Noelle I. Samia

Plague dynamics are driven by climate variation

The bacterium Yersinia pestis causes bubonic plague. In Central Asia, where human plague is still reported regularly, the bacterium is common in natural populations of great gerbils. By using field data from 1949–1995 and previously undescribed statistical techniques, we show that Y. pestis prevalence in gerbils increases with warmer springs and wetter summers: A 1°C increase in spring is predicted to lead to a >50% increase in prevalence. Climatic conditions favoring plague apparently existed in this region at the onset of the Black Death as well as when the most recent plague pandemic arose in the same region, and they are expected to continue or become more favorable as a result of climate change. Threats of outbreaks may thus be increasing where humans live in close contact with rodents and fleas (or other wildlife) harboring endemic plague.

Dynamics of the plague–wildlife–human system in Central Asia are controlled by two epidemiological thresholds

Plague (caused by the bacterium Yersinia pestis) is a zoonotic reemerging infectious disease with reservoirs in rodent populations worldwide. Using one-half of a century of unique data (1949–1995) from Kazakhstan on plague dynamics, including data on the main rodent host reservoir (great gerbil), main vector (flea), human cases, and external (climate) conditions, we analyze the full ecoepidemiological (bubonic) plague system. We show that two epidemiological threshold quantities play key roles: one threshold relating to the dynamics in the host reservoir, and the second threshold relating to the spillover of the plague bacteria into the human population.

Elevated procalcitonin and C‐reactive protein as potential biomarkers of sepsis in a subpopulation of thrombotic microangiopathy patients

Thrombotic microangiopathy (TMA) comprises a group of microvascular thrombosis syndromes associated with multiple pathogenic factors. Deficient activity of ADAMTS13 is a pathogenic factor in a subset of TMA patients that provides a strong rationale for plasma exchange treatment. However, the subset of TMA patients with normal ADAMTS13 activity remains a heterogeneous group of patients in which the appropriate treatment is not well understood. In addition to the common forms of TMA thrombotic thrombocytopenic purpura and the hemolytic uremic syndrome, the differential diagnosis of TMA may include sepsis, autoimmune disorders, and disseminated intravascular coagulation. Optimal treatment of TMA depends on timely recognition of treatable pathogenic factors. We hypothesized that sepsis is a rapidly identifiable pathogenic factor in a subset of TMA patients. To test this hypothesis, we retrospectively measured the rapid biomarkers of sepsis C‐reactive protein (CRP) and procalcitonin (PCT), in a repository of pretreatment plasma samples from 61 TMA patients treated with plasma exchange. Levels were analyzed in 31 severely ADAMTS13‐deficient and 30 ADAMTS13‐normal patients. None of the 31 patients with severe deficiency of ADAMTS13 had elevated PCT. However, 11 of 30 (37%) non‐ADAMTS13‐deficient patient samples were strongly positive for PCT. These patient samples also had a >10‐fold higher median CRP level than patients with normal PCT. We conclude that rapid assays may help identify sepsis in a subset of TMA patients. J. Clin. Apheresis, 2009.

Antimicrobial Stewardship Lessons From Mupirocin Use and Resistance in Methicillin-Resitant Staphylococcus Aureus

Abstract Background The quantitative relationship between antimicrobial agent consumption and rise or fall of antibiotic resistance has rarely been studied. We began all admission surveillance testing for methicillin-resistant Staphylococcus aureus (MRSA) in August 2005 with subsequent contact isolation and decolonization using nasally applied mupirocin ointment for those colonized. In October 2012, we discontinued decolonization of medical (nonsurgical service) patients. Methods We conducted a retrospective study from 2007 through 2014 of 445680 patients; 35235 were assessed because of mupirocin therapy and positive test results for MRSA. We collected data on those patients receiving 2% mupirocin ointment for decolonization to determine the defined daily doses (DDDs). A nonparametric regression technique was used to quantitate the effect of mupirocin consumption on drug resistance in MRSA. Results Using regressive modeling, we found that, when consumption was consistently >25 DDD/1000 patient-days, there was a statistically significant increase in mupirocin resistance with a correlating positive rate of change. When consumption was ≤25 DDD/1000 patient-days, there was a statistically significant decrease in mupirocin resistance with a correlating negative rate of change. The scatter plot of fitted versus observed mupirocin resistance values showed an R2 value of 0.89—a high correlation between mupirocin use and resistance. Conclusions Use of the antimicrobial agent mupirocin for decolonization had a threshold of approximately 25 DDD/1000 patient-days that separated a rise and fall of resistance within the acute-care setting. This has implications for how widely mupirocin can be used for decolonization, as well as for setting consumption thresholds when prescribing antimicrobials as part of stewardship programs.

Hematocrit and C-reactive protein predict treatment response times in ADAMTS13-deficient thrombotic microangiopathy.

Thrombotic microangiopathy (TMA) syndromes are a heterogeneous group of microvascular syndromes that are typically treated with plasma exchange and other adjunctive therapies. Important pathogenic factors, such as ADAMTS13 deficiency, define distinct subsets of TMA. New treatments for TMA are being explored that are hypothesized to bring about remission more quickly. However, the existing factors that influence response to treatment time are poorly understood. We hypothesized that common laboratory parameters available at the time of treatment initiation might correlate with the number of days of plasma exchange required to induce remission. We therefore retrospectively compared pretreatment platelet counts, hematocrit levels, and C‐reactive protein (CRP) levels to the number of days of plasma exchange treatment in 27 ADAMTS13‐deficient TMA patients and 25 non‐ADAMTS13‐deficient patients that achieved remission. Using quantile regression analysis, we observed that in ADAMTS13‐deficient patients, higher initial hematocrit levels significantly correlated with shorter treatment response times. In addition, for ADAMTS13‐deficient patients, elevated levels of CRP correlated directly with longer response times. Higher platelet counts were associated with a nonsignificant trend toward shorter response times. In non‐ADAMTS13‐deficient TMA patients no significant correlations were observed. Our results suggest that when conducting clinical trials of adjunctive treatments for TMA, clinical data, including ADAMTS13 levels, pretreatment hematocrit levels, and CRP levels may be informative in interpreting response to treatment times. J. Clin. Apheresis, 2011.