Extensively-drug-resistant Klebsiella pneumoniae ST307 outbreak strain from north-eastern Germany does not show increased tolerance to quaternary ammonium compounds and chlorhexidine.

BACKGROUND: An outbreak of extensively-drug-resistant Klebsiella pneumoniae strain ST307 in a cluster of hospitals in north-east Germany gave rise to the assumption that the epidemiological success of the strain could be based on increased tolerance to biocides. METHODS: The tolerance of the outbreak strain was compared with epidemiologically unrelated clinical isolates of K. pneumoniae, and reference strains of Pseudomonas aeruginosa (ATCC 15442) and Escherichia coli K12 (NCTC 10538). Tests were performed in a miniaturized assay based on European Standard EN 1040. The widely used biocides benzalkonium chloride (BAC) and didecyl dimethyl ammonium chloride (DDAC), their commercial formulation Descosept spezial (DS), and the antiseptic agent chlorhexidine digluconate (CHG) were selected as test substances. These biocides are used regularly in the hospitals involved in the outbreak. FINDINGS: All biocides had a bactericidal effect against all tested strains in the quantitative suspension test within 5 min at typically used concentrations and dilutions. The effectiveness of BAC and DDAC alone and in combination, and CHG antisepsis were not impaired under tested conditions. CONCLUSION: The outbreak strain did not show significantly increased tolerance towards biocides regarding the antiseptic. Thus, the epidemiological success of the strain has to be ascribed to other causes, such as inadequate hand hygiene of visitors.

Impact of antibiotic administration on blood culture positivity at the beginning of sepsis: a prospective clinical cohort study.

OBJECTIVES: Sepsis guidelines recommend obtaining blood cultures before starting anti-infective therapy in patients with sepsis. However, little is known of how antibiotic treatment before sampling affects bacterial growth. The aim of this study was to compare the results of blood cultures drawn before and during antibiotic therapy. METHODS: Prospective clinical cohort study of septic patients. Adult intensive care unit patients with two or three blood culture sets at the beginning of sepsis between 2010 and 2017 were included. Patients with blood culture samples obtained before antibiotic therapy were compared with patients with samples taken during antibiotic therapy. Blood culture positivity, defined as presence of a microbiological pathogen, was compared between the groups. Logistic regression was performed to adjust the impact of different factors with respect to blood culture positivity. RESULTS: In total, 559 patients with 1364 blood culture sets at the beginning of sepsis were analysed. Blood culture positivity was 50.6% (78/154) among patients with sepsis who did not receive antibiotics and only 27.7% (112/405) in those who were already receiving antibiotics (p <0.001). Logistic regression revealed antibiotic therapy as an independent factor for less pathogen identification (odds ratio 0.4; 95% CI 0.3-0.6). Gram-positive pathogens (28.3% (111/392) versus 11.9% (116/972); p <0.001) and also Gram-negative pathogens (16.3% (64/392) versus 9.3% (90/972); p <0.001) were more frequent in blood culture sets drawn before antibiotic therapy compared with sets obtained during antibiotic therapy. CONCLUSIONS: Obtaining blood cultures during antibiotic therapy is associated with a significant loss of pathogen detection. This strongly emphasizes the current recommendation to obtain blood cultures before antibiotic administration in patients with sepsis.

Evaluation of loop-mediated isothermal amplification for the rapid identification of bacteria and resistance determinants in positive blood cultures.

The use of molecular assays to rapidly identify pathogens and resistance genes directly from positive blood cultures (BCs) contribute to shortening the time required for the diagnosis of bloodstream infections. In this work, loop-mediated isothermal amplification (LAMP) assays have been examined for their potential use in BC diagnosis. Three different assays were applied. The commercially available eazyplex® MRSA test detects Staphylococcus aureus, S. epidermidis, mecA, and mecC. Two in-house assays [Gram-positive (GP) and Gram-negative (GN)] have been developed for the detection of streptococci, enterococci, vanA, vanB, Pseudomonas spp., Enterobacteriaceae, and the bla CTX-M family. A total of 370 positive BCs were analyzed. LAMP test results were obtained within 30 min, including sample preparation. Amplification was measured by real-time fluorescence detection. The threshold time for fluorescence intensity values ranged from 6.25 to 13.75 min. The specificity and sensitivity of the assays varied depending on the target. Overall, from 87.7% of BCs, true-positive results were obtained, compared to routine standard diagnosis. Twenty-one tests were true-negative because of the lack of an appropriate target (5.7%). The concordance of positive test results for resistance genes with subsequent antibiotic susceptibility testing was 100%. From 15 BC bottles with mixed cultures, eazyplex® assays produced correct results in 73% of the cases. This study shows that LAMP assays are fast and cost-saving tools for rapid BC testing in order to expedite the diagnostic report and improve the antibiotic stewardship for sepsis patients.

Simulating pulmonary vein activity leading to atrial fibrillation using a rule-based approach on realistic anatomical data.

Atrial fibrillation (AF) is the most common cardiac arrhythmia leading to a high rate of stroke. The underlying mechanisms of initiation and maintenance of AF are not fully understood. Several findings suggest a multitude of factors to leave the atria vulnerable to AF. In this work, a rule-based approach is taken to simulate the initiation of AF in a computer model for the purpose of generating a model with which the influence of anatomical structures, electrophysiological properties of the atria and arrhythmogenic activity can be evaluated. Pulmonary vein firing has been simulated leading to AF in 65.7 % of all simulations. The excitation pattern generated resemble chaotic excitation behavior, which is characteristic for AF as well as stable reentrant circuits responsible for atrial flutter. The findings compare well with literature. In future, the presented computer model of AF can be used in therapy planning such as ablation therapy or overdrive pacing.

Fluoroquinolone resistance of Escherichia coli at a cancer center: epidemiologic evolution and effects of discontinuing prophylactic fluoroquinolone use in neutropenic patients with leukemia.

The aim of the present study was to investigate the epidemiologic evolution of fluoroquinolone resistance of E. coli clinical isolates from patients admitted to a hematology-oncology service where fluoroquinolone prophylaxis during neutropenia was recommended as the standard of care for many years but was then discontinued in a trial conducted in patients with acute leukemia. Fluoroquinolones had been shown to decrease the incidence of gram-negative bacteremia in cancer patients with neutropenia, yet it was thought that the emergence of resistance in Escherichia coli and other gram-negative bacteria may have caused a progressive lack of efficacy of fluoroquinolone prophylaxis. Epidemiologic surveillance of fluoroquinolone resistance of E. coli clinical isolates at our cancer center since 1992 showed a continuing influx of new clones not previously observed in the population of cancer patients, an increase in the number of cancer patients per year colonized and/or infected by fluoroquinolone-resistant E. coli (1992-1994, 10-16 patients; 1995-1997, 24-27 patients), and a resistance rate of >50% among E. coli bloodstream isolates of hematology-oncology patients. A 6-month fluoroquinolone prophylaxis discontinuation intervention trial in 1998 suggested that despite increasing resistance among E. coli isolates, fluoroquinolone prophylaxis in acute leukemia patients was still effective in the prevention of gram-negative bacteremia (incidence rates, 8% during the pre-intervention period vs. 20% after discontinuation; p<0.01). The resumption of fluoroquinolone prophylaxis in acute leukemia patients thereafter decreased the incidence of gram-negative bacteremia to the pre-intervention level (9%; p=0.03), while the proportion of in vitro fluoroquinolone resistance in E. coli bacteremia isolates again increased (from 15% during the intervention period to >50% in the post-intervention period). Relative rates of resistance thus were a poor indicator of the potential clinical benefits associated with fluoroquinolone prophylaxis in cancer patients.

Rapid identification of Enterobacteriaceae using a novel 23S rRNA-targeted oligonucleotide probe.

The aim of this study was to rapidly identify bacteria of the family of Enterobacteriaceae using fluorescent in situ hybridization (FISH). A comparative sequence analysis was carried out and a 23S rRNA signature sequence for Enterobacteriaceae was identified. A 23S rRNA-targeted oligonucleotide probe (EBAC1790) was constructed and subsequently tested against 40 reference strains. Nearly all of the Enterobacteriaceae used in this study yielded positive results with EBAC1790, except for Edwardsiella tarda (ATCC 15947). None of the non-Enterobacteriaceae reference strains gave positive signals with the probe. The possibility of a rapid detection of Enterobacteriaceae in groundwater was demonstrated using colony hybridization.

Controlled release of proteins from 2-hydroxyethyl methacrylate copolymer gels.

A series of hydrogels with large pores was synthesized by the precipitation polymerization of 2-hydroxyethyl methacrylate (HEMA) with crosslinking agent in aqueous solution. Such gels are potentially useful for the controlled release of large-molecular-weight species such as proteins. In this study, the release behavior of lysozyme and alpha-amylase from hydrogels formed from HEMA or HEMA with a comonomer was studied. It was found that the polymer composition affected the total amount of lysozyme released and its activity. Effects were smaller with alpha-amylase. Charged gels, containing a phosphate moiety, released larger amounts of lysozyme at a reduced rate as a result of charge-charge interactions.

Platelet activation and aggregation during cardiopulmonary bypass.

Increases in plasma concentrations of platelet granule products such as platelet factor 4 and beta-thromboglobulin during cardiopulmonary bypass suggest that platelets are activated during extracorporeal circulation. Subsequent circulation of these activated platelets may be responsible for the ubiquitous platelet dysfunction associated with cardiopulmonary bypass. Using flow cytometry and a monoclonal antibody directed against an alpha-granule membrane protein, granule membrane protein 140 (GMP-140), which is expressed on the platelet surface membrane after activation, we directly measured the percentage of circulating activated platelets in 41 patients before, during, and after cardiopulmonary bypass. In addition, we compared the GMP-140 expression with platelet aggregation in response to adenosine diphosphate (ADP). Cardiopulmonary bypass produced a significant increase in the percentage of GMP-140-positive platelets persisting in the circulation; the percentage peaked at a mean of 29% (range 10-58%) before separation from extracorporeal circulation. A significant percentage of these activated platelets continued to circulate in the early postoperative period. Simultaneous measurement of platelet aggregation in response to ADP demonstrated an aggregation defect that had a time course distinct from platelet activation and whose magnitude did not correlate with the degree of platelet activation in individual patients. We conclude that cardiopulmonary bypass causes a complex constellation of platelet defects, which include alpha-granule release, prolonged circulation of activated, "spent" platelets, and impaired platelet aggregation.

Plasma gas discharge deposited fluorocarbon polymers exhibit reduced elutability of adsorbed albumin and fibrinogen.

The adsorption and subsequent detergent elutability of fibrinogen and albumin were measured on various treated and untreated polymer films in order to determine whether the relative adsorption of these proteins was responsible for the enhanced thromboresistance of Dacron vascular grafts treated with tetrafluoroethylene in a radio frequency glow discharge (RFGD) apparatus. Fluorocarbon-coated surfaces varying in the relative proportions of CF, CF2, and CF3 groups and in the ratio of fluorine to carbon were prepared by RFGD treatment of poly(ethylene terephthalate) (PET) films with tetrafluoroethylene or perfluoropropane. The adsorption of fibrinogen and albumin to these fluorocarbon-coated surfaces was comparable to the adsorption of the proteins to polytetrafluoroethylene (PTFE) and PET. However, the elutability of fibrinogen and albumin from the RFGD fluorocarbon surfaces with sodium dodecyl sulfate was much lower than that from PTFE or PET. Other RFGD treatments of PET, such as ethylene deposition or argon etching, did not reduce the extent of albumin elutability as dramatically as did the RFGD fluorocarbon treatments. The strong albumin binding to RFGD fluorocarbon surfaces may be exploited clinically to enhance the retention of albumin preadsorbed to blood-contacting surfaces to render them thromboresistant.

Adsorption of proteins from artificial tear solutions to contact lens materials.

A series of polymers and copolymers of 2-hydroxyethyl methacrylate (HEMA) and methyl methacrylate (MMA) were synthesized in order to find surfaces that would adsorb minimal amounts of protein. The adsorption of albumin, lysozyme and immunoglobulin G from a three-way mixture of these proteins in isotonic buffered saline to the polymers was measured using 125I-labeled proteins. Apparently high protein uptake on copolymers rich in HEMA was found to be due to sorption of unbound 125I by the polymers. 125I sorption by the polymers was minimized by dialysis of the protein solution to remove unbound 125I iodide and inclusion of 0.01 M sodium iodide to block uptake of residual 125I iodide. Using these improved protocols, minimal total protein uptake was observed on copolymers containing 50% or more HEMA. The majority of adsorbed protein on all p(MMA-HEMA) polymers was albumin. Total protein uptake was greatest on pMMA. Commercial contact lenses composed of copolymers of HEMA and N-vinyl pyrrolidone (NVP) or acrylamide (AAm) adsorbed small amounts of all proteins whereas copolymers of methacrylic acid (MAAc) and HEMA adsorbed much larger quantities of lysozyme. These results indicate that protein uptake by contact lens materials varies greatly with polymer composition. Artifactually high "adsorption" can occur if precautions are not taken to prevent uptake of unbound 125I.

The effects of surface chemistry and coagulation factors on fibrinogen adsorption from plasma.

Fibrinogen adsorption from plasma exhibits an unusual displacement phenomenon (the Vroman effect) in that decreases in adsorption occur after longer contact time or as the plasma concentration increases. Fibrinogen adsorption and the displacement effect were found to depend markedly on the nature of the surface, the time and temperature of adsorption, and to a lesser extent on certain contact activation factors. Displacement still occurred from plasmas lacking kininogens, factor IX, and prekallikrein, and from plasma that had been treated with BaSO4 to remove factors II, VII, IX, and X. Furthermore, displacement was also observed from fibrinogen solutions to which either albumin or hemoglobin had been added. In addition, competitive adsorption of binary protein mixtures was also shown to depend strongly on surface type. It therefore appears that fibrinogen adsorption from plasma is subject to similar if not identical competitive processes that occur in simpler protein mixtures. The final adsorption then reflects the influence of all the proteins in plasma, each competing for the limited number of adsorption sites according to the fundamental physical properties of surface activity and mass concentration.

Reconstitution of types I and II adenosine cyclic 3',5'-phosphate dependent protein kinase.

Fluorescence intensity and anisotropy measurements using the fluorescent adenosine cyclic 3',5'-phosphate (cAMP) analogue 1,N6-ethenoadenosine cyclic 3',5'-phosphate (epsilon-cAMP) are sensitive to the dissociation of epsilon-cAMP which occurs when either the type I or the type II regulatory subunit (RI or RII) of cAMP-dependent protein kinase associates with the catalytic subunit. Studies using epsilon-cAMP show that MgATP has opposite effects on the reconstitution of both types of protein kinase: MgATP strongly stabilizes the type I holoenzyme while it slightly destabilizes the type II holoenzyme. The synthetic substrate Kemptide has a small inhibitory effect on the reconstitution of both holoenzymes when tested at 10 microM concentration. The protein kinase inhibitor has a larger effect which is especially pronounced in the reassociation of the type I enzyme. The diminished relative ability of the type I regulatory subunit to compete with the protein kinase inhibitor suggests that the combined effects of the two opposing equilibria (epsilon-cAMP and catalytic subunit binding) are different for the two types of regulatory subunits. Displacement experiments show that cAMP and epsilon-cAMP bind about equally well to the type I subunit. Slow conformational changes accompanying the binding of epsilon-cAMP by both regulatory subunits are greatly accelerated with the holoenzymes, suggesting that dissociation of the holoenzymes occurs via ternary complexes. The time courses of epsilon-cAMP binding also show the heterogeneity of binding characteristics of RII. The 37 000-dalton fragment of type II subunit retains the epsilon-cAMP binding properties of the native subunit. However, only a fraction of the fragment preparation (approximately 32% estimated from sedimentation measurements) binds the catalytic subunit well, suggesting heterogeneity of cleavage.

Binding of 5,5'-bis[8-(phenylamino)-1-naphthalenesulfonate] by the regulatory subunits of adenosine cyclic 3',5'-phosphate dependent protein kinase.

Binding to the regulatory subunits of types I and II adenosine cyclic 3',5'-phosphate (cAMP) dependent protein kinase (RI and RII, respectively) produces large distinctive increases in fluorescence and optical activity of 5,5'-bis[8-(phenylamino)-1-naphthalenesulfonate] [bis(ANS)]. Both specific and nonspecific interactions are involved. Association of the regulatory subunits with either the catalytic subunit or cAMP results in dissociation of a major portion of the bound bis(ANS) as detected by changes in fluorescence and circular dichroism. The results are consistent with the accepted cAMP binding properties of RI and RII, showing cooperativity in case of RI and two heterologous binding sites for RII. cGMP has the same overall effect on bis(ANS) binding as cAMP. However, very high concentrations are required for complete dissociation of bis(ANS) from RII, consistent with the observation that cGMP is inefficient in bringing about the dissociation of the type II holoenzyme. Magnesium binding to sites having dissociation constants of ca. 12 mM increases the interaction of bis(ANS) with both of the isolated regulatory subunits. Experiments involving the 37 000-dalton fragment of RII indicate that the limited proteolytic cleavage was heterogeneous, with only 24-39% of the resulting population interacting strongly with the catalytic subunit.

Functional interactions between smooth muscle myosin light chain kinase and calmodulin.

Calmodulin (CaM) binding by turkey gizzard myosin light chain kinase (MLCK) causes subtle changes in the fluorescence emission and polarization excitation spectra of the enzyme. Fluorescence experiments using 9-anthroyl-choline (9AC), which competes with ATP in binding, demonstrate mutually stabilizing interactions between the CaM and ATP binding sites corresponding to delta G = -0.6 to -0.7 kcal/mol. Fluorescence titrations in the presence of 9AC or 5,5'-bis[8-(phenylamino)-1-naphthalenesulfonate] confirm the stoichiometry of 1 mol of CaM/MLCK. Phosphorylation of MLCK has no effect on either the protein fluorescence or the binding of ATP and 9AC. The dissociation constant for the MLCL-CaM complex is increased approximately 500-fold on phosphorylation. Values of Kd for the phosphorylated enzyme range from 0.5 to 1.1 microM in 0.2 N KCl, pH 7.3, 25 degrees C. We showed competition between MLCK and other CaM binding proteins and peptides by using both fluorescence and catalytic activity measurements. Competition for CaM occurs with ACTH, beta-endorphin, substance P, glucagon, poly(L-arginine), myelin basic protein, troponin I, and histone H2A. Phosphorylation of the last three proteins by the adenosine cyclic 3',5'-phosphate dependent protein kinase diminishes their ability to compete. Phosphorylation of MLCK by the protein kinase gives 0.95 +/- 0.04 and 2.2 +/- 0.4 mol of incorporated 32P in the presence and absence of CaM, respectively. These stoichiometries agree with those recently reported [Conti, M. A. & Adelstein, R. S. (1981) J. Biol. Chem. 256, 3178].

Study of equilibration of the system involving two alternative, enzymically active complementing structures simultaneously formed from two overlapping fragments of staphylococcal nuclease.

Quantitative complementation of two overlapping fragments of staphylococcal nuclease, Nuclease-(1-126) (residues 1 to 126) and Nuclease-T-(50-149) (residues 50 to 149), simultaneously forms in 1 min, two alternative, enzymically active ordered structures (types I and II) resembling nuclease (149 residues) (Taniuchi, H., and Anfinsen, C.B. (1971) J. Biol. Chem. 246, 2291-2301). We determined the ratio of type I to type II complex formed from the two fragments as a function of time, temperature, and the presence or absence of the ligands thymidine 3',5'-diphosphate and calcium ion. The ratio of type I to type II complex was determined on the basis of the quantities of their derived complexes obtained after each experiment by removing the redundant amino acid sequences by limited digestion with trypsin in the presence of ligands. The quantity of the derived complexes was estimated by quantitative determination of the component fragments separated by gel filtration. The ratio of type I to type II complex formed in 2 min after mixing the two fragments was approximately 0.3 and appears to be independent of temperature and the presence or absence of ligands. The equilibrium of the system of type I and II complexes is attained through unfolding and folding. The ratios of type I to type II complex at the apparent equilibrium state of the system at 6 and 23 degrees were approximately 1.1 and 2.4, respectively. The observations indicate that the rate of unfolding of type II complex is greater than that of type I complex at 6 degrees and increases more than that of type I complex with increasing temperature. Thus, the change of the complementing structure from type I complex with increasing temperature. Thus, the change of the complementing structure from type I to type II causes a decrease in the activation free energy, an increase in the activation enthalpy, and thereby an increase in the activation entropy of unfolding. Since the unfolded states with which type I and II complexes are in equilibrium are the same, the distribution of the population of type I and II complexes at the equilibrium state will be determined on the basis of the respective decreases in Gibbs standard free energy from the unfolded state to type I and II complexes. On this basis type I complex has a lower energy by deltaG0 = -0.05 and -0.51 kcal mol-1 at 6 and 23 degrees, respectively, than type II complex. Nevertheless, at the initial complementation the population of type I complex formed is approximately one-third that of type II complex at both 6 and 23 degrees. That is, the probability (rate) of folding is not related to the decrease in energy from the unfolded to the folded state. Using van't Hoff's equation deltaH = 7.5 kcal mol-1 and then deltaS degrees = 27 cal deg-1 mol-1 from type II to type I complex.

The mechanism of stabilization of the structure of nuclease-T by binding of ligands.

The rate of unfolding of Nuclease-T at pH 8,20 degrees was determined as a function of concentration of the ligands deoxythymidine 3',5'-diphosphate (pdTp) and Ca2+ on the basis of the rate of exchange between free fragment, Nuclease-T(50-149) and labeled fragment, Nuclease-T-(50-149) incorporated in the structure of nuclease-T (Taniuchi, H. (1973) J. Biol. Chem. 248, 5164-5174). The rate constant of unfolding of unliganded Nuclease-T' was 4.6 times 10-4s-1. Those of Nuclease-T' bound with pdTp, with Ca2+, and with both pdtp and Ca2+ were 9.0 times 10-5, 1.6 times 10-4, and 2.2 times 10-5s-1, respectively. The association constants of pdTp and Ca2+ with Nuclease-T' were found to be 1.0 times 10-4 and 2.0 times 10-2 m-1, respectively. Those of pdTp with Nuclease-T' plus Ca2+ and of Ca2+ with Nuclease-T' plus pdTp were 4 times 10-5 and 1.4 times 10-4M-1, respectively. The calculation of free energy change on the basis of the association constants shows that the magnitude of negative free energy change involved in the binding of either of the two ligands increases by approximately 2 kcal when the other ligand is already bound. There is a correlation between the free energy change and the specifically coupled with the cooperative interacions operating throught the three-dimensional structure resulting in strengthening of the interactions throughtout the structure, including those with the ligands, without a large change in conformation.