Optimisation of clinical workflow and monitor settings safely reduces alarms in the NICU.

AIM: To address alarm fatigue, a new alarm management system which ensures a quicker delivery of alarms together with waveform information on nurses' handheld devices was implemented and settings optimised. The effects of this clinical implementation on alarm rates and nurses' responsiveness were measured in an 18-bed single family rooms neonatal intensive care unit (NICU). METHODS: The technical implementation of the alarm management system was followed by clinical workflow optimisation. Alarms and vital parameters from October 2017 to December 2019 were analysed. Measures included monitoring alarms, nurses' response to alarms and time spent by patients in different saturation ranges. A survey among nurses was performed to evaluate changes in alarm rate and use of protocols. RESULTS: A significant reduction of monitoring alarms per patient days was detected after the optimisation phase (in particular for SpO2 ≤ 80%, P < .001). More time was spent by infants within the optimal peripheral oxygen saturation range (88% < SpO2 < 95%, P < .001). Results from the surveys showed that false alarms are less likely to cause an inappropriate response after the optimisation phase. CONCLUSION: The implementation of an alarm management solution and an optimisation programme can safely reduce the alarm burden inside of the NICU environment.

Alarm fatigue: impacts on patient safety.

PURPOSE OF REVIEW: Electronic medical devices are an integral part of patient care. As new devices are introduced, the number of alarms to which a healthcare professional may be exposed may be as high as 1000 alarms per shift. The US Food and Drug Administration has reported over 500 alarm-related patient deaths in five years. The Joint Commission, recognizing the clinical significance of alarm fatigue, has made clinical alarm management a National Patient Safety Goal. RECENT FINDINGS: Potential solutions to alarm fatigue include technical, organizational, and educational interventions. Selecting only the right monitors (i.e., avoiding overmonitoring), judicious selection of alarm limits, and multimodal alarms can all reduce the number of nuisance alarms to which a healthcare worker is exposed. SUMMARY: Alarm fatigue can jeopardize safety, but some clinical solutions such as setting appropriate thresholds and avoiding overmonitoring are available.

The bacterial defensin resistance protein MprF consists of separable domains for lipid lysinylation and antimicrobial peptide repulsion.

Many bacterial pathogens achieve resistance to defensin-like cationic antimicrobial peptides (CAMPs) by the multiple peptide resistance factor (MprF) protein. MprF plays a crucial role in Staphylococcus aureus virulence and it is involved in resistance to the CAMP-like antibiotic daptomycin. MprF is a large membrane protein that modifies the anionic phospholipid phosphatidylglycerol with l-lysine, thereby diminishing the bacterial affinity for CAMPs. Its widespread occurrence recommends MprF as a target for novel antimicrobials, although the mode of action of MprF has remained incompletely understood. We demonstrate that the hydrophilic C-terminal domain and six of the fourteen proposed trans-membrane segments of MprF are sufficient for full-level lysyl-phosphatidylglycerol (Lys-PG) production and that several conserved amino acid positions in MprF are indispensable for Lys-PG production. Notably, Lys-PG production did not lead to efficient CAMP resistance and most of the Lys-PG remained in the inner leaflet of the cytoplasmic membrane when the large N-terminal hydrophobic domain of MprF was absent, indicating a crucial role of this protein part. The N-terminal domain alone did not confer CAMP resistance or repulsion of the cationic test protein cytochrome c. However, when the N-terminal domain was coexpressed with the Lys-PG synthase domain either in one protein or as two separate proteins, full-level CAMP resistance was achieved. Moreover, only coexpression of the two domains led to efficient Lys-PG translocation to the outer leaflet of the membrane and to full-level cytochrome c repulsion, indicating that the N-terminal domain facilitates the flipping of Lys-PG. Thus, MprF represents a new class of lipid-biosynthetic enzymes with two separable functional domains that synthesize Lys-PG and facilitate Lys-PG translocation. Our study unravels crucial details on the molecular basis of an important bacterial immune evasion mechanism and it may help to employ MprF as a target for new anti-virulence drugs.

Molecular basis of resistance to muramidase and cationic antimicrobial peptide activity of lysozyme in staphylococci.

It has been shown recently that modification of peptidoglycan by O-acetylation renders pathogenic staphylococci resistant to the muramidase activity of lysozyme. Here, we show that a Staphylococcus aureus double mutant defective in O-acetyltransferase A (OatA), and the glycopeptide resistance-associated two-component system, GraRS, is much more sensitive to lysozyme than S. aureus with the oatA mutation alone. The graRS single mutant was resistant to the muramidase activity of lysozyme, but was sensitive to cationic antimicrobial peptides (CAMPs) such as the human lysozyme-derived peptide 107R-A-W-V-A-W-R-N-R115 (LP9), polymyxin B, or gallidermin. A comparative transcriptome analysis of wild type and the graRS mutant revealed that GraRS controls 248 genes. It up-regulates global regulators (rot, sarS, or mgrA), various colonization factors, and exotoxin-encoding genes, as well as the ica and dlt operons. A pronounced decrease in the expression of the latter two operons explains why the graRS mutant is also biofilm-negative. The decrease of the dlt transcript in the graRS mutant correlates with a 46.7% decrease in the content of esterified d-alanyl groups in teichoic acids. The oatA/dltA double mutant showed the highest sensitivity to lysozyme; this mutant completely lacks teichoic acid-bound d-alanine esters, which are responsible for the increased susceptibility to CAMPs and peptidoglycan O-acetylation. Our results demonstrate that resistance to lysozyme can be dissected into genes mediating resistance to its muramidase activity (oatA) and genes mediating resistance to CAMPs (graRS and dlt). The two lysozyme activities act synergistically, as the oatA/dltA or oatA/graRS double mutants are much more susceptible to lysozyme than each of the single mutants.

Alarm Fatigue: Using Alarm Data from a Patient Data Monitoring System on an Intensive Care Unit to Improve the Alarm Management.

Excessive numbers of clinical alarms reduce the awareness of caregivers. Frequent alarms, many of which are non-actionable, can lead to cognitive overload, stress, and desensitization to alarms, called "Alarm Fatigue", which can severely impact patient safety. Due to the multifactorial nature of excessive alarming quantitative data about many facets of alarm generation and management are required in order to tackle the problem efficiently and effectively. Since there is no system available which would provide said data, we set out to develop one in the form of a data warehouse based on a thorough understanding of clinicians' needs. The developed system answers the users' needs in terms of readily providing them information on a daily basis, but also serves as a data source for further research. Further work is needed to include alarm sources from outside the patient monitoring infrastructure.

An Extension of the Arden Syntax to Facilitate Clinical Document Generation.

While clinical information systems usually store patient records in database tables, human interpretations as well as information transfer between institutions often require that clinical data can be represented as documents. To automate document generation from patient data in conjunction with the rich computational facilities of clinical decision support, we propose a template-based extension of the Arden Syntax, and discuss the benefits and limitations observed during a pilot application for patient recruitment. While the original Arden Syntax supports string concatenation as well as the substitution of unnamed placeholders, we integrated an additional method based on embedding expressions into strings. A dedicated parser identifies the expressions and automatically substitutes them at runtime, which can for example be harnessed to display the most recent value from a time series. The resulting mechanism supports the generation of extensive clinical documents without the need to apply specific operators. To evaluate the proposed extension, we implemented an Arden module that identifies an intensive care patient cohort that conforms to the eligibility criteria of a clinical trial and outputs a concise patient overview in different document formats. While string interpolation in the original Arden standard has been tailored to clinical event monitoring, we interpret that our accessible approach usefully extends Arden's data-to-text capabilities. Future research might target the development of an interactive template editor that would hide the complexity of formatting directives and conditional expressions behind a graphical user interface, and explore how computer-linguistic formalisms might facilitate advanced features such as automatic inflections of verbs and nouns.

The virulence regulator Sae of Staphylococcus aureus: promoter activities and response to phagocytosis-related signals.

The two-component system SaeRS of Staphylococcus aureus is closely involved in the regulation of major virulence factors. However, little is known about the signals leading to saeRS activation. A total of four overlapping transcripts (T1 to T4) from three different transcription starting points are expressed in the sae operon. We used a beta-galactosidase reporter assay to characterize the putative promoter regions within the saeRS upstream region. The main transcript T2 is probably generated by endoribonucleolytic processing of the T1 transcript. Only two distinct promoter elements (P1 and P3) could be detected within the saeRS upstream region. The P3 promoter, upstream of saeRS, generates the T3 transcript, includes a cis-acting enhancer element and is repressed by saeRS. The most distal P1 promoter is strongly autoregulated, activated by agr, and repressed by sigma factor B. In strain Newman a mutation within the histidine kinase SaeS leads to a constitutively activated sae system. Evaluation of different external signals revealed that the P1 promoter in strain ISP479R and strain UAMS-1 is inhibited by low pH and high NaCl concentrations but activated by hydrogen peroxide. The most prominent induction of P1 was observed at subinhibitory concentrations of alpha-defensins in various S. aureus strains, with the exception of strain ISP479R and strain COL. P1 was not activated by the antimicrobial peptides LL37 and daptomycin. In summary, the results indicate that the sensor molecule SaeS is activated by alteration within the membrane allowing the pathogen to react to phagocytosis related effector molecules.

The GraRS regulatory system controls Staphylococcus aureus susceptibility to antimicrobial host defenses.

BACKGROUND: Modification of teichoic acids with D-alanine by the products of the dlt operon protects Gram-positive bacteria against major antimicrobial host defense molecules such as defensins, cathelicidins, myeloperoxidase or phospholipase. The graRS regulatory genes have recently been implicated in the control of D-alanylation in Staphylococcus aureus. RESULTS: To determine the impact of the GraRS regulatory system on resistance to antimicrobial host defense mechanisms and virulence of S. aureus, we compared inactivation of S. aureus SA113 wild type and its isogenic graRS deletion mutant by the human cathelicidin LL-37 or human neutrophil granulocytes in vitro, and the ability to cause infection in vivo. We show here that graRS deletion considerably alters bacterial surface charge, increases susceptibility to killing by human neutrophils or the defense peptide LL-37, and attenuates virulence of S. aureus in a mouse infection model. CONCLUSION: Our results indicate that S. aureus can regulate its surface properties in order to overcome innate host defenses.

The mammalian ionic environment dictates microbial susceptibility to antimicrobial defense peptides.

Antimicrobial peptides (AMPs) have been shown in animal and human systems to be effective natural antibiotics. However, it is unclear how they convey protection; they often appear inactive when assayed under culture conditions applied to synthetic antibiotics. This inactivation has been associated with loss of function in physiological concentrations of NaCl or serum. In this study we show that the balance of host ionic conditions dictate microbial sensitivity to AMPs. Carbonate is identified as the critical ionic factor present in mammalian tissues that imparts the ability of AMPs such as cathelicidins and defensins to kill at physiological NaCl concentrations. After adapting to carbonate-containing solutions, global changes occur in Staphylococcus aureus and Escherichia coli structure and gene expression despite no change in growth rate. Our findings show that changes in cell wall thickness and Sigma factor B expression correspond to the increased susceptibility to the AMP LL-37. These observations provide new insight into the factors involved in enabling function of innate immune effector molecules, and suggest that discovery of new antimicrobials should specifically target pathogens as they exist in the host and not the distinctly different phenotype of bacteria grown in culture broth.

Alarm Fatigue: Causes and Effects.

The term "Alarm fatigue" is commonly used to describe the effect which a high number of alarms can have on caregivers: Frequent alarms, many of which are avoidable, can lead to inadequate responses, severely impacting patient safety. In the first step of a long-term effort to address this problem, both the direct and indirect impact of alarms, as well as possible causes of unnecessary alarms were focused. Models of these causes and impacts were developed using a scoping review which included guided interviews with experts from medical informatics, clinicians and medical device manufacturers. These models can provide the methodical grounds for the definition of targeted interventions and the assessment of their effects.

The lipid-modifying multiple peptide resistance factor is an oligomer consisting of distinct interacting synthase and flippase subunits.

UNLABELLED: Phospholipids are synthesized at the inner leaflet of the bacterial cytoplasmic membrane but have to be translocated to the outer leaflet to maintain membrane lipid bilayer composition and structure. Even though phospholipid flippases have been proposed to exist in bacteria, only one such protein, MprF, has been described. MprF is a large integral membrane protein found in several prokaryotic phyla, whose C terminus modifies phosphatidylglycerol (PG), the most common bacterial phospholipid, with lysine or alanine to modulate the membrane surface charge and, as a consequence, confer resistance to cationic antimicrobial agents such as daptomycin. In addition, MprF is a flippase for the resulting lipids, Lys-PG or Ala-PG. Here we demonstrate that the flippase activity resides in the N-terminal 6 to 8 transmembrane segments of the Staphylococcus aureus MprF and that several conserved, charged amino acids and a proline residue are crucial for flippase function. MprF protects S. aureus against the membrane-active antibiotic daptomycin only when both domains are present, but the two parts do not need to be covalently linked and can function in trans. The Lys-PG synthase and flippase domains were each found to homo-oligomerize and also to interact with each other, which illustrates how the two functional domains may act together. Moreover, full-length MprF proteins formed oligomers, indicating that MprF functions as a dimer or larger oligomer. Together our data reveal how bacterial phospholipid flippases may function in the context of lipid biosynthetic processes. IMPORTANCE: Bacterial cytoplasmic membranes are crucial for maintaining and protecting cellular integrity. For instance, they have to cope with membrane-damaging agents such as cationic antimicrobial peptides (CAMPs) produced by competing bacteria (bacteriocins), secreted by eukaryotic host cells (defensins), or used as antimicrobial therapy (daptomycin). The MprF protein is found in many Gram-positive, Gram-negative, and even archaeal commensals or pathogens and confers resistance to CAMPs by modifying anionic phospholipids with amino acids, thereby compromising the membrane interaction of CAMPs. Here we describe how MprF does not only modify phospholipids but uses an additional, distinct domain for translocating the resulting lysinylated phospholipids to the outer leaflet of the membrane. We reveal critical details for the structure and function of MprF, the first dedicated prokaryotic phospholipid flippase, which may pave the way for targeting MprF with new antimicrobials that would not kill bacteria but sensitize them to antibiotics and innate host defense molecules.

Staphylococcus aureus evasion of innate antimicrobial defense.

Bacterial pathogens colonize human body surfaces soon after birth. In order to survive the constant threat of invasion and infection, the human innate immune system has evolved several efficient mechanisms to prevent harmful microorganisms from traversing epithelial barriers. These include cationic antimicrobial peptides (CAMPs) such as defensins and the cathelicidin LL-37, bacteriolytic enzymes such as lysozyme, antimicrobial fatty acids, toxic oxygen- or nitrogen-containing molecules, the bacteriolytic complement components and further mechanisms with indirect impacts on bacterial multiplication. Staphylococcus aureus is an important human commensal and pathogen. In order to successfully establish an infection, S. aureus has evolved several mechanisms to resist the innate immune system. In this review, we focus on the mechanisms employed by S. aureus to achieve protection against antimicrobial host defense molecules with special emphasis on CAMPs. Lessons from recent studies on antimicrobial host defense molecules and cognate bacterial resistance adaptation should help in the development of more sustainable anti-infective compounds.

Muropeptide modification-amidation of peptidoglycan D-glutamate does not affect the proinflammatory activity of Staphylococcus aureus.

Peptidoglycan muropeptides, potent proinflammatory components, are amidated in Staphylococcus aureus for unknown reasons. To study whether this modification may modulate proinflammatory capacity, cytokine induction by isogenic S. aureus strains with different amidation levels and by synthetic amidated/nonamidated muramyldipeptides was evaluated. However, amidation did not significantly affect cytokine induction. This finding contributes to defining peptidoglycan receptor specificities and indicates that further rationales for muropeptide amidation have to be considered.

Large-conductance calcium-activated potassium channel activity is absent in human and mouse neutrophils and is not required for innate immunity.

Large-conductance Ca(2+)-activated K(+) (BK) channels are reported to be essential for NADPH oxidase-dependent microbial killing and innate immunity in leukocytes. Using human peripheral blood and mouse bone marrow neutrophils, pharmacological targeting, and BK channel gene-deficient (BK(-/-)) mice, we stimulated NADPH oxidase activity with 12-O-tetradecanoylphorbol-13-acetate (PMA) and performed patch-clamp recordings on isolated neutrophils. Although PMA stimulated NADPH oxidase activity as assessed by O(2)(-) and H(2)O(2) production, our patch-clamp experiments failed to show PMA-activated BK channel currents in neutrophils. In our studies, PMA induced slowly activating currents, which were insensitive to the BK channel inhibitor iberiotoxin. Instead, the currents were blocked by Zn(2+), which indicates activation of proton channel currents. BK channels are gated by elevated intracellular Ca(2+) and membrane depolarization. We did not observe BK channel currents, even during extreme depolarization to +140 mV and after elevation of intracellular Ca(2+) by N-formyl-L-methionyl-L-leucyl-phenylalanine. As a control, we examined BK channel currents in cerebral and tibial artery smooth muscle cells, which showed characteristic BK channel current pharmacology. Iberiotoxin did not block killing of Staphylococcus aureus or Candida albicans. Moreover, we addressed the role of BK channels in a systemic S. aureus and Yersinia enterocolitica mouse infection model. After 3 and 5 days of infection, we found no differences in the number of bacteria in spleen and kidney between BK(-/-) and BK(+/+) mice. In conclusion, our experiments failed to identify functional BK channels in neutrophils. We therefore conclude that BK channels are not essential for innate immunity.