Efficacy and safety of clindamycin-based treatment for bone and joint infections: a cohort study.

Clindamycin has high bioavailability together with good diffusion in bone tissue and could represent an alternative antibiotic compound for the treatment of bone and joint infections (BJIs). However, data regarding the efficacy and safety of clindamycin for BJIs are limited. A monocentric cohort study based on our medical dashboard, which prospectively recorded 28 characteristics for all hospitalized patients since July 2005, was performed. BJIs were selected, and then, all mono-microbial BJI managed with clindamycin-based therapy were included. Remission was defined as the absence of clinical and/or microbiological relapse after treatment. The duration of follow-up without relapse was determined retrospectively using computerized medical records. For 10 years, 196 BJIs, of which 80 (41%) were device-associated infections, were treated with clindamycin-based therapy. The bacterial causative agent was Staphylococcus aureus in 130 cases (66%), coagulase-negative staphylococci in 29 cases (15%), streptococci in 31 cases (16%) and other bacteria in 6 cases (3%). When used in combination therapy, clindamycin was mainly paired with fluoroquinolones (31%) or rifampin (27%). The mean duration of clindamycin treatment was 7.4 ± 3.2 weeks (range, 1-24). An AE was recorded for 9 (4.5%) patients. Remission was recorded for 111 (57%) patients, with a mean duration of clinical follow-up of 28 ± 24 months. Treatment failure occurred in 22 (11%) patients, 50 patients (25%) were lost to follow-up, and 8 (4%) required long-term suppressive therapy. Among the assessable patients, clindamycin-based therapy was efficient in 111/133 cases (83%) and thus represents a reliable and safe alternative treatment option.

Bacteraemic urinary tract infections may mimic respiratory infections: a nested case-control study.

Daily practice suggests that respiratory signs may be observed in bacteraemic urinary infections (BUI). Our objective was to search for an association between the presence of respiratory symptoms and the bacteraemic nature of urinary tract infections (UTI). A nested case-control study was carried out based on our computerised dashboard from January 2011 to June 2015. Cases were defined as patients with a BUI due to Enterobacteriaceae species, identified in blood and urine cultures. Controls had fever and a positive urinary sample but sterile blood cultures (NBUI) and a final diagnosis of urinary infection. Patients from the BUI group were 1:1 matched to the NBUI group according to four parameters: age, gender, cardiovascular and pulmonary comorbid conditions. Subjects with cognitive impairment limiting clinical accuracy and those with healthcare-associated infections were excluded. We compared systematically recorded respiratory and urinary symptoms between groups: signs on auscultation, dyspnoea, chest pain, cough and sputum, dysuria with burning, pollakiuria, flank or costovertebral angle tenderness and ischuria. One hundred BUI were compared to 100 NBUI, both groups exhibiting a similar rate for all considered comorbid conditions. In the BUI group, 58 % showed at least one respiratory sign vs. 20 % in the NBUI group, p < 0.001, while urinary signs were less frequent: 54 % vs. 71 %, p = 0.013. In the multivariate analysis, BUI was associated with the presence of abnormal pulmonary auscultation [adjusted odds ratio (AOR), 5.91; p < 0.001] and a trend towards less urinary symptoms (AOR, 1.58; p = 0.058). Patients with BUI presented with significantly more respiratory signs, which overshadowed urinary symptoms, compared to those with non-bacteraemic UTI. Such observations impact clinical decision-making.

Antimicrobial stewardship policy: time to revisit the strategy?

Recent data indicate that both the overall numbers of antibiotic prescription and the frequency of multidrug-resistant bacteria are increasing significantly. These threatening features are observed, despite national antimicrobial stewardship (AMS) policies aimed at decreasing antibiotic use. AMS should also focus on the initial steps leading to antibiotic prescription. Physicians and their patients should benefit from the structured clinical pathways, the latter being adapted to regional epidemiological data and resources. Continuous evaluation of these predefined clinical paths through a computerized medical dashboard will allow a critical review and finally the optimization of medical practices. These innovative behavioural approaches for clinicians will supply precise information on the relationship among the diagnosis, therapeutics and outcome. This changing environment will carry out the adapted therapeutic procedures, and appropriate antibiotic use will inherently improve.

Community-acquired pneumonia: impact of empirical antibiotic therapy without respiratory fluoroquinolones nor third-generation cephalosporins.

Guidelines for inpatients with community-acquired pneumonia (CAP) propose to use respiratory fluoroquinolone (RFQ) and/or third-generation cephalosporins (Ceph-3). However, broad-spectrum antibiotic therapy is associated with the emergence of drug-resistant bacteria. We established a guideline in which RFQ and Ceph-3 were excluded as a first course. Our aim was to evaluate the impact of our therapeutic choices for CAP on the length of hospital stay (LOS) and patient outcome. This was a cohort study of patients with CAP from July 2005 to June 2014. We compared patients benefiting from our guideline established in 2008 to those receiving non-consensual antibiotics. Disease severity was evaluated through the Pneumonia Severity Index (PSI). The empirical treatment for PSI III to V was a combination therapy of amoxicillin-clavulanic acid (AMX-C) + roxithromycin (RX) or AMX + ofloxacin. Adherence to guidelines was defined by the prescription of one of these antibiotic agents. Requirement for intensive care or death defined unfavorable outcome. Among 1,370 patients, 847 were treated according to our guideline (61.8 %, group 1) and 523 without concordant therapy (38.2 %, group 2). The mean PSI was similar: 82 vs. 83, p > 0.5. The mean LOS was lower in group 1: 7.6 days vs. 9.1 days, p < 0.001. An unfavorable outcome was less frequent in group 1: 5.4 % vs. 9.9 %, p = 0.001. In logistic regression models, concordant therapy was associated with a favorable outcome: adjusted odds ratio (AOR) [95 % confidence interval (CI)] 1.85 [1.20-2.88], p = 0.005. CAP therapy without RFQ and Ceph-3 use was associated with a shorter LOS and fewer unfavorable outcomes.

Early infectious acute respiratory distress syndrome is characterized by activation and proliferation of alveolar T-cells.

Acute respiratory distress syndrome (ARDS) in humans is characterized by the infiltration of polymorphonuclears in the alveolar spaces. However, the role of T-cells in ARDS is unknown. Our aim was to characterize the T-cell phenotype in bronchoalveolar lavage (BAL) during the early phase of acute lung infection(ALI)/ARDS-infected patients in comparison to a control group (CG). BAL lymphocyte phenotypes of two ALI, 16 ARDS, and eight CG were examined by flow cytometry. ALI/ARDS showed a significant increase in CD4 and CD8 T-cell activation as compared to CG. Moreover, a significant level of proliferation was observed using the Ki67 marker in ARDS patients as compared to controls (median): 37 versus 6 % for CD4 T-cells (p = 0.022) and 34 versus 2 % for CD8 T-cells (p = 0.009). In contrast, the percentage of T-regulatory cells and apoptotic T-cells were similar in both groups. Among costimulatory molecules, we observed an overexpression of CTLA-4/CD152 on CD4 T-cells in ALI/ARDS as compared to CG: 30 versus 7 %, respectively (p = 0.063). In further characterizing T-cell subsets expressing high levels of CD152, we found the presence of IL-17 secreting CD4 T-cells in ALI/ARDS. In humans, ALI/ARDS due to infection is associated with a high level of T-cell activation and proliferation, along with the presence of Th17 cells, which are known to attract polymorphonuclears.

Severe community-acquired pneumonia and positive urinary antigen test for S. pneumoniae: amoxicillin is associated with a favourable outcome.

Positive urinary antigen tests (UAT) for pneumococcal infection in community-acquired pneumonia (CAP) may lead to targeted antibiotic therapy. We report an audit aimed at defining the link between mortality and targeted therapy. We conducted a retrospective multicentre audit of patients with severe CAP for whom a UAT was positive for S. pneumoniae. Patients admitted from January 2010 to December 2013 to 8 medical centres (from A to H) were included. Co-morbidities were defined by the specific treatment administered before hospital care, or if the diagnosis was newly established during the hospital stay. We used the Pneumonia Severity Index (PSI) to assess disease severity. Only patients with PSI > 90 were included. Antibiotic treatments and the PSI were extracted from patients' charts. Amoxicillin had to be prescribed as a targeted antibiotic treatment or at the time of antibiotic reassessment. A total of 389 patients were included. The mean (±STD) PSI score was 128 ± 29; 38.9% of the patients had a class 5 PSI score. Intensive care was required for 36.6% of the patients. Amoxicillin was initially prescribed in 47 cases (12.1%) and in 34 cases after reassessment (8.7%). In logistic regression analysis, we found three parameters associated with mortality: being hospitalised in institution D, class 5 PSI score, and metastatic cancer. In contrast, three antibiotic regimens were protective factors, including targeted therapy: OR = 0.09, p < 0.001. In the context of severe CAP with positive UAT for S. pneumoniae, targeted therapy was associated with a reduction in mortality.

T cells from chronic bone infection show reduced proliferation and a high proportion of CD28⁻ CD4 T cells.

Chronic bone infection is associated with bone resorption. From animal studies, CD3/CD28-activated T cells are known to enhance osteoclastogenesis and bone resorption. Because CD28 is expressed constitutively on T cells and its expression is down-regulated by chronic exposure to the inflammatory environment, we characterized co-stimulatory molecule expression on T cells from chronically infected patients. We used cytofluorometric techniques to phenotypically characterize T cells, its co-stimulatory molecules and perforin secretion from infected and non-infected human bones. Chronic bone infection was defined as infection lasting for more than a month. We show a higher T cell activation [human leucocyte antigen D-related (HLA-DR⁺)] in infected compared to non-infected bones: median being 16 versus 7%, P = 0·009 for CD4 T cells, and 33 versus 15%, P = 0·038 for CD8 T cells, respectively. However, T cell proliferation (Ki67⁺) was lower for CD8 T cells in infected bones: 26 versus 34%, P = 0·045. In contrast, we detected no difference in apoptosis and regulatory T cells. In infected bone, we found higher CD28-negative CD4⁺ T cells compared to non-infected bone: 20 versus 8%, respectively (P = 0·005); this T cell subset had higher CD11b expression and perforin secretion. Chronically infected human bones are characterized by an increase of CD28-negative CD4⁺ T cells, indicating long-term activated cells with cytotoxic ability. Therefore, this alteration of co-stimulatory molecules may modify interactions with osteoclasts and impact bone resorption.

Antibiotics-related adverse events in the infectious diseases department of a French teaching hospital: a prospective study.

Antibiotics are a significant cause of adverse events (AE), but few studies have focused on prescriptions in hospitalized patients. In infectious diseases departments, the high frequency and diversity of antibiotics prescribed makes AE post-marketing monitoring easier. The aim of our study was to assess the incidence and type of AE in the infectious diseases department of a French teaching tertiary-care hospital. The main characteristics of each hospitalization, including all antibiotics prescribed and any significant AE were recorded prospectively in the medical dashboard of the department. We included all patients having suffered an AE due to systemic antibiotics between January 2008 and March 2011. Among the 3963 hospitalized patients, 2682 (68%) received an antibiotic and 151/2682 (5.6%) suffered an AE. Fifty-two (34%) AE were gastrointestinal disorders, 32 (21%) dermatological, 20 (13%) hepatobiliary, 16 (11%) renal and urinary disorders, 13 (9%) neurological and 11 (7%) blood disorders. Rifampin, fosfomycin, cotrimoxazole and linezolid were the leading causes of AE. Sixty-two percent of the antibiotics causing an AE were stopped and 38% were continued (including 11% with a dose modification). Patients suffering from AE had an increased length of stay (18 vs 10 days, P < 0.001). Our data could help choosing the safest antibiotic when several options are possible.

The role of diagnostic CT imaging in the acute assessment of battlefield external genital injuries.

INTRODUCTION: The external genitalia are routinely included in the 'CT-Traumagram' at the Role 3 hospital in Afghanistan. Although the radiologist may have the opportunity to diagnose clinically undetected genital injury, little emphasis has been placed on the CT appearances of the external genitalia after Improvised Explosive Device related injury. METHODS: A prospective observational study was carried out on casualties admitted during 1 month in 2011. Genital findings on CT were correlated with clinical operative findings. RESULTS: One hundred and twenty-eight casualties were admitted of which 12 (9%) had genital injury. 17 testes were exposed to blast injury-5/17 (29%) were unharmed, one was dislocated, two were lost, one had a testicular haematoma and 8/17 (47%) were disrupted and underwent salvage. The CT findings-loss of the definition of the tunica albuginea and intra-testicular contrast blushing correlated with testicular disruption in all cases. The single dislocated testis and the two cases where there were no testes remaining after injury were all evident on CT. DISCUSSION: The CT appearance of the external genitalia following trauma are unfamiliar. However, despite the small numbers and clear limitations, the results suggest that CT has an important role to play in the diagnosis of significant genital trauma. Ultrasound assessment should be considered if there is persisting uncertainty. CONCLUSIONS: 'CT-Traumagram' provides rapid, whole body information in casualties exposed to blast injury and this should be exploited in its entirety by the trauma team. Abnormal genital findings on contrast CT should alert radiologists and surgeons to the possibility of significant genital trauma.

Increased time exposure to tenofovir is associated with a greater decrease in estimated glomerular filtration rate in HIV patients with kidney function of less than 60 ml/min/1.73 m2.

Tenofovir (TDF), atazanovir (ATAZ) and indinavir (IND) have been reported as possible risk factors for incident chronic kidney disease (CKD) in HIV-infected patients. We investigated the relationship between the duration of antiretroviral exposure and estimated glomerular filtration rate (eGFR) evolution in CKD patients. In a cohort of 1,750 HIV-infected patients, we identified 121 CKD patients with a mean follow-up of 44 ± 35 months. The relationship between mean eGFR at baseline, eGFR slope and time exposure to antiretroviral treatment as well as confounding factors were investigated using a joint modeling procedure. Seventy (58%), 30 (25%) and 33 patients (27%), with a mean age of 50.3 ± 11.7 years, mean eGFR at baseline of 53.0 ± 0.8 (ml/min/1.73 m(2)) and eGFR slope of 0.46 ± 0.07 ml/min/1.73 m(2)/year, were exposed to TDF, ATAZ and IND, respectively. In univariate analysis, hepatitis C virus infection, decreased nadir of log CD4 count, high blood pressure at baseline, angiotensin-converting enzyme inhibitor treatment and greater time exposure to TDF during follow-up were associated with a higher slope, whereas greater time exposure to IND was associated with a lower slope. In multivariate analysis, higher TDF time exposure was still significantly associated with eGFR decline, with a dose-effect relationship (slope ± standard error of the mean: 1.1 ± 0.1, 0.5 ± 0.1, -0.07 ± 0.08 and -0.87 ± 0.06 ml/min/1.73 m(2)/year for no time exposure, <34, 34-67 and ≥67%, respectively; trend test: p < 0.001), whereas the IND time exposure association was abolished. In HIV patients with CKD, a greater TDF time exposure was independently associated, in a graded manner, with a greater eGFR decline.

Teleconsultation in family medicine amid the Covid-19 pandemic: An adequate tool?

INTRODUCTION: Teleconsultation is an emerging tool whose utilization dramatically increased during the Covid-19 pandemic. Our aim was to determine its clinical accuracy. METHODS: This prospective study was carried out during the first wave of Covid-19. Patients were teleconsulted by either general practitioners or emergency doctors reporting clinical exam results to the ID physicians by phone. Five signs were specifically checked: dyspnea, fever, cough, anosmia and flu-like illness. Data collected by remote consultation were compared to face-to-face examination in an ID Department. RESULTS: From March to April 2020, 149 patients were seen by remote medical care. Dyspnea was found in 14.1% of the teleconsultation patients vs 3.4% in face-to-face consultation; fever in 47.0 vs. 15.4%; cough in 69.1 vs. 16.1%; anosmia in 3.4 vs. 1.3%; flu-like illness in 53.0 vs. 7.4% (all differences significant: P<0.001). CONCLUSION: We observed incongruency between remote and face-to-face consultation for the main clinical signs of Covid-19.

Successful high flow nasal cannula therapy for severe COVID-19 pneumonia is associated with tocilizumab use.

INTRODUCTION: Our aim was to determine the rate of success of HFNO and its relationship with current treatments for severe COVID-19. METHOD: This was a cohort study including patients admitted for HFNO because of respiratory failure despite oxygen therapy through a facial mask. Care was standardized, with systematic use of steroids and prevention or treatment of thromboembolic complications, and tocilizumab when deemed useful. HFNO failure was defined by the requirement for mechanical ventilation and/or death. RESULTS: In August 2021, among 1397 patients with COVID-19 admitted in the emergency department, 110 (7.8%) received HFNO (mean age 55 years, sex-ratio M/F 1.4). Thirteen patients (12%) had received a steroid treatment before hospital admission. At least one comorbid condition was observed in 57% of the patients. Mean duration of the disease at admission was 8.8 days and mean respiratory rate was 34/min. A CT scan was performed for 101 patients (92%), among whom 13 had a pulmonary embolism. All patients received a steroid treatment, and tocilizumab was prescribed in 79 cases (72%). Failure of HFNO was observed in 54 cases (49%); the only risk factor was the absence of tocilizumab administration: AOR [IC95%] 3.50 [1.40-8.69]. We observed a trend toward failure with steroid use before hospital admission: AOR 3.83 [0.96-16.66]. CONCLUSION: Success of HFNO, when all therapeutic means of treatment for severe COVID-19 pneumonia were applied, was associated with tocilizumab administration. Our data suggest the interest of a randomized study to determine whether HFNO is the right signal for prescription of anti-IL6 drugs.

Multifaceted effects of synthetic TLR2 ligand and Legionella pneumophilia on Treg-mediated suppression of T cell activation.

BACKGROUND: Regulatory T cells (Treg) play a crucial role in maintaining immune homeostasis and self-tolerance. The immune suppressive effects of Tregs should however be limited in case effective immunity is required against pathogens or cancer cells. We previously found that the Toll-like receptor 2 (TLR2) agonist, Pam3CysSK4, directly stimulated Tregs to expand and temporarily abrogate their suppressive capabilities. In this study, we evaluate the effect of Pam3CysSK4 and Legionella pneumophila, a natural TLR2 containing infectious agent, on effector T (Teff) cells and dendritic cells (DCs) individually and in co-cultures with Tregs. RESULTS: TLR2 agonists can directly provide a co-stimulatory signal inducing enhanced proliferation and cytokine production of naive CD4+ Teff cells. With respect to cytokine production, DCs appear to be most sensitive to low amounts of TLR agonists. Using wild type and TLR2-deficient cells in Treg suppression assays, we accordingly show that all cells (e.g. Treg, Teff cells and DCs) contributed to overcome Treg-mediated suppression of Teff cell proliferation. Furthermore, while TLR2-stimulated Tregs readily lost their ability to suppress Teff cell proliferation, cytokine production by Teff cells was still suppressed. Similar results were obtained upon stimulation with TLR2 ligand containing bacteria, Legionella pneumophila. CONCLUSIONS: These findings indicate that both synthetic and natural TLR2 agonists affect DCs, Teff cells and Treg directly, resulting in multi-modal modulation of Treg-mediated suppression of Teff cells. Moreover, Treg-mediated suppression of Teff cell proliferation is functionally distinct from suppression of cytokine secretion.

Cotrimoxazole for community-acquired urinary tract infections leads to more adverse effects than fluoroquinolones.

BACKGROUND: For several years, we applied an internal guideline for community-acquired urinary tract infections (cUTI), targeting the reduction of fluoroquinolone use (FQ) and thereby favouring cotrimoxazole (CTM) prescription. Our aim was to report adverse effects (AE) and outcome for patients presenting with cUTI and treated with these compounds. METHODS: This cohort study was based on the dashboard of our department, bringing together 28 parameters for all patients, including diagnosis, microbiological data, antibiotic therapy, AE, length of hospital stay (LHS) and outcome. We included all patients with cUTI due to Enterobacteriaeae treated with CTM or FQ, and compared these 2 groups on in-hospital AE, LHS, and unfavourable outcome defined as intensive care requirement or death. RESULTS: From June 2008 to June 2019, 640 cUTI due to Enterobacteriaeae were observed, among which 295 (46%) treated with CTM and 345 (54%) with a FQ. There were 25 AE (3.9%): 17 (5.7%) in the CTM group, and 8 (2.3%) in the FQ group (P=0.025). Adverse effects were associated with increased LHS compared to patients without AE: 11±6 vs. 7±4 days respectively, P<0.001, 11.4±6.2 days in the CTM group vs. 9.2±5.8 in the FQ group (relative LHS increase of 73.5% and 29.5%, respectively). Unfavorable outcome occurred for 1 patient (0.3%) in the CTM group, and 5 (1.4%) in the FQ group, P=0.297. CONCLUSION: Favouring cotrimoxazole for cUTI due to Enterobacteriaceae was associated compared to FQ with more AE and prolonged LHS. A cost-effectiveness analysis to validate such therapeutic strategy is warranted.

Antibiotic guidelines coupled with selective reporting of antibiograms.

OBJECTIVES: We reported the impact of internal guidelines coupled with selective reporting of antibiotic susceptibility tests (srAST) on antibiotic adequacy in healthcare facilities. METHODS: This prospective study involved clinicians from three clinics with medical and surgical activities employing a full-time infectious disease (ID) specialist. Internal guidelines were updated in 2016. The clinics were working with the same laboratory, which delivered the srAST introduced in March 2017. Two weeks per month over a 6-month period, all isolated bacterial specimens, empirical antibiotic therapies (EAT) and the documented ones were analyzed. An EAT listed in the guidelines and a documented therapy mentioned in the srAST defined their adequacy. RESULTS: A total of 257 positive bacterial samples were analyzed in 199 patients, for which 106 infections were studied. Of these, 32% were urinary tract infections, 15% were primary bloodstream infections, 11% were bone infections, and 42% were other types of infection. The three main bacteria were Escherichia coli (27%), Staphylococcus aureus (24%), and Enterococcus faecalis (14%). The total number of antibiotic prescriptions was 168, with 75 (45%) EATs and 93 (55%) documented therapies. There were 35/75 (47%) adequate EATs and 86/93 (92%) adequate documented therapies. The ID specialist was not involved in 90/168 (53.5%) prescriptions, of which 43/90 (48%) were adequate, with 21/35 (60%) EATs and 22/86 (25%) documented therapies. There was a statistical correlation between compliance of the EATs with guidelines and of the documented therapy with srAST (p=0.02). CONCLUSION: Combining internal guidelines and srAST led to a high rate of antibiotic adequacy.

Seroprevalence of SARS-CoV-2 IgG antibodies among workers in the University Hospital of Guadeloupe.

OBJECTIVE: The Covid-19 pandemic is the major global health crisis of our time. The purpose of this study is to estimate the seroprevalence of IgG against SARS-CoV-2 among workers in the University Hospi-tal of Guadeloupe and to assess this seroprevalence in asymptomatic personnel as well as the proportion of asymptomatic agents among seropositive agents. SETTING AND METHODS: We carried out a seroprevalence study in the staff of the University Hospital of Guadeloupe. The presence of IgG anti SARS-CoV-2 was determined by a micro-particulate immunolo-gical assay using the chemiluminescence technique (CMIA, Architect i2000SR, Abbott). Data on the previous presence of symptoms sugge-stive of COVID-19, were identified using a standardized questionnaire. Statistical analyses were performed using Epi Info® software. RESULTS: From 07/05/2020 to 28/10/2020, 892 serologies were performed, 45 of which were positive for SARS-CoV-2 : a prevalence of 5.0% [95% CI: 3.6% - 6.5%]. Seroprevalence was 1.5% [95% CI: 0.6% - 2.3%] among agents who reported being asymptomatic. Among seropositive individuals, 24.4% [95% CI:12% - 36%] was totally asymptomatic. CONCLUSION: Our results highlight the importance of continuing seroprevalence studies for SARS-CoV-2 in hospital staff, which can provide important information on the level of exposure in healthcare workers and asymptomatic transmission of SARS-CoV-2 in clinical set-tings.

Six weeks antibiotic therapy for all bone infections: results of a cohort study.

There is no consensus on the antibiotic therapy for bone infection due to the heterogeneous spectrum of diseases. Most authors suggest different durations of treatment based on pathophysiological considerations. However, adverse effects are related, at least in part, to the duration of treatment. We, therefore, investigated a 6 weeks antibiotic combination therapy for all cases of bone infection. Herewith, we report the results of this therapeutic approach. This is a cohort study including all patients presenting with bone infection, regardless of the mechanism involved. The diagnosis was based on bone biopsy obtained through invasive procedures. Chronic bone infection was defined as a history of disease of over 1 month duration. The duration of clinical follow-up following treatment discontinuation was at least 6 months. Cured bone infection was defined as the absence of relapse after antibiotic discontinuation. One hundred and eighteen patients were included between July 2005 and March 2009; 61 presented with bone infection following prosthetic implant (52%) and the 57 remaining patients had bone infection without foreign material (48%). Surgery was required for 80 patients (68%). Microbial agents were identified in 116/118 patients, with 24 patients presenting with polymicrobial sepsis (20%). The mean duration of antibiotic treatment was 42 +/- 0.2 days and the mean clinical follow-up was 27 +/- 14 months. The treatment success rate was 91.5% (108/118). Six weeks of antimicrobial therapy appears to be effective for nearly all bone infections, regardless of the pathophysiology. These results encourage us to pursue attempts to simplify the management of bone infection without obvious prejudice to the patient.

TLR ligands in the local treatment of established intracerebral murine gliomas.

Local TLR stimulation is an attractive approach to induce antitumor immunity. In this study, we compared various TLR ligands for their ability to affect murine GL261 cells in vitro and to eradicate established intracerebral murine gliomas in vivo. Our data show that GL261 cells express TLR2, TLR3, and TLR4 and respond to the corresponding TLR ligands with increasing MHC class I expression and inducing IL-6 secretion in vitro, while TLR5, TLR7, and TLR9 are essentially absent. Remarkably, CpG-oligonucleotides (CpG-ODN, TLR9) appeared to inhibit GL261 cell proliferation in a cell-type specific, but CpG-motif and TLR9-independent manner. A single intratumoral injection of CpG-ODN most effectively inhibited glioma growth in vivo and cured 80% of glioma-bearing C57BL/6 mice. Intratumoral injection of Pam3Cys-SK4 (TLR1/2) or R848 (TLR7) also produced a significant survival benefit, whereas poly(I:C) (TLR3) or purified LPS (TLR4) stimulation alone was not effective. Additional studies using TLR9(+/+) wild-type and TLR9(-/-) knockout mice revealed that the efficacy of local CpG-ODN treatment in vivo required TLR9 expression on nontumor cells. Additional experiments demonstrated increased frequencies of tumor-infiltrating IFN-gamma producing CD4(+) and CD8(+) effector T cells and a marked increase in the ratio of CD4(+) effector T cells to CD4(+)FoxP3(+) regulatory T cells upon CpG-ODN treatment. Surviving CpG-ODN treated mice were also protected from a subsequent tumor challenge without further addition of CpG-ODN. In summary, this study underlines the potency of local TLR treatment in antiglioma therapy and demonstrates that local CpG-ODN treatment most effectively restores antitumor immunity in a therapeutic murine glioma model.

Toll-like receptor 2 controls expansion and function of regulatory T cells.

Tregs play a central role in the suppression of immune reactions and prevention of autoimmune responses harmful to the host. During acute infection, however, Tregs might hinder effector T cell activity directed toward the elimination of the pathogenic challenge. Pathogen recognition receptors from the TLR family expressed by innate immune cells are crucial for the generation of effective immunity. We have recently shown the CD4CD25 Treg subset in TLR2 mice to be significantly reduced in number compared with WT littermate control mice, indicating a link between Tregs and TLR2. Here, we report that the TLR2 ligand Pam3Cys, but not LPS (TLR4) or CpG (TLR9), directly acts on purified Tregs in a MyD88-dependent fashion. Moreover, when combined with TCR stimulation, TLR2 triggering augmented Treg proliferation in vitro and in vivo and resulted in a temporal loss of the suppressive Treg phenotype in vitro by directly affecting Tregs. Importantly, WT Tregs adoptively transferred into TLR2 mice were neutralized by systemic administration of TLR2 ligand during the acute phase of a Candida albicans infection, resulting in a 100-fold reduced C. albicans outgrowth. This demonstrates that in vivo TLR2 also controls the function of Tregs and establishes a direct link between TLRs and the control of immune responses through Tregs.