Comparison of Experimental Middle East Respiratory Syndrome Coronavirus Infection Acquired by Three Individual Routes of Infection in the Common Marmoset.

Two strains of Middle East respiratory syndrome coronavirus (MERS-CoV), England 1 and Erasmus Medical Centre/2012 (EMC/2012), were used to challenge common marmosets (Callithrix jacchus) by three routes of infection: aerosol, oral, and intranasal. Animals challenged by the intranasal and aerosol routes presented with mild, transient disease, while those challenged by the oral route presented with a subclinical immunological response. Animals challenged with MERS-CoV strain EMC/2012 by the aerosol route responded with primary and/or secondary pyrexia. Marmosets had minimal to mild multifocal interstitial pneumonia, with the greatest relative severity being observed in animals challenged by the aerosol route. Viable virus was isolated from the host in throat swabs and lung tissue. The transient disease described is consistent with a successful host response and was characterized by the upregulation of macrophage and neutrophil function observed in all animals at the time of euthanasia. IMPORTANCE Middle East respiratory syndrome is caused by a human coronavirus, MERS-CoV, similar to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Humans typically exhibit fever, cough, shortness of breath, gastrointestinal issues, and breathing difficulties, which can lead to pneumonia and/or renal complications. This emerging disease resulted in the first human lethal cases in 2012 and has a case fatality rate of approximately 36%. Consequently, there is a need for medical countermeasures and appropriate animal models for their assessment. This work has demonstrated the requirement for higher concentrations of virus to cause overt disease. Challenge by the aerosol, intranasal, and oral routes resulted in no or mild disease, but all animals had an immunological response. This shows that an appropriate early immunological response is able to control the disease.

Efficacy of Co-Trimoxazole against Experimental Melioidosis Acquired by Different Routes of Infection.

Burkholderia pseudomallei is the causative agent of melioidosis and presents with diverse clinical manifestations. Naturally occurring infection occurs following contamination of cuts or skin abrasions, or ingestion of contaminated water, and occasionally through inhalational of infected soil or water particles. The influence of the route of disease acquisition on the efficacy of medical countermeasures has not been explored in humans or in appropriate animal models. The efficacy of co-trimoxazole against melioidosis acquired by different routes of exposure was assessed in postexposure prophylaxis (PEP) and treatment studies in marmoset models of melioidosis. Following challenge with B. pseudomallei by the inhalational, subcutaneous, or ingestion routes of administration, animals were given co-trimoxazole at 12 hourly intervals for 14 days, starting either 6 h postchallenge or at the onset of fever. Animals were then observed for 28 days. All animals that received antibiotic 6 h postchallenge survived the duration of dosing. All animals that received antibiotics at the onset of fever completed the treatment, but 10%, 57%, and 60% of those with ingestion, subcutaneous, and inhalation challenge relapsed, respectively. Bacteriological and histological differences were observed between placebo-control animals and those that relapsed. Immunological profiles indicate difference between animals given placebo and those that relapsed or survived the duration of the study. A broad T-cell activation was observed in animals that survived. Overall, these data suggest the efficacy of co-trimoxazole, as measured in the incidence of relapse, differs depending on the disease-acquisition route. Therefore, there are implications in treating this disease in regions of endemicity.

Usability of Light-Linking Technology for Infusion Line Identification: A Simulation Study With ICU Nurses.

Critical care nurses are faced with increasing task loads due to increasing patient complexity. In addition to this complexity, most critical care patients have a maze of infusion and monitoring lines that must be navigated when administering medications. Task load is escalated when a nurse must identify an injection port and administer a medication rapidly. This study tested a commercially available light-linking infusion line identification device. Researchers compared standard labeling practices to the light-linking technology on time to injection, error rate, usability, and task load. Forty-seven intensive care nurses completed 188 critical care simulations using a randomized cross-over design. Simulations were carried out in both daylight and low-light conditions. The light-linking technology reduced overall time to injection compared to standard labeling practices and demonstrated a significant decrease in time to injection in low-light settings, greater perceived usability, and lower perceived task load. Injection error rate could not be adequately assessed, but 6 of 8 errors were committed in low-light conditions.

Predictors of Survival after Vaccination in a Pneumonic Plague Model.

Background: The need for an updated plague vaccine is highlighted by outbreaks in endemic regions together with the pandemic potential of this disease. There is no easily available, approved vaccine. Methods: Here we have used a murine model of pneumonic plague to examine the factors that maximise immunogenicity and contribute to survival following vaccination. We varied vaccine type, as either a genetic fusion of the F1 and V protein antigens or a mixture of these two recombinant antigens, as well as antigen dose-level and formulation in order to correlate immune response to survival. Results: Whilst there was interaction between each of the variables of vaccine type, dose level and formulation and these all contributed to survival, vaccine formulation in protein-coated microcrystals (PCMCs) was the key contributor in inducing antibody titres. From these data, we propose a cut-off in total serum antibody titre to the F1 and V proteins of 100 µg/mL and 200 µg/mL, respectively. At these thresholds, survival is predicted in this murine pneumonic model to be >90%. Within the total titre of antibody to the V antigen, the neutralising antibody component correlated with dose level and was enhanced when the V antigen in free form was formulated in PCMCs. Antibody titre to F1 was limited by fusion to V, but this was compensated for by PCMC formulation. Conclusions: These data will enable clinical assessment of this and other candidate plague vaccines that utilise the same vaccine antigens by identifying a target antibody titre from murine models, which will guide the evaluation of clinical titres as serological surrogate markers of efficacy.

Surgical intensive care unit mobility is increased after institution of a computerized mobility order set and intensive care unit mobility protocol: a prospective cohort analysis.

In some populations, intensive care unit (ICU) mobility has been shown to be safe and beneficial. We gathered data on 50 nonintubated surgical patients in a 10-bed surgical ICU (SICU) who met physiologic inclusion criteria beginning in May 2008 (A group). In January 2009, we began mandatory entry of computerized mobility orders as part of a standardized ICU order set. We also created a mobility protocol for nurses in this ICU. We then collected data on 50 patients in this postintervention cohort (B group). Both groups had similar baseline characteristics. A group patients had some form of mobility orders entered in 29 patients (58%) versus 47 patients (82%) in the B group, P < 0.05. In the A group, 11 patients (22%) were mobilized; in the B group, 40 patients (80%) were mobilized, P < 0.05. In our SICU patient population, mandatory entry of computerized mobility orders as part of a standard SICU order set and establishment of an ICU mobility nursing protocol was associated with an increase in number of mobility orders entered as well as an increase in SICU patient activity. Further studies should focus on measurement of the effect of mobility interventions on patient outcomes.

Glucosamine-NISV delivers antibody across the blood-brain barrier: Optimization for treatment of encephalitic viruses.

The field of brain drug delivery faces many challenges that hinder development and testing of novel therapies for clinically important central nervous system disorders. Chief among them is how to deliver large biologics across the highly restrictive blood-brain barrier. Non-ionic surfactant vesicles (NISV) have long been used as a drug delivery platform for cutaneous applications and have benefits over comparable liposomes in terms of greater stability, lower cost and suitability for large scale production. Here we describe a glucosamine-coated NISV, for blood-brain barrier GLUT1 targeting, capable of traversing the barrier and delivering active antibody to cells within the brain. In vitro, we show glucosamine vesicle transcytosis across the blood-brain barrier with intact cargo, which is partially dynamin-dependent, but is clathrin-independent and does not associate with sorting endosome marker EEA1. Uptake of vesicles into astrocytes follows a more classical pathway involving dynamin, clathrin, sorting endosomes and Golgi trafficking where the cargo is released intracellularly. In vivo, glucosamine-coated vesicles are superior to uncoated or transferrin-coated vesicles for delivering cargo to the mouse brain. Finally, mice infected with Venezuelan equine encephalitis virus (VEEV) were successfully treated with anti-VEEV monoclonal antibody Hu1A3B-7 delivered in glucosamine-coated vesicles and had improved survival and reduced brain tissue virus levels. An additional benefit was that the treatment also reduced viral load in peripheral tissues. The data generated highlights the huge potential of glucosamine-decorated NISV as a drug delivery platform with wider potential applications.

Exploitation of the bilosome platform technology to formulate antibiotics and enhance efficacy of melioidosis treatments.

Burkholderia pseudomallei is a Gram-negative intracellular bacterium which is recalcitrant to antibiotic therapy. There also is currently no licensed vaccine for this potentially fatal pathogen, further highlighting the requirement for better therapeutics to treat the disease melioidosis. Here we use an oral delivery platform, the bilosome to entrap already- licensed antibiotics. Bilosome-entrapped antibiotics were used to treat mice infected via the aerosol route with B. pseudomallei. When treatment was started by the oral route at 6 h post-infection and continued for 7 days, bilosome levofloxacin and bilosome doxycycline formulations were significantly more efficacious than free antibiotics in terms of survival rates. Additionally, bilosome formulated levofloxacin protected mice from antibiotic and infection induced weight loss following B. pseudomallei infection. The microbiomes of mice treated with levofloxacin were depleted of all phyla with the exception of Firmicutes, but doxycycline treatment had minimal effect on the microbiome. Encapsulation of either drug in bilosomes had no deleterious or clear advantageous effect on microbiome. This indicates that the ability of bilosomes to ameliorate antibiotic induced weight loss is not due to microbiome effects. The bilosome platform not only has potential to reduce adverse effects of orally delivered antimicrobials, but has potential for other therapeutics which may cause detrimental side-effects or require enhanced delivery.

Concomitant administration of Yersinia pestis specific monoclonal antibodies with plague vaccine has a detrimental effect on vaccine mediated immunity.

Antibodies can be used to confer rapid immunity against infectious agents for short periods of time. By comparison, vaccine induced immunity is more protective, but takes a relatively long time to develop. Concomitant administration of antibody and vaccine by different routes was evaluated as a means of providing both rapid and long-term protection against plague. BALB/c mice were treated intraperitoneally with monoclonal antibodies, with specificities for Yersinia pestis LcrV and F1 antigens. A cohort of these mice was simultaneously vaccinated with rF1 and rLcrV by the intramuscular route. Antibody co-administration with vaccine reduced the level of vaccine mediated protection afforded against a high level Y. pestis challenge. Conversely, antibody-mediated protection was unaffected by vaccine co-administration and lasted for at least 8 weeks post administration. We also evaluated the effect of administering vaccine intradermally and antibody intratracheally and observed that, irrespective of administration route, concomitant administration of antibody reduced the effectiveness of vaccine mediated immunity. The results of passive transfer experiments supported the thesis that the development of protective antibody responses following vaccination is impaired by the presence of circulating monoclonal antibodies with specificities for important B-cell epitopes in the vaccine. We also noted that intradermal injection of LcrV antigen and cholera toxin adjuvant afforded good levels of protection against systemic and aerosol challenge with Y. pestis: intradermal injection might therefore be considered as a potential minimally invasive method of plague vaccine administration. These data have implications for the design of therapeutic strategies against plague infection.