Multi-institute analysis of carbapenem resistance reveals remarkable diversity, unexplained mechanisms, and limited clonal outbreaks.

Carbapenem-resistant Enterobacteriaceae (CRE) are among the most severe threats to the antibiotic era. Multiple different species can exhibit resistance due to many different mechanisms, and many different mobile elements are capable of transferring resistance between lineages. We prospectively sampled CRE from hospitalized patients from three Boston-area hospitals, together with a collection of CRE from a single California hospital, to define the frequency and characteristics of outbreaks and determine whether there is evidence for transfer of strains within and between hospitals and the frequency with which resistance is transferred between lineages or species. We found eight species exhibiting resistance, with the majority of our sample being the sequence type 258 (ST258) lineage of Klebsiella pneumoniae There was very little evidence of extensive hospital outbreaks, but a great deal of variation in resistance mechanisms and the genomic backgrounds carrying these mechanisms. Local transmission was evident in clear phylogeographic structure between the samples from the two coasts. The most common resistance mechanisms were KPC (K. pneumoniae carbapenemases) beta-lactamases encoded by blaKPC2, blaKPC3, and blaKPC4, which were transferred between strains and species by seven distinct subgroups of the Tn4401 element. We also found evidence for previously unrecognized resistance mechanisms that produced resistance when transformed into a susceptible genomic background. The extensive variation, together with evidence of transmission beyond limited clonal outbreaks, points to multiple unsampled transmission chains throughout the continuum of care, including asymptomatic carriage and transmission of CRE. This finding suggests that to control this threat, we need an aggressive approach to surveillance and isolation.

Critical role of the tumor suppressor tuberous sclerosis complex 1 in dendritic cell activation of CD4 T cells by promoting MHC class II expression via IRF4 and CIITA.

Dendritic cell (DC) maturation is characterized by upregulation of cell-surface MHC class II (MHC-II) and costimulatory molecules, and production of a variety of cytokines that can shape both innate and adaptive immunity. Paradoxically, transcription of the MHC-II genes, as well as its activator, CIITA, is rapidly silenced during DC maturation. The mechanisms that control CIITA/MHC-II expression and silencing have not been fully understood. We report in this article that the tumor suppressor tuberous sclerosis complex 1 (TSC1) is a critical regulator of DC function for both innate and adaptive immunity. Its deficiency in DCs results in increased mammalian target of rapamycin (mTOR) complex 1 but decreased mTORC2 signaling, altered cytokine production, impaired CIITA/MHC-II expression, and defective Ag presentation to CD4 T cells after TLR4 stimulation. We demonstrate further that IFN regulatory factor 4 can directly bind to CIITA promoters, and decreased IFN regulatory factor 4 expression is partially responsible for decreased CIITA/MHC-II expression in TSC1-deficient DCs. Moreover, we identify that CIITA/MHC-II silencing during DC maturation requires mTOR complex 1 activity. Together, our data reveal unexpected roles of TSC1/mTOR that control multifaceted functions of DCs.

Cefepime vs other antibacterial agents for the treatment of Enterobacter species bacteremia.

BACKGROUND: Carbapenems are recommended for treatment of Enterobacter infections with AmpC phenotypes. Although isolates are typically susceptible to cefepime in vitro, there are few data supporting its clinical efficacy. METHODS: We reviewed all cases of Enterobacter species bacteremia at 2 academic hospitals from 2005 to 2011. Outcomes of interest were (1) persistent bacteremia ≥1 calendar day and (2) in-hospital mortality. We fit logistic regression models, adjusting for clinical risk factors and Pitt bacteremia score and performed propensity score analyses to compare the efficacy of cefepime and carbapenems. RESULTS: Three hundred sixty-eight patients experienced Enterobacter species bacteremia and received at least 1 antimicrobial agent, of whom 52 (14%) died during hospitalization. Median age was 59 years; 19% were neutropenic, and 22% were in an intensive care unit on the day of bacteremia. Twenty-nine (11%) patients had persistent bacteremia for ≥1 day after antibacterial initiation. None of the 36 patients who received single-agent cefepime (0%) had persistent bacteremia, as opposed to 4 of 16 (25%) of those who received single-agent carbapenem (P < .01). In multivariable models, there was no association between carbapenem use and persistent bacteremia (adjusted odds ratio [aOR], 1.52; 95% CI, .58-3.98; P = .39), and a nonsignificant lower odds ratio with cefepime use (aOR, 0.52; 95% CI, .19-1.40; P = .19). In-hospital mortality was similar for use of cefepime and carbapenems in adjusted regression models and propensity-score matched analyses. CONCLUSIONS: Cefepime has a similar efficacy as carbapenems for the treatment of Enterobacter species bacteremia. Its use should be further explored as a carbapenem-sparing agent in this clinical scenario.

The role of tuberous sclerosis complex 1 in regulating innate immunity.

The mechanisms that control TLR-induced responses, including endotoxin tolerance, have been not well understood. The tuberous sclerosis complex 1 (TSC1) is a tumor suppressor that inhibits the mammalian target of rapamycin (mTOR). We show in this study that deficiency of TSC1 results in enhanced activation of not only mTOR complex 1 (mTORC1), but also JNK1/2, following LPS stimulation in macrophages. TSC1-deficient macrophages produce elevated proinflammatory cytokines and NO in response to multiple TLR ligands. Such enhanced TLR-induced responses can be inhibited by reducing mTORC1 and JNK1/2 activities with chemical inhibitors or small hairpin RNA, suggesting that TSC1 negatively controls TLR responses through both mTORC1 and JNK1/2. The impact of TSC1 deficiency appeared not limited to TLRs, as NOD- and RIG-I/MDA-5-induced innate responses were also altered in TSC1-deficient macrophages. Furthermore, TSC1 deficiency appears to cause impaired induction of endotoxin tolerance in vitro and in vivo, which is correlated with increased JNK1/2 activation and can be reversed by JNK1/2 inhibition. Our results reveal a critical role of TSC1 in regulating innate immunity by negative control of mTORC1 and JNK1/2 activation.

Differential regulation of primary and memory CD8 T cell immune responses by diacylglycerol kinases.

The manipulation of signals downstream of the TCR can have profound consequences for T cell development, function, and homeostasis. Diacylglycerol (DAG) produced after TCR stimulation functions as a secondary messenger and mediates the signaling to Ras-MEK-Erk and NF-κB pathways in T cells. DAG kinases (DGKs) convert DAG into phosphatidic acid, resulting in termination of DAG signaling. In this study, we demonstrate that DAG metabolism by DGKs can serve a crucial function in viral clearance upon lymphocytic choriomeningitis virus infection. Ag-specific CD8(+) T cells from DGKα(-/-) and DGKζ(-/-) mice show enhanced expansion and increased cytokine production after lymphocytic choriomeningitis virus infection, yet DGK-deficient memory CD8(+) T cells exhibit impaired expansion after rechallenge. Thus, DGK activity plays opposing roles in the expansion of CD8(+) T cells during the primary and memory phases of the immune response, whereas consistently inhibiting antiviral cytokine production.

Integrated Multilevel Surveillance of the World's Infecting Microbes and Their Resistance to Antimicrobial Agents.

Microbial surveillance systems have varied in their source of support; type of laboratory reporting (patient care or reference); inclusiveness of reports filed; extent of microbial typing; whether single hospital, multihospital, or multicountry; proportion of total medical centers participating; and types, levels, integration across levels, and automation of analyses performed. These surveillance systems variably support the diagnosis and treatment of patients, local or regional infection control, local or national policies and guidelines, laboratory capacity building, sentinel surveillance, and patient safety. Overall, however, only a small fraction of available data are under any surveillance, and very few data are fully integrated and analyzed. Advancing informatics and genomics can make microbial surveillance far more efficient and effective at preventing infections and improving their outcomes. The world's microbiology laboratories should upload their reports each day to programs that detect events, trends, and epidemics in communities, hospitals, countries, and the world.

Regulation of T-cell survival and mitochondrial homeostasis by TSC1.

The mammalian target of rapamycin (mTOR) is a key regulator of cell growth and metabolism. It associates with multiple proteins and forms two distinct signaling complexes, mTORC1 and mTORC2. Accumulating evidence has revealed critical roles for intact mTOR signaling during T-cell activation and responses to microbial infection. However, the importance of mTOR regulation in T cells has yet to be explored. The TSC1/TSC2 complex has been shown to inhibit mTORC1 signaling in cell line models. We show here that deletion of TSC1 in the murine T-cell lineage results in a dramatic reduction of the peripheral T-cell pool, correlating with increased cell death. While mTORC1 is constitutively activated, mTORC2 signaling, reflected by Akt phosphorylation and activity, is decreased in TSC1-deficient T cells. Furthermore, TSC1-deficient T cells contain elevated reactive oxygen species (ROS) and exhibit decreased mitochondrial content and membrane potential, which is correlated with the activation of the intrinsic death pathway. Overall, our results demonstrate that TSC1 differentially regulates mTORC1 and mTORC2 activity, promotes T-cell survival, and is critical for normal mitochondrial homeostasis in T cells.

Chondromyxoid fibroma of the orbit.

A 51-year-old woman with a history of migraine headaches was found to have an incidental right orbital mass on MRI during neurologic evaluation for headaches. The orbital mass was a well-defined, lobulated, intraosseous soft tissue lesion with circumscribed margins. Clinically, there was noted proptosis, tenderness to palpation, and slight limitation to right abduction. An orbitotomy with incisional biopsy revealed a lesion arising within the lateral orbital rim extending to the subperiosteal space. Intraoperative frozen sections indicated a low grade sarcoma, possibly metastatic. The extraosseous component was excised, and the bone was curetted until all visible tumor was removed. A diagnosis of chondromyxoid fibroma was made. The patient did well until 5 months postoperatively, when right-sided proptosis returned due to recurrent tumor. Repeat surgical resection with removal of the lateral orbital rim was performed. Histopathology was consistent with recurrent chondromyxoid fibroma.

Staphylococcus aureus antimicrobial susceptibility trends and cluster detection in Vermont: 2012-2018.

Objectives: This study presents demographic and temporal trends in the isolation of Staphylococcus aureus in Vermont clinical microbiology laboratories and explores the use of statistical algorithms and multi-resistance phenotypes to improve outbreak detection.Methods: Routine microbiology test results downloaded from Vermont clinical laboratory information systems were used to monitor S. aureus antimicrobial resistance trends. The integrated WHONET-SaTScan software used multi-resistance phenotypes to identify possible acute outbreaks with the space-time permutation model and slowly emerging geographic clusters using the spatial-only multinomial model.Results: Data were provided from seven hospital laboratories from 2012 to 2018 for 19,224 S. aureus isolates from 14,939 patients. Statistically significant differences (p ≤ 0.05) in methicillin-resistant S. aureus (MRSA) isolation were seen by age group, specimen type, and health-care setting. Among MRSA, multi-resistance profiles permitted the recognition and tracking of 6 common and 21 rare 'phenotypic clones.' We identified 43 acute MRSA clusters and 7 significant geographic clusters (p ≤ 0.05).Conclusions: There was significant heterogeneity in MRSA strains between facilities and the use of multi-resistance phenotypes facilitated the recognition of possible outbreaks. Comprehensive electronic surveillance of antimicrobial resistance utilizing routine clinical microbiology data with free software tools offers early recognition and tracking of emerging resistance threats.

Automated detection of infectious disease outbreaks in hospitals: a retrospective cohort study.

BACKGROUND: Detection of outbreaks of hospital-acquired infections is often based on simple rules, such as the occurrence of three new cases of a single pathogen in two weeks on the same ward. These rules typically focus on only a few pathogens, and they do not account for the pathogens' underlying prevalence, the normal random variation in rates, and clusters that may occur beyond a single ward, such as those associated with specialty services. Ideally, outbreak detection programs should evaluate many pathogens, using a wide array of data sources. METHODS AND FINDINGS: We applied a space-time permutation scan statistic to microbiology data from patients admitted to a 750-bed academic medical center in 2002-2006, using WHONET-SaTScan laboratory information software from the World Health Organization (WHO) Collaborating Centre for Surveillance of Antimicrobial Resistance. We evaluated patients' first isolates for each potential pathogenic species. In order to evaluate hospital-associated infections, only pathogens first isolated >2 d after admission were included. Clusters were sought daily across the entire hospital, as well as in hospital wards, specialty services, and using similar antimicrobial susceptibility profiles. We assessed clusters that had a likelihood of occurring by chance less than once per year. For methicillin-resistant Staphylococcus aureus (MRSA) or vancomycin-resistant enterococci (VRE), WHONET-SaTScan-generated clusters were compared to those previously identified by the Infection Control program, which were based on a rule-based criterion of three occurrences in two weeks in the same ward. Two hospital epidemiologists independently classified each cluster's importance. From 2002 to 2006, WHONET-SaTScan found 59 clusters involving 2-27 patients (median 4). Clusters were identified by antimicrobial resistance profile (41%), wards (29%), service (13%), and hospital-wide assessments (17%). WHONET-SaTScan rapidly detected the two previously known gram-negative pathogen clusters. Compared to rule-based thresholds, WHONET-SaTScan considered only one of 73 previously designated MRSA clusters and 0 of 87 VRE clusters as episodes statistically unlikely to have occurred by chance. WHONET-SaTScan identified six MRSA and four VRE clusters that were previously unknown. Epidemiologists considered more than 95% of the 59 detected clusters to merit consideration, with 27% warranting active investigation or intervention. CONCLUSIONS: Automated statistical software identified hospital clusters that had escaped routine detection. It also classified many previously identified clusters as events likely to occur because of normal random fluctuations. This automated method has the potential to provide valuable real-time guidance both by identifying otherwise unrecognized outbreaks and by preventing the unnecessary implementation of resource-intensive infection control measures that interfere with regular patient care. Please see later in the article for the Editors' Summary.

Surveillance of antimicrobial resistance and evolving microbial populations in Vermont: 2011-2018.

OBJECTIVE: This study presents trends in organism isolation and antimicrobial resistance in routine microbiology test results from acute-care hospital microbiology laboratories in Vermont. METHODS: Organism identifications and antimicrobial susceptibility test results were captured from acute-care hospital laboratories to monitor geographic and temporal trends in resistance and emerging microbial threats with the free WHONET software. RESULTS: Data were provided from 12 acute care hospital laboratories from 2011 through 2018 for 318,833 isolates from 148,994 patients (70% female, 74% outpatient, and 63% urine). Significant differences (p < 0.05) in age, gender, and antimicrobial susceptibility results (e.g. Escherichia coli and levofloxacin) between outpatient and inpatient isolates were identified with temporal increases in certain species (e.g. Aerococcus urinae) and resistance (e.g. Streptococcus pneumoniae and erythromycin). The use of multi-resistance phenotypes demonstrated significant heterogeneity (p < 0.05) in MRSA strains between facilities, for example Staphylococcus aureus resistant to six priority antimicrobials were found in no critical access hospitals (fewer than 25 inpatient beds) but in all non-critical access hospitals. CONCLUSIONS: Comprehensive electronic surveillance of antimicrobial resistance utilizing routine clinical microbiology data with free software tools offers early recognition and tracking of emerging community and healthcare resistance threats at the local and state level.

Why surveillance of antimicrobial resistance needs to be automated and comprehensive.

OBJECTIVES: Surveillance of antimicrobial resistance (AMR) can now be automated to analyse the reports of microbiology laboratories continually without operator assistance. It can also be made comprehensive to monitor all the reports of all the world's microbiology laboratories. METHODS AND RESULTS: As illustrated through examples provided in this work, each clinical report can be scanned automatically by algorithms to suspect emerging problems and to prompt sampling to confirm such problems, now increasingly by nucleotide sequencing. An emerging problem may be an excess (clustering) of similar microbes owing to their spread among patients who are interrelated in some way, as by shared locations, caregivers or food products. Or it might be a microbe new to an area or to a laboratory but already seen nearby, such as Elizabethkingia anophelis or mcr-1-positive Escherichia coli. Automated early alerting of responders enables them to contain spread sooner and to avert infections downstream. 'Big Data' informatics now also enables surveillance of AMR to be made comprehensive, to monitor all reports of all the world's microbiology laboratories. Such orders of magnitude increase in analysed data would accordingly increase its granularity and thus detect many more global problems sooner. It would also reduce surveillance-blind areas where problems may now emerge and spread undetected. CONCLUSIONS: The world's microbiology laboratories need to integrate and analyse all of their reports for surveillance to make their own patients safer from existing and approaching problems otherwise hard to notice. Making automated surveillance an easy-to-adopt laboratory standard of care can make it comprehensive.

Esophageal Actinomycoses Mimicking Malignancy.

Actinomycosis is caused by anaerobic bacteria and rarely affects the esophagus. We present a case of esophageal actinomycosis in a 55-year old woman that mimicked malignancy. The patient presented with dysphagia and weight loss. Preoperative esophagogastroscopic biopsy revealed purulent material, but was inconclusive. Endoscopic ultrasonography suggested esophageal cancer, and chest computed tomography showed a mass in the lower esophagus surrounded by inflammation. The patient underwent esophagogastrectomy, and histopathology examination of the specimen revealed distal esophageal actinomycosis. Preoperative diagnosis of esophageal actinomycosis is difficult, but clinicians should be aware of its unusual presentations and its ability to mimic malignancy.

Statistical detection of geographic clusters of resistant Escherichia coli in a regional network with WHONET and SaTScan.

BACKGROUND: While antimicrobial resistance threatens the prevention, treatment, and control of infectious diseases, systematic analysis of routine microbiology laboratory test results worldwide can alert new threats and promote timely response. This study explores statistical algorithms for recognizing geographic clustering of multi-resistant microbes within a healthcare network and monitoring the dissemination of new strains over time. METHODS: Escherichia coli antimicrobial susceptibility data from a three-year period stored in WHONET were analyzed across ten facilities in a healthcare network utilizing SaTScan's spatial multinomial model with two models for defining geographic proximity. We explored geographic clustering of multi-resistance phenotypes within the network and changes in clustering over time. RESULTS: Geographic clustering identified from both latitude/longitude and non-parametric facility groupings geographic models were similar, while the latter was offers greater flexibility and generalizability. Iterative application of the clustering algorithms suggested the possible recognition of the initial appearance of invasive E. coli ST131 in the clinical database of a single hospital and subsequent dissemination to others. CONCLUSION: Systematic analysis of routine antimicrobial resistance susceptibility test results supports the recognition of geographic clustering of microbial phenotypic subpopulations with WHONET and SaTScan, and iterative application of these algorithms can detect the initial appearance in and dissemination across a region prompting early investigation, response, and containment measures.

Antimicrobial resistance in developing countries. Part I: recent trends and current status.

The global problem of antimicrobial resistance is particularly pressing in developing countries, where the infectious disease burden is high and cost constraints prevent the widespread application of newer, more expensive agents. Gastrointestinal, respiratory, sexually transmitted, and nosocomial infections are leading causes of disease and death in the developing world, and management of all these conditions has been critically compromised by the appearance and rapid spread of resistance. In this first part of the review, we have summarised the present state of resistance in these infections from the available data. Even though surveillance of resistance in many developing countries is suboptimal, the general picture is one of accelerating rates of resistance spurred by antimicrobial misuse and shortfalls in infection control and public health. Reservoirs for resistance may be present in healthy human and animal populations. Considerable economic and health burdens emanate from bacterial resistance, and research is needed to accurately quantify the problem and propose and evaluate practicable solutions. In part II, to be published next month, we will review potential containment strategies that could address this burgeoning problem.

Antimicrobial resistance in developing countries. Part II: strategies for containment.

The growing threat from resistant organisms calls for concerted action to prevent the emergence of new resistant strains and the spread of existing ones. Developing countries have experienced unfavourable trends in resistance-as detailed in part I, published last month--and implementation of many of the containment strategies recommended by WHO is complicated by universal, as well as developing country-specific, factors. The control of selective pressure for resistance could potentially be addressed through educational and other interventions for orthodox and unorthodox prescribers, distributors, and consumers of antimicrobials. At national levels, the implementation of drug use strategies--eg, combination therapy or cycling--may prove useful to lengthen the lifespan of existing and future agents. Programmes such as the Integrated Management of Childhood Illnesses (IMCI) and directly observed short-course therapy (DOTS) for tuberculosis are prescriber-focused and patient-focused, respectively, and have both been shown to positively influence factors that contribute to the selective pressure that affects resistance. The institution of interventions to prevent the transmission of infectious diseases could also lead to beneficial effects on the prevalence of resistance, as has vaccination against Haemophilus influenzae type B and Streptococcus pneumoniae. There has been an upsurge in the number of organisations and programmes that directly address issues of resistance, and collaboration could be one way to stem the dire trend. Additional factors such as unregulated drug availability, inadequate antimicrobial drug quality assurance, inadequate surveillance, and cultures of antimicrobial abuse must be addressed to permit a holistic strategy for resistance control.

Origin and proliferation of multiple-drug resistance in bacterial pathogens.

SUMMARY: Many studies report the high prevalence of multiply drug-resistant (MDR) strains. Because MDR infections are often significantly harder and more expensive to treat, they represent a growing public health threat. However, for different pathogens, different underlying mechanisms are traditionally used to explain these observations, and it is unclear whether each bacterial taxon has its own mechanism(s) for multidrug resistance or whether there are common mechanisms between distantly related pathogens. In this review, we provide a systematic overview of the causes of the excess of MDR infections and define testable predictions made by each hypothetical mechanism, including experimental, epidemiological, population genomic, and other tests of these hypotheses. Better understanding the cause(s) of the excess of MDR is the first step to rational design of more effective interventions to prevent the origin and/or proliferation of MDR.