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Introduction Antimicrobial resistance is a growing global health threat, driven by increasing inappropriate use of antimicrobials. High prevalence of unnecessary use of antimicrobials in residential aged care facilities (RACFs) has driven demand for the development and implementation of antimicrobial stewardship (AMS) programmes. The Stepped-wedge Trial to increase antibiotic Appropriateness in Residential aged care facilities and model Transmission of antimicrobial resistance (START) will implement and evaluate the impact of a nurse-led AMS programme on antimicrobial use in 12 RACFs. Methods and analysis The START trial will implement and evaluate a nurse-led AMS programme via a stepped-wedge cluster randomised controlled trial design in 12 RACFs over 16 months. The AMS programme will incorporate education, aged care-specific treatment guidelines, documentation forms, and audit and feedback strategies that will target aged care staff, general practitioners, pharmacists, and residents and their families. The intervention will primarily focus on urinary tract infections, lower respiratory tract infections, and skin and soft tissue infections. RACFs will transition from control to intervention phases in random order, two at a time, every 2 months, with a 2-month transition, wash-in period. The primary outcome is the cumulative proportion of residents within each facility prescribed an antibiotic during each month and total days of antibiotic use per 1000 occupied bed days. Secondary outcomes include the number of courses of systemic antimicrobial therapy, antimicrobial appropriateness, antimicrobial resistant organisms, Clostridioides difficile infection, change in antimicrobial susceptibility profiles, hospitalisations and all-cause mortality. Analyses will be conducted according to the intention-to-treat principle. Ethics and dissemination Ethics approval has been granted by the Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/591). Research findings

Lasting immunity following SARS-CoV-2 infection is questioned because serum antibodies decline in convalescence. However, functional immunity is mediated by long-lived memory T and B (Bmem) cells. Therefore, we generated fluorescently-labeled tetramers of the spike receptor binding domain (RBD) and nucleocapsid protein (NCP) to determine the longevity and immunophenotype of SARS-CoV-2-specific Bmem cells in COVID-19 patients. A total of 36 blood samples were obtained from 25 COVID-19 patients between 4 and 242 days post-symptom onset including 11 paired samples. While serum IgG to RBD and NCP was identified in all patients, antibody levels began declining at 20 days post-symptom onset. RBD- and NCP-specific Bmem cells predominantly expressed IgM+ or IgG1+ and continued to rise until 150 days. RBD-specific IgG+ Bmem were predominantly CD27+, and numbers significantly correlated with circulating follicular helper T cell numbers. Thus, the SARS-CoV-2 antibody response contracts in convalescence with persistence of RBD- and NCP-specific Bmem cells. Flow cytometric detection of SARS-CoV-2-specific Bmem cells enables detection of long-term immune memory following infection or vaccination for COVID-19.Copyright © 2020, American Association for the Advancement of Science.

Introduction Antimicrobial resistance is a growing global health threat, driven by increasing inappropriate use of antimicrobials. High prevalence of unnecessary use of antimicrobials in residential aged care facilities (RACFs) has driven demand for the development and implementation of antimicrobial stewardship (AMS) programmes. The Stepped-wedge Trial to increase antibiotic Appropriateness in Residential aged care facilities and model Transmission of antimicrobial resistance (START) will implement and evaluate the impact of a nurse-led AMS programme on antimicrobial use in 12 RACFs. Methods and analysis The START trial will implement and evaluate a nurse-led AMS programme via a stepped-wedge cluster randomised controlled trial design in 12 RACFs over 16 months. The AMS programme will incorporate education, aged care-specific treatment guidelines, documentation forms, and audit and feedback strategies that will target aged care staff, general practitioners, pharmacists, and residents and their families. The intervention will primarily focus on urinary tract infections, lower respiratory tract infections, and skin and soft tissue infections. RACFs will transition from control to intervention phases in random order, two at a time, every 2 months, with a 2-month transition, wash-in period. The primary outcome is the cumulative proportion of residents within each facility prescribed an antibiotic during each month and total days of antibiotic use per 1000 occupied bed days. Secondary outcomes include the number of courses of systemic antimicrobial therapy, antimicrobial appropriateness, antimicrobial resistant organisms, Clostridioides difficile infection, change in antimicrobial susceptibility profiles, hospitalisations and all-cause mortality. Analyses will be conducted according to the intention-to-treat principle. Ethics and dissemination Ethics approval has been granted by the Alfred Hospital Human Research Ethics Committee (HREC/18/Alfred/591). Research findings

Lasting immunity following SARS-CoV-2 infection is questioned because serum antibodies decline in convalescence. However, functional immunity is mediated by long-lived memory T and B (Bmem) cells. Therefore, we generated fluorescently-labeled tetramers of the spike receptor binding domain (RBD) and nucleocapsid protein (NCP) to determine the longevity and immunophenotype of SARS-CoV-2-specific Bmem cells in COVID-19 patients. A total of 36 blood samples were obtained from 25 COVID-19 patients between 4 and 242 days post-symptom onset including 11 paired samples. While serum IgG to RBD and NCP was identified in all patients, antibody levels began declining at 20 days post-symptom onset. RBD- and NCP-specific Bmem cells predominantly expressed IgM+ or IgG1+ and continued to rise until 150 days. RBD-specific IgG+ Bmem were predominantly CD27+, and numbers significantly correlated with circulating follicular helper T cell numbers. Thus, the SARS-CoV-2 antibody response contracts in convalescence with persistence of RBD- and NCP-specific Bmem cells. Flow cytometric detection of SARS-CoV-2-specific Bmem cells enables detection of long-term immune memory following infection or vaccination for COVID-19.Copyright © 2020, American Association for the Advancement of Science.

Objectives: Primary Objective: To determine the efficacy of a candidate antiviral on time to virological cure compared to standard of care within 14 days of randomisation Secondary objectives: * To determine the safety of the antiviral * To determine the clinical benefit of the antiviral over placebo according to the WHO 7-point ordinal scale * To determine the clinical benefit of the antiviral over placebo on time to resolution of clinical symptoms * To determine the effect of the antiviral over placebo on biomarkers of inflammation and immune activation Trial design: This is a multi-centre, triple-blind, randomised placebo controlled phase II, 2-arm trial with parallel-group design with allocation ratio 1:1. Participant(s): Inclusion Criteria: * Provision of informed consent by the participant * Age >=18 years * Confirmed SARS-CoV-2 by nucleic acid testing in the past 5 days * COVID-19 related symptom initiation within 5 days * Female patients of childbearing potential must have a negative pregnancy test at Screening. Female patients of childbearing potential and fertile male patients who are sexually active with a female of childbearing potential must use highly effective methods of contraception throughout the study and for 1 week following the last dose of study treatment. Exclusion criteria: * Known allergy to the study medication * Is on another clinical trial investigating an antiviral treatment for COVID-19 * Pregnancy * Patients with severe hepatic dysfunction equivalent to Grade C in the Child-Pugh classification * Patients with renal impairment requiring dialysis * Is deemed by the Investigator to be ineligible for any reason Participants will be recruited from, and the study visits will take place at Alfred Hospital, Monash Health, Austin Health in Victoria, Australia for hospitalised participants as well as recruitment in the community in participants homes for eligible people not requiring hospitalisation. Intervention and comparator: The first candid

Aim: To determine if empirical anti-pseudomonal beta-lactam antibiotic (BLA) dosing achieves adequate drug exposure in septic patients. Method(s): A single-centre, prospective pharmacokinetic study was conducted in Intensive Care Unit (ICU) patients with sepsis, receiving empirical therapy with piperacillin/tazobactam or meropenem. The pharmacokinetic/pharmacodynamic (PK/PD) targets were free BLA concentrations above the MIC at the mid-point (Concentration A, 50%f T > MIC) and end of the dosing interval (Concentration B, 100% fT > MIC). Sub-therapeutic concentrations were defined as concentration A < MIC, and sub-optimal as concentration B < MIC. The MIC breakpoint for Pseudomonas aeruginosa, as defined by The European Committee on Antimicrobial Susceptibility Testing (EUCAST) (available from ) was used. Result(s): Of the 37 eligible patients, 20 were receiving piperacillin/tazobactam (TZP), and 17 meropenem (MEM). PK data were available for 36 patients (concentration A) and 34 patients (concentration B). The median measured plasma concentrations (mg/L) were: piperacillin for doses 4 g 8-hourly and 4 g 6-hourly - concentration A 53.9 [14.38-123.71] and 36.44 [13.38-107.45], concentration B 8.01 [2.57-71.08] and 27.31 [3.32-59.76], MEM for doses 1 g 8-hourly and 2 g 8-hourly - concentration A 12.49 [7.35-23.63] and 30.5, concentration B 7.47 [2.97-11.33] and 9.31. 27.8% (10 of 36) of patients had sub-therapeutic concentrations (concentration A) and 50% (17 of 34) had sub-optimal concentrations (concentration B). Conclusion(s): Our study confirms that sub-therapeutic unbound plasma anti-pseudomonal BLA concentrations are common in critically ill septic patients and underscores the urgent need for future trials exploring the efficacy of BLA therapeutic drug monitoring in these patients.Copyright © 2020 The Society of Hospital Pharmacists of Australia

BACKGROUND: Multi-resistant organisms (MROs) pose a critical threat to public health. Population-based programs for control of MROs such as Carbapenemase-producing Enterobacterales (CPE) have emerged and evaluation is needed. We assess the feasibility and impact of a state-wide CPE surveillance and response program deployed in December 2015 across Victoria, Australia (population 6.5 million). METHOD(S): A prospective multi-modal intervention including active screening, carrier isolation, centralised case investigation and comparative pathogen genomics was implemented. We analyze trend in CPE incidence and clinical presentation, risk factors and local transmission over the program's first three years (January 2016 to December 2018). RESULT(S): CPE case ascertainment increased over the study period to 1.42 cases/100,000 population, linked to increased screening without a concomitant rise in active clinical infections (0.45-0.60 infections/100,000 population, p=0.640). KPC-2 infection decreased from 0.29 infections/100,000 population prior to intervention to 0.03 infections/100,000 population in 2018 (p=0.003). Comprehensive case investigation identified putative overseas community acquisition. Median time between isolate referral and initial genomic and epidemiological assessment for local transmission was 11 days (IQR 9-14). Prospective surveillance identified numerous small transmission networks (median 2, range 1-19 cases), predominantly IMP and KPC, with median pairwise distance of 8 (IQR 4-13) single nucleotide polymorphisms; low diversity between clusters of the same sequence type suggested genomic cluster definitions alone are insufficient for targeted response. CONCLUSION(S): We demonstrate the value of centralised CPE control programs to increase case ascertainment, resolve risk factors and identify putative local transmission through prospective genomic and epidemiological surveillance; methodologies are transferable to low-prevalence settings and MROs globa

Background: Loss of tolerance to MPO in ANCA-associated glomerulonephritis (GN) is poorly understood. It is unknown whether molecular mimicry plays any role in this process. We tested whether microbial peptides homologous to a dominant pathogenic MPO CD4+ T cell epitope (MPO409-428), relevant to several MHCII and lying within an MPO epitope hot spot, would induce anti-MPO autoimmunity. Method(s): Immunity to MPO and MPO409-428 was studied in microbial peptide immunized C57BL/6 (B/6, I-Ab), BALB/c (I-Ad/Ed) and HLA-DR15 transgenic mice (proliferation, IFN-gamma and IL-17A ELISPOT). Anti-MPO GN and anti-MPO immunity in response to peptides, proteins (MPO/ovalbumin as positive/negative controls) and S.aureus strains with/without plasmids carrying the relevant 6-phosphogluconate dehydrogenase (6PGD) sequence were studied in B/6 mice (I-Ab/MPO415-428 tetramers, cytokines, MPOANCA IIF/ELISA, neutrophil ROS production, MPO-ANCA transfer). Anti-6PGD antibodies (Ab) were measured in sera of healthy humans and patients. Result(s): The 4 most homologous microbial peptides were immunogenic but did not induce anti-MPO autoreactivity. However, a plasmid-derived peptide from 6PGD (6PGDp) with similar critical binding residues for MPO409-428 in B/6, BALB/c and DR15+ mice, found in some S.aureus strains, induced expansion of MPO415-428 tetramer+CD4+ cells, anti-MPO T cell autoimmunity (to MPO408-428 and whole MPO) and bioactive MPO-ANCA in B/6 mice. 6PGDp induced anti-MPO autoreactivity in mice with different MHCII (I-Ad/Ed and DR15). Related 6PGD sequences from other S.aureus strains did not induce anti-MPO responses. Healthy human and vasculitis patient sera contained anti-6PGD Ab, demonstrating its immunogenicity in humans. 6PGDp-immunized mice developed GN when MPO was deposited in glomeruli by anti-basement membrane globulin. Immunization with S.aureus containing a plasmid with the mimic 6PGD sequence, or another S.aureus strain transformed with a different plasmid expressing t

INTRODUCTION: This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial. METHOD(S): Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations. RESULT(S): 320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%). CONCLUSION(S): After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.Copyright © The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permission

Aim: To determine if empirical anti-pseudomonal beta-lactam antibiotic (BLA) dosing achieves adequate drug exposure in septic patients. Method(s): A single-centre, prospective pharmacokinetic study was conducted in Intensive Care Unit (ICU) patients with sepsis, receiving empirical therapy with piperacillin/tazobactam or meropenem. The pharmacokinetic/pharmacodynamic (PK/PD) targets were free BLA concentrations above the MIC at the mid-point (Concentration A, 50%f T > MIC) and end of the dosing interval (Concentration B, 100% fT > MIC). Sub-therapeutic concentrations were defined as concentration A < MIC, and sub-optimal as concentration B < MIC. The MIC breakpoint for Pseudomonas aeruginosa, as defined by The European Committee on Antimicrobial Susceptibility Testing (EUCAST) (available from ) was used. Result(s): Of the 37 eligible patients, 20 were receiving piperacillin/tazobactam (TZP), and 17 meropenem (MEM). PK data were available for 36 patients (concentration A) and 34 patients (concentration B). The median measured plasma concentrations (mg/L) were: piperacillin for doses 4 g 8-hourly and 4 g 6-hourly - concentration A 53.9 [14.38-123.71] and 36.44 [13.38-107.45], concentration B 8.01 [2.57-71.08] and 27.31 [3.32-59.76], MEM for doses 1 g 8-hourly and 2 g 8-hourly - concentration A 12.49 [7.35-23.63] and 30.5, concentration B 7.47 [2.97-11.33] and 9.31. 27.8% (10 of 36) of patients had sub-therapeutic concentrations (concentration A) and 50% (17 of 34) had sub-optimal concentrations (concentration B). Conclusion(s): Our study confirms that sub-therapeutic unbound plasma anti-pseudomonal BLA concentrations are common in critically ill septic patients and underscores the urgent need for future trials exploring the efficacy of BLA therapeutic drug monitoring in these patients.Copyright © 2020 The Society of Hospital Pharmacists of Australia

Objectives: Primary Objective: To determine the efficacy of a candidate antiviral on time to virological cure compared to standard of care within 14 days of randomisation Secondary objectives: * To determine the safety of the antiviral * To determine the clinical benefit of the antiviral over placebo according to the WHO 7-point ordinal scale * To determine the clinical benefit of the antiviral over placebo on time to resolution of clinical symptoms * To determine the effect of the antiviral over placebo on biomarkers of inflammation and immune activation Trial design: This is a multi-centre, triple-blind, randomised placebo controlled phase II, 2-arm trial with parallel-group design with allocation ratio 1:1. Participant(s): Inclusion Criteria: * Provision of informed consent by the participant * Age >=18 years * Confirmed SARS-CoV-2 by nucleic acid testing in the past 5 days * COVID-19 related symptom initiation within 5 days * Female patients of childbearing potential must have a negative pregnancy test at Screening. Female patients of childbearing potential and fertile male patients who are sexually active with a female of childbearing potential must use highly effective methods of contraception throughout the study and for 1 week following the last dose of study treatment. Exclusion criteria: * Known allergy to the study medication * Is on another clinical trial investigating an antiviral treatment for COVID-19 * Pregnancy * Patients with severe hepatic dysfunction equivalent to Grade C in the Child-Pugh classification * Patients with renal impairment requiring dialysis * Is deemed by the Investigator to be ineligible for any reason Participants will be recruited from, and the study visits will take place at Alfred Hospital, Monash Health, Austin Health in Victoria, Australia for hospitalised participants as well as recruitment in the community in participants homes for eligible people not requiring hospitalisation. Intervention and comparator: The first candid

BACKGROUND: Multi-resistant organisms (MROs) pose a critical threat to public health. Population-based programs for control of MROs such as Carbapenemase-producing Enterobacterales (CPE) have emerged and evaluation is needed. We assess the feasibility and impact of a state-wide CPE surveillance and response program deployed in December 2015 across Victoria, Australia (population 6.5 million). METHOD(S): A prospective multi-modal intervention including active screening, carrier isolation, centralised case investigation and comparative pathogen genomics was implemented. We analyze trend in CPE incidence and clinical presentation, risk factors and local transmission over the program's first three years (January 2016 to December 2018). RESULT(S): CPE case ascertainment increased over the study period to 1.42 cases/100,000 population, linked to increased screening without a concomitant rise in active clinical infections (0.45-0.60 infections/100,000 population, p=0.640). KPC-2 infection decreased from 0.29 infections/100,000 population prior to intervention to 0.03 infections/100,000 population in 2018 (p=0.003). Comprehensive case investigation identified putative overseas community acquisition. Median time between isolate referral and initial genomic and epidemiological assessment for local transmission was 11 days (IQR 9-14). Prospective surveillance identified numerous small transmission networks (median 2, range 1-19 cases), predominantly IMP and KPC, with median pairwise distance of 8 (IQR 4-13) single nucleotide polymorphisms; low diversity between clusters of the same sequence type suggested genomic cluster definitions alone are insufficient for targeted response. CONCLUSION(S): We demonstrate the value of centralised CPE control programs to increase case ascertainment, resolve risk factors and identify putative local transmission through prospective genomic and epidemiological surveillance; methodologies are transferable to low-prevalence settings and MROs globa

INTRODUCTION: This study aims to assess the association of piperacillin/tazobactam and meropenem minimum inhibitory concentration (MIC) and beta-lactam resistance genes with mortality in the MERINO trial. METHOD(S): Blood culture isolates from enrolled patients were tested by broth microdilution and whole genome sequencing at a central laboratory. Multivariate logistic regression was performed to account for confounders. Absolute risk increase for 30-day mortality between treatment groups was calculated for the primary analysis (PA) and the microbiologic assessable (MA) populations. RESULT(S): 320 isolates from 379 enrolled patients were available with susceptibility to piperacillin/tazobactam 94% and meropenem 100%. The piperacillin/tazobactam non-susceptible breakpoint (MIC > 16 mg/L) best predicted 30-day mortality after accounting for confounders (odds ratio 14.9, 95% CI 2.8 - 87.2). The absolute risk increase for 30-day mortality for patients treated with piperacillin/tazobactam compared with meropenem was 9% (95% CI 3% - 15%) and 8% (95% CI 2% - 15%) for the original PA population and the post-hoc MA populations, which reduced to 5% (95% CI -1% - 10%) after excluding strains with piperacillin/tazobactam MIC values > 16 mg/L. Isolates co-harboring ESBL and OXA-1 genes were associated with elevated piperacillin/tazobactam MICs and the highest risk increase in 30-mortality of 14% (95% CI 2% - 28%). CONCLUSION(S): After excluding non-susceptible strains, the 30-day mortality difference was from the MERINO trial was less pronounced for piperacillin/tazobactam. Poor reliability in susceptibility testing performance for piperacillin/tazobactam and the high prevalence of OXA co-harboring ESBLs suggests meropenem remains the preferred choice for definitive treatment of ceftriaxone non-susceptible E. coli and Klebsiella.Copyright © The Author(s) 2020. Published by Oxford University Press for the Infectious Diseases Society of America. All rights reserved. For permission

Background: Loss of tolerance to MPO in ANCA-associated glomerulonephritis (GN) is poorly understood. It is unknown whether molecular mimicry plays any role in this process. We tested whether microbial peptides homologous to a dominant pathogenic MPO CD4+ T cell epitope (MPO409-428), relevant to several MHCII and lying within an MPO epitope hot spot, would induce anti-MPO autoimmunity. Method(s): Immunity to MPO and MPO409-428 was studied in microbial peptide immunized C57BL/6 (B/6, I-Ab), BALB/c (I-Ad/Ed) and HLA-DR15 transgenic mice (proliferation, IFN-gamma and IL-17A ELISPOT). Anti-MPO GN and anti-MPO immunity in response to peptides, proteins (MPO/ovalbumin as positive/negative controls) and S.aureus strains with/without plasmids carrying the relevant 6-phosphogluconate dehydrogenase (6PGD) sequence were studied in B/6 mice (I-Ab/MPO415-428 tetramers, cytokines, MPOANCA IIF/ELISA, neutrophil ROS production, MPO-ANCA transfer). Anti-6PGD antibodies (Ab) were measured in sera of healthy humans and patients. Result(s): The 4 most homologous microbial peptides were immunogenic but did not induce anti-MPO autoreactivity. However, a plasmid-derived peptide from 6PGD (6PGDp) with similar critical binding residues for MPO409-428 in B/6, BALB/c and DR15+ mice, found in some S.aureus strains, induced expansion of MPO415-428 tetramer+CD4+ cells, anti-MPO T cell autoimmunity (to MPO408-428 and whole MPO) and bioactive MPO-ANCA in B/6 mice. 6PGDp induced anti-MPO autoreactivity in mice with different MHCII (I-Ad/Ed and DR15). Related 6PGD sequences from other S.aureus strains did not induce anti-MPO responses. Healthy human and vasculitis patient sera contained anti-6PGD Ab, demonstrating its immunogenicity in humans. 6PGDp-immunized mice developed GN when MPO was deposited in glomeruli by anti-basement membrane globulin. Immunization with S.aureus containing a plasmid with the mimic 6PGD sequence, or another S.aureus strain transformed with a different plasmid expressing t

Autoreactivity to myeloperoxidase (MPO) causes anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), with rapidly progressive glomerulonephritis. Here, we show that a Staphylococcus aureus peptide, homologous to an immunodominant MPO T-cell epitope (MPO409-428), can induce anti-MPO autoimmunity. The peptide (6PGD391-410) is part of a plasmid-encoded 6-phosphogluconate dehydrogenase found in some S. aureus strains. It induces anti-MPO T-cell autoimmunity and MPO-ANCA in mice, whereas related sequences do not. Mice immunized with 6PGD391-410, or with S. aureus containing a plasmid expressing 6PGD391-410, develop glomerulonephritis when MPO is deposited in glomeruli. The peptide induces anti-MPO autoreactivity in the context of three MHC class II allomorphs. Furthermore, we show that 6PGD391-410 is immunogenic in humans, as healthy human and AAV patient sera contain anti-6PGD and anti-6PGD391-410 antibodies. Therefore, our results support the idea that bacterial plasmids might have a function in autoimmune disease.Copyright © 2019, The Author(s).

Uncomplicated urinary tract infection is one of the most common indications for antibiotic use in the community. However, the Gram-negative organisms that can cause the infection are becoming more resistant to antibiotics. Many multidrug resistant organisms retain susceptibility to two old antibiotics, nitrofurantoin and fosfomycin. Advantages over newer drugs include their high urinary concentrations and minimal toxicity. Fosfomycin is a potential treatment option for patients with uncomplicated urinary tract infection due to resistant organisms. Nitrofur

Autoreactivity to myeloperoxidase (MPO) causes anti-neutrophil cytoplasmic antibody (ANCA)-associated vasculitis (AAV), with rapidly progressive glomerulonephritis. Here, we show that a Staphylococcus aureus peptide, homologous to an immunodominant MPO T-cell epitope (MPO409-428), can induce anti-MPO autoimmunity. The peptide (6PGD391-410) is part of a plasmid-encoded 6-phosphogluconate dehydrogenase found in some S. aureus strains. It induces anti-MPO T-cell autoimmunity and MPO-ANCA in mice, whereas related sequences do not. Mice immunized with 6PGD391-410, or with S. aureus containing a plasmid expressing 6PGD391-410, develop glomerulonephritis when MPO is deposited in glomeruli. The peptide induces anti-MPO autoreactivity in the context of three MHC class II allomorphs. Furthermore, we show that 6PGD391-410 is immunogenic in humans, as healthy human and AAV patient sera contain anti-6PGD and anti-6PGD391-410 antibodies. Therefore, our results support the idea that bacterial plasmids might have a function in autoimmune disease.Copyright © 2019, The Author(s).

Importance: Extended-spectrum β-lactamases mediate resistance to third-generation cephalosporins (eg, ceftriaxone) in Escherichia coli and Klebsiella pneumoniae. Significant infections caused by these strains are usually treated with carbapenems, potentially selecting for carbapenem resistance. Piperacillin-tazobactam may be an effective “carbapenem-sparing” option to treat extended-spectrum β-lactamase producers. Objectives: To determine whether definitive therapy with piperacillin-tazobactam is noninferior to meropenem (a carbapenem) in patients with bloodstream infection caused by ceftriaxone-nonsusceptible E coli or K pneumoniae. Design, Setting, and Participants: Noninferiority, parallel group, randomized clinical trial included hospitalized patients enrolled from 26 sites in 9 countries from February 2014 to July 2017. Adult patients were eligible if they had at least 1 positive blood culture with E coli or Klebsiella spp testing nonsusceptible to ceftriaxone but susceptible to piperacillin-tazobactam. Of 1646 patients screened, 391 were included in the study. Interventions: Patients were randomly assigned 1:1 to intravenous piperacillin-tazobactam, 4.5 g, every 6 hours (n = 188 participants) or meropenem, 1 g, every 8 hours (n = 191 participants) for a minimum of 4 days, up to a maximum of 14 days, with the total duration determined by the treating clinician. Main Outcomes and Measures: The primary outcome was all-cause mortality at 30 days after randomization. A noninferiority margin of 5% was used. Results: Among 379 patients (mean age, 66.5 years; 47.8% women) who were randomized appropriately, received at least 1 dose of study drug, and were included in the primary analysis population, 378 (99.7%) completed the trial and were assessed for the primary outcome. A total of 23 of 187 patients (12.3%) randomized to piperacillin-tazobactam met the primary outcome of mortality at 30 days compared with 7 of 191 (3.7%) randomized to meropenem (risk difference, 8.6

IMPORTANCE Extended-spectrum beta-lactamases mediate resistance to third-generation cephalosporins (eg, ceftriaxone) in Escherichia coli and Klebsiella pneumoniae. Significant infections caused by these strains are usually treated with carbapenems, potentially selecting for carbapenem resistance. Piperacillin-tazobactam may be an effective "carbapenem-sparing" option to treat extended-spectrum beta-lactamase producers. OBJECTIVES To determine whether definitive therapy with piperacillin-tazobactam is noninferior to meropenem (a carbapenem) in patients with bloodstream infection caused by ceftriaxone-nonsusceptible E coli or K pneumoniae. DESIGN, SETTING, AND PARTICIPANTS Noninferiority, parallel group, randomized clinical trial included hospitalized patients enrolled from 26 sites in 9 countries from February 2014 to July 2017. Adult patients were eligible if they had at least 1 positive blood culture with E coli or Klebsiella spp testing nonsusceptible to ceftriaxone but susceptible to piperacillin-tazobactam. Of 1646 patients screened, 391 were included in the study. INTERVENTIONS Patients were randomly assigned 1:1 to intravenous piperacillin-tazobactam, 4.5 g, every 6 hours (n = 188 participants) or meropenem, 1 g, every 8 hours (n = 191 participants) for a minimum of 4 days, up to a maximum of 14 days, with the total duration determined by the treating clinician. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 30 days after randomization. A noninferiority margin of 5% was used. RESULTS Among 379 patients (mean age, 66.5 years; 47.8% women) who were randomized appropriately, received at least 1 dose of study drug, and were included in the primary analysis population, 378 (99.7%) completed the trial and were assessed for the primary outcome. A total of 23 of 187 patients (12.3%) randomized to piperacillin-tazobactam met the primary outcome of mortality at 30 days compared with 7 of 191 (3.7%) randomized to meropenem (risk difference, 8.6

IMPORTANCE Extended-spectrum beta-lactamases mediate resistance to third-generation cephalosporins (eg, ceftriaxone) in Escherichia coli and Klebsiella pneumoniae. Significant infections caused by these strains are usually treated with carbapenems, potentially selecting for carbapenem resistance. Piperacillin-tazobactam may be an effective "carbapenem-sparing" option to treat extended-spectrum beta-lactamase producers. OBJECTIVES To determine whether definitive therapy with piperacillin-tazobactam is noninferior to meropenem (a carbapenem) in patients with bloodstream infection caused by ceftriaxone-nonsusceptible E coli or K pneumoniae. DESIGN, SETTING, AND PARTICIPANTS Noninferiority, parallel group, randomized clinical trial included hospitalized patients enrolled from 26 sites in 9 countries from February 2014 to July 2017. Adult patients were eligible if they had at least 1 positive blood culture with E coli or Klebsiella spp testing nonsusceptible to ceftriaxone but susceptible to piperacillin-tazobactam. Of 1646 patients screened, 391 were included in the study. INTERVENTIONS Patients were randomly assigned 1:1 to intravenous piperacillin-tazobactam, 4.5 g, every 6 hours (n = 188 participants) or meropenem, 1 g, every 8 hours (n = 191 participants) for a minimum of 4 days, up to a maximum of 14 days, with the total duration determined by the treating clinician. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality at 30 days after randomization. A noninferiority margin of 5% was used. RESULTS Among 379 patients (mean age, 66.5 years; 47.8% women) who were randomized appropriately, received at least 1 dose of study drug, and were included in the primary analysis population, 378 (99.7%) completed the trial and were assessed for the primary outcome. A total of 23 of 187 patients (12.3%) randomized to piperacillin-tazobactam met the primary outcome of mortality at 30 days compared with 7 of 191 (3.7%) randomized to meropenem (risk difference, 8.6

Objectives: In microscopic polyangiitis, autoreactivity to myeloperoxidase (MPO) can cause rapidly progressive glomerulonephritis. While it is unknown how tolerance to MPO is lost, infections have been implicated in the development of autoimmunity and disease. MPO409-428 is a promiscuous MPO CD4+ T-cell epitope overlapping a pathogenic B cell MPO epitope. This study tests the hypothesis that molecular mimicry can induce pathogenic anti-MPO autoimmunity. Method(s): BLAST searches were used to identify candidate microbial peptides with homology to MPO409-428. Anti-MPO T-cell responses were determined by immunizing C57BL/6 mice with candidate peptides, then measuring recall responses to MPO by 3[H]-T proliferation and IFN-g and IL-17A ELISPOTs. Anti-MPO antibodies were measured by ELISA, indirect immunofluorescence, and their activity by ex vivo ROS production and by neutrophil glomerular recruitment after passive antibody transfer. Disease was induced by immunizing mice with peptide or whole bacteria, followed by depositing MPO in the glomerulus using low-dose sheep anti-mouse basement membrane globulin. Result(s): Immunizing C57BL/6 mice with 4 different peptides from human pathogens most homologous to the core residues of MPO409-428 did not trigger autoreactivity to MPO or MPO409-428. However, immunization with a peptide derived from 6-phosphogluconate dehydrogenase (mimic-6-pgd), found only in some strains of Staphylococci, did induce T cell autoreactivity to MPO. The corresponding mammalian and closely related bacterial 6-pgd sequences did not induce anti-MPO autoimmunity, demonstrating the specificity of this sequence. Mimic-6-pgd peptide immunization induced MPOANCA that stained neutrophils in a p-ANCA pattern and were functionally active in vitro and in vivo. Mimic-6-pgd-induced MPO T cell autoreactivity resulted in anti-MPO glomerulonephritis in a T cell mediated model. Furthermore, when MPO was planted in glomeruli, mice immunized with whole killed Staphyloco

Objectives To define standardized endpoints to aid the design of trials that compare antibiotic therapies for bloodstream infections (BSI). Methods Prospective studies, randomized trials or registered protocols comparing antibiotic therapies for BSI, published from 2005 to 2016, were reviewed. Consensus endpoints for BSI studies were defined using a modified Delphi process. Results Different primary and secondary endpoints were defined for pilot (small-scale studies designed to evaluate protocol design, feasibility and implementation) and definitive trials (larger-scale studies designed to test hypotheses and influence clinical practice), as well as for Staphylococcus aureus and Gram-negative BSI. For pilot studies of S. aureus BSI, a primary outcome of success at day 7 was defined by: survival, resolution of fever, stable/improved Sequential Organ Failure Assessment (SOFA) score and clearance of blood cultures, with no microbiologically confirmed failure up to 90 days. For definitive S. aureus BSI studies, a primary outcome of success at 90 days was defined by survival and no microbiologically confirmed failure. For pilot studies of Gram-negative BSI, a primary outcome of success at day 7 was defined by: survival, resolution of fever and symptoms related to BSI source, stable or improved SOFA score and negative blood cultures. For definitive Gram-negative BSI studies, a primary outcome of survival at 90 days supported by a secondary outcome of success at day 7 (as previously defined) was agreed. Conclusions These endpoints provide a framework to aid future trial design. Further work will be required to validate these endpoints with respect to patient-centred clinical outcomes.Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases

Objectives To define standardized endpoints to aid the design of trials that compare antibiotic therapies for bloodstream infections (BSI). Methods Prospective studies, randomized trials or registered protocols comparing antibiotic therapies for BSI, published from 2005 to 2016, were reviewed. Consensus endpoints for BSI studies were defined using a modified Delphi process. Results Different primary and secondary endpoints were defined for pilot (small-scale studies designed to evaluate protocol design, feasibility and implementation) and definitive trials (larger-scale studies designed to test hypotheses and influence clinical practice), as well as for Staphylococcus aureus and Gram-negative BSI. For pilot studies of S. aureus BSI, a primary outcome of success at day 7 was defined by: survival, resolution of fever, stable/improved Sequential Organ Failure Assessment (SOFA) score and clearance of blood cultures, with no microbiologically confirmed failure up to 90 days. For definitive S. aureus BSI studies, a primary outcome of success at 90 days was defined by survival and no microbiologically confirmed failure. For pilot studies of Gram-negative BSI, a primary outcome of success at day 7 was defined by: survival, resolution of fever and symptoms related to BSI source, stable or improved SOFA score and negative blood cultures. For definitive Gram-negative BSI studies, a primary outcome of survival at 90 days supported by a secondary outcome of success at day 7 (as previously defined) was agreed. Conclusions These endpoints provide a framework to aid future trial design. Further work will be required to validate these endpoints with respect to patient-centred clinical outcomes.Copyright © 2016 European Society of Clinical Microbiology and Infectious Diseases

Objectives: In microscopic polyangiitis, autoreactivity to myeloperoxidase (MPO) can cause rapidly progressive glomerulonephritis. While it is unknown how tolerance to MPO is lost, infections have been implicated in the development of autoimmunity and disease. MPO409-428 is a promiscuous MPO CD4+ T-cell epitope overlapping a pathogenic B cell MPO epitope. This study tests the hypothesis that molecular mimicry can induce pathogenic anti-MPO autoimmunity. Method(s): BLAST searches were used to identify candidate microbial peptides with homology to MPO409-428. Anti-MPO T-cell responses were determined by immunizing C57BL/6 mice with candidate peptides, then measuring recall responses to MPO by 3[H]-T proliferation and IFN-g and IL-17A ELISPOTs. Anti-MPO antibodies were measured by ELISA, indirect immunofluorescence, and their activity by ex vivo ROS production and by neutrophil glomerular recruitment after passive antibody transfer. Disease was induced by immunizing mice with peptide or whole bacteria, followed by depositing MPO in the glomerulus using low-dose sheep anti-mouse basement membrane globulin. Result(s): Immunizing C57BL/6 mice with 4 different peptides from human pathogens most homologous to the core residues of MPO409-428 did not trigger autoreactivity to MPO or MPO409-428. However, immunization with a peptide derived from 6-phosphogluconate dehydrogenase (mimic-6-pgd), found only in some strains of Staphylococci, did induce T cell autoreactivity to MPO. The corresponding mammalian and closely related bacterial 6-pgd sequences did not induce anti-MPO autoimmunity, demonstrating the specificity of this sequence. Mimic-6-pgd peptide immunization induced MPOANCA that stained neutrophils in a p-ANCA pattern and were functionally active in vitro and in vivo. Mimic-6-pgd-induced MPO T cell autoreactivity resulted in anti-MPO glomerulonephritis in a T cell mediated model. Furthermore, when MPO was planted in glomeruli, mice immunized with whole killed Staphyloco

Microscopic polyangiitis is a small-vessel vasculitic autoimmune disease whereby autoreactivity to the neutrophil enzyme myeloperoxidase (MPO) causes rapidly progressive glomerulonephritis. It is unknown how tolerance is lost, but there are reports in patients that S aureus infections precede anti- MPO autoimmunity, and in other forms of vasculitis, molecular mimicry has been shown to induce cross-reactive pathogenic autoimmunity. This study tests the hypothesis that molecular mimicry induces cross-reactive pathogenic anti-MPO autoimmunity. A BLAST search was used to identify 5 candidate microbial peptides with homology to the immunodominant MPO T-cell epitope, MPO409-428. Anti-MPO T-cell responses were determined by immunizing C57BL/6 mice with candidate peptides then measuring recall responses ex vivo to MPO by 3 [H]-T proliferation and IFN-gamma and IL-17 ELISPOTs. Anti-MPO antibodies were measured by ELISA, immunofluorescence on ethanol-fixed neutrophils and by enumerating neutrophil glomerular recruitment after passive transfer of antibody. Disease was assessed by immunizing mice with peptide or whole bacteria followed by depositing MPO in the glomerulus using low-dose sheep anti-mouse glomerular basement membrane antibodies, then measuring functional and histological endpoints. Only 1 peptide induced cross-reactive T-cell responses to MPO. This peptide was derived from a S aureus plasmid. Antibodies from mice immunized with this peptide cross-reacted with MPO, bound to neutrophils in a perinuclear fashion, and induced neutrophil glomerular recruitment. Furthermore, mice immunized with either this peptide or a clinical strain of S aureus containing the plasmid, developed albuminuria and focal necrotizing glomerulonephritis. This shows that molecular mimicry by a S aureus plasmid derived peptide induces anti-MPO pathogenic autoimmunity.

Microscopic polyangiitis is a small-vessel vasculitic autoimmune disease whereby autoreactivity to the neutrophil enzyme myeloperoxidase (MPO) causes rapidly progressive glomerulonephritis. It is unknown how tolerance is lost, but there are reports in patients that S aureus infections precede anti- MPO autoimmunity, and in other forms of vasculitis, molecular mimicry has been shown to induce cross-reactive pathogenic autoimmunity. This study tests the hypothesis that molecular mimicry induces cross-reactive pathogenic anti-MPO autoimmunity. A BLAST search was used to identify 5 candidate microbial peptides with homology to the immunodominant MPO T-cell epitope, MPO409-428. Anti-MPO T-cell responses were determined by immunizing C57BL/6 mice with candidate peptides then measuring recall responses ex vivo to MPO by 3 [H]-T proliferation and IFN-gamma and IL-17 ELISPOTs. Anti-MPO antibodies were measured by ELISA, immunofluorescence on ethanol-fixed neutrophils and by enumerating neutrophil glomerular recruitment after passive transfer of antibody. Disease was assessed by immunizing mice with peptide or whole bacteria followed by depositing MPO in the glomerulus using low-dose sheep anti-mouse glomerular basement membrane antibodies, then measuring functional and histological endpoints. Only 1 peptide induced cross-reactive T-cell responses to MPO. This peptide was derived from a S aureus plasmid. Antibodies from mice immunized with this peptide cross-reacted with MPO, bound to neutrophils in a perinuclear fashion, and induced neutrophil glomerular recruitment. Furthermore, mice immunized with either this peptide or a clinical strain of S aureus containing the plasmid, developed albuminuria and focal necrotizing glomerulonephritis. This shows that molecular mimicry by a S aureus plasmid derived peptide induces anti-MPO pathogenic autoimmunity.

Background: Gram-negative bacteria such as Escherichia coli or Klebsiella spp. frequently cause bloodstream infections. There has been a worldwide increase in resistance in these species to antibiotics such as third generation cephalosporins, largely driven by the acquisition of extended-spectrum beta-lactamase or plasmid-mediated AmpC enzymes. Carbapenems have been considered the most effective therapy for serious infections caused by such resistant bacteria; however, increased use creates selection pressure for carbapenem resistance, an emerging threat arising predominantly from the dissemination of genes encoding carbapenemases. Recent retrospective data suggest that beta-lactam/beta-lactamase inhibitor combinations, such as piperacillin-tazobactam, may be non-inferior to carbapenems for the treatment of bloodstream infection caused by extended-spectrum beta-lactamase-producers, if susceptible in vitro. This study aims to test this hypothesis in an effort to define carbapenem-sparing alternatives for these infections. Methods/Design: The study will use a multicentre randomised controlled open-label non-inferiority trial design comparing two treatments, meropenem (standard arm) and piperacillin-tazobactam (carbapenem-sparing arm) in adult patients with bacteraemia caused by E. coli or Klebsiella spp. demonstrating non-susceptibility to third generation cephalosporins. Recruitment is planned to occur in sites across three countries (Australia, New Zealand and Singapore). A total sample size of 454 patients will be required to achieve 80% power to determine non-inferiority with a margin of 5%. Once randomised, definitive treatment will be for a minimum of 4 days, but up to 14 days with total duration determined by treating clinicians. Data describing demographic information, antibiotic use, co-morbid conditions, illness severity, source of infection and other risk factors will be collected. Vital signs, white cell count, use of vasopressors and days to bacteraemia c

Background: Gram-negative bacteria such as Escherichia coli or Klebsiella spp. frequently cause bloodstream infections. There has been a worldwide increase in resistance in these species to antibiotics such as third generation cephalosporins, largely driven by the acquisition of extended-spectrum beta-lactamase or plasmid-mediated AmpC enzymes. Carbapenems have been considered the most effective therapy for serious infections caused by such resistant bacteria; however, increased use creates selection pressure for carbapenem resistance, an emerging threat arising predominantly from the dissemination of genes encoding carbapenemases. Recent retrospective data suggest that beta-lactam/beta-lactamase inhibitor combinations, such as piperacillin-tazobactam, may be non-inferior to carbapenems for the treatment of bloodstream infection caused by extended-spectrum beta-lactamase-producers, if susceptible in vitro. This study aims to test this hypothesis in an effort to define carbapenem-sparing alternatives for these infections. Methods/Design: The study will use a multicentre randomised controlled open-label non-inferiority trial design comparing two treatments, meropenem (standard arm) and piperacillin-tazobactam (carbapenem-sparing arm) in adult patients with bacteraemia caused by E. coli or Klebsiella spp. demonstrating non-susceptibility to third generation cephalosporins. Recruitment is planned to occur in sites across three countries (Australia, New Zealand and Singapore). A total sample size of 454 patients will be required to achieve 80% power to determine non-inferiority with a margin of 5%. Once randomised, definitive treatment will be for a minimum of 4 days, but up to 14 days with total duration determined by treating clinicians. Data describing demographic information, antibiotic use, co-morbid conditions, illness severity, source of infection and other risk factors will be collected. Vital signs, white cell count, use of vasopressors and days to bacteraemia c

Background: Information about the feasibility, barriers and facilitators of antimicrobial stewardship (AMS) in residential aged care facilities (RACFs) has been scant. Exploring the prevailing perceptions and attitudes of key healthcare providers towards antibiotic prescribing behaviour, antibiotic resistance and AMS in the RACF setting is imperative to guide AMS interventions. Method(s): Semi-structured interviews and focus groups were conducted with key RACF healthcare providers until saturation of themes occurred. Participants were recruited using purposive and snowball sampling. The framework approach was applied for data analysis. Result(s): A total of 40 nurses, 15 general practitioners (GPs) and 6 pharmacists from 12 RACFs were recruited. Five major themes emerged; perceptions of current antibiotic prescribing behaviour, perceptions of antibiotic resistance, attitude towards and understanding of AMS, perceived barriers to and facilitators of AMS implementation, and feasible AMS interventions. A higher proportion of GPs and pharmacists compared with nurses felt there was over-prescribing of antibiotics in the RACF setting. Antibiotic resistance was generally perceived as an issue for infection control rather than impacting clinical decisions. All key stakeholders were supportive of AMS implementation in RACFs; however, they recognized barriers related to workload and logistical issues. A range of practical AMS interventions were identified, with nursing-based education, aged-care specific antibiotic guidelines and regular antibiotic surveillance deemed most useful and feasible. Conclusion(s): Areas of antibiotic over-prescribing have been identified from different healthcare providers' perspectives. However, concern about the clinical impact of antibiotic resistance was generally lacking. Importantly, information gathered about feasibility, barriers and facilitators of various AMS interventions will provide important insights to guide development of AMS progra

Background: Information about the feasibility, barriers and facilitators of antimicrobial stewardship (AMS) in residential aged care facilities (RACFs) has been scant. Exploring the prevailing perceptions and attitudes of key healthcare providers towards antibiotic prescribing behaviour, antibiotic resistance and AMS in the RACF setting is imperative to guide AMS interventions. Method(s): Semi-structured interviews and focus groups were conducted with key RACF healthcare providers until saturation of themes occurred. Participants were recruited using purposive and snowball sampling. The framework approach was applied for data analysis. Result(s): A total of 40 nurses, 15 general practitioners (GPs) and 6 pharmacists from 12 RACFs were recruited. Five major themes emerged; perceptions of current antibiotic prescribing behaviour, perceptions of antibiotic resistance, attitude towards and understanding of AMS, perceived barriers to and facilitators of AMS implementation, and feasible AMS interventions. A higher proportion of GPs and pharmacists compared with nurses felt there was over-prescribing of antibiotics in the RACF setting. Antibiotic resistance was generally perceived as an issue for infection control rather than impacting clinical decisions. All key stakeholders were supportive of AMS implementation in RACFs; however, they recognized barriers related to workload and logistical issues. A range of practical AMS interventions were identified, with nursing-based education, aged-care specific antibiotic guidelines and regular antibiotic surveillance deemed most useful and feasible. Conclusion(s): Areas of antibiotic over-prescribing have been identified from different healthcare providers' perspectives. However, concern about the clinical impact of antibiotic resistance was generally lacking. Importantly, information gathered about feasibility, barriers and facilitators of various AMS interventions will provide important insights to guide development of AMS progra