Prevalence of enterococcal groin colonization in patients undergoing cardiac interventions: challenging antimicrobial prophylaxis with cephalosporins in patients undergoing transcatheter aortic valve replacement.

BACKGROUND: Cephalosporins are recommended for prophylaxis before transcatheter aortic valve replacement (TAVR). Infective endocarditis (IE) after TAVR is caused by enterococci in up to 30% of cases, particularly early after TAVR. Enterococcal colonization in the groin has been postulated as a source of infection, not only because prophylaxis does not cover enterococci but also because most TAVR procedures are performed by transfemoral access. There are few data analysing the groin microbiome to demonstrate the presence of enterococci. AIM: To assess the prevalence of enterococci in the groins of cardiological patients receiving transfemoral interventions. METHODS: This prospective cohort study was undertaken at University Hospital Basel, Switzerland between February and August 2020. Two skin swabs were taken from the groins of consecutive patients undergoing transfemoral cardiac interventions before the administration of antibiotic prophylaxis; for each patient, swabs were taken before and after groin disinfection. Swabs were analysed in the local microbiological laboratory following validated culture methods. FINDINGS: Of 290 included patients, 245 (84.5%) underwent coronary angiography, 31 (10.7%) underwent TAVR, eight (2.8%) underwent right heart catheterization, five (1.7%) underwent closure of patent foramen ovale, and one (0.3%) underwent a MitraClip procedure. Enterococci were detected before disinfection in 48 patients, enterococci were still cultured after disinfection in three patients, and enterococci were detected after disinfection alone (i.e. not detected before disinfection) in one patient. The prevalence of enterococci was 16.6% before disinfection and 1.4% after disinfection. Patients colonized with enterococci had a significantly higher body mass index and were more likely to be diabetic than uncolonized patients. CONCLUSION: Common enterococcal colonization of the groin, coupled with frequent isolation of enterococci from patients with TAVR-associated IE, provides strong evidence that the current recommendation of antimicrobial prophylaxis with cephalosporins before TAVR should be changed to antimicrobial prophylaxis with a compound that is active against enterococci.

Matching Clostridioides difficile strains obtained from shoe soles of healthcare workers epidemiologically linked to patients and confirmed by whole-genome sequencing.

BACKGROUND: The source of transmission of Clostridioides difficile in healthcare institutions is frequently unknown. The aim of this prospective cohort study was to assess the association between strains cultured from patients and shoe soles of healthcare workers (HCWs), as already shown in the operating theatre, but not on general hospital wards in an acute-care institution. METHODS: We conducted a study at a university tertiary care centre in Switzerland. From October 2019 to July 2020, shoe soles of HCWs were cultured for C. difficile twice per shift while taking care of a patient infected with toxigenic C. difficile. Additional risk factors were assessed by interviewing involved HCWs. Patients' faecal samples were processed by routine microbiological methods. Similarity of the HCWs' and patients' strains was determined by whole-genome sequencing (WGS). RESULTS: A total of 103 HCWs exposed to 42 hospitalized patients participated in the study, providing 206 samples. Contamination of shoe soles with C. difficile was detected in 37 samples (17.8%) of HCWs taking care of patients infected with C. difficile. Overall, transmission was suspected by epidemiological link and matching strains demonstrated by WGS in 74%. CONCLUSIONS: HCWs' shoe soles were positive in 17.8% with C. difficile strains linked epidemiologically and confirmed by WGS to infected patients suggesting potential transmission by HCWs' shoe soles. This pilot study provides sufficient evidence to further evaluate this potential mode of healthcare-associated transmission of C. difficile by a larger clinical trial.

Does high adherence to contact precautions lead to low in-hospital transmission of multi-drug-resistant micro-organisms in the endemic setting?

BACKGROUND: Conflicting results have been published on the impact of contact precautions (CPs) on reduction of transmission of multi-drug-resistant micro-organisms (MDROs) in the endemic setting. Ambiguous definitions coupled with low adherence partly explain these differences. AIM: We prospectively monitored the level of adherence to CPs and aimed to relate it to in-hospital transmission of MDROs. METHODS: Between January 2016 and March 2018, all patients under CPs underwent continuous monitoring of adherence to CPs by routine on-site visits on days 0, 3 and 7 after initiating CPs using a standardized checklist. The protocol included 10 interventions that were routinely checked such as CP sign at the door as well as wearing of gowns and gloves upon entry to the patient room. Patients requiring CPs were defined as colonized or infected with MDROs (meticillin-resistant Staphylococcus aureus (MRSA), non-Escherichia coli extended-spectrum beta lactamase (ESBL) Enterobacterales, vancomycin-resistant enterococci (VRE) and carbapenem-resistant Gram-negative micro-organisms (CRGN)) as well as patients infected with respiratory viruses, norovirus, scabies and hypervirulent strains of Clostridioides difficile. FINDINGS: Overall, data from 13,756 CP records from 1378 visits of 812 patients were analysed. Adherence varied between 93% and 100% for each intervention, except for "separate space for contaminated material" with an adherence of 5.3-6.1%. The incidence of in-hospital transmission during the study period was extremely low for MRSA, VRE, non-E.coli ESBL Enterobacterales and CRGN with 0.00-0.064 cases/1000 patient days. CONCLUSION: High adherence coupled with continuous monitoring of CPs correlated with a very low in-hospital transmission rate. These results indicate that CPs are highly effective if routine monitoring of adherence is implemented.

Shallow retardation of the strontium isotope signal of agricultural liming - implications for isoscapes used in provenance studies.

An intensified debate centers on the use of strontium isotopes in surface water run-off as archive for bioavailable signatures in prehistoric provenance studies. Its use has been challenged by a recent suggestion that modern agricultural liming of farmlands exerts a serious imprint on the strontium isotope compositions of these waters. We here present results from a soil profile beneath agricultural farmland in the glaciogenic outwash plain of central West Jutland, Denmark, which show that strontium and its isotope composition derived from lime products is efficiently retained near the surface. Pore waters and bioavailable strontium from the acidic zone below the surface soil depict strontium isotope signatures that can best be explained by a mixture of silicate-derived and relic natural (not agriculturally added) carbonate-derived strontium. We therefore argue that agricultural liming does not contaminate groundwaters and groundwater-supported surface waters, rendering reference maps based on them relevant for modern and past provenance studies.

Overall bioburden by total colony count does not predict the presence of pathogens with high clinical relevance in hospital and community environments.

BACKGROUND: Healthcare-associated infections (HAIs) affect millions of patients, increasing morbidity and mortality. Pathogens of HAIs originate from both the patient's own flora and the environment, including multi-drug-resistant organisms. AIMS: To determine the bioburden on different types of high-touch surfaces, and to identify cultures to species level and stratify strains into those of low and high clinical relevance. DESIGN: Association between bioburden and presence of pathogens of high clinical relevance (PHCR) in a tertiary care centre and urban environment. METHODS: The overall bioburden measured by total colony count (TCC) was assessed using tryptic soy agar contact plates and two selective agars to improve detection of PHCR. Isolates were routinely identified to species level using matrix-assisted laser desorption/ionization - time of flight mass spectrometry (MALDI-TOF). The definition of PHCR was based on listings outlined by the Centers for Disease Control and Prevention. FINDINGS: In total, 1431 contact plates were processed from 477 surfaces: 153 from hospitals and 324 from publicly accessible institutions or devices. At least one PHCR was identified from cultures from 73 samples. TCC was found to be poorly correlated with the presence of PHCR. CONCLUSION: TCC poorly predicted the presence of PHCR, rendering the results from environmental sampling difficult to interpret. MALDI-TOF enables the identification of large numbers of isolates from the environment at low cost. Further studies on environmental contamination should use MALDI-TOF to identify all pathogens grown.

[Combined Symptomatic Treatment of Groin Pain Syndrome in Professional Football Players - Prospective Study Results]. / Kombinovaná symptomatická terapie syndromu bolestivého trísla u profesionálních fotbalistu ­ výsledky prospektivní studie.

PURPOSE OF THE STUDY The results of the prospective study evaluating the outcomes of a combined therapeutic approach of non-operative therapy of Groin Pain Syndrome (GPS) in professional football players are presented. MATERIAL AND METHODS The evaluated cohort consisted of a total of 31 football players of a professional football club divided into two groups. The Group 1 included 10 symptomatic patients suffering from GPS for at least 4 weeks, the Control Group 2 included 21 healthy football players not suffering from GPS. The symptomatic patients with GPS who had undergone any surgery or had sustained any major injury to their low back, groins, hip or knee joints were excluded from the study. It was a prospective non-randomized study. The results were evaluated using the HAGOS (Copenhagen Hip and Groin Outcome Score) questionnaire, which in Group 1 compared the results before the initiation of the new combined therapeutic approach of non-operative therapy developed by us and the results after the end of this treatment, i.e. after 6 weeks. Moreover, the HAGOS was used to compare the results of the Group 1 after the treatment and the Control Group 2, i.e. the healthy football players. The HAGOS evaluated six separate areas: Pain, Symptoms, Physical function in daily living, Physical function in sport and recreation, Participation in physical activities, and hip and/or groin-related Quality of Life. The resulting score for each domain ranges from 0 to 100 (100 = no problems, 0 = extreme problems). The results were statistically evaluated by an independent statistician. RESULTS In Group 1, after the end of the treatment a statistically significant improvement was observed in all the parameters assessed by HAGOS. Pain (70 before the treatment, 95 after the treatment), Symptoms (58.9 before/85.7 after), Physical function in daily living (70 before/100 after), Physical function in sport (46.9 before/90.6 after), Participation in physical activities (43.8 before/100 after), Quality of Life (66.3 before/95 after). When comparing the two groups, before the treatment a statistically significant difference was found in all the six parameters assessed by HAGOS, while after the treatment no significant difference between Group 1 and Group 2 was detected. DISCUSSION The most important result of our study is that by applying the new combined therapeutic approach of the GPS nonoperative therapy developed by us better HAGOS score were achieved in our cohort than those achieved by other types of non-operative therapy presented in recent literature. The approach proposed by us is more successful in terms of the speed of return to sport (6 weeks) than the multimodal therapy programme (12 weeks) and Training programme (18 weeks). CONCLUSIONS The results of this prospective study confirm that the Group 1 having undergone the 6-weeek long combined symptomatic non-operative therapy of GPS proposed by us showed a statistically significant improvement in all the parameters assessed by HAGOS and these values showed no statistically significant difference from those of the Control Group of healthy individuals. Key words: Groin Pain Syndrome (GPS), professional football player, HAGOS (Copenhagen Hip and Groin Outcome), symptomatic therapy.

[Evaluation of the MRI Findings on a Tendon Graft after the Anatomic Anterior Cruciate Ligament Reconstruction in Patients with Versus without the Application of Platelet-Rich Fibrin - Results of the Prospective Randomised Study]. / Zhodnocení MRI nálezu na slachovém stepu po anatomické rekonstrukci predního zkrízeného vazu u pacientu s aplikací versus bez aplikace fibrinu bohatého na krevní desticky ­ výsledky prospektivní randomizované studie.

PURPOSE OF THE STUDY The purpose of the prospective randomised study was to assess the benefits of the platelet-rich fibrin (PRF) application during the anatomic anterior cruciate ligament reconstruction (ACLR) for tendon graft healing. MATERIAL AND METHODS The study included 40 patients with an isolated rupture of the anterior cruciate ligament in the knee. The MRI findings on the tendon graft were evaluated at 6 months and 12 months after the surgery in a total of 33 patients, namely in 10 women/23 men (21 right knee/12 left knee), with the mean age of 29.1 years and at the mean follow-up of 15.9 weeks after the injury. The randomisation using envelopes was carried out at the beginning of arthroscopy either in the group with the PRF application (Group 1) (17 patients) or in the group without the PRF application (Group 2) (16 patients). The followed-up patients underwent the ACLR with targeting the femoral tunnel through anteromedial portal using the autografts of m. semitendinosusand m. graciliswith Tightrope femoral fixation and Inion implant in tibia. In Group 1, during the surgery PRF was applied both in the drilled tunnels (intraosseously) and directly to the surface of the tendon graft itself (intraarticular part). The Group 2 was a control group in which the same intervention was performed, however without the PRF application. In the 6 th and 12 th month after the surgery, the signal intensity of the knee and occurrence of the ACL graft failure, bone (marrow) oedema rate near the tunnels were assessed by an independent radiologist using a 3 Tesla MRI. RESULTS In the 6 th and also in the 12 th postoperative month, neither a complete, nor a partial graft failure was found in the group with PRF, whereas in Group 2 a complete or a partial graft failure was observed in 12.5% (p = 0.23). In the 6th month, a bone marrow oedema near the intraosseous parts of the graft was reported in 94.1% of patients in Group 1 and in 81.3% of patients in Group 2, while in the 12 th month it was 23.5% of evaluated patients in Group 1 and 37.5% patients in Group 2. The differences between the two groups were not statistically significant in the 6 th (p = 0.096) or in the 12 th month (p = 0.43). In the 6 th month, a fully ligamentised graft was found in 52.9% of patients in Group 1 and in 37.5% of patients in Group 2 (p = 0.061), a partially ligamentised graft was present in 47.1% of patients in Group 1 and in 50% of patients in Group 2. In the 12 th month, a fully ligamentised graft was seen in 94.1% of patients in Group 1 and in 75% of patients in Group 2 (p = 0.26) and a partially ligamentised graft was present in 5.9% of patients in Group 1 and in 12.5% of patients in Group 2. In the remaining 12.5% of patients in Group 2, the finding was assessed as a graft with no signs of ligamentisation. DISCUSSION We have not encountered a paper in the Czech or world literature which would present results of a similar study, i.e. which would evaluate the potential benefits of the platelet-rich fibrin application in the course of the anatomic anterior cruciate ligament reconstruction. Majority of studies evaluate the benefits of the application of platelet-rich plasma aimed to achieve a positive effect on the LCA graft healing. CONCLUSIONS Our study proved a higher percentage of ligamentisation and healed grafts into the bone as well as a lower occurrence of graft failure in the group with PRF compared to the group without the PRF application, namely both in the 6 th and in the 12 th month. Nonetheless, the differences between the two groups assessed at the same time were not statistically significant. Key words: anterior cruciate ligament, arthroscopy, anatomic ACL reconstruction, magnetic resonance imaging of the graft, platelet-rich fibrin, graft healing, MRI signal intensity of the graft.

Culture of Bone Biopsy Specimens Overestimates Rate of Residual Osteomyelitis After Toe or Forefoot Amputation.

BACKGROUND: Guidelines recommend both histological analysis and culture for definite diagnosis of osteomyelitis. It is not clear if histological and culture criteria can be used interchangeably in the clinical scenario of toe amputation. We therefore prospectively compared the results of intraoperative culture and those of histological examination in this setting. METHODS: Consecutive patients requiring toe or forefoot amputation at the University Hospital Basel during a 2-year period were included in the study. Biopsy specimens from the residual bone were cultured according to microbiological standards. Histological analysis was performed using standardized criteria for osteomyelitis. Clinical outcomes were assessed retrospectively via chart review. RESULTS: Of 51 patients included in the study, 33 (65%) had a positive culture of residual bone and 14 (27%) showed histological signs of osteomyelitis. A negative histological result but a positive culture was found for 21 (41%) of the patients, suggesting that culture has a high false-positive rate if histological analysis is used as the reference to rule out osteomyelitis. The recommended criteria of both positive histological findings and positive culture were fulfilled by 12 (24%) of the 51 patients. CONCLUSIONS: Positive cultures of residual bone after forefoot or toe amputation overestimate the true rate of osteomyelitis as defined by histological analysis, presumably because of contamination from soft tissue at the time of surgery. Additional studies are needed to evaluate the indications for, and the duration of, antibiotic treatment according to these findings. CLINICAL RELEVANCE: Our results cast doubt on the strategy of relying solely on culture of bone biopsy specimens when deciding whether antibiotic treatment for osteomyelitis is necessary after toe or forefoot amputation.

Exopolysaccharide from Bifidobacterium longum subsp. longum 35624™ modulates murine allergic airway responses.

Interactions between the host and the microbiota are thought to significantly influence immunological tolerance mechanisms at mucosal sites. We recently described that the loss of an exopolysaccharide (EPS) from Bifidobacterium longum 35624™ eliminated its protective effects in colitis and respiratory allergy murine models. Our goal was to investigate the immune response to purified EPS from B. longum 35624, determine if it has protective effects within the lung and identify the protective mechanisms. Isolated EPS from B. longum 35624 cultures was used for in vitro, ex vivo and in vivo studies. Human monocyte-derived dendritic cells (MDDCs) were used to investigate in vitro immunological responses to EPS. Cytokine secretion, expression of surface markers and signalling pathways were examined. The ovalbumin (OVA) respiratory allergy murine model was used to evaluate the in vivo immunomodulatory potential of EPS. In addition, interleukin (IL)-10 knockout (KO) mice and anti-Toll-like receptor (TLR)-2 blocking antibody were used to examine the underlying protective mechanisms of intranasal EPS administration. Stimulation of human MDDCs with EPS resulted in IL-10 secretion, but not proinflammatory cytokines. IL-10 secretion was TLR-2-dependent. Eosinophil recruitment to the lungs was significantly decreased by EPS intranasal exposure, which was associated with decreased expression of the Th2-associated markers C-C motif chemokine 11 (CCL11), C-C chemokine receptor type 3 (CCR3), IL-4 and IL-13. TLR-2-mediated IL-10 secretion was shown to be required for the reduction in eosinophils and Th2 cytokines. EPS-treatment reduced eosinophil recruitment within the lung in a respiratory inflammation mouse model, which is both TLR-2 and IL-10 mediated. EPS can be considered as a novel molecule potentially reducing the severity of chronic eosinophil-related airway disorders.

Histamine receptor 2 modifies iNKT cell activity within the inflamed lung.

BACKGROUND: Histamine is a key immunoregulatory mediator and can dampen proinflammatory responses via activation of histamine receptor 2 (H2 R). The aim of this study was to determine the role of H2 R in modulating lung inflammatory responses. METHODS: H2 R was blocked using famotidine or activated using dimaprit in both the ovalbumin (OVA) and house dust mite extract (HDM) murine models of respiratory inflammation. H2 R-deficient animals and CD1d/H2 R-deficient animals were utilized to examine the CD1d presentation of lipid antigens (αGalCer or OCH) to invariant natural killer T (iNKT) cells. RESULTS: Famotidine treatment resulted in more severe airway disease in the OVA model, while dimaprit treatment significantly reduced disease severity. Both OVA and HDM-induced airway diseases were more severe in H2 R-deficient animals. Flow cytometric analysis of lung tissue from H2 R-deficient animals revealed increased numbers of CD1d+ dendritic cells and increased numbers of iNKT cells. In vitro, αGalCer-stimulated iNKT cells from H2 R-deficient mice secreted higher levels of IL-4, IL-5, and GM-CSF. In vivo, αGalCer or OCH administration to the lung resulted in enhanced mucus secretion, inflammatory cell recruitment, and cytokine production in H2 R-deficient or famotidine-treated animals, while dimaprit dampened the lung iNKT cell response to αGalCer. Removal of iNKT cells in H2 R-deficient (CD1d-/- H2 R-/- ) animals normalized the lung response to HDM. CONCLUSION: The deliberate activation of H2 R, or its downstream signaling molecules, may represent a novel therapeutic target for chronic lung inflammatory diseases, especially when CD1d-mediated presentation of lipid antigens to iNKT cells is contributing to the pathology.

Altered fatty acid metabolism and reduced stearoyl-coenzyme a desaturase activity in asthma.

BACKGROUND: Fatty acids and lipid mediator signaling play an important role in the pathogenesis of asthma, yet this area remains largely underexplored. The aims of this study were (i) to examine fatty acid levels and their metabolism in obese and nonobese asthma patients and (ii) to determine the functional effects of altered fatty acid metabolism in experimental models. METHODS: Medium- and long-chain fatty acid levels were quantified in serum from 161 human volunteers by LC/MS. Changes in stearoyl-coenzyme A desaturase (SCD) expression and activity were evaluated in the ovalbumin (OVA) and house dust mite (HDM) murine models. Primary human bronchial epithelial cells from asthma patients and controls were evaluated for SCD expression and activity. RESULTS: The serum desaturation index (an indirect measure of SCD) was significantly reduced in nonobese asthma patients and in the OVA murine model. SCD1 gene expression was significantly reduced within the lungs following OVA or HDM challenge. Inhibition of SCD in mice promoted airway hyper-responsiveness. SCD1 expression was suppressed in bronchial epithelial cells from asthma patients. IL-4 and IL-13 reduced epithelial cell SCD1 expression. Inhibition of SCD reduced surfactant protein C expression and suppressed rhinovirus-induced IP-10 secretion, which was associated with increased viral titers. CONCLUSIONS: This is the first study to demonstrate decreased fatty acid desaturase activity in humans with asthma. Experimental models in mice and human epithelial cells suggest that inhibition of desaturase activity leads to airway hyper-responsiveness and reduced antiviral defense. SCD may represent a new target for therapeutic intervention in asthma patients.

Origin of hexavalent chromium in groundwater: The example of Sarigkiol Basin, Northern Greece.

Hexavalent chromium constitutes a serious deterioration factor for the groundwater quality of several regions around the world. High concentrations of this contaminant have been also reported in the groundwater of the Sarigkiol hydrological basin (near Kozani city, NW Greece). Specific interest was paid to this particular study area due to the co-existence here of two important factors both expected to contribute to Cr(VI) presence and groundwater pollution; namely the area's exposed ophiolitic rocks and its substantial fly ash deposits originating from the local lignite burning power plant. Accordingly, detailed geochemical, mineralogical, hydro-chemical, geophysical and hydrogeological studies were performed on the rocks, soils, sediments and water resources of this basin. Cr(VI) concentrations varied in the different aquifers, with the highest concentration (up to 120µgL-1) recorded in the groundwater of the unconfined porous aquifer situated near the temporary fly ash disposal site. Recharge of the porous aquifer is related mainly to precipitation infiltration and occasional surface run-off. Nevertheless, a hydraulic connection between the porous and neighboring karst aquifers could not be delineated. Therefore, the presence of Cr(VI) in the groundwater of this area is thought to originate from both the ophiolitic rock weathering products in the soils, and the local leaching of Cr(VI) from the diffused fly ash located in the area surrounding the lignite power plant. This conclusion was corroborated by factor analysis, and the strongly positively fractionated Cr isotopes (δ53Cr up to 0.83‰) recorded in groundwater, an ash leachate, and the bulk fly ash. An anthropogenic source of Cr(VI) that possibly influences groundwater quality is especially apparent in the eastern part of the Sarigkiol basin.

Simplifying the WHO 'how to hand rub' technique: three steps are as effective as six-results from an experimental randomized crossover trial.

OBJECTIVES: The World Health Organization (WHO) issued guidelines on hand hygiene recommending a six-step 'how to hand rub' technique for applying alcohol-based hand rub. However, adherence to all six steps is poor. We assessed a simplified three-step technique and compared it to the conventional WHO six-step technique in terms of bacterial count reduction on healthcare workers' hands. METHODS: Thirty-two participants were randomly assigned to clean their hands following the six-step 'how to hand rub' technique (WHO reference group) or a simplified three-step technique (intervention group). Assignments were reversed after 1 day. The degree of bacterial killing was assessed following the European norm for testing hand hygiene products. Hands were contaminated with Escherichia coli, and the mean logarithmic reduction in bacterial counts was compared between both techniques. RESULTS: Bacterial density before hand hygiene performance did not differ between the WHO reference group (median 6.37 log10 CFU, interquartile range (IQR) 6.19-6.54) and the intervention group (median 6.34 log10 CFU, IQR 6.17-6.60, p 0.513). After hand hygiene, the logarithmic reduction factor was higher in the intervention group (median 4.45, IQR 4.04-5.15) compared to the WHO reference group (median 3.91, IQR 3.69-4.62, p 0.021). CONCLUSIONS: The WHO six-step 'how to hand rub' technique can be simplified to a 3-step procedure based on the reduction of bacterial counts on healthcare workers' hands achieved under experimental conditions. The proposed technique is easier to perform and could improve adherence to the execution of hand hygiene action.

A switch in regulatory T cells through farm exposure during immune maturation in childhood.

BACKGROUND: Farm exposure protects against development of allergies early in life. At 4.5 years, protection against asthma by farm-milk exposure was partially mediated by regulatory T cells (Tregs). The aim of this study was to investigate the critical time window of the 'asthma-protective' farm effect via Tregs during childhood immune maturation. METHODS: Tregs were assessed longitudinally at 4.5 and 6 years in 111 children (56 farm and 55 reference children) from the PASTURE/EFRAIM birth cohort (flow cytometry). Peripheral blood mononuclear cells were cultured unstimulated (U), with phorbol 12-myristate 13-acetate/ionomycin (PI) or lipopolysaccharide (LPS), and stained for Tregs (CD4+ CD25high FOXP3upper20% ). mRNA expression of Treg/Th1/Th2/Th17-associated cell markers was measured ex vivo. Suppressive capacity of Tregs on effector cells and cytokines was assessed. Detailed questionnaires assessing farm exposures and clinical phenotypes from birth until age 6 years were answered by the parents. RESULTS: Treg percentage before and after stimulation and FOXP3mRNA expression ex vivo decreased from age 4.5 to 6 years (P(U,LPS) < 0.001; P(PI) = 0.051; P(FOXP3) < 0.001). High vs low farm-milk and animal-stable exposure was associated with decreased LPS-stimulated Treg percentage at age 6 years (P(LPS) = 0.045). Elevated LPS-stimulated-Treg percentage at age 6 was associated with increased risk of asthma (aOR = 11.29, CI: 0.96-132.28, P = 0.053). Tregs from asthmatics vs nonasthmatics suppressed IFN-γ (P = 0.015) and IL-9 (P = 0.023) less efficiently. mRNA expression of Th1/Th2/Th17-associated cell markers decreased between 4.5 and 6 years (P < 0.001). CONCLUSIONS: Tregs at the age of 6 years were decreased with farm exposure and increased within asthmatics, opposite to age 4.5 years. This immunological switch defines a critical 'time window' for Treg-mediated asthma protection via environmental exposure before age 6 years.

Association of daptomycin use with resistance development in Enterococcus faecium bacteraemia-a 7-year individual and population-based analysis.

OBJECTIVE: In this study we aimed to analyse the association between use of daptomycin and MICs of daptomycin in Enterococcus faecium bacteraemia. METHODS: We prospectively enrolled patients aged ≥18 years with E. faecium bacteraemia hospitalized at the University Hospital Basel from 2008 to 2014. We determined daptomycin MICs by Etests and used pulsed field gel electrophoresis to determine clonal relatedness. We recorded the defined daily dosages of daptomycin (DDDs) per 100 patient-days and clinical data from charts. We correlated daptomycin MIC with use of daptomycin in patients with recurrence/persistence. RESULTS: In 195 E. faecium bacteraemias originating from 162 patients the median MIC for daptomycin was 2 mg/L (IQR 2-3); 30% (15.4%) isolates had a MIC ≥4 mg/L and 6 (3.1%) were resistant (MIC >4 mg/L) according to CLSI criteria. The usage of daptomycin increased more than four-fold from 0.36 DDDs/100 patient-days in 2008 to 1.6 in 2014. In 13 of 28 (42.9%) patients with a relapsing or persisting bacteraemia, the daptomycin MIC of the second isolate increased from a median of 2.0 to 2.5 mg/L (p 0.010); 3/13 (23.1%) developed resistance. All patients with the same clone in the first and second episode and an increase of daptomycin MIC had been treated with daptomycin (6/6 versus 1/7 p 0.005). CONCLUSIONS: Daptomycin MICs and Daptomycin usage increased over time. On an individual patient level daptomycin exposure was associated with an increased MIC in subsequent bacteraemia episodes. Diversity did not indicate a clonal origin and argues for a de novo development of resistance.

Oral immunotherapy with low allergenic hydrolysed egg in egg allergic children.

BACKGROUND: A major drawback of oral immunotherapy for food allergy is the possibility of severe side-effects. We assessed both safety and efficacy of a low allergenic hydrolysed egg (HydE) preparation used in a double-blind placebo-controlled randomized study in egg allergic children. METHODS: In a pilot multicentre study, 29 egg allergic patients (aged 1-5.5 years) were administered daily for 6 months 9 g HydE or placebo in a blinded, randomized manner. Safety was verified by oral food challenge to assess tolerance towards HydE at the start and efficacy by an open oral food challenge (OFC, primary outcome) at the end. Additionally, changes in basophil activation and specific IgE and IgG4 were assessed. RESULTS: All egg allergic patients randomized to HydE (n = 15) tolerated the full dose at day 1 and received the maintenance dose from the start at home. No statistically significant difference was observed on the final OFC (36% and 21% had a negative OFC in the treatment and placebo groups, respectively). Specific IgG4 levels increased, while both CD203c+ and CD63+ basophils decreased significantly more over time in the treatment than in the placebo group. CONCLUSIONS: HydE can be regarded as a safe, low allergenic product to use in children allergic to egg. Although not significant, HydE given for 6 months increased numerically the proportion of patients becoming tolerant to egg. HydE induced a modulation of the immune response towards better tolerance. A longer treatment period and/or a higher dose may improve the clinical outcome and should be evaluated.

Cannabinoid receptor 2 augments eosinophil responsiveness and aggravates allergen-induced pulmonary inflammation in mice.

BACKGROUND: Accumulation of activated eosinophils in tissue is a hallmark of allergic inflammation. The endocannabinoid 2-arachidonoylglycerol (2-AG) has been proposed to elicit eosinophil migration in a CB2 receptor/Gi/o -dependent manner. However, it has been claimed recently that this process may also involve other mechanisms such as cytokine priming and the metabolism of 2-AG into eicosanoids. Here, we explored the direct contribution of specific CB2 receptor activation to human and mouse eosinophil effector function in vitro and in vivo. METHODS: In vitro studies including CB2 expression, adhesion and migratory responsiveness, respiratory burst, degranulation, and calcium mobilization were conducted in human peripheral blood eosinophils and mouse bone marrow-derived eosinophils. Allergic airway inflammation was assessed in mouse models of acute OVA-induced asthma and directed eosinophil migration. RESULTS: CB2 expression was significantly higher in eosinophils from symptomatic allergic donors. The selective CB2 receptor agonist JWH-133 induced a moderate migratory response in eosinophils. However, short-term exposure to JWH-133 potently enhanced chemoattractant-induced eosinophil shape change, chemotaxis, CD11b surface expression, and adhesion as well as production of reactive oxygen species. Receptor specificity of the observed effects was confirmed in eosinophils from CB2 knockout mice and by using the selective CB2 antagonist SR144528. Of note, systemic application of JWH-133 clearly primed eosinophil-directed migration in vivo and aggravated both AHR and eosinophil influx into the airways in a CB2 -specific manner. This effect was completely absent in eosinophil-deficient ∆dblGATA mice. CONCLUSION: Our data indicate that CB2 may directly contribute to the pathogenesis of eosinophil-driven diseases. Moreover, we provide new insights into the molecular mechanisms underlying the CB2 -mediated priming of eosinophils. Hence, antagonism of CB2 receptors may represent a novel pharmacological approach for the treatment of allergic inflammation and other eosinophilic disorders.

Validation of a treatment algorithm for orthopaedic implant-related infections with device-retention-results from a prospective observational cohort study.

Success rates for treatment regimens involving retention of an infected implant are conflicting and failure rates of up to 80% have been reported. We aimed to validate a proposed treatment algorithm, based on strict selection criteria, by assessing long-term outcome of treatment for orthopaedic device-related infection (ODRI) with retention. From January 1999 to December 2009, all patients diagnosed with ODRI at the University Hospital Basel, Switzerland were eligible for treatment with open surgical debridement, implant-retention and antibiotics, if duration of clinical symptoms was ≤3 weeks, the implant was stable, the soft-tissue had no abscess or sinus tract, and the causative pathogen was susceptible to antimicrobial agents with activity against surface-adhering microorganisms. Antimicrobial treatment was administered according to a predefined algorithm. The primary outcome was treatment failure after 2-year follow up. A total of 455 patients were diagnosed with an ODRI, of whom 233 (51.2%) patients were eligible for treatment involving implant-retention. Causative pathogens were mainly Staphylococcus aureus (41.6%) and coagulase-negative staphylococci (33.9%). Among patients with ODRIs related to prostheses, failure was documented in 10.8% (12/111) and in patients with ODRIs related to osteosyntheses, failure occurred in 9.8% (12/122) after 2 years of follow up. In all, 90% of ODRIs were successfully cured with surgical debridement and implant-retention in addition to long-term antimicrobial therapy according to a predefined treatment algorithm: if patients fulfilled strict selection criteria and there was susceptibility to rifampin for Gram-positive pathogens and ciprofloxacin for Gram-negative pathogens.