Negative Sepsis Research Articles

Culture negative sepsis: a national survey of variations in clinical practice.

Culture negative sepsis: a national survey of variations in clinical practice.

A machine learning-based electronic nose for detecting neonatal sepsis: Analysis of volatile organic compound biomarkers in fecal samples

BackgroundNeonatal sepsis is a global health threat, contributing to high morbidity and mortality rates among newborns. Recognizing the profound impact of neonatal sepsis on long-term health outcomes emphasizes the critical need for timely detection to mitigate its consequences and ensure optimal health for the affected newborns. Currently, various diagnostic approaches have been implemented, but they are limited by their invasiveness, high costs, centralized testing, frequent delays, inaccuracies in results, and the need for sophisticated laboratory equipment. MethodsWe introduced a novel, non-invasive, cost-efficient, and easy-to-use technology that can provide rapid results at a point-of-care. The technology utilized a lab-built metal oxide semiconductor-based electronic nose (cNose) combined with volatile organic compound (VOC) biomarkers identified through gas chromatography-mass spectrometry (GC–MS) analysis. The system was evaluated using fecal profiling tests involving a total of 32 samples, including 17 positive and 15 negative sepsis, confirmed by blood culture. To assess the performance in discriminating patients from healthy controls, four machine learning algorithms were implemented. ResultsBased on the cross-validation results, the MLPNN model provided the best results in distinguishing between neonates with positive and negative sepsis, achieving high-performance results of 90.63 % accuracy, 88.24 % sensitivity, and 93.33 % specificity at a 95 % confidence interval. Specific VOCs associated with neonatal sepsis, such as alcohols, acids, and esters, were successfully identified through GC–MS analysis, further validating the diagnostic capability of the cNose device. ConclusionThe overall observations show the feasibility of using cNose system as a promising tool for real-time and bedside sepsis detection, potentially improving patient outcomes.

The role of colonization with resistant Gram-negative bacteria in the treatment of febrile neutropenia after stem cell transplantation

Febrile neutropenia (FN) is one of the most common complications of stem cell transplantation. The aim of this analysis was to evaluate the frequency of sepsis in patients with FN colonized with resistant Gram negative bacteria (Extended spectrum β-lactamase positive, multidrug resistant (MDR) P. aeruginosa) and the choice of primary antibiotic in colonized patients. This was a retrospective study analyzed data from patients who underwent hematopoietic stem cell transplantation from 01/2018 to 09/2022. Data were extracted from the hospital information system. Carbapenem as the primary antibiotic of choice was chosen in 10.9% of non-colonized +/-AmpC patients, 31.5% of ESBL+ patients, and 0% of MDR P. aeruginosa patients. Patients with FN and MDR P. aeruginosa colonization had a high prevalence of sepsis (namely 100%, p = 0.0197). The spectrum of sepsis appeared to be different, with Gram negative bacilli predominating in the ESBL+ group (p = 0.0123, OR 5.39 [95% CI 1.55-18.76]). Colonizer sepsis was present in 100% of sepsis with MDR P. aeruginosa colonization (p=0.002), all in allogeneic transplantation (p=0.0003), with a mortality rate of 33.3% (p=0.0384). The incidence of sepsis in patients with ESBL+ colonization was 25.9% (p=0.0197), with colonizer sepsis in 50% of sepsis cases (p=0.0002), most in allogeneic transplantation (p=0.0003). The results show a significant risk of sepsis in FN with MDR P. aeruginosa colonization, this state is almost exclusively caused by the colonizer. At the same time, a higher risk of Gram negative sepsis has been demonstrated in patients colonized with ESBL+ bacteria.

Evidence further linking the intestine to cardiovascular disease.

To review recent publications linking the intestine to cardiovascular disease. Aromatic amino acid-derived metabolites produced by gut-bacteria were identified that increased or decreased the risk of cardiovascular events. Dietary phenylalanine was metabolized to phenylacetic acid by gut microbes, and converted into phenylacetylglutamine by the host, which increased thrombosis potential via adrenergic receptors and was associated with increased major adverse cardiovascular events. Another microbiota-associated metabolite of aromatic amino acids, indole-3-propionic acid, protected against heart failure with preserved ejection fraction. The mechanism by which dietary cholesterol is absorbed was found to involve the Nieman-Pick C1-like1 protein working together with a newly discovered protein called Aster. Levels of gut-derived bacterial lipopolysaccharide in serum that are an order of magnitude less than those seen in gram negative sepsis were shown to play a role in enhancing atherosclerosis and thrombosis. Promising new therapeutic targets in the intestine for preventing or treating cardiovascular disease have been identified.

The Diagnostic and Prognostic Values of Soluble CD14 Subtype (Presepsin) in Early Detection of Early Onset Neonatal Sepsis in Preterm Newborns

Abstract Background The diagnosis of “suspected sepsis” in neonates in the NICU is one of the most common and challenging diagnoses due to the nonspecific signs of sepsis. therefore, laboratory investigation is necessary in cases of doubt or if there are risk factors. A promising biomarker: Presepsin (P-SEP), or Soluble Cluster of Differentiation 14 Subtype (sCD14-ST) is generated as a part of the body’s response to bacterial infection. It is effective in the early phase of inflammation, and it is detected as an early marker of sepsis in neonates. Aim and Objectives to evaluate the diagnostic value of presepsin in early neonatal sepsis and prognostic value for severity, mortality and hospital stay length. Subjects and Methods This prospective observational study include two groups, one group included 36 neonates with risk factors for early-onset sepsis, along with 20 uninfected neonates as the control group. Both groups were subjected to the calculation of Rodwell score, SNAP II score, serum presepsin levels, CRP measurement, and blood culture and assessed for clinical severity, mortality, and hospital stay length. Result Serum baseline presepsin was significantly elevated in sepsis group (P < 0.001), Presepsin showed the best diagnostic performance over Rodwell score (AUC 0.989; sensitivity of 93.8% and specificity of 95%). Presepsin levels on day 3 were significantly elevated in non-survived patients (P < 0.001), with better predictive performance for 28-day mortality and rapid progression to death than SNAP II score (AUC 0.880; sensitivity of 83.3% and specificity of 87.5%). Conclusion presepsin day 1 was useful diagnostic tools in culture proven early onset neonatal sepsis, presepsin at day 3 could be a good predictor for gram negative infections, 28-day mortality, and sepsis severity.

#329 Effectiveness of dosing strategies of polymyxin B among sepsis patients with and without renal replacement therapies

Abstract Background and Aims Despite numerous population pharmacokinetic studies on polymyxin B, a gap exists in establishing uniform dosing strategies among sepsis patients due to various clinical and patient related factors. The International Consensus guidelines, provide detailed dosing calculation for colistin but not for polymyxin B in renal impairment patients [1]. We aimed to compare and evaluate the effect of various dosing strategies of both polymyxin B and colistin among sepsis patients with and without renal replacement therapies (RRT) in the clinical setting. Method We conducted a retrospective audit on adult patients (aged≥ 18 years) diagnosed with gram negative sepsis, both with and without RRT, who were administered polymyxins. Data was collected from the medical records of patients admitted to critical care setting of a tertiary care hospital from January 2018 to December 2022. Patients who received polymyxin B doses for less than 3 days, pediatric, neonate patients or those discharged against medical advice were excluded. Data such as demographic details, RRT, polymyxin type and dosage, and therapy outcomes were collected. Polymyxin B dosing strategies were converted into low dose group (LD) [≤100 mg >150 mg loading dose (ld) and <150 mg maintenance dose (md)], usual dose group (UD) [150 mg ld and 150 mg md] and high dose (HD) [150 mg ld and >150 mg md] to evaluate its effectiveness [2]. Linear and logistic regression were used for continuous and categorical outcomes respectively. All statistical analyses were performed using IBM SPSS vs 29.0 [3]. Results Our study cohort included 550 patients with mean age of 59.79 ± 15.78 years, and majority of them being male patients (55.2%). A total of 243 (39.6%) patients were on RRT. Among the study population, 465 (84.5%) patients were on polymyxin and 146 (26.5%) were on colistin therapy. Regression analysis of different regimens of Polymyxin B prescribed with various doses showed UD group (p = 0.04) as well as HD group (p = 0.05) with better outcome in terms of improvement. Among the Polymyxin B cohort patients on RRT, HD group showed better outcome (p = 0.045). There was a significant mean difference between polymyxin B dosing strategies with respect to ventilator-free days (p = 0.006), while the other clinical outcomes showed non-significant results. Conclusion Our results suggest polymyxin B dosing strategy with a loading and maintenance dose of 150 mg in general patients. In patients with RRT, a loading dose of 150 mg and maintenance dose of >150 mg is warranted. Further population pharmacokinetic studies with large sample size of RRT patients on polymyxin B is required.

The plasma proteome differentiates the multisystem inflammatory syndrome in children (MIS-C) from children with SARS-CoV-2 negative sepsis

BackgroundThe Multi-System Inflammatory Syndrome in Children (MIS-C) can develop several weeks after SARS-CoV-2 infection and requires a distinct treatment protocol. Distinguishing MIS-C from SARS-CoV-2 negative sepsis (SCNS) patients is important to quickly institute the correct therapies. We performed targeted proteomics and machine learning analysis to identify novel plasma proteins of MIS-C for early disease recognition.MethodsA case-control study comparing the expression of 2,870 unique blood proteins in MIS-C versus SCNS patients, measured using proximity extension assays. The 2,870 proteins were reduced in number with either feature selection alone or with a prior COMBAT-Seq batch effect adjustment. The leading proteins were correlated with demographic and clinical variables. Organ system and cell type expression patterns were analyzed with Natural Language Processing (NLP).ResultsThe cohorts were well-balanced for age and sex. Of the 2,870 unique blood proteins, 58 proteins were identified with feature selection (FDR-adjusted P < 0.005, P < 0.0001; accuracy = 0.96, AUC = 1.00, F1 = 0.95), and 15 proteins were identified with a COMBAT-Seq batch effect adjusted feature selection (FDR-adjusted P < 0.05, P < 0.0001; accuracy = 0.92, AUC = 1.00, F1 = 0.89). All of the latter 15 proteins were present in the former 58-protein model. Several proteins were correlated with illness severity scores, length of stay, and interventions (LTA4H, PTN, PPBP, and EGF; P < 0.001). NLP analysis highlighted the multi-system nature of MIS-C, with the 58-protein set expressed in all organ systems; the highest levels of expression were found in the digestive system. The cell types most involved included leukocytes not yet determined, lymphocytes, macrophages, and platelets.ConclusionsThe plasma proteome of MIS-C patients was distinct from that of SCNS. The key proteins demonstrated expression in all organ systems and most cell types. The unique proteomic signature identified in MIS-C patients could aid future diagnostic and therapeutic advancements, as well as predict hospital length of stays, interventions, and mortality risks.

The Diagnostic and Therapeutic Challenges of Culture Negative Sepsis

The Diagnostic and Therapeutic Challenges of Culture Negative Sepsis

Assessment of Platelet Indices as Biomarker for Neonatal Sepsis

Introduction: There is a need to increase the diagnostic capability of the traditional septic screen by adding additional markers. Platelet indices are one such marker that is readily available in routine hemogram reports. Materials and Methods: In this cross-sectional study, all newborn babies were recruited who had signs or symptoms of sepsis or had high-risk factors. Those who had clinical sepsis with positive cultures and/or a positive sepsis screen were classified under group “cases” ( n = 174), whereas all neonates suspected to have sepsis but who had a negative blood culture and a negative sepsis screen were classified under group “control” ( n = 126). Blood culture, sepsis screen, and platelet indices [platelet count, mean platelet volume (MPV), and platelet distribution width (PDW)] were performed on all babies. Babies with congenital or acquired causes of platelet abnormalities (including medication use by mothers with antiplatelet activity) were excluded from this study. Results: In this study, a total of 300 newborn babies were recruited for final analyses. Overall culture positivity was 38%. The mean platelet count was lower in the cases group ( P &lt; 0.001). MPV and PDW were higher in septic babies with statistically significant differences ( P &lt; 0.0001 and P = 0.012, respectively). Thrombocytopenia was the most sensitive marker (85.60%). However, it had low specificity (28.2%). On combining all three platelet markers, specificity increased to 48.4% (with a sensitivity of 64.5%) in detecting babies with neonatal sepsis. The sensitivity of the septic screen alone was 58% (with a specificity of 32.62%). When combining the sepsis screen and platelet indices, the specificity for the diagnosis of neonatal sepsis increased to 62.6%. On receiver operator curve analyses, thrombocytopenia had the highest area under the curve (0.692), followed by MPV (0.644). Conclusion: Platelet indices may be used as sensitive markers in combination with traditional sepsis screening to make an early diagnosis of neonatal sepsis.

Triple-P Panel (Procalcitonin, Presepsin and Pentraxin3) to Confirm Sepsis

A total of 65 blood samples (25 culture positive sepsis and 40 culture negative sepsis) from patients with sepsis symptoms who resided in the ICU of Hilla city hospitals, were collected, as well as 25 samples as a control (healthy persons) during a period from January to June 2022. Data was documented at the time of admission to the ICU. Regarding PSN and PCT concentration (P value= 0.001), the control group had a significant difference from both the two patients’ groups (culture positive and negative groups of sepsis). Whereas the difference was not significant for the PTX3 concentration among patients and control (P value = 0.56). Furthermore, PSN and PCT concentrations did not significantly differ between the culture positive and culture negative groups of sepsis (P value &gt; 0.05). Moreover, there was a significant strong positive correlation between PSN and PCT (r = 0.500; P &lt;0.001).

Sepsis and the killer platelets

Sepsis and the killer platelets Dermot Cox BSc, PG Dip Ed, PhD, Pharmacology Lead from the School of Pharmacy and Biomolecular Sciences – RCSI University of Medicine &amp; Health Sciences, discusses sepsis and the killer platelets. Sepsis is defined as “life-threatening organ dysfunction caused by a dysregulated host response to infection” (1) (Sepsis 3) and is typically diagnosed using the Sequential Organ Failure Assessment (SOFA) score. While sepsis typically arises in response to a bacterial infection, surprisingly, around 40% of cases are culture negative. The cause of culture negative sepsis is unclear but could be due to bacterial species that are difficult to grow in the lab.

Bacteriological Profile and Antibiogram of Isolates Causing Bloodstream Infection in Children

Objective: (1) To identify and characterize bacterial isolates causing blood stream infection in children. (2) To determine the antibiotic sensitivity pattern of isolates obtained. Materials And Methods: Study design: Descriptive study. Study population: Blood samples collected from pediatric patients aged upto 12 years who are admitted in Government Medical College Kottayam, with clinical features of blood stream infection. Sampling methodology: The sample size of suspected blood stream infection is 345. All pediatric patients with clinical features suggestive of blood stream infection in the study period satisfying inclusion and exclusion criteria will be included in the study. The identification of bacterial pathogens and antimicrobial susceptibility tests were done by conventional and automated methods like VITEK system. Results: Out of 345 study sample population, 46 were culture positive, of which 21(45.7%) were Gram negative isolates and 20(43.4%) were Gram positive. Major isolates obtained were Klebsiella spp (15%), Methicillin Resistant Coagulase negative Staphylococci (15%), followed by Staphylococcus aureus (13%), Coagulase negative Staphylococci (8%) and Acinetobacter baumannii (8%). Klebsiella pneumoniae was resistant to most of the antibiotics tested except meropenem. All isolates of Coagulase negative Staphylococci and Staphylococcus aureus were susceptible to vancomycin and linezolid. Conclusion: Gram negative organisms were predominant pathogens in blood stream infections. Klebsiella pneumoniae, Coagulase negative Staphylococci, Staphylococcus aureus were the most commonly isolated pathogens. Amikacin along with the third generation cephalosporins should be used for empirical treatment of Gram negative sepsis. Vancomycin and linezolid can be used for Gram positive pathogens.

Association between positive blood culture and clinical outcomes among children treated for sepsis in the emergency department

ObjectiveAmong children treated for sepsis in a pediatric emergency department (ED), compare clinical features and outcomes between those with blood cultures positive versus negative for a bacterial pathogen. DesignSingle-center retrospective cohort study. SettingPediatric emergency department (ED) at a quaternary pediatric care center. PatientsChildren aged 0–18 years treated for sepsis defined by the Children's Hospital Association's Improving Pediatric Sepsis Outcomes (IPSO) definition. InterventionsNone. Measurements and main resultsWe analyzed 1307 patients treated for sepsis during the study period, of which 117 (9.0%) had blood cultures positive for a bacterial pathogen. Of children with blood culture positive sepsis, 62 (53.0%) had organ dysfunction compared to 514 (43.2%) with culture negative sepsis (adjusted odds ratio 1.56, 95% confidence interval (CI) 1.04–2.34, adjusting for age, high risk medical conditions, and time to antibiotics). Children with blood culture positive sepsis had a larger base deficit, −4 vs −1 (p < 0.01), and higher procalcitonin, 3.84 vs 0.56 ng/mL (p < 0.01). ConclusionsChildren meeting the IPSO Sepsis definition with blood culture positive for a bacterial pathogen have higher rates of organ dysfunction than those who are culture negative, although our 9% rate of blood culture positivity is lower than previously cited literature from the pediatric intensive care unit.

Adaptive Manufacturing of LV20.19 CAR T-Cells for Relapsed, Refractory Mantle Cell Lymphoma

Introduction: Mantle cell lymphoma (MCL) is an aggressive B-cell malignancy characterized by the presence of t(11;14) and bright CD20 expression. Approved CD19 CAR T-cell therapy for relapsed/refractory (R/R) MCL is limited by both relapse and high rates of Grade 3+ cytokine release syndrome (CRS) and ICANS with 15% and 31% patients (pts) experiencing such toxicities, respectively. To improve outcomes we utilized dual targeted lentiviral anti-CD20/anti-CD19 (LV20.19) CAR T-cells with an adaptive manufacturing (MF) process to optimize the final CAR product as part of a Phase 1/2 clinical trial in R/R MCL. Methods: We conducted a Phase 1/2 single center, prospective trial (NCT04186520) evaluating LV20.19 CAR T-cells at a fixed dose of 2.5x10e6 cells/kg for pts with R/R B-cell non-Hodgkin Lymphoma. We report results of MCL pts from a fully enrolled Phase I safety run-in and Phase II efficacy cohort. The primary outcome for the Phase II cohort was day 90 complete response (CR) rate. The Phase II cohort utilized an adaptive 8/12 day MF process to enhance the percentages of T-SCM (stem cell-like memory) and T-CM (central memory) CAR T-cells in the final product by shortening culture time. CAR T-cells were harvested either on day 8 of MF or extended to a 12-day MF process depending on achieving target cell dose in culture. Fludarabine/cyclophosphamide lymphodepletion was started during MF to facilitate fresh infusion in eligible pts. Descriptive statistics were utilized for demographic data and the Kaplan Meier methodology for survival analysis. Results: In total 17 pts with R/R MCL received LV20.19 CAR T-cells (Phase 1=3 pts and Phase 2=14 patients). All pts achieved target cell dose. 13 pts received an 8-day product while 4 received a 12-day product. 14/17 pts received a fresh (non-cryopreserved) infusion. 8-day products were enriched for T-SCM/CM phenotype cells with significantly lower number of terminally differentiated effector memory (EMRA) T-cells in the CD4 compartment (p&amp;lt;0.05) than 12-day products. The median age was 63 (50-74 years) and 15 (88%) were cisgender male. The median number of lines of therapy was 4 (3-8). p53 deletions or mutation were present in 7 pts. Day 28 overall response rate (ORR) was 100%; CR rate=76% and partial response (PR) =24%. Initial ClonoSEQ MRD assay performed within the first 90 days of LV20.19 CAR T (n=13) was negative in 10 pts (77%). Among Phase II patients with day 90 results available (n=12) the ORR was 100%, CR rate=92% and PR rate=8% exceeding the Phase II efficacy threshold. Two pts have relapsed to date, +8 months and +2 years after infusion. There were two non-relapse mortality (NRM) events that occurred beyond day 28: gram negative rod sepsis &amp; COVID19 infection resulting in a 1-year NRM rate of 12%. The 1-year progression free survival (PFS) was 77%, 1-year duration of response (DOR) was 92%, and 1-year overall survival (OS) of 84%. Median PFS/DOR/OS have not been met with median follow-up of 14 months of surviving pts (Figure 1). In terms of safety, 94% (n=16) experienced CRS, all grade 1-2. 18% (n=3) had ICANS in the first 28-days, 2 pts with Grade 3 toxicity. There were two pts with late (&amp;gt;day 28) episodes of Grade 1 neurological toxicity. Both pts had immense expansion of lymphocytes in the CSF (total nucleated cell count of 386/µLand 1005/µL) with CAR+ T cells present. Both received only a single dose of intrathecal hydrocortisone (no systemic steroids) with resolution of neurotoxicity within 24 hours of administration. Conclusions: Bispecific LV20.19 CAR T-cells with adaptive MF process is feasible, safe, and efficacious for R/R MCL with ORR 100%, no Grade 3+ CRS and low rates of Grade 3+ ICANS (12%). Adaptive MF enriched the final product with higher percentages of T-SCM/T-CM CAR cells and allowed most pts to receive CAR-T cells within 8 days of apheresis. Dual targeting of CD20 and CD19 with CAR-T cells may improve outcomes in pts with relapsed, refractory MCL.

Inoculum-Based Dosing: A Novel Concept for Combining Time with Concentration-Dependent Antibiotics to Optimize Clinical and Microbiological Outcomes in Severe Gram Negative Sepsis.

Certain classes of antibiotics show "concentration dependent" antimicrobial activity; higher concentrations result in increased bacterial killing rates, in contrast to "time dependent antibiotics", which show antimicrobial activity that depends on the time that antibiotic concentrations remain above the MIC. Aminoglycosides and fluoroquinolones are still widely used concentration-dependent antibiotics. These antibiotics are not hydrolyzed by beta-lactamases and are less sensitive to the inoculum effect, which can be defined as an increased MIC for the antibiotic in the presence of a relatively higher bacterial load (inoculum). In addition, they possess a relatively long Post-Antibiotic Effect (PAE), which can be defined as the absence of bacterial growth when antibiotic concentrations fall below the MIC. These characteristics make them interesting complementary antibiotics in the management of Multi-Drug Resistant (MDR) bacteria and/or (neutropenic) patients with severe sepsis. Global surveillance studies have shown that up to 90% of MDR Gram-negative bacteria still remain susceptible to aminoglycosides, depending on the susceptibility breakpoint (e.g., CLSI or EUCAST) being applied. This percentage is notably lower for fluoroquinolones but depends on the region, type of organism, and mechanism of resistance involved. Daily (high-dose) dosing of aminoglycosides for less than one week has been associated with significantly less nephro/oto toxicity and improved target attainment. Furthermore, higher-than-conventional dosing of fluoroquinolones has been linked to improved clinical outcomes. Beta-lactam antibiotics are the recommended backbone of therapy for severe sepsis. Since these antibiotics are time-dependent, the addition of a second concentration-dependent antibiotic could serve to quickly lower the bacterial inoculum, create PAE, and reduce Penicillin-Binding Protein (PBP) expression. Inadequate antibiotic levels at the site of infection, especially in the presence of high inoculum infections, have been shown to be important risk factors for inadequate resistance suppression and therapeutic failure. Therefore, in the early phase of severe sepsis, effort should be made to optimize the dose and quickly lower the inoculum. In this article, the authors propose a novel concept of "Inoculum Based Dosing" in which the decision for antibiotic dosing regimens and/or combination therapy is not only based on the PK parameters of the patient, but also on the presumed inoculum size. Once the inoculum has been lowered, indirectly reflected by clinical improvement, treatment simplification should be considered to further treat the infection.

Treating relapsed B cell-precursor ALL in children with a setting-adapted mitoxantrone-based intensive chemotherapy protocol (TMH rALL-18 PROTOCOL) - experience from Tata Memorial Hospital, India.

The outlook of relapsed ALL in low- and middle-income countries (LMICs) is dismal due to high treatment-related toxicities and inadequate resources. We report our experience of using a locally adapted mitoxantrone-based protocol for non-high risk (HR) relapsed B-ALL (rALL). A retrospective cum prospective study of standard and intermediate risk (SR and IR) rALL patients treated on TMH rALL-18 protocol (adapted from COG/UKALLR3/Int-Re-ALL protocols) between November 2018 and January 2021 was analyzed. The protocol comprising of 7 blocks of multi-agent chemotherapy including mitoxantrone in induction followed by local irradiation and maintenance, underwent serial modifications based on our experience with initial patients. Eighty-two patients (SR rALL, 3; IR rALL, 79) were treated on TMH rALL-18 protocol. Of 321 grade 3/4 reported toxicities, around 43% (138 toxicities) were noted during induction. Induction chemotherapy was outpatient-based; however, 68 patients (82.9%) required supportive care admissions. Twelve out of 19 patients with gram negative bacilli sepsis (included 7 MDRO) died during reinduction. Five remission deaths were seen during block 3 after which cytarabine was dose reduced (3g to 2g/m2). Post-reinduction minimal residual disease was negative in 54 (80.6%) out of 67 evaluable patients. At a median follow-up of 24months (95% CI 22-27), the estimated 2-year event-free and overall survival of the entire cohort was 58% (95% CI 48.1-69.9) and 60.3% (95% CI 50.5-72). Until the time, targeted therapies are freely accessiblein LMICs, strengthening supportive careas well as local adaptation of protocols that strike a fine balance between efficacy and tolerability are mandated.

Optimizing the Use of Beta-Lactam Antibiotics in Clinical Practice: A Test of Time.

Despite their limitations, the pharmacokinetics (PK) and pharmacodynamics (PD) indices form the basis for our current understanding regarding antibiotic development, selection, and dose optimization. Application of PK-PD in medicine has been associated with better clinical outcome, suppression of resistance, and optimization of antibiotic consumption. Beta-lactam antibiotics remain the cornerstone for empirical and directed therapy in many patients. The percentage of time of the dosing interval that the free (unbound) drug concentration remains above the minimal inhibitory concentration (MIC) (%fT > MIC) has been considered the PK-PD index that best predicts the relationship between antibiotic exposure and killing for the beta-lactam antibiotics. Time dependence of beta-lactam antibiotics has its origin in the acylation process of the serine active site of penicillin-binding proteins, which subsequently results in bacteriostatic and bactericidal effects during the dosing interval. To enhance the likelihood of target attainment, higher doses, and prolonged infusion strategies, with/or without loading doses, have been applied to compensate for subtherapeutic levels of antibiotics related to PK-PD changes, especially in the early phase of severe sepsis. To minimize resistance and maximize clinical outcome, empirical therapy with a meropenem loading dose followed by high-dose-prolonged infusion should be considered in patients with high inoculum infections presenting as severe (Gram negative) sepsis. Subsequent de-escalation and dosing of beta-lactam antibiotics should be considered as an individualized dynamic process that requires dose adjustments throughout the time course of the disease process mediated by clinical parameters that indirectly assess PK-PD alterations.

A study of microbial pattern and antibiotic susceptibility in blood cultures among children aged upto thirty six months

Background: Sepsis is the most common cause of high morbidity and mortality among newborn, infants and young children. The organisms implicated in these infections vary with geographical alteration.so antibiotics used should be decided by local prevalence of microbial pathogen, and its bacterial susceptibility pattern. Methods: a prospective observational study among the different neonates and children aged 0 to 36 months. Blood samples are taken under aseptic precaution. Inocluted onto blood culture media (brain heart infusion broth). It is incubated at 37°C. Turbidity is observed daily and it is sub cultured on alternate days. If there is growth, the organism is identified by routine biochemical reactions and the antibiotic susceptibility test was done on the Muller Hinton agar using appropriate antibiotic discs. For testing antibiotic susceptibility, criteria defined by the clinical and laboratory standards institute (CLSI) were followed. Results: Among 148 subjects 102 found to be culture positive with positive rate of 69%. Gram negative organism is more prevalence in this study, most common isolates from gram negative sepsis was Klebsilla species (22.2%) followed by E. coli (18.1%). Conclusions: Gram negative organism form the majority of isolates in our setup with Klebsilla as the most common species among them, which was least sensitive to most of the drugs. Among gram positive organism MRSA as the most common isolates in our setup. Most of the antibiotic were sensitive. Limited and objective use of antibiotic therapy is a much-needed statergy and the new guidelines.

Myeloid-KLF2 knockout neonatal mice experience mortality from lipopolysaccharide in an age-dependent and cell-specific manner

Abstract Background: Preterm neonates exhibit increased mortality from Gram negative sepsis as compared to term neonates. The innate immune system is at a critical phase of development during the neonatal period. Mechanisms underlying activation of the preterm neonatal innate immune response are poorly understood. Our prior data has shown that Kruppel-like factor (KLF)-2 is a critical transcription factor to maintain murine myeloid cells in a quiescent state. We hypothesize that myeloid KLF2 plays a critical role in the neonatal immune response in Gram negative sepsis. Methods: Preterm neonatal (P4) and term neonatal (P12) myeloid KLF2 knockout (MyK2KO) and age matched Cre mice were given 5ug/gm of E. coli O55:B5 lipopolysachharide (LPS) via intraperitoneal (i.p.) injection. For cell depletion studies, antibodies were injected i.p. 24 hours prior to LPS injection, followed by a repeat dose 24h after LPS. Ly6G antibody was used for neutrophil depletion, CD115 for monocyte depletion and equal dose of both for depletion of both cell lines. Results: P4 MyK2KO mice have significantly increased mortality within 48 h of LPS exposure as compared to P4 Cre mice (81% vs 41%, n=19, p&amp;lt;0.01 χ2test). At P12, there is 100% survival of both groups of mice. Depletion of either neutrophils, monocytes or both together, decreased the mortality in P4 MyK2KO mice from 81% to 55%. Conclusion: Preterm neonatal mice lacking myeloid KLF2 have an exaggerated response to LPS as compared to term neonatal MyK2KO or age-matched control mice. In vivo depletion of neutrophils, monocytes or both prior to LPS attenuates this response. Future studies will focus on the mechanism underlying the postnatal age-specific and cell-specific role of KLF2 in the neonatal innate immune response. Supported by grants from Rainbow Faculty Pilot Grant (Mukherjee PI) and NIH (R01 HL142647 Nayak PI)

The effects of Gram-positive and Gram-negative bacterial toxins (LTA & LPS) on cardiac function in Drosophila melanogaster larvae

The effects of Gram negative and positive bacterial sepsis depend on the type of toxins released, such as lipopolysaccharides (LPS) or lipoteichoic acid (LTA). Previous studies show LPS to rapidly hyperpolarize larval Drosophila skeletal muscle, followed by desensitization and return to baseline. In larvae, heart rate increased then decreased with exposure to LPS. However, responses to LTA, as well as the combination of LTA and LPS, on the larval Drosophila heart have not been previously examined. This study examined the effects of LTA and a cocktail of LTA and LPS on heart rate. The combined effects were examined by first treating with either LTA or LPS only, and then with the cocktail. The results showed a rapid increase in heart rate upon LTA application, followed by a gradual decline over time. When applying LTA followed by the cocktail, an increase in the rate occurred. However, if LPS was applied before the cocktail, the rate continued declining. These responses indicate the receptors or cellular cascades responsible for controlling heart rate within seconds and the rapid desensitization are affected by LTA or LPS and a combination of the two. The mechanisms for rapid changes which are not regulated by gene expression by exposure to LTA or LPS or associated bacterial peptidoglycans have yet to be identified in cardiac tissues of any organism.