Refractory Pseudomonas aeruginosa infections treated with phage PASA16: A compassionate use case series.

BACKGROUND: A growing number of compassionate phage therapy cases were reported in the last decade, with a limited number of clinical trials conducted and few unsuccessful clinical trials reported. There is only a little evidence on the role of phages in refractory infections. Our objective here was to present the largest compassionate-use single-organism/phage case series in 16 patients with non-resolving Pseudomonas aeruginosa infections. METHODS: We summarized clinical phage microbiology susceptibility data, administration protocol, clinical data, and outcomes of all cases treated with PASA16 phage. In all intravenous phage administrations, PASA16 phage was manufactured and provided pro bono by Adaptive Phage Therapeutics. PASA16 was administered intravenously, locally to infection site, or by topical use to 16 patients, with data available for 15 patients, mainly with osteoarticular and foreign-device-associated infections. FINDINGS: A few minor side effects were noted, including elevated liver function enzymes and a transient reduction in white blood cell count. Good clinical outcome was documented in 13 out of 15 patients (86.6%). Two clinical failures were reported. The minimum therapy duration was 8 days with a once- to twice-daily regimen. CONCLUSIONS: PASA16 with antibiotics was found to be relatively successful in patients for whom traditional treatment approaches have failed previously. Such pre-phase-1 cohorts can outline potential clinical protocols and facilitate the design of future trials. FUNDING: The study was funded in part by The Israeli Science Foundation IPMP (ISF_1349/20), Rosetrees Trust (A2232), United States-Israel Binational Science Foundation (2017123), and the Milgrom Family Support Program.

Prevalence of Antibiotic Tolerance and Risk for Reinfection Among Escherichia coli Bloodstream Isolates: A Prospective Cohort Study.

BACKGROUND: Tolerance is the ability of bacteria to survive transient exposure to high concentrations of a bactericidal antibiotic without a change in the minimal inhibitory concentration, thereby limiting the efficacy of antimicrobials. The study sought to determine the prevalence of tolerance in a prospective cohort of E. coli bloodstream infection and to explore the association of tolerance with reinfection risk. METHODS: Tolerance, determined by the Tolerance Disk Test (TDtest), was tested in a prospective cohort of consecutive patient-unique E. coli bloodstream isolates and a collection of strains from patients who had recurrent blood cultures with E. coli (cohorts 1 and 2, respectively). Selected isolates were further analyzed using time-dependent killing and typed using whole-genome sequencing. Covariate data were retrieved from electronic medical records. The association between tolerance and reinfection was assessed by the Cox proportional-hazards regression and a Poisson regression models. RESULTS: In cohort 1, 8/94 isolates (8.5%) were tolerant. Using multivariate analysis, it was determined that the risk for reinfection in the patients with tolerant index bacteremia was significantly higher than for patients with a nontolerant strain, hazard ratio, 3.98 (95% confidence interval, 1.32-12.01). The prevalence of tolerance among cohort 2 was higher than in cohort 1, 6/21(28.6%) vs 8/94 (8.5%), respectively (P = .02). CONCLUSIONS: Tolerant E. coli are frequently encountered among bloodstream isolates and are associated with an increased risk of reinfection. The TDtest appears to be a practicable approach for tolerance detection and could improve future patient management.

Complete Genome Sequence of Pseudomonas aeruginosa Bacteriophage PASA16, Used in Multiple Phage Therapy Treatments Globally.

PASA16 is a Pseudomonas aeruginosa phage isolated from a soil sample and used to treat several patients suffering from persistent infections in various countries. PASA16's genome was sequenced, analyzed, and deposited in GenBank.

Clinical Phage Microbiology: a suggested framework and recommendations for the in-vitro matching steps of phage therapy.

Phage therapy is a promising solution for bacterial infections that are not eradicated by conventional antibiotics. A crucial element of this approach is appropriate matching of bacteriophages and antibiotics to the bacterial target according to the clinical setting. However, there is currently little consistency in the protocols used for the laboratory evaluation of bacteriophages intended for antibacterial treatment. In this Personal View, we suggest a framework aimed to match appropriate bacteriophage-based treatments in clinical microbiology laboratories. This framework, which we have termed Clinical Phage Microbiology, is based on the current research on phage treatments. In addition, we discuss special cases that might require additional relevant evaluation, including bacteriophage interactions with the host immune response, biofilm-associated infections, and polymicrobial infections. The Clinical Phage Microbiology pipeline could serve as the basis for future standardisation of laboratory protocols for personalised phage therapy.

The Israeli Phage Bank (IPB).

A key element in phage therapy is the establishment of large phage collections, termed herein "banks", where many well-characterized phages, ready to be used in the clinic, are stored. These phage banks serve for both research and clinical purposes. Phage banks are also a key element in clinical phage microbiology, the prior treatment matching of phages and antibiotics to specific bacterial targets. A worldwide network of phage banks can promote a phage-based solution for any isolated bacteria. Herein, we describe the Israeli Phage Bank (IPB) established in the Hebrew University, Jerusalem, which currently has over 300 phages matching 16 bacteria, mainly pathogens. The phage bank is constantly isolating new phages and developing methods for phage isolation and characterization. The information on the phages and bacteria stored in the bank is available online.

Combined bacteriophages and antibiotics as an efficient therapy against VRE Enterococcus faecalis in a mouse model.

Clinical applications of bacteriophage therapy have been recently gathering significant attention worldwide, used mostly as rescue therapy in cases of near-fatal antibiotic failure. Thus, clinically relevant in-vivo models presenting both short- and long-term implications of phage therapy given as rescue treatment for fulminant infections are of highest importance. In this study, a cocktail consisting of two lytic bacteriophages was used to evaluate the therapeutic efficacy of phage therapy as a rescue treatment for severe septic peritonitis in a mouse model. We established that a single injection of the bacteriophage cocktail was sufficient to completely reverse a 100% mortality trend caused by Vancomycin-Resistant Enterococcus faecalis, with significant improvement in both the clinical state and laboratory test results, and without harmful effects on the microbiome. The combination of bacteriophages with a suboptimal antibiotic regimen imparts an additional beneficial effect on the treatment success.

Prolonged platelet activation in individuals with elevated blood pressure in response to a moderate exercise challenge.

We examined the magnitude of 20-min moderate exercise-induced platelet activation in 50 volunteers with normal (n=31) or elevated blood pressure (EBP; n=19). Blood was drawn before, immediately after, and 25 min after exercise. Antibody-staining for platelet activation markers, P-selectin, and fibrinogen receptors was done with and without adenosine diphosphate (ADP) stimulation in whole blood for flow cytometric analyses. Exercise led to increases in percent aggregated platelets and percent platelets expressing P-selectin or PAC-1 binding (ps< or =.001). This increase in percent platelets expressing P-selectin continued even after a 25-min rest only in the EBP group (p< or =.01) accompanied by an increase in percent of aggregated platelets (p< or =.05). Although ADP stimulation led to increased platelet activation at rest, it was attenuated following exercise, even among EBP individuals. A moderate exercise challenge induced prolonged platelet activation in individuals with EBP but attenuation in activation to further stimulation by an agonist. Findings suggest that a recovery period after physical stress appears critical in individuals with high BP regarding platelet activation and aggregation, which can lead to an acute coronary syndrome in vulnerable individuals.

Short-term isocapnic hypoxia and coagulation activation in patients with sleep apnea.

Hemostatic changes might contribute to the increased risk of cardiovascular and cerebrovascular events in patients with obstructive sleep apnea (OSA). We investigated the effect of a short-term isocapnic hypoxic challenge on coagulation activation markers thrombin/antithrombin III complexes (TAT) and D-dimer in OSA. Thirty-two OSA patients (mean age 48 +/- 11 years) inhaled a gas mixture containing 10% O(2) and 90% N(2) and further adjusted to yield pulse oximetry saturation of 80-85% for 5 minutes. Plasma levels of TAT and D-dimer were measured immediately before and immediately after the hypoxic challenge. The hypoxic challenge provoked a significant increase in TAT (p < 0.001) and in D-dimer (p = 0.037). Mean nocturnal oxygen saturation from the sleep recordings correlated with D-dimer increase (r = -0.37, p = 0.041). Also, OSA patients with a history of hypertensive parents had greater D-dimer increase in response to hypoxia than patients having normotensive parents (p = 0.035). Parental hypertension independently explained 15% of the variance in D-dimer increase after hypoxia (p = 0.035). Oxygen desaturation during sleep may predispose OSA patients, in particular those with a parental history of hypertension, to a hypercoagulable state providing one explanation for the increased risk of atherothrombotic events in this population.

Coping processes and hemostatic reactivity to acute stress in dementia caregivers.

BACKGROUND: A hypercoagulable stress response might contribute to the increased cardiovascular risk in Alzheimer's caregivers. OBJECTIVES: (1) To evaluate whether coping processes affect hemostatic reactivity to acute psychological stress and (2) whether these effects differ substantially between caregivers and noncaregivers. METHODS: Sixty elderly community-dwelling spousal caregivers of patients with Alzheimer's disease and 33 noncaregiving controls completed the revised Ways of Coping Questionnaire to assess approach/problem-solving versus avoidant coping processes. Participants were administered an acute stress test that required them to deliver a 3-minute speech challenge to the interviewer on an assigned topic. The hypercoagulability marker D-dimer was measured at three time points: baseline, immediately postspeech, and during recovery (15 minutes postspeech). RESULTS: Multivariate analysis of covariance revealed that subjects who endorsed greater levels of approach coping had decreased levels of D-dimer at all time points (p = .048). A significant three-way interaction between planful problem solving, caregiver status, and the temporal pattern of D-dimer was found (p = .004), indicating that caregivers with low levels of planful problem solving exhibited greater increases in D-dimer from baseline to speech and recovery time points relative to controls. No relationship between avoidant coping and D-dimer was found. CONCLUSIONS: These findings suggest the possibility that approach and problem-solving coping processes buffer the impact of acute psychological stressors on procoagulant activity. It remains to be seen whether interventions that increase approach/problem-solving processes might produce salutary effects among caregiving populations.

The association between interleukin-6, sleep, and demographic characteristics.

We examined the relationship between the pro-inflammatory cytokine IL-6 and sleep architecture in 70 healthy men and women. Blood was drawn in the early morning for assessment of IL-6 followed by nocturnal sleep monitoring with polysomnography. Sleep records were scored for sleep stages using standard criteria. Morning IL-6 levels were positively correlated with REM latency after sleep onset [rho = .31, p = .01], percent (%) stage 1 sleep [rho = .23, p = .053], % wake after sleep onset (WASO) [rho = .29, p<.05]. IL-6 levels were negatively correlated with sleep efficiency [rho = -.36, p<.01] and slow wave sleep (SWS) [rho = -.26, p<.05]. After controlling for demographic variables including race, gender, age, and BMI, multiple hierarchical regression analyses revealed that morning IL-6 levels accounted for a significant portion of the variance of REM latency (p<.01), sleep efficiency (p<.01), and % WASO (p = .01). IL-6 was no longer associated with % stage 1 sleep, SWS, and total sleep time after controlling for the demographic characteristics. These findings suggest that the inflammatory marker IL-6 is associated with sleep quality and that certain individual characteristics such as race, gender, and age modify that relationship. Higher IL-6 levels were associated with lower quality of sleep among healthy asymptomatic men and women.

Exaggerated plasma fibrin formation (D-dimer) in elderly Alzheimer caregivers as compared to noncaregiving controls.

BACKGROUND: The chronic stress of providing care for a spouse suffering from Alzheimer's disease has been associated with an increased risk for coronary artery disease and overall mortality. Procoagulant changes are kindled by mental stress, and they are prospectively associated with atherothrombotic events. OBJECTIVE: To examine whether dementia caregivers would show greater coagulation activity and less fibrinolytic capacity than noncaregiving controls. METHODS: Subjects were 48 (30 female and 18 male) elderly (mean age +/- SD, 72 +/- 9 years) community-dwelling spousal Alzheimer caregivers and 20 noncaregiving age- and gender-matched controls. Plasma levels of thrombin-antithrombin III, fibrin D-dimer, von Willebrand factor, tissue-type plasminogen activator, and plasminogen activator inhibitor 1 were measured. RESULTS: D-dimer, a marker of fibrin formation and degradation, was significantly higher in caregivers than in controls (688 +/- 575 vs. 406 +/- 157 ng/ml, p = 0.021). Plasma levels of the four other hemostasis variables were not significantly different between the two groups. Controlling for the classic cardiovascular risk factors body mass index, hypertension status, smoking status, hypercholesterolemia, type II diabetes, and medication potentially affecting hemostasis did not change results. CONCLUSION: The findings suggest that Alzheimer caregivers have an increased fibrin turnover as compared to noncaregiving controls independent of common confounders of hemostasis. Such an elevated clotting diathesis might contribute to increased cardiovascular risk and overall mortality with dementia caregiving strain.

Relation of nocturnal blood pressure dipping to cellular adhesion, inflammation and hemostasis.

BACKGROUND: Subjects who fail to dip their nocturnal blood pressure (BP) are at substantially increased risk for cardiovascular diseases. The pathogenetic mechanisms of this relationship have not been elucidated. We investigated whether non-dipping would relate to procoagulant and proinflammatory activity. DESIGN: Study participants were 76 unmedicated normotensive and hypertensive subjects (44 male, 32 female; 41 white, 35 black; mean age, 36 +/- 8 years) who underwent 24-h outpatient ambulatory BP monitoring. Based on whether their average nocturnal systolic BP relative to their average daytime systolic BP declined by less than 10%, 34 subjects were categorized as non-dippers. D-dimer, plasminogen activator inhibitor-1, von Willebrand factor, soluble intercellular adhesion molecule-1, and interleukin-6 were measured in plasma. RESULTS: Multivariate analyses showed that D-dimer (median/interquartile range, 242/162-419 ng/ml versus 175/132-254 ng/ml; P=0.041), plasminogen activator inhibitor-1 (36/19-61 ng/ml versus 17/6-44 ng/ml; P=0.010), von Willebrand factor (122/91-179% versus 92/66-110%; P=0.001), and soluble intercellular adhesion molecule-1(227/187-291 ng/ml versus 206/185-247 ng/ml; P=0.044) were all higher in non-dippers than in dippers. Adjustment for gender, ethnicity, age, body mass index, smoking status, hypertension status, and social class revealed independent effects of non-dipping. Non-dippers continued to have higher D-dimer (P=0.030) and von Willebrand factor (P=0.034) than dippers. A similar trend not reaching statistical significance emerged for soluble intercellular adhesion molecule-1 (P=0.055). In contrast, dipping status had no effect on interleukin-6. CONCLUSION: Nocturnal BP non-dipping is associated with elevated levels of molecules related to endothelial dysfunction and atherosclerosis. The finding provides one possible mechanism linking non-dipping with cardiovascular disease.

The effects of standard anthracycline-based chemotherapy on soluble ICAM-1 and vascular endothelial growth factor levels in breast cancer.

PURPOSE: The circulating soluble form of intercellular adhesion molecule-1 (sICAM-1) and vascular endothelial growth factor (VEGF) are elevated in women with breast cancer and associated with tumor progression and poor prognosis. This study examined the effects of anthracycline-based chemotherapy on plasma sICAM-1 and VEGF, as well as soluble P-selectin, von Willebrand factor, and interleukin-6 levels. EXPERIMENTAL DESIGN: Twenty-six women diagnosed with stage I-IIIA breast cancer (mean age, 48.4 +/- 10.4 years; range, 34-79 years) were studied before (week 1) and at weeks 2 and 3 of cycles 1 and 4 of chemotherapy. RESULTS: The initial effect of chemotherapy was to reduce sICAM-1 levels; compared with pretreatment, sICAM-1 levels were decreased at week 2 of both cycles (P values < 0.01). sICAM-1 levels were elevated, however, at the start of cycle 4 as compared with pretreatment (P < 0.01). Chemotherapy led to an increase in sICAM-1 levels in node-positive but not node-negative patients (P < 0.01). VEGF levels were decreased at week 2 of cycle 4 (P = 0.001) and remained so at week 3. Similar to sICAM-1, VEGF levels were elevated at the start of cycle 4 as compared with pretreatment (P < 0.006). Soluble P-selectin levels decreased during week 2 of cycle 4 (P = 0.026). Neither interleukin-6 or von Willebrand factor were significantly changed in response to chemotherapy. CONCLUSIONS: The findings support prior studies suggesting that sICAM-1 levels derive from sources other than endothelial cells. In addition, whereas the more immediate effect of chemotherapy is to reduce sICAM-1 and VEGF, continued treatment may lead to significant elevations.

Vulnerable caregivers of Alzheimer disease patients have a deficit in beta 2-adrenergic receptor sensitivity and density.

OBJECTIVE: The chronic stress of caregiving may lead to sympathetic nervous system activation and immune suppression. beta(2)-adrenergic receptors are expressed on all immune cells and contribute to the stress-induced loss of immune-cell function. The authors examined the effects of being a spousal caregiver of a patient with Alzheimer disease (AD) on the lymphocyte beta(2)-adrenergic receptor. METHODS: One hundred and six women and men, spousal caregivers and non-caregivers, participated (mean age: 71.5 years). Caregivers were classified as either vulnerable or non-vulnerable on the basis of the amount of care required by the patient relative to the amount of respite the caregiver received during the previous 6 months. beta(2)-adrenergic receptor sensitivity (cyclic-AMP response to isoproterenol stimulation) and density (radioligand binding) were determined by use of whole lymphocytes. RESULTS: Vulnerable caregivers had reduced beta(2)-adrenergic receptor sensitivity and density when compared with their non-vulnerable counterparts or with non-caregivers. CONCLUSION: The findings indicate that for more vulnerable caregivers, the stress of caregiving leads to a loss of lymphocyte beta(2)-adrenergic receptors. This finding may be relevant to previous observations of clinically-relevant reduced immunity in highly stressed caregivers of AD patients.

Effects of depressive symptoms and anxiety on hemostatic responses to acute mental stress and recovery in the elderly.

Depression and anxiety are prospectively associated with cardiac morbidity and mortality. Increased clotting diathesis may mediate this link. We hypothesized that there would be an association between mood and hemostatic changes that occur during and following recovery from acute mental stress. Forty-eight community-dwelling elderly subjects underwent a laboratory speech stressor task. Plasma von Willebrand factor (vWF), thrombin/antithrombin III (TAT) complexes, D-dimer, tissue-type plasminogen activator (t-PA), and type I plasminogen activator inhibitor (PAI-1) were measured at rest, after conclusion of the speech, and 14 min afterwards (recovery). Mood was assessed with the Hamilton Rating Scales for Depression (Ham-D) and Anxiety (Ham-A). Mental stress elicited a hypercoagulable state as evidenced by increases in TAT and D-dimer, and by a decrease in t-PA. Overall, hypercoagulability had increased after recovery. Ham-D scores and Ham-A scores correlated with increases in D-dimer over the testing interval (i.e. area under the curve). Ham-A (but not Ham-D) uniquely explained 8% and 17% of the variance in resting D-dimer and D-dimer area under the curve, respectively. The independent association of anxiety symptoms with resting and stress-induced fibrin formation (D-dimer) may be a mechanism linking mood with cardiovascular disease risk in the elderly.

Effects of nonspecific beta-adrenergic stimulation and blockade on blood coagulation in hypertension.

A hypercoagulable state might contribute to increased atherothrombotic risk in hypertension. The sympathetic nervous system is hyperactive in hypertension, and it regulates hemostatic function. We investigated the effect of nonspecific beta-adrenergic stimulation (isoproterenol) and blockade (propranolol) on clotting diathesis in hypertension. Fifteen hypertensive and 21 normotensive subjects underwent isoproterenol infusion in two sequential, fixed-order doses of 20 and then 40 ng. kg(-1). min(-1) for 15 min/dose. Thirteen subjects were double-blind studied after receiving placebo or propranolol (100 mg/day) for 5 days each. In hypertensive subjects, isoproterenol elicited a dose-dependent increase in plasma von Willebrand factor (vWF) antigen [F(2,34) = 5.02; P = 0.032] and a decrease in D-dimer [F(2,34) = 4.57; P = 0.040], whereas soluble tissue factor remained unchanged. Propranolol completely abolished the increase in vWF elicited by isoproterenol [F(1,12) = 10.25; P = 0.008] but had no significant effect on tissue factor and D-dimer. In hypertension, vWF is readily released from endothelial cells by beta-adrenergic stimulation, which might contribute to increased cardiovascular risk. However, beta-adrenergic stimulation alone may not be sufficient to trigger fibrin formation in vivo.

The effects of spaceflight on adrenergic receptors and agonists and cell adhesion molecule expression.

Twenty-two astronauts who flew aboard 10 different US Space Shuttle flights were studied 10 days before launch, on landing day, and 2-4 days post-landing. After landing, plasma levels of norepinephrine (p<0.01) were elevated. Lymphocyte beta(2)-adrenergic receptors were desensitized 2-4 days post-landing (p<0.02). The density of CD62L on lymphocytes was unchanged but the densities of CD11a (p<0.01) and CD54 (p<0.001) were down-regulated. CD11a density was also down-regulated on monocytes (p<0.01). Neutrophils showed an up-regulation of CD11a (p<0.01) and a down-regulation of CD54 (p<0.01). CD11a density on neutrophils remained up-regulated (p<0.01) and CD54 density remained down-regulated (p<0.01) at 2-4 days post-landing. Circulating levels of soluble ICAM-1 (CD54) and soluble E-selectin (CD62E) were decreased after landing (p's<0.05). The data suggest that spaceflight leads to an environment that would support reduced leukocyte-endothelial adhesion. Sympathetic activation may contribute to this phenomenon.

Health consequences of Alzheimer's caregiving transitions: effects of placement and bereavement.

OBJECTIVE: To determine the extent to which the chronic stress of Alzheimer's disease caregiving may be alleviated by placement or death of the Alzheimer's disease patient, we prospectively compared groups of caregivers (CG) who continued to care for their Alzheimer's disease spouse at home, CG who placed their spouses, and CG whose spouses died with similarly aged noncaregiving comparison subjects (control subjects). METHODS: A sample of 119 CG who had been studied for at least 18 months at 6-month intervals was included in the present analyses (ie, had at least three assessments). Data were gathered on CG mood, blood pressure, and medical symptoms among 38 CG whose spouses were at home at all three visits (home-home-home [HHH]); 28 CG who placed their spouse at follow-up (home-placed-placed [HPP]); 27 CG whose spouses were placed and subsequently died at follow-up (home-placed-deceased [HPD]); and 26 CG whose spouses died at home (home-deceased-deceased [HDD]). Data were compared with 48 noncaregiving control subjects (NC group). RESULTS: CG in the HPP, HPD, and HDD groups showed improvement in depressive and physical symptoms compared with HHH and NCs. CG had significantly higher systolic blood pressure at rest than did NCs. Both placement and death of the Alzheimer's disease spouse were associated with higher systolic blood pressure in response to postural challenge in CG experiencing these transitions. CONCLUSIONS: Despite improvement seen in mood and medical symptoms among CG who place their spouses or experience the spouse's death, there may be longer term physiological alterations, possibly in sympathoadrenalmedullary arousal, that cause the cardiovascular system to continue to respond to acute stressors such as postural challenge more actively for a period of 6 to 12 months after such transitions.

Temporal stability of acute stress-induced changes in leukocyte subsets and cellular adhesion molecules in older adults.

This study investigated the temporal stability of enumerative immune and catecholamine responses to acute psychosocial stress in 67 Alzheimer's caregivers ages 56-82 years (45 women and 22 men) who were required to prepare and deliver two 3-min speeches on three occasions at 2-week and 6-week intervals. All leukocyte subsets and adhesion molecules (CD62L and CD11a) changed significantly from rest to postspeak at each of the three testing sessions (p's <.0005). Responses showed moderate to high temporal stability across baseline and absolute task values (r's =.65-.96). Reliability was predictably lower for both forms of change scores (r's = -.16-.64). The level of temporal stability achieved is comparable to that seen previously in younger adults, indicating that acute psychosocial stress produces reliable changes in circulating leukocytes and cell adhesion molecules in older adults.