Christian Theilacker

Mortality of S. aureus bacteremia and infectious diseases specialist consultation – A study of 521 patients in Germany

OBJECTIVESnTo evaluate the relationship between mortality of bloodstream infection due to Staphylococcus aureus and infectious diseases specialist consultation and other factors potentially associated with outcomes.nnnMETHODSnA 6-year cohort study was conducted at a 1600-bed university hospital. Consecutive adult patients with S. aureus bacteremia were assessed using a standardised data collection and review form. A new infectious diseases service increased its consultations for S. aureus bacteremia from 33% of cases in 2002 to >80% in 2007. Infectious disease consultation and other factors potentially associated with in-hospital mortality were analysed by multivariate logistic regression.nnnRESULTSnA total of 521 patients were studied. All-cause in-hospital mortality was 22%, 90-day mortality was 32%. Factors significantly associated with in-hospital mortality in multivariate analysis were ICU admission (OR 5.8, CI 3.5-9.7), MRSA (OR 2.6, CI 1.4-4.9), age >/=60 years (OR 2.4, CI 1.4-4.2), a diagnosis of endocarditis (OR 2.8, CI 1.4-5.7), a non-fatal underlying disease/comorbidity according to the McCabe classification (OR 0.2, CI 0.1-0.4), and infectious disease specialist consultation (OR 0.6, CI 0.4-1.0).nnnCONCLUSIONSnThese data suggest that outcome of S. aureus bacteremia may be improved by an expert consultation service.

Glycolipids are involved in biofilm accumulation and prolonged bacteraemia in Enterococcus faecalis

Biofilm production is thought to be an important step in many enterococcal infections. In several Gram‐positive bacteria, membrane glycolipids have been implicated in biofilm formation. We constructed a non‐polar deletion mutant of a putative glucosyltransferase designated biofilm‐associated glycolipid synthesis A (bgsA) in Enterococcus faecalis 12030. Analysis of major extracted glycolipids by nuclear magnetic resonance spectroscopy revealed that the cell membrane of 12030ΔbgsA was devoid of diglucosyl–diacylglycerol (DGlcDAG), while monoglucosyl–diacylglycerol was overrepresented. The cell walls of 12030ΔbgsA contained longer lipoteichoic acid molecules and were less hydrophobic than wild‐type bacteria. Inactivation of bgsA in E.u2003faecalis 12030 and E.u2003faecalis V583 led to an almost complete arrest of biofilm formation on plastic surfaces. Overexpression of bgsA, on the other hand, resulted in increased biofilm production. While initial adherence was not affected, bgsA‐deficient bacteria did not accumulate in the growing biofilm. Also, adherence of E.u2003faecalisΔbgsA to Caco‐2 cells was impaired. In a mouse bacteraemia model, E.u2003faecalis 12030ΔbgsA was cleared more rapidly from the bloodstream than the wild‐type strain. In summary, BgsA is a glycosyltransferase synthetizing DGlcDAG, a glycolipid and lipoteichoic acid precursor involved in biofilm accumulation, adherence to host cells, and virulence in vivo.

Serodiversity of Opsonic Antibodies against Enterococcus faecalis —Glycans of the Cell Wall Revisited

In a typing system based on opsonic antibodies against carbohydrate antigens of the cell envelope, 60% of Enterococcus faecalis strains can be assigned to one of four serotypes (CPS-A to CPS-D). The structural basis for enterococcal serotypes, however, is still incompletely understood. Here we demonstrate that antibodies raised against lipoteichoic acid (LTA) from a CPS-A strain are opsonic to both CPS-A and CPS-B strains. LTA-specific antibodies also bind to LTA of CPS-C and CPS-D strains, but fail to opsonize them. From CPS-C and CPS-D strains resistant to opsonization by anti-LTA, we purified a novel diheteroglycan with a repeating unit of →6)-β-Galf-(1→3)- β-D-Glcp-(1→ with O-acetylation in position 5 and lactic acid substitution at position 3 of the Galf residue. The purified diheteroglycan, but not LTA absorbed opsonic antibodies from whole cell antiserum against E. faecalis type 2 (a CPS-C strain) and type 5 (CPS-D). Rabbit antiserum raised against purified diheteroglycan opsonized CPS-C and CPS-D strains and passive protection with diheteroglycan-specific antiserum reduced bacterial counts by 1.4 – 3.4 logs in mice infected with E. faecalis strains of the CPS-C and CPS-D serotype. Diheteroglycan-specific opsonic antibodies were absorbed by whole bacterial cells of E. faecalis FA2-2 (CPS-C) but not by its isogenic acapsular cpsI-mutant and on native PAGE purified diheteroglycan co-migrated with the gene product of the cps-locus, suggesting that it is synthesized by this locus. In summary, two polysaccharide antigens, LTA and a novel diheteroglycan, are targets of opsonic antibodies against typeable E. faecalis strains. These cell-wall associated polymers are promising candidates for active and passive vaccination and add to our armamentarium to fight this important nosocomial pathogen.

Tick-borne lymphadenopathy (TIBOLA) acquired in Southwestern Germany

BackgroundTick-borne lymphadenopathy (TIBOLA) was first described in 1997 in a patient in France. The causative agent, Rickettsia slovaca, is transmitted by Dermacentor ticks.Case presentationIn southwestern Germany we encountered a patient with a tick bite at the dorsal scalp that resulted in an eschar and nuchal lymphadenopathy. Additionally, fever, malaise as well as elevated inflammatory markers and transaminases occurred. The characteristic clinical picture along with positive antibody testing for rickettsiae of the tick-borne spotted fever group strongly suggest the diagnosis TIBOLA.ConclusionHuman rickettsioses are emerging infections. Clinicians should be aware of TIBOLA as a newly described rickettsial disease. As in our case, TIBOLA may be encountered in regions/countries where R. slovaca and Dermacentor ticks are prevalent but autochthonous acquisition was not described before.

Outcomes of Invasive Infection due to Vancomycin-Resistant Enterococcus faecium during a Recent Outbreak

Background:Earlier reports have shown a high mortality of invasive infection due to vancomycin-resistant Enterococcus faecium (VREF). Most of these studies have been conducted in US hospitals prior to the advent of newer VREF-active antimicrobials, and the reported poor outcomes have been explained by the limited choices for effective antimicrobial therapy.Patients and Methods:A total of 25 cases of invasive VREF infection were seen during an outbreak in a tertiary care hospital. Patient characteristics and outcomes were evaluated by a structured retrospective chart review and descriptive analysis.Results:Severe underlying diseases such as leukemia not in remission (86%) were highly prevalent among patients with invasive VREF infection. Fifty-two percent of underlying diseases and/or comorbidities were considered according to the McCabe classification as rapidly fatal. Most patients had received high-dose cytotoxic chemotherapy, and many were neutropenic at the onset of VREF infection. Concomitant infection due to other organisms was found in 48% of the patients. All patients had received extensive antibiotic treatment prior to the onset of VREF infection. Resistance to linezolid was observed in four cases. Overall survival at day 30 was 48%. Four deaths were considered to be directly related to VREF infection.Conclusion:Invasive VREF infection during this outbreak was confined to patients with severe underlying comorbidity. The mortality of VREF infection remained high, despite treatment with newer VREF-active antibiotics such as linezolid and quinupristin–dalfopristin.

Protection Against Staphylococcus aureus by Antibody to the Polyglycerolphosphate Backbone of Heterologous Lipoteichoic Acid

Type 1 lipoteichoic acid (LTA) is present in many clinically important gram-positive bacteria, including enterococci, streptococci, and staphylococci, and antibodies against LTA have been shown to opsonize nonencapsulated Enterococcus faecalis strains. In the present study, we show that antibodies against E. faecalis LTA also bind to type 1 LTA from other gram-positive species and opsonized Staphylocccus epidermidis and Staphylcoccus aureus strains as well as group B streptococci. Inhibition studies using teichoic acid oligomers indicated that cross-reactive opsonic antibodies bind to the teichoic acid backbone. Passive immunization with rabbit antibodies against E. faecalis LTA promoted the clearance of bacteremia by E. faecalis and S. epidermidis in mice. Furthermore, passive protection also reduced mortality in a murine S. aureus peritonitis model. The effectiveness of rabbit antibody against LTA suggests that this conserved bacterial structure could function as a single vaccine antigen that targets multiple gram-positive pathogens.

Deletion of the glycosyltransferase bgsB of Enterococcus faecalis leads to a complete loss of glycolipids from the cell membrane and to impaired biofilm formation

BackgroundDeletion of the glycosyltransferase bgsA in Enterococcus faecalis leads to loss of diglucosyldiacylglycerol from the cell membrane and accumulation of its precursor monoglucosyldiacylglycerol, associated with impaired biofilm formation and reduced virulence in vivo. Here we analyzed the function of a putative glucosyltransferase EF2890 designated biofilm-associated glycolipid synthesis B (bgsB) immediately downstream of bgsA.ResultsA deletion mutant was constructed by targeted mutagenesis in E. faecalis strain 12030. Analysis of cell membrane extracts revealed a complete loss of glycolipids from the cell membrane. Cell walls of 12030ΔbgsB contained approximately fourfold more LTA, and 1H-nuclear magnetic resonance (NMR) spectroscopy suggested that the higher content of cellular LTA was due to increased length of the glycerol-phosphate polymer of LTA. 12030ΔbgsB was not altered in growth, cell morphology, or autolysis. However, attachment to Caco-2 cells was reduced to 50% of wild-type levels, and biofilm formation on polystyrene was highly impaired. Despite normal resistance to cationic antimicrobial peptides, complement and antibody-mediated opsonophagocytic killing in vitro, 12030ΔbgsB was cleared more rapidly from the bloodstream of mice than wild-type bacteria. Overall, the phenotype resembles the respective deletion mutant in the bgsA gene. Our findings suggest that loss of diglucosyldiacylglycerol or the altered structure of LTA in both mutants account for phenotypic changes observed.ConclusionsIn summary, BgsB is a glucosyltransferase that synthesizes monoglucosyldiacylglycerol. Its inactivation profoundly affects cell membrane composition and has secondary effects on LTA biosynthesis. Both cell-membrane amphiphiles are critical for biofilm formation and virulence of E. faecalis.

Microarray-Based Genotyping and Clinical Outcomes of Staphylococcus aureus Bloodstream Infection: An Exploratory Study

The clinical course of Staphylococcus aureus bacteremia varies extensively. We sought to determine the relationship between genetic characteristics of the infecting pathogen and clinical outcomes in an exploratory study. In two study centers, 317 blood culture isolates were analyzed by DNA microarray and spa genotyping. By uni- and multivariate regression analyses associations of genotype data with 30-day all-cause mortality, severe sepsis/septic shock, disseminated disease, endocarditis, and osteoarticular infection were investigated. Univariate analysis showed significant association between S. aureus genes/gene-clusters or clonal complexes and clinical endpoints. For example CC15 was associated with 30-day mortality and CC22 with osteoarticular infection. In multivariate analysis methicillin resistance (mecA, OR 4.8 [1.43–16.06]) and the beta-lactamase-gene (bla, OR 3.12 [1.17–8.30]) remained independently associated with 30-day mortality. The presence of genes for enterotoxins (sed/sej/ser) was associated with endocarditis (OR 5.11 [1.14–18.62]). Host factors such as McCabe classification (OR 4.52 [2.09–9.79] for mortality), age (OR 1.06 [1.03–1.10] per year), and community-acquisition (OR 3.40 [1.31–8.81]) had a major influence on disease severity, dissemination and mortality. Individual genotypes and clonal complexes of S. aureus can only partially explain clinical features and outcomes of S. aureus bacteremia. Genotype-phenotype association studies need to include adjustments for host factors like age, comorbidity and community-acquisition.

Prolonged polyarthralgia in a German traveller with Mayaro virus infection without inflammatory correlates.

BackgroundMayaro virus is endemic in South America and sporadic outbreaks have been described. It causes a dengue-like febrile illness accompanied by severe and long-lasting polyarthralgias. Outside endemic regions, however, the disease is not well known and can be misdiagnosed as dengue. International travellers are at risk to acquire Mayaro virus and due to increased worldwide travel infectious disease specialists need to be aware of such rare clinical entities.Case presentationWe report the first Mayaro virus infection imported into Germany. A 20-year-old woman developed fever, myalgia, maculopapular rash, and polyarthralgias following a 10-day trip in the Rurrenabaque region of Bolivia. Severe polyarthralgias persisted for 5xa0months and were treated with non-steroidal anti-inflammatory drugs. Serological analysis demonstrated Mayaro virus-specific-IgM and -IgG antibodies two months after onset of symptoms. Except for CXCL8/IL-8 other proinflammatory chemokines and cytokines were unremarkable at this time.ConclusionsDissemination of knowledge on rare disease might improve patient management. Understanding the inherent features of Mayaro virus infection and how the virus interacts with its host are essential for optimal patient care and therapy.

Chemical structure of wall teichoic acid isolated from Enterococcus faecium strain U0317.

Wall teichoic acid (WTA) was isolated from Enterococcus faecium strain U0317 and structurally characterized using (1)H, (13)C, and (31)P NMR spectroscopy, including two-dimensional COSY, TOCSY, ROESY, HMQC, and HMBC experiments. Further compositional determination was undertaken using classical chemical methods and HF treatment followed by GLC and GLC-MS analyses. The repeating unit of WTA consisted of two residues of 2-acetamido-2-deoxy-D-galactose, glycerol (Gro), and phosphate, and has the structure shown below: [See formula in text].