A purified capsular polysaccharide markedly inhibits inflammatory response during endotoxic shock.

Capsular material of the opportunistic fungus Cryptococcus neoformans is composed mainly of a polysaccharide named glucuronoxylomannan (GXM). In this study, the effects of GXM were analyzed in an in vivo experimental system of lipopolysaccharide (LPS)-induced shock. Endotoxic shock was induced in mice by a single intraperitoneal injection of LPS from Escherichia coli. GXM treatment reduced the mortality of mice at early stages. Mice treated with LPS alone showed markedly increased plasma levels of tumor necrosis factor alpha (TNF-α), interleukin-1ß (IL-1ß), and IL-6, whereas mice that were also treated with GXM showed significantly lower plasma levels of these cytokines. This effect was related to a marked suppression of Akt and IκBα activation. Importantly, the inhibitory effect of GXM on proinflammatory cytokine secretion was reproduced by treatment with wortmannin, an inhibitor of the Akt transcription pathway. Our results indicate that GXM has a beneficial effect on endotoxic shock, resulting in a significant increase in the rate of survival by dampening the hyperinflammatory response.

Capsular Material of Cryptococcus neoformans: Virulence and Much More.

The capsule is generally considered one of the more powerful virulence factors of microorganisms, driving research in the field of microbial pathogenesis and in the development of vaccines. Cryptococcus neoformans is unique among the most common human fungal pathogens in that it possesses a complex polysaccharide capsule. This review focuses on the Cryptococcus neoformans capsule from the viewpoint of fungal pathogenesis, and the effective immune response target of the capsule's main component, glucuronoxylomannan.

A critical role for FcgammaRIIB in up-regulation of Fas ligand induced by a microbial polysaccharide.

The microbial capsular polysaccharide glucuronoxylomannan (GXM) from the opportunistic fungus Cryptoccocus neoformans is able to alter the innate and adaptive immune response through multi-faceted mechanisms of immunosuppression. The ability of GXM to dampen the immune response involves the induction of T cell apoptosis, which is dependent on GXM-induced up-regulation of Fas ligand (FasL) on antigen-presenting cells. In this study we elucidate the mechanism exploited by GXM to induce up-regulation of FasL. We demonstrate that (i) the activation of FasL is dependent on GXM interaction with FcgammaRIIB (FcγRIIB); (ii) GXM induces activation of c-Jun NH(2) -terminal kinase (JNK) and p38 signal transduction pathways via FcγRIIB; (iii) this leads to downstream activation of c-Jun; (iv) JNK and p38 are simultaneously, but independently, activated; (v) FasL up-regulation occurs via JNK and p38 activation; and (vi) apoptosis occurs via FcγRIIB engagement with consequent JNK and p38 activation. Our results highlight a fast track to FasL up-regulation via FcγRIIB, and assign to this receptor a novel anti-inflammatory role that also accounts for induced peripheral tolerance. These results contribute to our understanding of the mechanism of immunosuppression that accompanies cryptococcosis.

Follow-up blood cultures are associated with improved outcome of patients with gram-negative bloodstream infections: retrospective observational cohort study.

OBJECTIVES: We examined factors associated with follow-up blood cultures (FUBCs) in patients with monomicrobial Gram-negative (GN) bloodstream infection (BSI) and investigated the impact of FUBCs on therapeutic management and patient outcome. METHODS: A retrospective cohort analysis was conducted of adult patients diagnosed with GN-BSI at a tertiary-care university hospital during 2013-2016. FUBCs performed between 24 hours and 7 days after index BCs was the exposure variable. Risk factors for 30-day mortality were analysed by multivariate Cox analysis on the overall cohort, including FUBCs as a time-varying covariate and on 1:1 matched patients according to Sequential Organ Failure Assessment (SOFA) score and time to FUBC. RESULTS: In 278 (17.6%) of 1576 patients, FUBCs were performed within a median of 3 and 2 days after index BCs and active antibiotic therapy initiation. Persistent BSI was found in 107 (38.5%) of 278 patients. FUBCs were performed in more severely ill patients, with nonurinary sources, difficult-to-treat pathogens and receipt of initial inappropriate therapy. Source control and infectious disease consultation rates were higher among patients with preceding FUBCs and was associated with longer treatment duration. Thirty-day mortality was 10.4%. Independent risk factors for mortality were Charlson comorbidity index (hazard ratio (HR) 1.12) SOFA (HR 1.11), septic shock (HR 2.64), urinary source (HR 0.60), central venous catheter source (HR 2.30), complicated BSI (HR 2.10), carbapenem resistance (HR 2.34), active empiric therapy (HR 0.68), source control (HR 0.34) and FUBCs (HR 0.48). Association between FUBCs and lower mortality was confirmed in the 274 matched pairs. CONCLUSIONS: FUBCs were performed in more severe GN-BSIs, yielding a high rate of persistent BSI. In this context, FUBCs were associated with lower mortality.

The effect of an antimicrobial stewardship programme in two intensive care units of a teaching hospital: an interrupted time series analysis.

OBJECTIVES: To evaluate the effect of an antimicrobial stewardship programme in two intensive care units (ICUs) of a teaching hospital. METHODS: Between January 2017 and June 2018 we conducted a prospective, interventional, interrupted time-series study, based on Prospective Audit and Feedback in two ICUs of an acute-care teaching hospital. The primary outcomes were the difference in the antibiotic consumption, and the incidence of bloodstream infections (BSI) caused by multidrug-resistant (MDR) organisms. The secondary outcomes included the hospital mortality rate, the mean length of stay and the antibiotic expense. RESULTS: During the study, 231 audits were performed, evaluating 693 antibiotic prescriptions. The programme led to a global reduction in antibiotic consumption, with a change in level (CL) of -324.8 defined daily doses (DDD)/100 patient-days (PD), p 0.04, and particularly in the use of fluoroquinolone: (CL: -63.48 DDD/100 PD, p < 0.001). A non-significant reduction was obtained for the consumption of carbapenems (CL: -34.7 DDD/100 PD, p 0.25) and third- and fourth-generation cephalosporins (CL: -27.3 DDD/100 PD, p 0.102). Furthermore, we registered a significant decrease in all BSI (CL: -5.8 events/100 PD, p 0.026) and in BSI due to MDR Gram-negative organisms (CL: -2.96 events/100 PD, p 0.043). No difference was observed in the hospital mortality and length of stay. CONCLUSIONS: Our study demonstrated that implementation of an antimicrobial stewardship programme in two ICUs of a teaching hospital induced a significant reduction in antibiotic consumption and in the incidence of BSI due to MDR Gram-negative organisms, without any impact on the mortality rate.

Normalization of anti-cryptococcal activity and interleukin-12 production after highly active antiretroviral therapy.

OBJECTIVE: To investigate the effect of highly active antiretroviral treatment (HAART) on antifungal and secretory functions of polymorphonuclear leukocytes (PMNL) from HIV-infected patients with high viral load. DESIGN: Antifungal activity, oxygen-dependent mechanisms and interleukin (IL)-12 secretion were evaluated in PMNL from HIV-infected patients before and 3 months after commencing HAART. METHODS: PMNL antifungal activity was evaluated by effects on fungal colony-forming units. Superoxide anion (O2-) production was determined by superoxide dismutase reduction and IL-12 was determined by enzyme-linked immunosorbent assay in supernatant fluids of PMNL cultured for 18 h. RESULTS: PMNL from HIV-infected patients showed dysregulation of antimicrobial and secretory functions. A selective defect in antimicrobial activity against encapsulated Cryptococcus neoformans correlated with baseline O2- overproduction, which drastically decreased upon microbial stimulation. Similarly, constitutive secretion of IL-12 was blocked by exposure to microbial products. PMNL analysed after 3 months of HAART showed restoration of antimicrobial activity against encapsulated C. neoformans, reduction in O2- formation by unstimulated cells and restoration of oxidative burst after appropriate stimulation, and reduction of IL-12 hypersecretion. CONCLUSIONS: PMNL from HIV-infected patients with high viral load have impaired function; HAART normalizes antimicrobial and secretory activities. The effects of HAART on innate immunity provide new prospects for reduction of HAART-mediated opportunistic infections.

Antibody to capsular polysaccharide enhances the function of neutrophils from patients with AIDS against Cryptococcus neoformans.

OBJECTIVE: To determine the contribution of anti-glucuronoxylomannan monoclonal antibody (MAb18B7) to the fungicidal capacity of polymorphonuclear leukocytes (PMNL) from HIV-infected patients towards Cryptococcus neoformans. DESIGN: Killing activity and superoxide anion generation were evaluated in the presence or absence of MAb18B7 in an in vitro system. METHODS: Killing activity was determined by colony forming unit inhibition assay. Superoxide generation was measured in the presence or absence of zymosan, C. neoformans, or Candida albicans. CD16, CD32, and CD64 molecules on PMNL were evaluated by cytofluorometric analysis. RESULTS: MAb18B7 strongly influenced the phagocytic and killing activities against encapsulated C. neoformans and consistently enhanced superoxide anion generation. Expression of CD16, and to a lesser extent CD64, on PMNL was required for MAb18B7-induced superoxide generation. By blocking CD16 and CD64 molecules with anti-CD16 and anti-CD64 MAb, a significant down-regulation of MAb18B7-induced fungicidal activity was observed. CONCLUSIONS: Our results demonstrate that MAb18B7 selectively enhances the killing mechanisms of PMNL from HIV-infected patients against encapsulated C. neoformans. The availability of CD16 and CD64 molecules on PMNL plays a critical role.

HIV type 1 envelope glycoprotein gp120 induces development of a T helper type 2 response to Cryptococcus neoformans.

OBJECTIVE: To analyse the contribution of HIV type 1 envelope glycoprotein gp120 to regulation of a T-cell response to Cryptococcus neoformans. DESIGN: Monocytes treated with recombinant gp120 and exposed to C. neoformans were used as antigen presenting cells (APC) in coculture with autologous T lymphocytes. METHODS: Costimulatory and major histocompatibility complex class II molecules were evaluated on APC by flow cytometry analysis. T-cell proliferation was determined as 3H thymidine incorporation. Cytokine production was analysed by enzyme-linked immunosorbent assay. RESULTS: gp120 had multiple effects on APC and the T-cell response including: (i) up-regulation of major histocompatibility complex class II antigens on the APC surface resulting from both redistribution of molecules from the intracellular pool and synthesis of new molecules; (ii) up-regulation of B7-2 molecules on the APC surface; (iii) altered T-cell proliferation; and (iv) promotion of interleukin-4 and inhibition of interferon-gamma synthesis and release. CONCLUSIONS: These data indicate that gp120 alters the normal T-cell response to C. neoformans, promoting a T-helper type 2 response. The altered T-cell response produced by gp120 may play an important role in the pathogenesis of cryptococcosis in the patient with AIDS.

Inhibition of fungicidal activity of polymorphonuclear leukocytes from HIV-infected patients by interleukin (IL)-4 and IL-10.

OBJECTIVE: To investigate the effect of human recombinant interleukin (hrIL)-4 or hrIL-10 on the functional status of polymorphonuclear leukocytes (PMNL) from normal subjects and HIV-infected patients. DESIGN: In an in vitro system we studied the effect of hrIL-4 or hrIL-10 on phagocytosis, fungicidal activity and superoxide anion production by PMNL. METHODS: PMNL were treated in vitro with hrIL-4 or hrIL-10 or their combination for 6 h and then candidacidal activity was evaluated in a colony-forming unit inhibition assay. Superoxide anion generation by PMNL was measured in the presence or absence of preopsonized zymosan or Candida albicans. RESULTS: Treatment in vitro with hrIL-4 or hrIL-10 of PMNL for 6 h was able to impair candidacidal activity of neutrophils in both normal or HIV-infected patients. The inhibitory effect was time- and dose-dependent and was more evident in PMNL from HIV-infected subjects, and reflected in these latter cells a decrease of superoxide anion generation. The impairment of candidacidal activity in PMNL from HIV-infected patients was accompanied by survival of the yeasts shown by budding formation into phagosomic organelles of cytokine-treated PMNL. CONCLUSIONS: Our data highlight new biological effects of IL-4 and IL-10 evidenced by suppressed effector function of neutrophils; this phenomenon is emphasized in HIV-infected patients suggesting a role for these cytokines in mediating increased susceptibility to microbial infection during AIDS progression.

Monocyte dysfunction in patients with acquired immunodeficiency syndrome (AIDS) versus Cryptococcus neoformans.

In the present study we investigated the response of monocytes from AIDS patients, susceptible to cryptococcosis (<200 CD4 cells/microl), against Cryptococcus neoformans. Different patterns of response were observed in these cells compared to cells from healthy donors. In particular, fungicidal activity versus this fungus was impaired; this phenomenon could be due to the difficulty of monocytes to internalize C. neoformans in the presence of an intact complement system. Impairment of complement receptor type 3 and direct involvement of this receptor in phagocytosis of C. neoformans were found in monocytes from AIDS patients, which may account for the difficulty in phagocytosis of the fungus. Also, superoxide anion production was dramatically reduced in monocytes from AIDS patients. An increase of spontaneous tumor necrosis factor (TNF) production was evidenced after in vitro addition of C. neoformans. However, this did not activate the antifungal capacity of monocytes from AIDS patients. Moreover, cryptococcus-laden monocytes from AIDS patients were able to induce only a weak response of autologous T-lymphocytes. Hence, monocyte dysfunction could play a part in the progression of cryptococcosis in AIDS.

Continuous measurement of vascular access recirculation by conductivity.

Vascular access recirculation is one of the main factors influencing dialysis efficiency. The underestimation of or mistakes in the measurement of access recirculation causes a discrepancy between dialysis prescription and the actual dose of dialysis administered. Moreover, access recirculation is known to increase during a dialysis session. Therefore, the evaluation of recirculation is necessary to correctly prescribe dialysis and the ideal measurement method should be very accurate and feasible at any moment during a dialysis session.

Specific antibody to Cryptococcus neoformans alters human leukocyte cytokine synthesis and promotes T-cell proliferation.

Addition of a monoclonal antibody which binds the Cryptococcus neoformans capsule to suspensions of human monocytes, T lymphocytes, and cryptococcal cells (i) enhances interleukin-1beta (IL-1beta), tumor necrosis factor alpha, and IL-2 production; (ii) reduces IL-10 secretion; and (iii) promotes T-cell proliferation. The ability of specific antibody to influence cytokine production and lymphoproliferation suggests a mechanism by which humoral immunity can influence cell-mediated immunity.

Cryptococcus neoformans and Candida albicans regulate CD4 expression on human monocytes.

This study examined the capability of Candida albicans and Cryptococcus neoformans to modulate CD4 expression on human monocytes. C. albicans and an acapsular strain of C. neoformans induced higher levels of CD4 expression than encapsulated strains. Purified glucuronoxylomannan did not regulate CD4 expression on monocytes, but down-regulation of CD4 expression compared with stimulation by acapsular C. neoformans alone was observed when glucuronoxylomannan was used in combination with acapsular C. neoformans. The ability of opsonic factors to facilitate fungal-mediated CD4 overexpression suggests that binding or internalization (or both) of the yeast cells is a critical event. Protein synthesis was required, excluding redistribution of the intracellular pool of CD4 receptors to the cellular surface as the sole possible mechanism. Results demonstrate a new effect of fungi on professional phagocytic cells and raise the possibility that modulation of CD4 could influence gp120-mediated human immunodeficiency virus entry.