Cathelicidin LL-37 restoring glucocorticoid function in smoking and lipopolysaccharide-induced airway inflammation in rats.

BACKGROUND: Glucocorticoids have been widely used to treat patients with chronic obstructive pulmonary disease (COPD). Nevertheless, corticosteroid insensitivity is a major barrier to the effective treatment of COPD and its mechanism remains unclear. This study aimed to evaluate the effect of cathelicidin LL-37 on corticosteroid insensitivity in COPD rat model, and to explore the involved mechanisms. METHODS: COPD model was established by exposing male Wistar rats to cigarette smoke combined with intratracheal instillation of lipopolysaccharide (LPS). Inhaled budesonide and LL-37 were consequently applied to COPD models separately or collectively to confirm the effects on inflammatory cytokines (tumor necrosis factor [TNF]-α and transforming growth factor [TGF]-ß) by enzyme-linked immunosorbent assay (ELISA) and lung tissue histopathological morphology. Expression of histone deacetylase-2 (HDAC2) and phosphorylation of Akt (p-AKT) in lung were also measured. RESULTS: Briefly, COPD model rats showed an increased basal release of inflammatory cytokines (lung TNF-α: 45.7 ±â€Š6.1 vs. 20.1 ±â€Š3.8 pg/mL, P < 0.01; serum TNF-α: 8.9 ±â€Š1.2 vs. 6.7 ±â€Š0.5 pg/mL, P = 0.01; lung TGF-ß: 122.4 ±â€Š20.8 vs. 81.9 ±â€Š10.8 pg/mL, P < 0.01; serum TGF-ß: 38.9 ±â€Š8.5 vs. 20.6 ±â€Š2.3 pg/mL, P < 0.01) and COPD related lung tissue histopathological changes, as well as corticosteroid resistance molecular profile characterized by an increase in phosphoinositide 3-kinase (PI3K)/Akt (0.5 ±â€Š0.1 fold of control vs. 0.2 ±â€Š0.1 fold of control, P = 0.04) and a decrease in HDAC2 expression and activity (expression: 13.1 ±â€Š0.4 µmol/µg vs. 17.4 ±â€Š1.1 µmol/µg, P < 0.01; activity: 1.1 ±â€Š0.1 unit vs. 1.4 ±â€Š0.1 unit, P < 0.01), compared with control group. In addition, LL-37 enhanced the anti-inflammatory effect of budesonide in an additive manner. Treatment with combination of inhaled corticosteroids (ICS) and LL-37 led to a significant increase of HDAC2 expression and activity (expression: 15.7 ±â€Š0.4 µmol/µg vs. 14.1 ±â€Š0.9 µmol/µg, P < 0.01; activity: 1.3 ±â€Š0.1 unit vs. 1.0 ±â€Š0.1 unit, P < 0.01), along with decrease of p-AKT compared to budesonide monotherapy (0.1 ±â€Š0.0 fold of control vs. 0.3 ±â€Š0.1 fold of control, P < 0.01). CONCLUSIONS: This study suggested that LL-37 could improve the anti-inflammatory activity of budesonide in cigarette smoke and LPS-induced COPD rat model by enhancing the expression and activity of HDAC2. The mechanism of this function of LL-37 might involve the inhibition of PI3K/Akt pathway.

Double-Blind Randomized Trial of Pirfenidone in Chinese Idiopathic Pulmonary Fibrosis Patients.

Idiopathic pulmonary fibrosis (IPF) lacks effective treatment. Pirfenidone has been used to treat IPF patients. N-acetylcysteine (NAC) exerts antioxidant and antifibrotic effects on IPF cases.This study is a double-blind, modified placebo-controlled, randomized phase II trial of pirfenidone in Chinese IPF patients. We randomly assigned the enrolled Chinese IPF patients with mild to moderate impairment of pulmonary function to receive either oral pirfenidone (1800 mg per day) and NAC (1800 mg per day) or placebo and NAC (1800 mg per day) for 48 weeks. The primary endpoints were the changes in forced vital capacity (FVC) and walking distance and the lowest SPO2 during the 6-minute walk test (6MWT) at week 48. The key secondary endpoint was the progression-free survival time. This study is registered in ClinicalTrials.gov as number NCT01504334.Eighty-six patients were screened, and 76 cases were enrolled (pirfenidone + NAC: 38; placebo + NAC: 38). The effect of pirfenidone treatment was significant at the 24th week, but this effect did not persist to the 48th week. At the 24th week, the mean decline in both FVC and ΔSPO2 (%) during the 6MWT in the pirfenidone group was lower than that in the control group (-0.08 ± 0.20 L vs -0.22 ± 0.29 L, P = 0.02 and -3.44% ± 4.51% vs -6.29% ± 6.06%, P = 0.03, respectively). However, there was no significant difference between these 2 groups at the 48th week (-0.15 ± 0.25 L vs -0.25 ± 0.28 L, P = 0.11 and -4.25% ± 7.27% vs -5.31% ± 5.49%, P = 0.51, respectively). The pirfenidone treatment group did not achieve the maximal distance difference on the 6MWT at either the 24th or the 48th week. But pirfenidone treatment prolonged the progression-free survival time in the IPF patients (hazard ratio = 1.88, 95% confidence interval: 1.092-3.242, P = 0.02). In the pirfenidone group, the adverse event (AE) rate (52.63%) was higher than that in the control group (26.3%, P = 0.03). Rash was more common in the pirfenidone group (39.5% vs 13.2%, P = 0.02).Compared with placebo combined with high-dose NAC, pirfenidone combined with high-dose NAC prolonged the progression-free survival of Chinese IPF patients with mild to moderate impairment of pulmonary function. (ClinicalTrials.gov number, NCT01504334).

Antimicrobial peptide LL-37 circulating levels in chronic obstructive pulmonary disease patients with high risk of frequent exacerbations.

BACKGROUND: Exacerbations of chronic obstructive pulmonary disease (COPD) increase the decline in lung function, deterioration in health status and risk of death. The assessment of exacerbation risk is important in the grading of COPD. The most common cause of COPD exacerbation is respiratory tract infection. The only known human cathelicidin antimicrobial peptide, LL-37, play an important role in innate defense against infection. Its gene expression is regulated by the bioactive form of vitamin D. The objective of the present study was to explore the relationship between LL-37 plasma levels, vitamin D status and exacerbation risk in patients with COPD. METHODS: COPD patients and normal subjects were recruited from Beijing Hospital for this study. COPD patients were divided into low risk group and high risk group according to the criteria of GOLD strategy. The plasma concentrations of LL-37 were measured by ELISA technique to explore the difference in LL-37 levels between groups. The plasma levels of 25-hydroxy vitamin D [25(OH)D] were analyzed using electrochemiluminescence immunoassay (ECLIA). RESULTS: A total of 84 COPD patients and 51 normal subjects (control group) were recruited. COPD patients were divided into low risk group (37 cases) and high risk group (47 cases), depending on forced expiratory volume in one second (FEV1)%pred and exacerbation frequency in the previous year. The plasma concentrations of LL-37 in control group, low risk group and high risk group were 20.7±5.8, 19.5±4.1 and 17.9±3.9 µg/L respectively. The plasma concentration of LL-37 was significantly lower in high risk group than in control group (P=0.006). But there was no significant difference between low risk group and high risk group (P=0.152). The plasma concentrations of 25(OH)D in control group, low risk group and high risk group were 18.1±9.4, 13.1±6.9 and 9.3±5.8 ng/mL respectively. The plasma concentration of 25(OH)D was significantly higher in control group than in low risk group (P=0.004) or high risk group (P<0.001). The plasma concentration of 25(OH)D was significantly lower in high risk group than in low risk group (P=0.031). Hospitalization frequency for COPD exacerbations was negative correlated with plasma levels of LL-37 (r=-0.290, P=0.048) and 25(OH)D (r=-0.341, P=0.020) in high risk group. There was not significant correlation between LL-37 and 25(OH)D in COPD patients (r=0.115, P=0.303). CONCLUSIONS: The plasma levels of LL-37 and 25(OH)D were lower in COPD patients with high risk of frequent exacerbations than normal subjects. Low plasma levels of LL-37 and 25(OH)D might be predictors of exacerbation risk in COPD patients.

Expert consensus on acute exacerbation of chronic obstructive pulmonary disease in the People's Republic of China.

Chronic obstructive pulmonary disease (COPD) is a common disease that severely threatens human health. Acute exacerbation of COPD (AECOPD) is a major cause of disease progression and death, and causes huge medical expenditures. This consensus statement represents a description of clinical features of AECOPD in the People's Republic of China and a set of recommendations. It is intended to provide clinical guidelines for community physicians, pulmonologists and other health care providers for the prevention, diagnosis, and treatment of AECOPD.

[Pulmonary mucormycosis: report of 5 cases and review of 46 cases reported in China].

OBJECTIVE: To describe the clinical manifestations and diagnosis of pulmonary mucormycosis. METHODS: We presented 5 proven diagnosed cases of pulmonary mucormycosis in our hospital and reviewed all proven cases of pulmonary mucormycosis previously reported in mainland China. Publications in the form of case reports and articles between January 1982 and December 2011 were searched from Wan Fang Data and China Hospital Knowledge Database. RESULTS: Of the 5 patients in our hospital, the main symptoms included cough, fever, and hemoptysis. Two cases were diagnosed by transbronchial lung biopsy (TBLB), 1 by surgery, 1 by CT-guided percutaneous lung biopsy, and 1 by blood culture. Three patients were cured by antifungal chemotherapy alone, 1 was cured by surgery, and 1 died. Forty-six proven diagnosed cases of pulmonary mucormycosis were retrieved from Wan Fang Data and China Hospital Knowledge Database using key word (pulmonary mucormycosis). Of the 51 patients in total, there were 31 males and 20 females, with a mean age of (47 ± 13)years. The most common risk factors for pulmonary mucormycosis were poorly controlled diabetes mellitus (18 cases), administration of immunosuppressants (7 cases), malignancy (5 cases) and kidney diseases (5 cases). Chest CT showed nodules (27 cases), infiltrates (21 cases), and cavities (18 cases). White blood cell count and neutrophil percentage were elevated in 26 patients. Eighteen cases were diagnosed by histological study of transbronchial biopsy or TBLB specimen. The diagnosis was proven with surgical specimen in 15 patients, CT-guided percutaneous lung biopsy specimen in 7 patients, autopsy in 4 patients, skin biopsy in 1 patient, and renal biopsy in one patient. Three cases were diagnosed by pleural effusion cultures and 2 were diagnosed by blood cultures. Administration of low-dose liposomal amphotericin B (AMB) alone or combined with posaconazole in 12 patients were effective and safe. Fourteen patients who had received surgical resection were cured. CONCLUSIONS: There were no specific clinical features of pulmonary mucormycosis. Transbronchial biopsy and CT-guided percutaneous lung biopsy are useful diagnostic tools for pulmonary mucormycosis. Surgical resection and administration of low-dose liposomal AMB alone or combined with posaconazole were all effective and safe.

[Clinical analysis of 15 cases of saddle pulmonary embolism].

OBJECTIVE: To improve recognition of saddle pulmonary embolism (SPE). METHODS: A retrospectively review was performed for patients diagnosed with SPE determined by CTPA from Jan 2004 to Jan 2012. RESULTS: Fifteen SPE patients(4.44%) were found in 338 documented PE patients confirmed by CTPA. There were 7 males and 8 females, with an average age of (57 ± 13) years. The bifurcation of the main pulmonary artery was completely blocked in one case, while partial obstruction was found in the others. Hemodynamic stability was observed in 11 cases, shock in 1 case, and hypotension in 3 cases. Thromboembolectomy was performed in 1 case accompanied by patent foramen ovale straddling thrombus, and thrombolytic therapy was administered in 5 cases while anticoagulant therapy alone in 9 cases. All the cases survived. Minor bleeding was observed in 2 patients and no major bleeding occurred. CONCLUSION: The prevalence of SPE in this series was similar to that reported in the literature. But the incidence might be underestimated. Mortality rate was low. No more aggressive therapeutic interventions (thrombolytics or catheter thrombectomy) were needed in those patients with hemodynamic stability and without patent foramen ovale straddling thrombus.

Prevalence and clinical prognosis of heteroresistant vancomycin-intermediate Staphylococcus aureus in a tertiary care center in China.

BACKGROUND: The emergence of heteroresistant vancomycin-intermediate Staphylococcus aureus (hVISA) is increasingly challenging the methods for detection in diagnostic microbiology laboratories. However, the report of hVISA is rare in China. This study summarizes the prevalence and clinical features associated with hVISA infections at our institution and the local impact they have on clinical outcome. METHODS: A total of 122 methicillin-resistant Staphylococcus aureus (MRSA) isolates which were of the causative pathogens were collected. One hundred and two patients for whom we had full information of MRSA pneumonia were included. Isolates of MRSA were collected using PCR to detect the mecA gene. Both Etest and macro Etest were performed to screen for hVISA. The Staphylococcal chromosome cassette mec (SCCmec) types were determined by multiplex PCR strategy. Logistic regression analysis was used to determine the risk factors. RESULTS: Among the 122 MRSA isolates collected, 25 (20.5%) strains were identified as hVISA. There were 119 (97.5%) SCCmec III isolates, two (1.6%) SCCmec II isolates, and one (0.8%) SCCmec V isolate. The 30-day mortality of MRSA-hospital acquired pneumonia (HAP) was 37.3%, and 62.5% for hVISA-HAP. Vancomycin treatment was the independent risk factor of hVISA. Factors independently associated with 30-day mortality in all patients were acute physiology and Chronic Health Evaluation (APACHE) II score >20, multiple lobe lesions, and creatinine clearance rate (CCR) < 15 ml/min. CONCLUSIONS: The prevalence of hVISA is 20.5% at our institution. hVISA-HAP patients had a poor clinical outcome. Vancomycin treatment was the independent predictors for hVISA infection. Factors independently associated with 30-day mortality in all patients were APACHE II score > 20, multiple lobe lesions and CCR < 15 ml/min.

[Regulation of NOD like receptors and inflammasome during the inflammation].

The innate immune system plays a crucial role in the rapid recognition and elimination of invading microbes. Detection of microbes relies on germ-line encoded pattern recognition receptors (PRRs) that recognize essential bacterial molecules, so-called pathogen-associated molecular patterns (PAMPs). A subset of PRRs, belonging to the nucleotide binding oligomerization domain (NOD)-like receptor (NLR) families, detects viral and bacterial pathogens in the cytosol of host cells and induces the assembly of a multi-protein signaling platform called the inflammasome. The inflammasome serves as an activation platform for the cysteine protease Caspase-1, a central mediator of innate immunity. Caspase-1 initiates a novel form of cell death called pyroptosis. Inflammasome activation by pathogen-associated signatures results in the autocatalytic cleavage of Caspase-1 and ultimately leads to the processing and thus secretion of pro-inflammatory cytokines, most importantly interleukin (IL)-1ß and IL-18. Here, we review the recent advancements of negative regulatory functions and mechanisms leading to the activation of NLRP1, NLRP3, NLRC4, and AIM2 inflammasomes.

Budesonide/formoterol maintenance and reliever therapy in Chinese patients with asthma.

BACKGROUND: Many studies have shown the superior efficacy of budesonide (BUD)/formoterol (FORM) maintenance and reliever therapy, but still lack evidence of its efficacy in Chinese asthma patients in a relative large patient-group. We finished this research to compare BUD/FORM maintenance and reliever therapy and high-dose salmeterol (SALM)/fluticasone (FP) maintenance plus an as-needed short-acting ß(2)-agonist in Chinese patients with persistent uncontrolled asthma. This was a post hoc analysis based on a 6-month, multicenter, randomized, double-blind study (NCT00242775). METHODS: A total of 222 eligible asthma patients from nine centers in China were randomized to either BUD/FORM+as-needed BUD/FORM (160/4.5 µg/inhalation) (640/18 µg/d; n = 111), or SALM/FP+as-needed terbutaline (0.4 mg/inhalation) (100/1000 µg/d; n = 111). The primary endpoint was time to first severe exacerbation while secondary endpoints included various measures of pulmonary function, symptom control and quality-of-life. RESULTS: Time to first severe exacerbation over six months was lower with the BUD/FORM than with the SALM/FP treatment (risk ratio = 0.52, 95%CI 0.22 - 1.22), but the difference did not achieve statistical significance (P = 0.13). The cumulative number of severe exacerbations in the BUD/FORM group was lower than in the SALM/FP group (7.2% vs. 13.5%; risk ratio = 0.45, P = 0.028). BUD/FORM produced significantly better improvements in reliever use, cumulative mild exacerbations, symptom-free days (%), and morning/evening peak expiratory flow (PEF) than SALM/FP (P < 0.05 in all cases). The two groups achieved similar improvements in their time to first mild exacerbation, forced expiratory volume in one second (FEV(1)), asthma control questionnaire and asthma symptom scores, and percentage of nights with awakening(s). Both treatments were well tolerated. CONCLUSIONS: In Chinese patients with persistent asthma, BUD/FORM decreased severe and mild exacerbations, decreased reliever use, increased symptom-free days, and improved morning/evening PEF compared with SALM/FP. There were no significant differences in time to first severe exacerbation or other assessments regarding daily asthma control between BUD/FORM and SALM/FP. BUD/FORM was more effective in this Chinese sub-group than in the total cohort involved in the original study.

[Adult hospital acquired pneumonia: a multicenter study on microbiology and clinical characteristics of patients from 9 Chinese cities].

OBJECTIVE: To investigate the etiology and clinical characteristics of hospital-acquired pneumonia (HAP) in China and to provide evidence for appropriate therapy. METHODS: We performed a prospective multicenter study in 13 Chinese urban tertiary hospitals. All HAP cases diagnosed at respiratory general ward and respiratory intensive care unit (RICU) from August 2008 to December 2010 were studied. Epidemiological data, etiology and clinical characteristics of enrolled patients were collected. Sputum or tracheal aspirate and blood cultures, Legionella antibodies and Streptococcus pneumoniae urinary antigen tests were performed. Bacteria to antimicrobial susceptibility test was performed. RESULTS: A total of 610 cases of HAP were diagnosed during the study, with an overall incidence of 1.4% among 42 877 hospitalized patients, while the incidence was 0.9% (362/41 261) in respiratory general ward and 15.4% (248/1616) in RICU. 93.9% (573 cases) of patients had at least one underlying disease, and 91.0% (555 cases) had exposure to at least one antimicrobial agent within 90 days prior to HAP diagnosis. Pathogens were identified in 487 patients, with Acinetobacter baumannii [30.0% (183/610)], Pseudomonas aeruginosa [22.0% (134/610)], Staphylococcus aureus [13.4% (82/610)] and Klebsiella pneumonia [9.7% (59/610)] being the most common pathogens. Eighteen patients (3.0%) had infection with fastidious bacteria. A. baumannii and S. aureus were the more frequent pathogens in the ventilator-associated pneumonia (VAP) cases [50.5% (97/192) and 21.4% (41/192)] as compared to non-VAP cases [20.6% (86/418) and 9.8% (41/418), P < 0.01]. A. baumannii and S. aureus were also frequent pathogens in cases with a score of more than 20 by the acute physiology and chronic health evaluation II (APACHEII) scoring [45.7% (69/151) and 20.5% (31/151)], as compared to cases with a score of less than 20 of APACHE II [24.8% (114/459) and 11.1% (51/459), P < 0.01]. A. baumannii showed high resistance rates to carbapenems [more than 70% (109/142)], and the susceptibility to cefoperazone/sulbactam, polymyxin B and tigecycline were 40.8% (58/142), 99.3% (141/142) and 95.8% (136/142) respectively. Resistance rates of P. aeruginosa to meropenem and imipenem were 48.8% (40/82) and 70.7% (58/82) respectively. Methicillin-resistant S. aureus (MRSA) accounted for 87.8% (43/49) in all strains of S. aureus. Mortality rate of VAP cases was 34.5% (61/177), significantly more than that of HAP patients [22.3% (135/605), P < 0.05]. The average hospital stay of patients with HAP was (23.8 ± 20.5) days, significantly more than that of the average for inpatients [(13.2 ± 13.6) days, P < 0.01] during the study period. Mean costs of HAP were (108 950 ± 116 608) yuan, significantly higher than the average hospital costs of respiratory inpatients (17 999 ± 33 364) yuan. CONCLUSIONS: Among Chinese patients hospitalized in urban tertiary medical centers, HAP incidence and mortality rate were high, which increased the patients' hospital stay and the medical costs. Common pathogens were A. baumannii, P. aeruginosa, S. aureus and K. pneumonia. The common bacteria of HAP in China showed high resistance rates to antibiotics.

Flagellin of Pseudomonas aeruginosa induces transforming growth factor beta 1 expression in normal bronchial epithelial cells through mitogen activated protein kinase cascades.

BACKGROUND: Acute lung infection due to Pseudomonas aeruginosa (P. aeruginosa) is a serious problem, especially in patients with structural lung conditions or immune compromised hosts, leading to an overwhelming threat with a high risk of morbidity and mortality. As an outcome of infection, fibrosis can be linked with chronic lung diseases. But some fibrotic manifestations, such as an irreversible decrease of lung function and fibrous bands seen on chest imaging, have been found after an acute infection with P. aeruginosa. Fibrogenesis/remodeling resulting from acute lung infection by P. aeruginosa is rarely reported. This study was designed to explore the relation between fibrogenesis/remodeling and acute infection by P. aeruginosa in vitro. We used flagellin protein from P. aeruginosa, a key initiator of acute P. aeruginosa lung infection, to elucidate mechanisms by which acute lung infection with P. aeruginosa can cause fibrogenesis/remodeling. METHODS: We studied the effect of flagellin from P. aeruginosa (flagellin for short) on the transforming growth factor beta 1 (TGF-ß1) and interleukin-8 (IL-8) expression, and the possible involvement of the signaling pathway, tumor necrosis factor receptor-associated factor 6 (TRAF6)/mitogen activated protein kinase (MAPK) pathway. Flagellin was purified from the P. aeruginosa standard strain, PAO1. Normal bronchial epithelial cells BEAS-2B were challenged with different concentrations of flagellin, and cell viability assessment was performed by cell counting kit-8. BEAS-2B cells were incubated with flagellin with the specific MAPK inhibitors or TRAF6 siRNA. Cell lysates and the cultured supernatant were collected. The level of TGF-ß1 and IL-8 were detected by enzyme-linked immunosorbant assay (ELISA). Western blotting was used to detect the protein levels of MAPK signal proteins p38, c-Jun NH(2)-terminal kinase (JNK) and extracellular regulated kinase (ERK). RESULTS: Expression of TGF-ß1 in BEAS-2B cells was elevated by flagellin vs. control groups ((104.3 ± 20.8) vs. (44.6 ± 4.4) pg/ml (P < 0.01)) and was ablated by either p38 or JNK inhibitors compared with flagellin treatment ((45.1 ± 18.8) vs. (104.3 ± 20.8) pg/ml and (48.1 ± 20.8) vs. (104.3 ± 20.8) pg/ml, respectively (P < 0.05)). Flagellin also elevated the expression of IL-8 in BEAS-2B cells vs. the control groups ((554.9 ± 57.7) vs. (51.4 ± 22.9) pg/ml (P < 0.01)), and p38 MAPK inhibitors weaken the expression by flagellin ((301.1 ± 155.1) vs. (554.9 ± 57.7) pg/ml (P < 0.05)). Western blotting revealed that all three MAPK proteins, p38, JNK and ERK were activated by flagellin challenge in an early phase, respectively in 15 minutes (P < 0.01), 30 minutes (P < 0.01) and 15 minutes (P < 0.01). TRAF6 siRNA which decreased expression of TRAF6, altered the activation of JNK, p38, and ERK following flagellin treatment, but its influence on the expression of TGF-ß1 and IL-8 has no statistical significance. CONCLUSIONS: Flagellin from P.aeruginosa PAO1 induces TGF-ß1 expression in normal bronchial epithelial cells, BEAS-2B, through the MAPK signal cascade in vitro. It suggests that the fibrogenesis/remodeling process may be initiated from an early stage of acute lung infection due to P. aeruginosa.

[A multicentre retrospective study of pulmonary mycosis clinically proven from 1998 to 2007].

OBJECTIVE: To investigate the pathogens, clinical manifestations, prognosis of and the risk factors for pulmonary mycosis in China. METHODS: All cases of pulmonary mycosis from 16 centers in 10 cities from Jan. 1998 to Dec. 2007 that met the diagnostic criteria were included for clinical, microbiological and radiological analysis. RESULTS: Totally 474 cases of pulmonary mycosis were retrieved. The top 5 pulmonary mycosis was pulmonary aspergillosis (180 cases, 37.9%), pulmonary candidiasis (162 cases, 34.2%), pulmonary cryptococcosis (74 cases, 15.6%), pneumocystis carinii pneumonia (23 cases, 4.8%) and pulmonary mucormycosis (10 cases, 2.1%). The constituent ratio in the last 3 years was similar to that in the former 7 years. The main pathogens of pulmonary candidiasis were Candida albicans (308/474, 65.0%) and Candida tropicalis (57/474, 12.0%), which were sensitive to common azoles. Compared with bacterial pneumonia, pulmonary mycosis showed more symptoms of hemoptysis (147/474, 31.0%) and pleural effusion (95/474, 20.0%), and less radiological specificity. Classical halo sign (4/474, 0.8%) and crescentic sign (17/474, 3.6%) were only shown in several cases of pulmonary mycosis. The most common underlying diseases were tumor (including solid tumor and malignant hematological diseases) (94/474, 19.8%), chronic obstructive pulmonary disease (52/474, 11.0%), pulmonary tuberculosis (50/474, 10.5%) and diabetes (48/474, 10.1%). Compared with the other common pulmonary mycosis, pulmonary cryptococcosis affected younger patients, and more cases were community-acquired, but fewer cases with underlining diseases or compromised immune function, and had a better prognosis. CONCLUSION: The ahead five species of pulmonary mycosis in China were orderly pulmonary aspergillosis, pulmonary candidosis, pulmonary cryptococcosis, pneumocystis carinii pneumonia and pulmonary mucormycosis. The main pathogens of pulmonary candidosis were Candida albicans and Candida tropicalis, which were sensitive to common azoles. Compared with the other common pulmonary mycosis, pulmonary cryptococcosis catch younger patients, had more community-acquired cases, and had better prognosis.

[Multiple serum antigenic assays for diagnosis of invasive fungal infections in non-neutropenic adult patients].

OBJECTIVE: To evaluate the value of plasma 1, 3-ß-D-glucan (G), serum mannan, galactomannan (GM) and cryptococcus capsular antigen assays for diagnosis of invasive fungal infections (IFI) in non-neutropenic adult patients. METHODS: This was a prospective case control study. Plasma and serum samples from 25 patients with IFI (candidiasis, aspergillosis, cryptococcosis, zygomycosis, pneumocystis carinii pneumonia), 27 patients with bacterial infections, and 25 healthy adults were collected from February 2007 to February 2009 in Beijing Hospital. The serum antigenic assays were performed and their sensitivity and specificity were analyzed. Optimal cut-off level of G test and mannan was established with receiver operating characteristic curve (ROC). RESULTS: The concentration of G test in plasma of patients with IFI [89.4 (25.8, 336.9) ng/L] was significantly higher than that of patients with bacterial infection [8.1 (5.0, 34.9) ng/L, U = 120.5, P < 0.001] and healthy adults [3.8 (3.8, 26.0) ng/L, U = 76.5, P < 0.001]. The area under curve (AUC) was 0.858, and the optimal cut-off value was 71.7 ng/L. The sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were 65.0% (13/20), 92.3% (48/52), 76.5% (13/17) and 87.2% (48/55) respectively. The concentration of mannan in serum from patients with candidiasis [1.13 (0.44, 1.22) µg/L] was significantly higher than that from patients with non-candidiasis IFI [0.21 (0.14, 0.27) µg/L, U = 19, P < 0.05], bacterial infection [0.26 (0.22, 0.32) µg/L, U = 36.5, P < 0.001] and healthy adults [0.25 (0.22, 0.30) µg/L, U = 29.5, P < 0.001]. The AUC was 0.894, and the optimal cut-off value was 0.41 µg/L. The sensitivity, specificity, PPV and NPV were 83.3% (10/12), 90.4% (47/52), 66.7% (10/15) and 96.0% (47/49) respectively. The sensitivity, specificity, PPV and NPV of GM antigen to diagnose aspergillosis were 25.0% (1/4), 96.1% (50/52), 33.3% (1/3) and 92.6% (50/54) respectively. The sensitivity, specificity, PPV and NPV of cryptococcus capsular antigen to diagnose cryptococcosis were all 100%. CONCLUSIONS: 1,3-ß-D-glucan, mannan and cryptococcus capsular antigen were useful for diagnosis of IFI in non-neutropenic adult patients. GM antigen did not show a good sensitivity for diagnosis of aspergillosis in non-neutropenic adult patients.

[Effect of different levels of environmental oxygen on the biofilm production of Pseudomonas aeruginosa].

OBJECTIVE: To investigate the relationship among oxygen concentration, quorum sensing system, type secretion system, and biofilm production of Pseudomonas aeruginosa. METHODS: A total of 23 clinical strains of Pseudomonas aeruginosa were cultured at different levels of environmental oxygen for three days. Then biofilm mass and alginate were quantified. The expression levels of LasI and RhlI were detected by real time polymerase chain reaction (PCR). The secretion of exoenzyme S was examined by Western blot. RESULTS: Both the biofilm mass (R=0.455, P=0.000) and alginate (R=0.367, P=0.000) were positively correlated with oxygen concentration. Real time PCR showed that the expression levels of LasI and RhlI were not significantly correlated with oxygen concentration (R=0.025, P=0.794; R=-0.044, P=0.653), the production of biofilm (R=0.001, P=0.990; R=0.011, P=0.909), or alginate(R=0.029, P=0.770; R=0.193, P=0.064). Western blot showed that the optimal oxygen concentration range for exoenzyme S secretion of Pseudomonas aeruginosa ranged 10% to 30%. CONCLUSIONS: Hyperoxia can promote the production of biofilm and alginate by Pseudomonas aeruginosa. Las/Rhl system may not participate in biofilm production at the early stage due to the low bacteria amount. The increased production of biofilm may inhibit the expression of Type Secretion system and thus inhibit bacterial virulence.

Clinical evaluation of oral levofloxacin 500 mg once-daily dosage for treatment of lower respiratory tract infections and urinary tract infections: a prospective multicenter study in China.

Levofloxacin (LVFX), a fluoroquinolone agent, has a broad spectrum that covers Gram-positive and -negative bacteria and atypical pathogens. It demonstrates good clinical efficacy in the treatment of various infections, including lower respiratory tract infections (LRTIs) and urinary tract infections (UTIs). To evaluate the efficacy and safety of oral LVFX 500 mg once daily, a large open-label clinical trial was conducted in 1266 patients (899 with LRTIs and 367 with UTIs) at 32 centers in China. In the per-protocol population, the clinical efficacy rate (cure or improvement) at 7 to 14 days after the end of treatment was 96.4% (666/691) for LRTIs and 95.7% (267/279) for UTIs. In 53 patients diagnosed with atypical pneumonia the treatment was effective. The bacteriological efficacy rate was 96.6% (256/265) for LRTIs and 93.3% (126/135) for UTIs. The eradication rate of the causative pathogens was 100% (33/33) for Haemophilus influenzae and 96.0% (24/25) for Streptococcus pneumoniae in LRTIs, and 94.1% (80/85) for Escherichia coli in UTIs. The overall efficacy rates were 89.3% (617/691) for LRTIs and 87.8% (245/279) for UTIs. The incidence of drug-related adverse events (ADRs) was 17.3% (215/1245), and the incidence of drug-related laboratory abnormalities was 15.7% (191/1213). Common ADRs were dizziness, nausea, and insomnia. Common laboratory abnormalities included "WBC decreased", "alanine aminotransferase (ALT) increased", "aspartate aminotransferase (AST) increased", and "lactate dehydrogenase (LDH) increased". All of these events were mentioned in the package inserts of fluoroquinolones including LVFX, and most events were mild and transient. Thirty-four patients (2.7%) were withdrawn from the study because of the ADRs. No new ADRs were found. This study concluded that the dosage regimen of LVFX 500 mg once daily was effective and tolerable for the treatment of LRTIs and UTIs.

[Methicillin resistant Staphyloccus aureus infection: a case report and literature review].

OBJECTIVE: To report a case of infection with methicillin resistant Staphyloccus aureus (MRSA) carrying Staphylococcal chromosome cassette mec (SCCmec) type V, and to identify the origin of the isolates. METHODS: A case of infection with MRSA carrying SCCmec type V was reported. The clinical characteristics of this patient were described. Screening for methicillin and other antibiotic resistant phenotypes by VITEK II compact was carried out. PCR was used to determine the MRSA mecA gene, and multiplex PCR assay was used for characterization of SCCmec. RESULTS: The 73-year old male patient was admitted to our hospital for exfoliative dermatitis, but the condition got worse with sepsis and hospital acquired pneumonia, and finally the patient died of septic shock. The isolated Staphyloccus aureus from peripheral blood and sputum showed resistance to beta-lactams alone, and susceptible to clindamycin, intermediate to moxifloxacin and gentamicin. The isolates were confirmed to be MRSA carrying SCCmec type V. CONCLUSION: A case of healthcare-acquired MRSA infection was identified, but the isolates also showed some characteristics of MRSA of the community origin.

[Expression of toll-like receptors on CD14+ monocytes from patients with chronic obstructive pulmonary disease and smokers].

OBJECTIVE: To investigate the expression of toll-like receptor-2 (TLR2), TLR4 on the CD14+ monocytes of patients with stable chronic obstructive pulmonary disease (COPD) and healthy smokers, and to explore the role of TLR2 and TLR4 in COPD pathogenesis. METHODS: Thirty COPD patients without evidence of acute exacerbation, 21 healthy smokers, and 25 healthy non-smokers underwent measurement of forced expiratory volume in 1 second (FEV(1))% predicted and FEV(1)/forced vital capacity (FVC) by spirometry. The expression of TLR2 and TLR4 surface molecules on human CD14+ monocytes was assessed using fluorescence activated cell sorter analysis by flow cytometry, expressed as relative mean fluorescence intensity (rmfi) and relative positive cell percent (rpcp), and the correlation of TLR expression with lung function parameters was analyzed. RESULTS: The rmfi and rpcp of TLR2 on CD14+ monocytes of the COPD patients were (6.3 +/- 1.4)% and (52.9 +/- 20.5)% respectively, both significantly lower than those of the healthy smokers [(8.2 +/- 2.2)% and (73.5 +/- 19.0)% respectively] and those of the nonsmokers [(11.0 +/- 2.4)% and (82.8 +/- 17.9)% respectively, all P < 0.01)]. The rmfi of TLR4 of the COPD patients was 2.2 +/- 0.9, significantly lower than that of the nonsmokers (3.0 +/- 0.5, P < 0.01), while similar to that of the healthy smokers (2.5 +/- 0.6, P > 0.05). The rpcp of TLR4 of the COPD patients (M = 1.3%, Q(1) - Q(3): 0.7% - 2.4%) was significantly lower than that of the healthy smokers (M = 4.7%, Q(1) - Q(3): 2.7% - 9.4%, P < 0.01) and nonsmokers (M = 5.3%, Q(1) - Q(3): 2.6% - 8.4%, P < 0.01). The rmfi of TLR2 and TLR4 on CD14+ monocytes of the healthy smokers was lower than that of the nonsmokers (P < 0.05), while the rpcp of TLR2 and TLR4 on CD14+ monocytes of the healthy smokers was similar to that of the nonsmoker (P < 0.05). The expression of TLR2 and TLR4 on monocytes was positively correlated with the lung function parameters, including FEV(1)% predicted and FEV(1)/FVC (all P < 0.01). CONCLUSIONS: The expression levels of TLR2 and TLR4 on CD14+ monocytes of the stable COPD patients and healthy smokers decreased significantly. The innate immune response may be depressed in the COPD patients and smokers, and the down-regulation of TLR is associated with reduced lung function parameters.