindamycin for its effect on toxin production, both in empirical therapy, and in targeted therapy for monomicrobial group A streptococcal and clostridial NSTI. The role of immunoglobulins and hyperbaric oxygen therapy remains controversial. IMPLICATIONS Close collaboration between intensive care, surgery, microbiology and infectious diseases, and centralization of care is fundamental in the approach to the severely ill patient with NSTI. As many aspects of management of these rare infections are supported by low-quality data only, multicentre trials are urgently needed.
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Affiliation(s)
- M Peetermans
- Department of Critical Care, Guy's and St. Thomas' NHS Foundation Trust, London, United Kingdom
| | - N de Prost
- Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor-Albert Chenevier, Assistance Publique-Hôpitaux de Paris, Créteil, France; Groupe de Recherche Clinique CARMAS, Université Paris-Est Créteil, IMRB, Créteil, France
| | - C Eckmann
- Department of General, Visceral and Thoracic Surgery, Klinikum Peine, Academic Hospital of Medical University Hannover, Germany
| | - A Norrby-Teglund
- Centre for Infectious Medicine, Karolinska Institute, Karolinska University Hospital, Huddinge, Sweden
| | - S Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway
| | - J J De Waele
- Department of Critical Care Medicine, Ghent University Hospital, Ghent, Belgium.
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25
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Todnem Sakkestad S, Steinsland H, Skrede S, Kleppa E, Lillebø K, Sævik M, Søyland H, Rykkje Heien A, Gjerde Tellevik M, Barry EM, Sommerfelt H, Hanevik K. Experimental Infection of Human Volunteers with the Heat-Stable Enterotoxin-Producing Enterotoxigenic Escherichia coli Strain TW11681. Pathogens 2019; 8:pathogens8020084. [PMID: 31234485 PMCID: PMC6630672 DOI: 10.3390/pathogens8020084] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [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: 05/24/2019] [Revised: 06/17/2019] [Accepted: 06/20/2019] [Indexed: 12/03/2022] Open
Abstract
Infection with enterotoxigenic Escherichia coli (ETEC) producing the heat-stable enterotoxin (ST) is one of the most important causes of childhood diarrhoea in low- and middle-income countries. Here, we undertook a controlled human infection model (CHIM) study to investigate whether ST-producing ETEC strain TW11681 would be suitable for testing the protective efficacy of new ST-based vaccine candidates in vaccine challenge models. In groups of three, nine volunteers ingested 1 × 106, 1 × 107, or 1 × 108 colony-forming units (CFU) of TW11681. Flow cytometry-based assays were used to measure CD4+ T cell responses and antibody levels targeting virulence factors expressed by the strain. We found that infection with TW11681 elicited few and mild symptoms, including mild diarrhoea in two volunteers, both of whom ingested 1 × 106 CFU. Averaged across all volunteers, the CD4+ T cell responses specific for E. coli YghJ mucinase peaked 10 days after infection (3.2-fold (p = 0.016)), while the CD4+ T cell responses specific for Colonization Factor Antigen I (CFA/I) major fimbrial subunit (CfaB) peaked after 28 days (3.6-fold (p = 0.063)). The serum CfaB-specific anti-IgA and anti-IgG/IgM levels were significantly increased and peaked 3 months after infection. Both remained elevated for the duration of the 12-month follow-up. The corresponding anti-YghJ serological response was strongest after 10 days, although a significant increase was seen only for IgA levels (3.2-fold (p = 0.008)). In conclusion, due to its low diarrhoea attack risk, TW11681 is probably not suitable for testing the efficacy of new vaccines in human challenge studies at doses 1 × 106 to 1 × 108. However, the strain may still be useful in CHIMs for studying ETEC host-pathogen interactions.
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Affiliation(s)
- Sunniva Todnem Sakkestad
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Postbox 7804, 5020 Bergen, Norway; (S.T.S.); steinar.skrede@helse-bergen-no (S.S.)
| | - Hans Steinsland
- Centre for International Health, Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Postbox 7894, 5020 Bergen, Norway;
- Department of Biomedicine, Faculty of Medicine, University of Bergen, Postbox 7804, 5020 Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Postbox 7804, 5020 Bergen, Norway; (S.T.S.); steinar.skrede@helse-bergen-no (S.S.)
- Division for Infectious Diseases, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway; (K.L.); (M.S.); (H.S.); (A.R.H.)
| | - Elisabeth Kleppa
- Department of Microbiology, Haukeland University Hospital, 5021 Bergen, Norway;
| | - Kristine Lillebø
- Division for Infectious Diseases, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway; (K.L.); (M.S.); (H.S.); (A.R.H.)
| | - Marianne Sævik
- Division for Infectious Diseases, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway; (K.L.); (M.S.); (H.S.); (A.R.H.)
| | - Hanne Søyland
- Division for Infectious Diseases, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway; (K.L.); (M.S.); (H.S.); (A.R.H.)
| | - Astrid Rykkje Heien
- Division for Infectious Diseases, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway; (K.L.); (M.S.); (H.S.); (A.R.H.)
| | - Marit Gjerde Tellevik
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway;
| | - Eileen M. Barry
- Center for Vaccine Development and Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA;
| | - Halvor Sommerfelt
- Centre for Intervention Science in Material and Child Health (CISMAC), Department of Global Public Health and Primary Care, Faculty of Medicine, University of Bergen, Postbox 7804, 5020 Bergen, Norway;
- Norwegian Institute of Public Health, 222 Oslo Postbox, Norway
| | - Kurt Hanevik
- Department of Clinical Science, Faculty of Medicine, University of Bergen, Postbox 7804, 5020 Bergen, Norway; (S.T.S.); steinar.skrede@helse-bergen-no (S.S.)
- Norwegian National Advisory Unit on Tropical Infectious Diseases, Department of Medicine, Haukeland University Hospital, 5021 Bergen, Norway;
- Correspondence: ; Tel.: +47-55-97-30-79
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26
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Skrede S. Riktige prioriteringer ved sepsis. Tidsskriftet 2019; 139:19-0320. [DOI: 10.4045/tidsskr.19.0320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
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27
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Rosén A, Arnell P, Madsen MB, Nedrebø BG, Norrby-Teglund A, Hyldegaard O, Dos Santos VM, Bergey F, Saccenti E, Skrede S. Diabetes and necrotizing soft tissue infections-A prospective observational cohort study: Statistical analysis plan. Acta Anaesthesiol Scand 2018; 62:1171-1177. [PMID: 29671865 DOI: 10.1111/aas.13130] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [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: 12/08/2017] [Revised: 03/09/2018] [Accepted: 03/21/2018] [Indexed: 12/26/2022]
Abstract
BACKGROUND Necrotizing soft tissue infections (NSTIs) are rare but carry a high morbidity and mortality. The multicenter INFECT project aims to improve the understanding of the pathogenesis, clinical characteristics, diagnosis, and prognosis of NSTIs. This article describes the study outline and statistical analyses that will be used. METHODS Within the framework of INFECT project, patients with NSTI at 5 Scandinavian hospitals are enrolled in a prospective observational cohort study. The goal is to evaluate outcome and characteristics for patients with NSTI and diabetes compared to patients with NSTI without diabetes. The primary outcome is mortality at 90 days after inclusion. Secondary outcomes include days alive and out of ICU and hospital, SAPS II, SOFA score, infectious etiology, amputation, affected body area, and renal replacement therapy. Comparison in mortality between patients with diabetes type 1 and 2 as well as between insulin-treated and non-insulin-treated diabetes patients will be made. Clinical data for diabetic patients with NSTI will be reported. CONCLUSION The study will provide important data on patients with NSTI and diabetes.
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Affiliation(s)
- A Rosén
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden
| | - P Arnell
- Department of Anaesthesia and Intensive Care Medicine, Sahlgrenska University Hospital/Ostra, Gothenburg, Sweden
| | - M B Madsen
- Department of Intensive Care, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - B G Nedrebø
- Department of Medicine, Haugesund County Hospital, Haugesund, Norway
- Department of Clinical Science, University of Bergen, Bergen, Norway
| | - A Norrby-Teglund
- Centre for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - O Hyldegaard
- Department of Anaesthesia, Center of Head and Orthopaedics, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - V M Dos Santos
- LifeGlimmer GmbH, Berlin, Germany
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, The Netherlands
| | - F Bergey
- LifeGlimmer GmbH, Berlin, Germany
| | - E Saccenti
- Laboratory of Systems and Synthetic Biology, Wageningen University & Research, Wageningen, The Netherlands
| | - S Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
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28
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Mosevoll KA, Skrede S, Markussen DL, Fanebust HR, Flaatten HK, Aßmus J, Reikvam H, Bruserud Ø. Inflammatory Mediator Profiles Differ in Sepsis Patients With and Without Bacteremia. Front Immunol 2018; 9:691. [PMID: 29681903 PMCID: PMC5897503 DOI: 10.3389/fimmu.2018.00691] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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: 10/27/2017] [Accepted: 03/20/2018] [Indexed: 12/29/2022] Open
Abstract
Systemic levels of cytokines are altered during infection and sepsis. This prospective observational study aimed to investigate whether plasma levels of multiple inflammatory mediators differed between sepsis patients with and those without bacteremia during the initial phase of hospitalization. A total of 80 sepsis patients with proven bacterial infection and no immunosuppression were included in the study. Plasma samples were collected within 24 h of hospitalization, and Luminex® analysis was performed on 35 mediators: 16 cytokines, six growth factors, four adhesion molecules, and nine matrix metalloproteases (MMPs)/tissue inhibitors of metalloproteinases (TIMPs). Forty-two patients (52.5%) and 38 (47.5%) patients showed positive and negative blood cultures, respectively. There were significant differences in plasma levels of six soluble mediators between the two “bacteremia” and “non-bacteremia” groups, using Mann–Whitney U test (p < 0.0014): tumor necrosis factor alpha (TNFα), CCL4, E-selectin, vascular cell adhesion molecule-1 (VCAM-1), intracellular adhesion molecule-1 (ICAM-1), and TIMP-1. Ten soluble mediators also significantly differed in plasma levels between the two groups, with p-values ranging between 0.05 and 0.0014: interleukin (IL)-1ra, IL-10, CCL2, CCL5, CXCL8, CXCL11, hepatocyte growth factor, MMP-8, TIMP-2, and TIMP-4. VCAM-1 showed the most robust results using univariate and multivariate logistic regression. Using unsupervised hierarchical clustering, we found that TNFα, CCL4, E-selectin, VCAM-1, ICAM-1, and TIMP-1 could be used to discriminate between patients with and those without bacteremia. Patients with bacteremia were mainly clustered in two separate groups (two upper clusters, 41/42, 98%), with higher levels of the mediators. One (2%) patient with bacteremia was clustered in the lower cluster, which compromised most of the patients without bacteremia (23/38, 61%) (χ2 test, p < 0.0001). Our study showed that analysis of the plasma inflammatory mediator profile could represent a potential strategy for early identification of patients with bacteremia.
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Affiliation(s)
- Knut Anders Mosevoll
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | | | | | | | - Jörg Aßmus
- Centre for Clinical Research, Haukeland University Hospital, Bergen, Norway
| | - Håkon Reikvam
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Øystein Bruserud
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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29
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Oppegaard O, Mylvaganam H, Skrede S, Kittang BR. Exploring the arthritogenicity of Streptococcus dysgalactiae subspecies equisimilis. BMC Microbiol 2018; 18:17. [PMID: 29482512 PMCID: PMC5828338 DOI: 10.1186/s12866-018-1160-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [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: 08/16/2017] [Accepted: 02/20/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND During the past decades, Streptococcus dysgalactiae subspecies equisimilis (SDSE) has been increasingly recognized as an important human pathogen. Osteoarticular infections is one of the predominant disease manifestations of SDSE, but the pathogenetic rationale for its arthritogenicity has yet to be unravelled. We aimed to explore if the rising incidence of osteoarticular infections caused by this pathogen in our region emanated from clonal expansion of strains with enhanced tropism for bone and joint tissue components or orthopaedic implants. RESULTS Twenty-nine SDSE-isolates associated with osteoarticular infections were retrospectively identified. Their genomic content and affinity for fibronectin, collagen and stainless steel were compared to 24 temporally and geographically matched SDSE blood culture isolates obtained from patients without bone or joint infections. Despite a thorough genetic and phenotypic dissection, neither the presence or absence of any single gene, nor the binding abilities of the SDSE isolates, were predictive of clinical entity. SNP analysis revealed a heterogenous population, and a correlation between phylogenetic relationships and disease manifestation was not evident. However, we identified a strong concordance between phenotypic binding abilities and genetic variations in the pilus-region, also denoted as the FCT-region (Fibronectin binding, Collagen binding and T-antigen). This observation could be related to the ample and varied repertoire of putative adhesins residing within this region, including proteins predicted to adhere to fibronectin and collagen, as well as fibrinogen. CONCLUSIONS SDSE strains associated with osteoarticular infections do not emanate from subpopulation characterized by distinct genetic or phenotypic traits. The genetic architecture of the pilus region was predictive of the adhesive properties of the SDSE-isolates, but its role in tissue tropism needs further investigation. To the best of our knowledge, this is the first comprehensive characterization of the genetic landscape of the SDSE pilus region.
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Affiliation(s)
- Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway. .,Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Haima Mylvaganam
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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30
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Madsen MB, Skrede S, Bruun T, Arnell P, Rosén A, Nekludov M, Karlsson Y, Bergey F, Saccenti E, Martins dos Santos VAP, Perner A, Norrby-Teglund A, Hyldegaard O. Necrotizing soft tissue infections - a multicentre, prospective observational study (INFECT): protocol and statistical analysis plan. Acta Anaesthesiol Scand 2018; 62:272-279. [PMID: 29082520 DOI: 10.1111/aas.13024] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 10/08/2017] [Indexed: 12/18/2022]
Abstract
BACKGROUND The INFECT project aims to advance our understanding of the pathophysiological mechanisms in necrotizing soft tissue infections (NSTIs). The INFECT observational study is part of the INFECT project with the aim of studying the clinical profile of patients with NSTIs and correlating these to patient-important outcomes. With this protocol and statistical analysis plan we describe the methods used to obtain data and the details of the planned analyses. METHODS The INFECT study is a multicentre, prospective observational cohort study. Patients with NSTIs are enrolled in five Scandinavian hospitals, which are all referral centres for NSTIs. The primary outcomes are the descriptive variables of the patients. Secondary outcomes include identification of factors associated with 90-day mortality and amputation; associations between affected body part, maximum skin defect and Laboratory Risk Indicator for Necrotizing Fasciitis (LRINEC) score and 90-day mortality; 90-day mortality in patients with and without acute kidney injury (AKI) and LRINEC score of six and above or below six; and association between affected body part at arrival and microbiological findings. Exploratory outcomes include univariate analyses of baseline characteristics associations with 90-day mortality. The statistical analyses will be conducted in accordance with the predefined statistical analysis plan. CONCLUSION Necrotizing soft tissue infections result in severe morbidity and mortality. The INFECT study will be the largest prospective study in patients with NSTIs to date and will provide important data for clinicians, researchers and policy makers on the characteristics and outcomes of these patients.
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Affiliation(s)
- M. B. Madsen
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - S. Skrede
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - T. Bruun
- Department of Medicine; Haukeland University Hospital; Bergen Norway
| | - P. Arnell
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - A. Rosén
- Department of Anaesthesia and Intensive Care; Sahlgrenska University Hospital; Gothenburg Sweden
| | - M. Nekludov
- Department of Anaesthesia; Surgical Services and Intensive Care; Karolinska Institutet; Karolinska University Hospital; Stockholm Sweden
| | - Y. Karlsson
- Department of Anaesthesiology and Intensive Care; Blekinge County Hospital; Karlskrona Sweden
| | | | - E. Saccenti
- Laboratory of Systems and Synthetic Biology; Wageningen University & Research; Wageningen the Netherlands
| | - V. A. P. Martins dos Santos
- LifeGlimmer GmBH; Berlin Germany
- Laboratory of Systems and Synthetic Biology; Wageningen University & Research; Wageningen the Netherlands
| | - A. Perner
- Department of Intensive Care; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
| | - A. Norrby-Teglund
- Centre for Infectious Medicine; Karolinska Institutet; Karolinska University Hospital; Huddinge Sweden
| | - O. Hyldegaard
- Department of Anaesthesia; Centre of Head and Orthopaedics; Copenhagen University Hospital; Rigshospitalet; Copenhagen Denmark
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Sriskandarajah S, Bostad L, Myklebust TÅ, Møller B, Skrede S, Bjørneklett R. Cancer in ANCA-Associated Glomerulonephritis: A Registry-Based Cohort Study. Int J Nephrol 2017; 2017:6013038. [PMID: 29403663 PMCID: PMC5748316 DOI: 10.1155/2017/6013038] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [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: 09/22/2017] [Accepted: 11/27/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Immunosuppressive therapy for antineutrophil cytoplasmic antibody-associated vasculitis has been associated with increased malignancy risk. OBJECTIVES To quantify the cancer risk associated with contemporary cyclophosphamide-sparing protocols. METHODS Patients from the Norwegian Kidney Biopsy Registry between 1988 and 2012 who had biopsy-verified pauci-immune glomerulonephritis and positive antineutrophil cytoplasmic antibody (ANCA) serology were included. Standardised incidence ratios (SIRs) were calculated to compare the study cohort with the general population. RESULTS The study cohort included 419 patients. During 3010 person-years, cancer developed in 41 patients (9.79%); the expected number of cancer cases was 37.5 (8.95%). The cohort had SIRs as follows: 1.09, all cancer types (95% CI, 0.81 to 1.49); 0.96, all types except nonmelanoma skin cancer (95% CI, 0.69 to 1.34); 3.40, nonmelanoma skin cancer (95% CI, 1.62 to 7.14); 3.52, hematologic cancer (95% CI, 1.32 to 9.37); 2.12, posttransplant cancer (95% CI, 1.01 to 4.44); and 1.53, during the 1-5-year follow-up after diagnosis (95% CI, 1.01 to 2.32). CONCLUSIONS Cancer risk did not increase significantly in this cohort with ANCA-associated glomerulonephritis. However, increased risk of nonmelanoma skin cancer, posttransplant cancer, and hematologic cancer indicates an association between immunosuppression and malignancy.
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Affiliation(s)
| | - Leif Bostad
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Department of Pathology, Haukeland University Hospital, Bergen, Norway
| | - Tor Åge Myklebust
- Department of Clinical and Registry-Based Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research, Oslo, Norway
| | - Bjørn Møller
- Department of Clinical and Registry-Based Research, Cancer Registry of Norway, Institute of Population-Based Cancer Research, Oslo, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Rune Bjørneklett
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Emergency Care Clinic, Haukeland University Hospital, Bergen, Norway
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Knoop ST, Skrede S, Langeland N, Flaatten HK. Epidemiology and impact on all-cause mortality of sepsis in Norwegian hospitals: A national retrospective study. PLoS One 2017; 12:e0187990. [PMID: 29149187 PMCID: PMC5693291 DOI: 10.1371/journal.pone.0187990] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [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: 07/04/2017] [Accepted: 10/30/2017] [Indexed: 12/29/2022] Open
Abstract
Background Although sepsis is the leading cause of death from infection, there are few population-level epidemiological sepsis reports. The impact of sepsis-related deaths on all-cause hospital mortality is insufficiently described, in particular in Europe where data are non-existent. The objective of this study was to provide nationwide epidemiological results on sepsis hospitalizations in Norway and to estimate sepsis’ contribution to overall hospital mortality in a European setting. Methods We performed a retrospective study using data from the Norwegian Patient Registry and Statistics Norway. The occurrence, patient characteristics and outcomes of sepsis hospitalizations during the years 2011 and 2012 were estimated and compared with Norwegian population data. Sepsis was defined as organ dysfunction caused by a dysregulated host response to infection and identified with International Classification of Diseases 10th revision codes. Results We identified 18 460 sepsis admissions occurring in 13 582 individuals. The annual population incidence of hospitalized sepsis was 140 patients per 100 000 inhabitants; ranging from 10 to 2270 per 100 000 in different age groups and with statistically significant male predominance in all adult cohorts. Hospital mortality for sepsis admissions was 19.4% and overall, 26.4% of the included patients died while hospitalized for sepsis. Sepsis related deaths constituted 12.9% of all hospital fatalities, while hospitalizations with sepsis accounted for 1.0% of the total number of admissions and 3.5% of the total admission days during 2011 and 2012. Conclusions This study confirms that hospitalized sepsis is frequent in Norway and a major contributor to hospital fatalities in a European setting. The incidence is higher among men than women. Sepsis is in particular a disease of the elderly, and its impact on health-care will assumingly continue to increase in parallel with an aging population. Improvements in treatment and survival of sepsis could influence population mortality, and sepsis should receive greater attention in official death statistics in the future.
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Affiliation(s)
- Siri Tandberg Knoop
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Nina Langeland
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Hans Kristian Flaatten
- Department of Anaesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
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Oppegaard O, Mylvaganam H, Skrede S, Lindemann PC, Kittang BR. Emergence of a Streptococcus dysgalactiae subspecies equisimilis stG62647-lineage associated with severe clinical manifestations. Sci Rep 2017; 7:7589. [PMID: 28790435 PMCID: PMC5548910 DOI: 10.1038/s41598-017-08162-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [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: 04/25/2017] [Accepted: 07/07/2017] [Indexed: 12/03/2022] Open
Abstract
Increasing incidence rates of invasive Streptococcus dysgalactiae subspecies equisimilis (SDSE) infections have been reported worldwide, but the evolutionary mechanisms underlying this development remain elusive. Through prospective surveillance of invasive SDSE infections in western Norway, we observed the emergence of a novel and virulent SDSE genotype, stG62647. This emm-type, rarely encountered as a cause of invasive disease during 1999–2012, emerged in 2013 as the predominant SDSE-genotype. The stG62647-infections were associated with an aggressive clinical course, including the occurrence of streptococcal toxic shock syndrome, necrotizing soft-tissue infections and endocarditis. All the invasive stG62647-isolates were subjected to whole genome sequencing, attempting to explore the genetic events underpinning its epidemicity. Although 10% of the genomes was unique for stG62647-genotype, notably 18 out of 19 isolates contained a disrupted streptococcal invasive locus (sil) due to the insertion of a transposase, IS1548, into the silB-gene. We postulate that the virulence of stG6267-isolates could be partly attributable to the abrogation of the attenuating control normally exerted by this regulon, although experimental verification was not performed. To the best of our knowledge, this is the first study employing large scale whole genome sequencing to illuminate the genetic landscape of epidemic lineages in SDSE.
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Affiliation(s)
- Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway. .,Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Haima Mylvaganam
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
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Abstract
BACKGROUND In the early 20th century, the face was the predominant site of cellulitis. Despite a relative decrease in the incidence of facial cellulitis, it is still common. There are few studies on this condition during the last decades. The aim of this study was to describe contemporary aetiological and clinical characteristics of patients admitted to hospital with non-suppurative facial cellulitis. METHODS Patients were included prospectively. Clinical details, comorbidities and biochemistry results were recorded. Investigations included cultures of skin swab and blood and tests for streptococcal antibodies during the acute and convalescent stages. RESULTS Sixty-five patients were included. Serology, cultures and response to penicillin monotherapy identified probable or confirmed β-haemolytic streptococci (BHS) aetiology in 75% (49/65) of cases. Significant comorbidities were present in 54% (35/65). Fever, chills or rigors before or at admission was noted in 91% (59/65). Patients presented most often with sharply demarcated erythema and raised borders (54/64). Penicillin or penicillinase-resistant penicillin alone or in combination cured 68% (44/65) of the patients. Supplementary clindamycin was used in 28% (18/65), most often only for 1-3 days. Only four patients needed a second course of antibiotics. Clinical failure was more often seen in patients with non-BHS aetiology (p = .037). Few complications were noted; 14.5% (9/62) experienced transient diarrhoea, and only one had confirmed Clostridium difficile infection. No patients developed cerebral venous sinus thrombosis, and there were no fatalities. CONCLUSIONS Our findings indicate that BHS are the leading cause of facial cellulitis. Most patients exhibit sharply demarcated lesions and systemic symptoms. Narrow-spectrum β-lactam antibiotics and short hospital stay appear sufficient. Few complications and low recurrence rates were seen.
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Affiliation(s)
- Eivind Rath
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Steinar Skrede
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
| | - Haima Mylvaganam
- c Department of Microbiology and Immunology , Haukeland University Hospital , Bergen , Norway
| | - Trond Bruun
- a Department of Clinical Science , University of Bergen , Bergen , Norway.,b Department of Medicine , Haukeland University Hospital , Bergen , Norway
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Oppegaard O, Mylvaganam H, Skrede S, Jordal S, Glambek M, Kittang BR. Clinical and molecular characteristics of infective β-hemolytic streptococcal endocarditis. Diagn Microbiol Infect Dis 2017; 89:135-142. [PMID: 28780243 DOI: 10.1016/j.diagmicrobio.2017.06.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [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: 03/27/2017] [Revised: 06/15/2017] [Accepted: 06/23/2017] [Indexed: 10/19/2022]
Abstract
Streptococcus pyogenes (S. pyogenes) and Streptococcus dysgalactiae subspecies equisimilis (SDSE) cause considerable morbidity and mortality, and show similarities in disease manifestations and pathogenic mechanisms. Their involvement in infective endocarditis, however, has not been well described. Invasive S. pyogenes and SDSE infections in Health Region Bergen, Norway, in the period 1999-2013 were reviewed, and sixteen cases of endocarditis were identified. The median duration of symptoms was 2.5days, the frequency of embolic events 50%, 38% received valve replacement and the 30-day mortality was 25%. In S. pyogenes, a significant correlation was observed between the repertoire of fibronectin-binding genes, phenotypic binding ability to fibronectin and disease manifestations. Conversely, no associations between phenotypic and genotypic characteristics were detected in SDSE. S. pyogenes and SDSE endocarditis is characterized by rapid and severe clinical manifestations. The pathogenesis is multifactorial, but our results infer a potential role of fibronectin binding in the development of S. pyogenes endocarditis.
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Affiliation(s)
- Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Haima Mylvaganam
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway.
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway; Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Stina Jordal
- Department of Medicine, Haukeland University Hospital, Bergen, Norway.
| | - Marte Glambek
- Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway.
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Kittang BR, Pettersen VK, Oppegaard O, Skutlaberg DH, Dale H, Wiker HG, Skrede S. Zoonotic necrotizing myositis caused by Streptococcus equi subsp. zooepidemicus in a farmer. BMC Infect Dis 2017; 17:147. [PMID: 28201995 PMCID: PMC5312586 DOI: 10.1186/s12879-017-2262-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [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: 11/04/2016] [Accepted: 02/10/2017] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND Streptococcus equi subsp. zooepidemicus is a beta-hemolytic group C streptococcus mainly causing infections in domesticated animals. Here we describe the first case of zoonotic necrotizing myositis caused by this bacterium. CASE PRESENTATION The patient was a 73-year-old, previously healthy farmer with two asymptomatic Shetland ponies in his stable. After close contact with the ponies while feeding them, he rapidly developed erythema of his left thigh and sepsis with multiple organ failure. The clinical course was severe and complicated, requiring repetitive surgical excision of necrotic muscle, treatment with vasopressors, mechanical ventilation and continuous venovenous hemofiltration, along with adjunctive hyperbaric oxygen therapy. The patient was discharged from hospital at day 30, without obvious sequelae. The streptococcal isolate was identified as Streptococcus equi by MALDI-ToF MS, and was later assigned subspecies identification as S. equi subsp. zooepidemicus. Multilocus sequence typing identified the strain as a novel sequence type (ST 364), closely related to types previously identified in horses and cattle. A focused proteomic analysis revealed that the ST 364 expressed putative virulence factors similar to that of Streptococcus pyogenes, including homologues of the M protein, streptodornases, interleukin 8-protease and proteins involved in the biosynthesis of streptolysin S. CONCLUSION This case illustrates the zoonotic potential of S. equi subsp. zooepidemicus and the importance of early clinical recognition, rapid and radical surgical therapy, appropriate antibiotics and adequate supportive measures when necrotizing soft tissue infection is suspected. The expression of Streptococcus pyogenes-like putative virulence determinants in ST 364 might partially explain the fulminant clinical picture.
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Affiliation(s)
| | - Veronika Kuchařová Pettersen
- The Gade Research Group for Infection and Immunity, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Oddvar Oppegaard
- The Gade Research Group for Infection and Immunity, Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Dag Harald Skutlaberg
- The Gade Research Group for Infection and Immunity, Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Håvard Dale
- Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
| | - Harald G Wiker
- The Gade Research Group for Infection and Immunity, Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- The Gade Research Group for Infection and Immunity, Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Nygård ST, Skrede S, Langeland N, Flaatten HK. An observational study of community-acquired severe sepsis comparing intensive care and non-intensive care patients. Acta Anaesthesiol Scand 2017; 61:194-204. [PMID: 28058720 DOI: 10.1111/aas.12848] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2016] [Revised: 11/22/2016] [Accepted: 11/24/2016] [Indexed: 12/26/2022]
Abstract
BACKGROUND Most studies of sepsis are from intensive care units (ICUs). We aimed to investigate community-acquired severe sepsis in a broader population, in order to compare patients treated in or outside an ICU . METHODS We performed a 1-year prospective observational study with enrollment of patients from three units; a general ICU, a combined ICU/non-ICU and a medical ward with limited surveillance facilities. Hospital survivors were followed up for 5 years. RESULTS Overall, 220 patients were included, of which 107 received ICU treatment. The majority of abdominal (77%, P = 0.003) and genitourinary (81%, P < 0.001) infections were found in ICU and non-ICU patients, respectively. Time to first antibiotic administration was longer in ICU-patients (median 3.5 vs. 2.0 h in non-ICU patients, P = 0.011). ICU developed more organ dysfunctions than non-ICU patients (P < 0.001), nevertheless supportive therapy with vasoactive drugs and non-invasive ventilation was documented in 22% and 27% of the latter. Median hospital length of stay was 15 vs. 9 days (P = 0.001), and hospital and 5-year mortality rates 35% vs. 16% (P = 0.002) and 57% vs. 58% (P = 0.892) among ICU and non-ICU patients, respectively. Increasing age (HR 1.06 (1.04, 1.07) per year, P < 0.001), not care level during hospitalization (HR 1.19 (0.70, 2.02), P = 0.514), influenced long-term survival. CONCLUSION Half of the subjects with community-acquired severe sepsis never received ICU treatment. Still, use of organ supportive therapy outside the ICU was considerable. Hospital mortality was higher, whereas 5-year survival was similar when comparing ICU with non-ICU patients.
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Affiliation(s)
- S. T. Nygård
- Department of Medicine; Haukeland University Hospital; Bergen Norway
| | - S. Skrede
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - N. Langeland
- Department of Medicine; Haukeland University Hospital; Bergen Norway
- Department of Clinical Science; University of Bergen; Bergen Norway
| | - H. K. Flaatten
- Department of Anaesthesia and Intensive Care; Haukeland University Hospital; Bergen Norway
- Department of Clinical Medicine; University of Bergen; Bergen Norway
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Steine IM, Zayats T, Stansberg C, Pallesen S, Mrdalj J, Håvik B, Soulé J, Haavik J, Milde AM, Skrede S, Murison R, Krystal J, Grønli J. Implication of NOTCH1 gene in susceptibility to anxiety and depression among sexual abuse victims. Transl Psychiatry 2016; 6:e977. [PMID: 27959334 PMCID: PMC5290341 DOI: 10.1038/tp.2016.248] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2016] [Revised: 10/17/2016] [Accepted: 10/20/2016] [Indexed: 11/22/2022] Open
Abstract
Sexual abuse contributes to the development of multiple forms of psychopathology, including anxiety and depression, but the extent to which genetics contributes to these disorders among sexual abuse victims remains unclear. In this translational study, we first examined gene expression in the brains of rodents exposed to different early-life conditions (long, brief or no maternal separation). Hypothesizing that genes revealing changes in expression may have relevance for psychiatric symptoms later in life, we examined possible association of those genes with symptoms of anxiety and depression in a human sample of sexual abuse victims. Changes in rodent brain gene expression were evaluated by means of correspondence and significance analyses of microarrays by comparing brains of rodents exposed to different early-life conditions. Tag single-nucleotide polymorphisms (SNPs) of resulting candidate genes were genotyped and tested for their association with symptoms of anxiety and depression (Hospital Anxiety and Depression Scale) in a sample of 361 sexual abuse victims, using multinomial logistic regression. False discovery rate was applied to account for multiple testing in the genetic association study, with q-value of 0.05 accepted as significant. We identified four genes showing differential expression among animals subjected to different early-life conditions as well as having potential relevance to neural development or disorders: Notch1, Gabrr1, Plk5 and Zfp644. In the human sample, significant associations were observed for two NOTCH1 tag SNPs: rs11145770 (OR=2.21, q=0.043) and rs3013302 (OR=2.15, q=0.043). Our overall findings provide preliminary evidence that NOTCH1 may be implicated in the susceptibility to anxiety and depression among sexual abuse victims. The study also underscores the potential importance of animal models for future studies on the health consequences of early-life stress and the mechanisms underlying increased risk for psychiatric disorders.
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Affiliation(s)
- I M Steine
- Department of Psychology, University of California, Berkeley, Berkeley, CA, USA,Department of Clinical Psychology, University of Bergen, Christiesgate 12, 5015 Bergen, Norway. E-mail:
| | - T Zayats
- K.G. Jebsen Centre for Neuropsychiatric Disorders, Department of Biomedicine, University of Bergen, Bergen, Norway
| | - C Stansberg
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, Bergen, Norway,Genomics Core Facility, Department of Clinical Science, University of Bergen, Bergen, Norway
| | - S Pallesen
- Department of Psychosocial Science, University of Bergen, Bergen, Norway,Norwegian Competence Center of Sleep Disorders, Haukeland University Hospital, Bergen, Norway
| | - J Mrdalj
- Norwegian Competence Center of Sleep Disorders, Haukeland University Hospital, Bergen, Norway,Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - B Håvik
- The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, Haukeland University Hospital, Bergen, Norway
| | - J Soulé
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway,Department of Biology, University of Bergen, Bergen, Norway
| | - J Haavik
- K.G. Jebsen Centre for Neuropsychiatric Disorders, Department of Biomedicine, University of Bergen, Bergen, Norway,Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - A M Milde
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway,Regional Centre for Child and Youth Mental Health and Child Welfare, Bergen, Norway
| | - S Skrede
- The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, Haukeland University Hospital, Bergen, Norway
| | - R Murison
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway
| | - J Krystal
- Clinical Neuroscience Division, VA National Center for PTSD, West Haven, CT, USA,Department of Psychiatry, Yale University School of Medicine, New Haven, CT, USA
| | - J Grønli
- Department of Biological and Medical Psychology, University of Bergen, Bergen, Norway,Elson S. Floyd College of Medicine, Washington State University, Spokane, WA, USA
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Oppegaard O, Skrede S, Mylvaganam H, Kittang BR. Temporal trends of β-haemolytic streptococcal osteoarticular infections in western Norway. BMC Infect Dis 2016; 16:535. [PMID: 27716100 PMCID: PMC5050853 DOI: 10.1186/s12879-016-1874-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [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: 06/07/2016] [Accepted: 09/27/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Beta-haemolytic streptococci are important contributors to the global burden of osteoarticular infections (OAI). Knowledge on the disease traits specific for streptococcal OAI, however, remains scarce. We wished to explore temporal trends of OAI caused by Group A Streptococci (GAS), Group B Streptococci (GBS) and Group C and G Streptococci (GCGS), and furthermore, to describe the associated host and pathogen characteristics. METHODS All cases of microbiologically verified β-haemolytic streptococcal OAI in Health Region Bergen, Norway, in the period 1999-2013 were retrospectively identified. Clinical data were extracted from medical records. Microbial isolates were submitted to antibiotic susceptibility testing and molecular typing. RESULTS A total of 24 GAS, 45 GBS and 42 GCGS acute OAI were identified. The cumulative incidence of GCGS OAI, but not GAS or GBS OAI, increased significantly from the first to the last 5-year period (IRR 5.7, p = 0.0003), with the annual incidence peaking at 1.9/100 000 in 2013. GAS OAI generally produced the most acute and severe clinical presentation, whereas GBS and GCGS predominantly affected the elderly, and were significantly associated with the presence of host risk factors of systemic and focal origin, respectively. CONCLUSIONS We found a significantly increasing incidence of GCGS OAI, likely related to the presence of host susceptibility factors, including prosthetic material and pre-existing joint disease. With an increasing application of therapeutic and diagnostic bone and joint procedures, the rising trend of OAI caused by GCGS is likely to continue. Sustained epidemiological attentiveness to GCGS seems warranted.
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Affiliation(s)
- Oddvar Oppegaard
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway. .,Department of Clinical Science, University of Bergen, Bergen, Norway.
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, 5021, Bergen, Norway.,Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Haima Mylvaganam
- Department of Microbiology, Haukeland University Hospital, Bergen, Norway
| | - Bård Reiakvam Kittang
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
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Bruun T, Oppegaard O, Hufthammer KO, Langeland N, Skrede S. Early Response in Cellulitis: A Prospective Study of Dynamics and Predictors. Clin Infect Dis 2016; 63:1034-1041. [PMID: 27402819 PMCID: PMC5036916 DOI: 10.1093/cid/ciw463] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [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: 03/16/2016] [Accepted: 06/30/2016] [Indexed: 11/15/2022] Open
Abstract
In this prospective study of cellulitis, several nonpharmacological factors were associated with lack of early response. Such early nonresponse was rarely related to inappropriate therapy but strongly predictive of early treatment escalation, suggesting that broadening antibiotic treatment often may be premature. Background. Skin and soft tissue infections are common reasons for medical care. Use of broad-spectrum therapy and costs have increased. Assessment of early treatment response has been given a central role both in clinical trials and everyday practice. However, there is a paucity of data on the dynamics of response, causes of early nonresponse, and how early nonresponse affects resource use and predicts outcome. Methods. We prospectively enrolled 216 patients hospitalized with cellulitis. Clinical and biochemical response data during the first 3 days of treatment were analyzed in relation to baseline factors, antibiotic use, surgery, and outcome. Multivariable analysis included logistic lasso regression. Results. Clinical or biochemical response was observed in the majority of patients the day after treatment initiation. Concordance between clinical and biochemical response was strongest at days 2 and 3. Female sex, cardiovascular disease, higher body mass index, shorter duration of symptoms, and cellulitis other than typical erysipelas were predictors of nonresponse at day 3. In contrast, baseline factors were not predictive of clinical failure assessed posttreatment. Among cases with antibiotic treatment escalation by day 2, 90% (37/41) had nonresponse at day 1, but only 5% (2/40) had inappropriate initial therapy. Nonresponse at day 3 was a predictor of treatment duration >14 days, but not of clinical failure. Conclusions. Nonpharmacological factors had a major impact on early response dynamics. Delayed response was rarely related to inappropriate therapy but strongly predictive of early treatment escalation, suggesting that broadening antibiotic treatment may often be premature.
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Affiliation(s)
- Trond Bruun
- Department of Clinical Science, University of Bergen.,Department of Medicine
| | - Oddvar Oppegaard
- Department of Clinical Science, University of Bergen.,Department of Medicine
| | | | - Nina Langeland
- Department of Clinical Science, University of Bergen.,National Centre for Tropical Infectious Diseases, Haukeland University Hospital, Bergen, Norway
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen.,Department of Medicine
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Siemens N, Chakrakodi B, Shambat SM, Morgan M, Bergsten H, Hyldegaard O, Skrede S, Arnell P, Madsen MB, Johansson L, Juarez J, Bosnjak L, Mörgelin M, Svensson M, Norrby-Teglund A. Biofilm in group A streptococcal necrotizing soft tissue infections. JCI Insight 2016; 1:e87882. [PMID: 27699220 DOI: 10.1172/jci.insight.87882] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Necrotizing fasciitis caused by group A streptococcus (GAS) is a life-threatening, rapidly progressing infection. At present, biofilm is not recognized as a potential problem in GAS necrotizing soft tissue infections (NSTI), as it is typically linked to chronic infections or associated with foreign devices. Here, we present a case of a previously healthy male presenting with NSTI caused by GAS. The infection persisted over 24 days, and the surgeon documented the presence of a "thick layer biofilm" in the fascia. Subsequent analysis of NSTI patient tissue biopsies prospectively included in a multicenter study revealed multiple areas of biofilm in 32% of the patients studied. Biopsies associated with biofilm formation were characterized by massive bacterial load, a pronounced inflammatory response, and clinical signs of more severe tissue involvement. In vitro infections of a human skin tissue model with GAS NSTI isolates also revealed multilayered fibrous biofilm structures, which were found to be under the control of the global Nra gene regulator. The finding of GAS biofilm formation in NSTIs emphasizes the urgent need for biofilm to be considered as a potential complicating microbiological feature of GAS NSTI and, consequently, emphasizes reconsideration of antibiotic treatment protocols.
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Affiliation(s)
- Nikolai Siemens
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Bhavya Chakrakodi
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Srikanth Mairpady Shambat
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Marina Morgan
- Department of Microbiology, Royal Devon and Exeter NHS Foundation Trust, Exeter, United Kingdom
| | - Helena Bergsten
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Ole Hyldegaard
- Department of Anaesthesia, Rigshospitalet, Copenhagen, Denmark
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Per Arnell
- Department of Anaesthesiology and Intensive Care Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Martin B Madsen
- Department of Intensive Care, Rigshospitalet, Copenhagen, Denmark
| | - Linda Johansson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | | | - Julius Juarez
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Lidija Bosnjak
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Matthias Mörgelin
- Division of Infection Medicine, Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Mattias Svensson
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Anna Norrby-Teglund
- Center for Infectious Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
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42
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Aase A, Sommerfelt H, Petersen LB, Bolstad M, Cox RJ, Langeland N, Guttormsen AB, Steinsland H, Skrede S, Brandtzaeg P. Salivary IgA from the sublingual compartment as a novel noninvasive proxy for intestinal immune induction. Mucosal Immunol 2016; 9:884-93. [PMID: 26509875 DOI: 10.1038/mi.2015.107] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Accepted: 09/11/2015] [Indexed: 02/04/2023]
Abstract
Whole-saliva IgA appears like an attractive noninvasive readout for intestinal immune induction after enteric infection or vaccination, but has failed to show consistent correlation with established invasive markers and IgA in feces or intestinal lavage. For reference, we measured antibodies in samples from 30 healthy volunteers who were orally infected with wild-type enterotoxigenic Escherichia coli. The response against these bacteria in serum, lavage, and lymphocyte supernatants (antibody-in-lymphocyte-supernatant, ALS) was compared with that in targeted parotid and sublingual/submandibular secretions. Strong correlation occurred between IgA antibody levels against the challenge bacteria in sublingual/submandibular secretions and in lavage (r=0.69, P<0.0001) and ALS (r=0.70, P<0.0001). In sublingual/submandibular secretions, 93% responded with more than a twofold increase in IgA antibodies against the challenge strain, whereas the corresponding response in parotid secretions was only 67% (P=0.039). With >twofold ALS as a reference, the sensitivity of a >twofold response for IgA in sublingual/submandibular secretion was 96%, whereas it was only 67% in the parotid fluid. To exclude that flow rate variations influenced the results, we used albumin as a marker. Our data suggested that IgA in sublingual/submandibular secretions, rather than whole saliva with its variable content of parotid fluid, is a preferential noninvasive proxy for intestinal immune induction.
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Affiliation(s)
- A Aase
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
| | - H Sommerfelt
- Center for Intervention Science in Maternal and Child Health and Centre for International health, Centre for International Health, University of Bergen, Bergen, Norway.,Department of International Public Health, Norwegian Institute of Public Health, Oslo, Norway
| | - L B Petersen
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
| | - M Bolstad
- Division of Infectious Disease Control, Norwegian Institute of Public Health, Oslo, Norway
| | - R J Cox
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Department of Research and Development, Haukeland University Hospital, Bergen, Norway
| | - N Langeland
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Division for Infectious Disease, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - A B Guttormsen
- Department of Anesthesia and Intensive Care, Haukeland University Hospital, Bergen, Norway.,Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - H Steinsland
- Center for Intervention Science in Maternal and Child Health and Centre for International health, Centre for International Health, University of Bergen, Bergen, Norway.,Department of Biomedicine, University of Bergen, Bergen, Norway
| | - S Skrede
- Department of Clinical Science, University of Bergen, Bergen, Norway.,Division for Infectious Disease, Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - P Brandtzaeg
- LIIPAT, Centre for Immune Regulation, University of Oslo, Oslo, Norway.,Department of Pathology, Oslo University Hospital Rikshospitalet, Oslo, Norway
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Bruun T, Oppegaard O, Kittang BR, Mylvaganam H, Langeland N, Skrede S. Etiology of Cellulitis and the Validity of New and Old Methods. Clin Infect Dis 2016; 62:954-5. [DOI: 10.1093/cid/ciw003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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44
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Bruun T, Oppegaard O, Kittang BR, Mylvaganam H, Langeland N, Skrede S. Etiology of Cellulitis and Clinical Prediction of Streptococcal Disease: A Prospective Study. Open Forum Infect Dis 2015; 3:ofv181. [PMID: 26734653 PMCID: PMC4699398 DOI: 10.1093/ofid/ofv181] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [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: 10/22/2015] [Accepted: 11/15/2015] [Indexed: 11/14/2022] Open
Abstract
Background. The importance of bacteria other than group A streptococci (GAS) in different clinical presentations of cellulitis is unclear, commonly leading to treatment with broad-spectrum antibiotics. The aim of this study was to describe the etiological and clinical spectrum of cellulitis and identify clinical features predicting streptococcal etiology. Methods. We prospectively enrolled 216 patients hospitalized with cellulitis. Clinical details were registered. Bacterial culture was performed from blood, cutaneous or subcutaneous tissue, and/or swabs from skin lesions. Paired serum samples were analyzed for anti-streptolysin O and anti-deoxyribonuclease B antibodies. Results. Serology or blood or tissue culture confirmed β-hemolytic streptococcal (BHS) etiology in 72% (146 of 203) of cases. An additional 13% (27 of 203) of cases had probable BHS infection, indicated by penicillin response or BHS cultured from skin swabs. β-hemolytic streptococcal etiology was predominant in all clinical subgroups, including patients without sharply demarcated erythema. β-hemolytic group C or G streptococci (GCS/GGS) were more commonly isolated than GAS (36 vs 22 cases). This predominance was found in the lower extremity infections. Group C or G streptococci in swabs were associated with seropositivity just as often as GAS. Staphylococcus aureus was cultured from swabs as a single pathogen in 24 cases, 14 (64%) of which had confirmed BHS etiology. Individual BHS-associated clinical characteristics increased the likelihood of confirmed BHS disease only slightly; positive likelihood ratios did not exceed 2.1. Conclusions. β-hemolytic streptococci were the dominating cause of cellulitis in all clinical subgroups and among cases with S aureus in cutaneous swabs. Group C or G streptococci were more frequently detected than GAS. No single clinical feature substantially increased the probability of confirmed BHS etiology.
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Affiliation(s)
- Trond Bruun
- Department of Clinical Science, University of Bergen; Departments of Medicine
| | - Oddvar Oppegaard
- Department of Clinical Science, University of Bergen; Departments of Medicine
| | - Bård R Kittang
- Department of Clinical Science, University of Bergen; Department of Medicine, Haraldsplass Deaconess Hospital, Bergen, Norway
| | | | - Nina Langeland
- Department of Clinical Science, University of Bergen; Departments of Medicine
| | - Steinar Skrede
- Department of Clinical Science, University of Bergen; Departments of Medicine
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45
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Tvedt TH, Orstad S, Skrede S. [Black skin blisters and Enterobacter in the blood]. Tidsskr Nor Laegeforen 2015; 135:1454. [PMID: 26356455 DOI: 10.4045/tidsskr.15.0318] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022] Open
Affiliation(s)
- Tor Henrik Tvedt
- Hematologisk seksjon Medisinsk avdeling Haukeland universitetssykehus
| | - Silje Orstad
- Infeksjonsseksjonen Medisinsk avdeling Haukeland universitetssykehus
| | - Steinar Skrede
- Infeksjonsseksjonen Medisinsk avdeling Haukeland universitetssykehus
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46
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Fernø J, Ersland KM, Duus IH, González-García I, Fossan KO, Berge RK, Steen VM, Skrede S. Olanzapine depot exposure in male rats: Dose-dependent lipogenic effects without concomitant weight gain. Eur Neuropsychopharmacol 2015; 25:923-32. [PMID: 25823694 DOI: 10.1016/j.euroneuro.2015.03.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2014] [Revised: 01/29/2015] [Accepted: 03/09/2015] [Indexed: 11/28/2022]
Abstract
Treatment with second-generation antipsychotic agents such as olanzapine frequently results in metabolic adverse effects, e.g. hyperphagia, weight gain and dyslipidaemia in patients of both genders. The molecular mechanisms underlying metabolic adverse effects are still largely unknown, and studies in rodents represent an important approach in their exploration. However, the validity of the rodent model is hampered by the fact that antipsychotics induce weight gain in female, but not male, rats. When administered orally, the short half-life of olanzapine in rats prevents stable plasma concentrations of the drug. We recently showed that a single intramuscular injection of long-acting olanzapine formulation yields clinically relevant plasma concentrations accompanied by several dysmetabolic features in the female rat. In the current study, we show that depot injections of 100-250 mg/kg olanzapine yielded clinically relevant plasma olanzapine concentrations also in male rats. In spite of transient hyperphagia, however, olanzapine resulted in weight loss rather than weight gain. The resultant negative feed efficiency was accompanied by a slight elevation of thermogenesis markers in brown adipose tissue for the highest olanzapine dose, but the olanzapine-related reduction in weight gain remains to be explained. In spite of the absence of weight gain, an olanzapine dose of 200mg/kg or above induced significantly elevated plasma cholesterol levels and pronounced activation of lipogenic gene expression in the liver. These results confirm that olanzapine stimulates lipogenic effects, independent of weight gain, and raise the possibility that endocrine factors may influence gender specificity of metabolic effects of antipsychotics in the rat.
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Affiliation(s)
- J Fernø
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, N-5021 Bergen, Norway; The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, University of Bergen, Norway.
| | - K M Ersland
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, N-5021 Bergen, Norway; The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, University of Bergen, Norway
| | - I H Duus
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, N-5021 Bergen, Norway; The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, University of Bergen, Norway
| | - I González-García
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, N-5021 Bergen, Norway; The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, University of Bergen, Norway
| | - K O Fossan
- Section of Clinical Pharmacology, Laboratory of Clinical Biochemistry, Haukeland University Hospital, Bergen, Norway
| | - R K Berge
- The Lipid Research Group, Section for Medical Biochemistry, Department of Clinical Science, University of Bergen, 5021 Norway; Department of Heart Disease, University of Bergen, 5021 Norway
| | - V M Steen
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, N-5021 Bergen, Norway; The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, University of Bergen, Norway
| | - S Skrede
- Dr. Einar Martens Research Group for Biological Psychiatry, Center for Medical Genetics and Molecular Medicine, Haukeland University Hospital, N-5021 Bergen, Norway; The Norwegian Centre for Mental Disorders Research (NORMENT) and the K.G. Jebsen Centre for Psychosis Research, Department of Clinical Science, University of Bergen, Norway
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47
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Skrede S, Wu P, Bremer J. Tetradecylthioacrylic acid, a beta-oxidation metabolite of tetradecylthiopropionic acid, inhibits fatty acid activation and oxidation in rat. World Rev Nutr Diet 2015; 75:30-4. [PMID: 7871830 DOI: 10.1159/000423548] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- S Skrede
- Institute of Medical Biochemistry, University of Oslo, Norway
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48
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Sriskandarajah S, Aasarød K, Skrede S, Knoop T, Reisæter AV, Bjørneklett R. Improved prognosis in Norwegian patients with glomerulonephritis associated with anti-neutrophil cytoplasmic antibodies. Nephrol Dial Transplant 2015; 30 Suppl 1:i67-75. [PMID: 25694535 PMCID: PMC4371773 DOI: 10.1093/ndt/gfv008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [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] [Indexed: 12/29/2022] Open
Abstract
Background Glomerulonephritis associated with anti-neutrophil cytoplasmic antibodies (ANCA) is associated with increased mortality and a high risk of end-stage renal disease (ESRD). Here, we investigated whether the prognosis has improved over the last 25 years. Methods Patients were identified in the Norwegian Kidney Biopsy Registry. We included all patients with pauci-immune crescentic glomerulonephritis and a positive ANCA test from 1988 to 2012. Deaths and ESRD in the cohort were identified through record linkage with the Norwegian Population Registry (deaths) and the Norwegian Renal Registry (ESRD). Outcomes of patients diagnosed in 1988–2002 were compared with outcomes of patients diagnosed in 2003–12. Results A cohort of 455 patients with ANCA-associated glomerulonephritis was identified. The mean follow-up was 6.0 years (range, 0.0–23.4). During the study period, 165 (36%) patients died and 124 (27%) progressed to ESRD. Compared with patients diagnosed in 1988–2002, those diagnosed in 2003–12 had higher mean initial estimated glomerular filtration rates (37 versus 27 mL/min/1.73 m2) and lower risk of ESRD (1-year risk: 13 versus 19%; 10-year risk: 26 versus 37%). The composite endpoint, ESRD or death within 0–1 year after diagnosis, was reduced from 34 to 25%. In patients over 60 years old, 1-year mortality fell from 33 to 20%. Conclusions In Norwegian patients with ANCA-associated glomerulonephritis, prognosis was significantly better in 2003–12 compared with 1988–2002. This improvement was probably partly due to a shorter diagnostic delay, and better therapeutic management in older patients.
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Affiliation(s)
| | - Knut Aasarød
- Department of Nephrology, St Olavs University Hospital, Trondheim, Norway Faculty of Medicine, Norwegian University of Science and Technology, Trondheim, Norway
| | - Steinar Skrede
- Department of Medicine, Haukeland University Hospital, Bergen, Norway Department of Clinical Science, University of Bergen, Bergen, Norway
| | - Thomas Knoop
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway Department of Medicine, Haukeland University Hospital, Bergen, Norway
| | - Anna Varberg Reisæter
- Norwegian Renal Registry, Section of Nephrology, Department of Transplant Medicine, Oslo University Hospital, Rikshospitalet, Oslo, Norway
| | - Rune Bjørneklett
- Renal Research Group, Department of Clinical Medicine, University of Bergen, Bergen, Norway Department of Medicine, Haukeland University Hospital, Bergen, Norway
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Mosevoll KA, Reikvam H, Fanebust HR, Flaaten H, Skrede S, Bruserud Ø. IN SEPSIS, 88% OF BACTERAEMIA PATIENTS ARE DISCRIMINATED BY UNSUPERVISED HIERARCHICAL CLUSTER ANALYSIS OF 5 INFLAMMATORY MEDIATORS. Intensive Care Med Exp 2015. [PMCID: PMC4796990 DOI: 10.1186/2197-425x-3-s1-a881] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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50
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Toresen KH, Salte IM, Skrede S, Nilsen RM, Leiva RA. Clinical outcomes in a cohort of anti-hepatitis C virus-positive patients with significant barriers to treatment referred to a Norwegian outpatient clinic. Scand J Gastroenterol 2014; 49:465-72. [PMID: 24472091 DOI: 10.3109/00365521.2013.863965] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE Patient selection and management of chronic hepatitis C (CHC) in Norwegian outpatient clinics is not well studied. The aim of the study was to characterize CHC patients referred to a large university hospital in Norway, identify treatment barriers, and investigate the course and outcomes of treatment. MATERIAL AND METHODS In this retrospective observational cohort study, all anti-HCV-positive patients referred to Haukeland University Hospital, Bergen, for treatment evaluation during the period 2007-2010 were included. Demographics, clinical, laboratory, and treatment results were obtained from electronic medical records. RESULTS A total of 256 patients were included. The patients were young (mean age 36 ± 10.3), with a high prevalence of genotypes 3 (55%) and 1 (43%) and low levels of fibrosis (77% <F2). The majority of patients were former or current injection drug users (85%). Treatment uptake among patients attending the clinic was 47% (n = 91). Treatment was significantly less common in patients who were unemployed, those who had nonattendances during clinical evaluation, those with genotypes 1 or 4, those ≥50 years of age, and patients with no biopsy. For patients initiating treatment, the total sustained virologic response (SVR) rate was 63% (by complete case analysis 73%). For genotypes 1 and 3, SVR was achieved in 44% and 75%, respectively, by intention to treat. CONCLUSIONS A high treatment uptake of CHC patients in a cohort with high prevalence of injection drug use was found. Young age, low degrees of fibrosis, and good patient attendance ensured a high rate of SVR.
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Affiliation(s)
- Kyrre H Toresen
- Department of Clinical Science, University of Bergen , Bergen , Norway
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