Microbiology / Infectious Disease
Permanent URI for this collectionhttps://hdl.handle.net/20.500.12503/21689
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Item Characterization and description of APPE rotations and their intended outcomes at practice sites with exposure to HIV patients(2017-03-14) Hall, Brenton; Clay, Patrick; Rybalchenko, AndreyPurpose: Although the past two decades have seen significant progress and improved disease outcomes in the treatment of HIV and AIDS, the condition continues to be a significant cause of morbidity and mortality in the United States. In particular, certain population groups are disproportionately affected by the disease, indicating the need for specific targeting of treatment in order to maximize intervention effectiveness. Just as other healthcare professionals, pharmacists can play a key role in HIV interventions by facilitating pharmaceutical treatment, conducting medication therapy management, and performing other key interventions. As with any other disease state, specific training of practitioners is of great importance in the treatment of HIV and AIDS. Therefore, the availability of HIV APPE pharmacy school rotations, geographically matched to meet HIV population demand, constitutes a desirable goal. Methods: Our project sets out to find gaps in HIV coverage which could be filled by the creation of novel clinical practice sites or HIV APPE rotations. We will be conducting a survey of ACPE accredited colleges of pharmacy APPE preceptors and collecting syllabi with the intent of identifying and characterizing APPE rotations that have exposure to HIV populations. Through varied means of outreach, we will identify points of contact at each ACPE accredited college of pharmacy in the US deemed likely to be able to most accurately and correctly provide responses to our survey. Once identified, survey recipients will receive an email with a cover letter summarizing our research goals, along with a link to complete the Qualtrics survey electronically. Results/Conclusions: Survey results will allow us to describe areas in the US where HIV APPE rotations are offered. Following this, we will next align this geographic distribution with HIV surveillance, HIV clinician workforce supply, and CDC chronic disease and health indicators data. Collectively these representations will provide invaluable insight for colleges of pharmacy and healthcare institutions when determining where to develop/initiate clinical practice sites for clinical faculty and APPE rotations. This abstract is being submitted in order to solicit feedback on project design and methodology.Item The In Vitro Adherence and Virulence Factors of Clostridium Difficile Ribotypes 027 and Non-027 is Not Predicative of Virulence in the Murine or Hamster CDAD Model(2017-03-14) Vitucci, JohnBackground: C. difficile ribotype 027 (RT027) is the North American epidemic strain. Studies suggest an enhanced virulence phenotype for RT027 such as increased toxin production, but the impact on disease severity on in vivo models is not well understood. This study describes the in vitro characterization of important virulence characteristics for several RT027 and non-RT027 C. difficile clinical isolates, and how these factors are not predictive of disease severity in the hamster C. difficile associated disease (HCDAD) model. Methods: Six RT027 and six non-RT027 clinical isolates were evaluated in vitro for total spore counts and Toxin A/B titers in 72H broth cultures. Spore counts were generated from heat/ethanol shock culture samples and plated onto CB + taurocholate + antibiotics, and toxin A/B titers were determined from spent broth with an ELISA assay. The Murine C. difficile model involved antibiotics administered for 5 days through drinking water. The mice were then given 48 hours to clear the antibiotic from their system before the administration of 10 mg/kg clindamycin, followed 24H later by administration of spores from either an 027 or non-027 isolate. Survival was monitored for 10 days and fecal samples were taken each day to be processed for CFU/spore counts. The HCDAD studies involved infecting male Golden Syrian hamsters with varying titers of RT027 and non-RT027 spore isolates, followed by subcutaneous administration of 10 mg/kg clindamycin 24H post-infection. All groups were left untreated and survival was monitored for 7 days after infection, samples were collected every day for CFU/spore counts and Toxin A/B titers. Results: The RT027 and the non-RT027 strains generated similar mean CFU/mL in 72H broth cultures, while the mean spore counts were 83 spores/one million cells for the RT027 strains and 123 spores/one million cells for the non-RT027 strains. While, the 72H broth-associated mean toxin A/B titers were 2.8-fold higher for RT027 strains when compared to the 72H titers of non-RT027 strains. In the HCDAD studies the non-027 infected hamsters survived with inoculation counts of up to 20,000 spores, while hamsters infected with the RT027 isolates survived inoculation with counts below 300 spores. The mean cecal fluid toxin A/B titers for RT027 infected hamsters were 2.3 to 9-fold higher than the titers for non-RT027 infected hamsters. In the mouse model, 90% of the animals infected with the non-027 isolate survived no matter the antibiotic dosing. In contrast, 13-26% morbidity was associated with mice infected with the RT027 isolate after being given antibiotics in multiple doses or in a single does through over time through supplemented water. Conclusions: The results highlight that C. difficile RT027 isolates, when compared to non-RT027 clinical isolates, have enhanced virulence in vivo that does not correspond to a strain’s predicted virulence from in vitro characterization.Item Evaluation of the Sepsis Screening Tool’s Efficacy in Assessing Organ Dysfunction(2017-03-14) Nguyen, Julian; Gelvez, Javier; Williams, Lorrainea; Darnell, Charity; Hamby, Tyler; Issa, TesneemBackground: Sepsis is a life threatening condition caused by the dysregulation of the immune system due to multiple organ dysfunction. It is usually caused by an infection that can affect the respiratory, neurological, circulatory, and metabolic systems. The best way to help these patients is to give them the appropriate care as quickly as possible. In order to help make this possible, a sepsis screening tool was developed for patients at Cook Children’s Medical Center (CCMC). Purpose: The purpose of this project was to see if patients screened for sepsis were less likely to develop organ dysfunction. A new adult definition of sepsis was developed in February 2016 by the European Society of Intensive Care Medicine and the Society of Critical Care Medicine; this definition, modified to apply pediatric norms, was applied at CCMC in order to assess the level of organ dysfunction in children. Methods: The level of organ dysfunction was based on the first set of vitals at admission to the pediatric intensive care unit (PICU) at CCMC. To be included in this study, patients had to have had an initial PICU visit between the dates of 10/12-5/16, and the providers’ diagnoses had to have included billing codes related to sepsis. There were 520 patients meeting these criteria. Patients were screened for respiratory, neurological, circulatory, or metabolic dysfunction, and then were given an organ dysfunction score. Results: The results showed that 82% of the patients who were not screened had organ dysfunction compared to only 69% of those for which the sepsis screening tool was utilized. Thus, those who were not screened were more likely to have organ dysfunction than those who were screened, P=.001, OR=2.08. Among those screened, patients with positive screens (73%) were more likely to have organ dysfunction than those with negative screens (60%), P=.03, OR=1.78. Conclusions: In conclusion, patients who were screened were significantly less likely to have organ dysfunction than those who were not screened, and among those screened, those with positive screens were significantly more likely to have organ dysfunction. The tool successfully assessed the risk of sepsis and septic shock at CCMC and could be used to increase sepsis awareness if it was to be used at other hospitals.Item Medication Adherence on People Living with HIV and AIDS with Concomitant Diabetes(2017-03-14) Clay, Patrick; Elrod, Shara; Liu, ZichangObjective: The aim of this study is to determine the medication adherence rate in people living with HIV and AIDS (PLWHA) and concomitant diabetes Methods: This retrospective review was conducted as a part of a larger study examining communication patterns between pharmacists and PLWHA using medication refill data obtained from community pharmacies between June 2014 to September 2015. Medication refill history, which included initial research participation date, prescription fill history, and day supply were collected. Patients were included in this retrospective review if they were enrolled in the study for at least 3 months, and are taking both highly active antiretroviral therapy (HAART) and antidiabetic medications. Descriptive analyses were used to determine the proportion of days covered (PDC), or the number of days that a patient has a medication for a specific period of time. PDC > 80% for antidiabetic medication and PDC > 90% for HAART will be considered as adherent to medications. Results: A total of 37 patients met inclusion criteria and were included in this review. The mean age was 53.9 years (n=36, range 20-73) and 73% (n=27) were male. The mean PDC of HAART is 97.8% and the mean PDC of antidiabetic medications is 96.4%. The mean PDC of females taking antidiabetic medications was found to be significantly lower than that of males (89.3%,100.2%, p=0.03). The mean PDC of females taking HAART was also found to be significantly lower than that of males (94.2%,99%, p=0.013). The mean PDC of patients who are younger than age 50 taking both HAART and antidiabetic medications is 93.5%, the mean PDC of patients between 50 to 60 years old taking both HAART and antidiabetic medication is 98.6%, and the mean PDC of patients who are older than age 60 taking both HAART and antidiabetic medication is 97.7%. Conclusions: The adherence rate for females taking both HAART and antidiabetic medication was found to be significantly lower than that of males. The adherence rate is higher in ages between 50 to 60 than other age groups. Although the adherence rate varies between gender and different age groups, the overall adherence rate for both male and female reaches the goal of PDC > 80% for antidiabetic medication and PDC > 90% for HAART. Future studies should examine barriers to adherence for women who have HIV and concomitant diabetes.Item Adherence Rates of Antibiotic Use During Antiretroviral Therapy in People Living with HIV/AIDS(2017-03-14) Clay, Patrick; Elrod, Shara; Truong, DorisObjective: To determine frequency of antibiotic use and medication adherence to antibiotics used for opportunistic infections (OI) in people living with HIV/AIDS (PLWHA) who are taking anti-retroviral therapy (ART). Methods: This retrospective review was conducted as a part of a larger study examining communication patterns between pharmacists and PLWHA using medication refill data obtained from community pharmacies between June 2014 to September 2015. Medication refill history, which included initial research participation date, prescription fill history, and day supply were collected. Patients were included in this study if they were aged 25 years or older, infected with HIV and received both ART and antibiotic therapy for 6 months or longer. To distinguish OI and non-OI antibiotic regimens, medications were classified according to the Guidelines for Prevention and Treatment of Opportunistic Infections in HIV-Infected Adults and Adolescents from the U.S. Department of Health & Human Services. The adherence rates of ART and OI antibiotics was determined using standard metrics of proportion of days covered (PDC), or the number of days that a patient has had a medication for a specific period of time. Satisfactory PDC value for adherence is ≥ 95%. Results: A total of 155 patients were included in this study with a mean age of 48.8 years (range 25-73). The total proportion of males was 66.9% (n=101). Overall, 72 (46.5%) participants were taking antibiotics for OI, 106 (68.4%) subjects were taking antibiotics for non-OI infections, and 25 (16.1%) subjects were taking both therapies. More males were using OI antibiotics than females (p=0.021). There was no difference between genders with respect to non-OI antibiotic use (p=0.239). The most common antibiotic for OI was sulfamethoxazole/trimethoprim and the most common non-OI antibiotic was doxycycline. The mean PDC for ART and antibiotics for OI are 93.5% and 88.1%, respectively. Conclusions: Antibiotic use is common for opportunistic infections and short term infections in PLWHA. Adherence to both ART and antibiotics for opportunistic infections was good overall, but less than ideal. Future interventions should be targeted at increasing adherence to ART and OI antibiotic therapies.Item Oxidized LDL for the Early Detection of Atherosclerosis in Human Immunodeficiency Virus Patients on Antiretroviral Therapy(2017-03-14) Clay, Patrick; Ma, AntuanBackground: Currently, HIV patients have established higher rates of cardiovascular disease compared to matched cohorts of non-HIV infected persons. Morbidity and mortality clinical trials are unlikely ever to be conducted providing which anti-HIV medications place persons at higher risks for cardiovascular risk factors. Oxidized forms of low density lipoprotein (oxLDL) can provide an earlier method of detecting the formation of atherosclerotic cardiovascular disease (ASCVD). In antiretroviral therapy (ART) treated human immunodeficiency virus (HIV) patients, ASCVD risk quantified by oxLDL levels may reveal variation in ASCVD progression between the different ART regimens. Input is being sought through this submission on project design and conduct. Methods: We hypothesize that a cohort study methodology is the optimal design. In this proposed study, blood samples from HIV patients, matched for age, gender and past medical history, on varying similar/identical initial ART regimens for different periods of time will be attained. These samples will then be analyzed for their oxLDL levels. oxLDL levels will be compared and evaluated for trends related to characteristics such as ART, duration of HIV infection, duration of ART, gender, body weight (BMI), and lab values. Conclusions: The goal of this study is to measure the degree of ASCVD progression in patients on one ART regimen relative to patients on other regimens. Any discovered differences can then lead to further studies on the factors of causality as well as prospective clinical trials.Item Thoracic Duct Lymph Suppresses Macrophage Activation after Stimulation with Lipotheichoic Acid(2017-03-14) Hodge, Lisa M.; Castillo, Rudy; Nguyen, NghiaPurpose: Streptococcus pneumoniae is a gram positive bacterium that is a major cause of community acquired pneumonia. Lipoteichoic acid (LTA) can be found on the outermost surface of gram positive bacteria, including S. pneumoniae. These bacterial components activate macrophages to release pro-inflammatory substances, such as nitric oxide (NO), which can cause oxidative damages to bacteria. Tumor necrosis factor alpha (TNFα) is a cytokine involved in cell signaling pathways as part of the immune response. In recent studies, osteopathic manipulative therapy (OMT) was shown to protect against acute pneumonia. Our lab has demonstrated that osteopathic lymphatic pump technique (LPT) enhanced the flux of cytokines, reactive oxygen and nitrogen species in thoracic and mesenteric lymph. By enhancing lymph flow, LPT may boost the innate immune response against pneumonia. In this study, we hypothesized that factors in lymph would stimulate macrophage activity Methods: To test this hypothesis, thoracic duct lymph (TDL) was collected from 8 dogs before, during and after OMT sessions using the lymphatic pump technique (LPT). These lymphatic pools were labeled as baseline TDL, LPT TDL, and recovery TDL, respectively. In addition, a mouse alveolar macrophage cell line (MH-S) was used for this in vitro study. Phosphate-buffered saline (PBS), baseline TDL, LPT TDL and recovery TDL were added at 5% total volume per well. To activate macrophages LTA (100 micrograms) were added for 24 hours. The concentration of nitrite and TNF-α using were measured in culture supernatants. Results: TDL had no effect on macrophages cultured without LTA. Following activation with LTA baseline, LPT and recovery TDL suppressed the production of NO (33%, 21% and 19% decrease, respectively) and TNFα (75%, 75% and 80% decrease, respectively) compared to macrophages cultured with 5% PBS. Conclusions: Our results suggest that lymph suppress LTA-induced activation of alveolar macrophages. One explanation is that in healthy individuals, the gastrointestinal environment is normally immune suppressive. During OMT, these anti-inflammatory substances may be mobilized to target tissue via the lymphatic system.Item TAARgeting Astrocyte Mitochondrial Dysfunction during HIV-associated Neuroinflammation and METH Exposure.(2017-03-14) Ghorpade, Anuja; Borgmann, KathleenPurpose: Methamphetamine (METH) use exacerbates HIV-1 infection, accelerating the severity and onset of HIV-associated neurocognitive disorders (HAND), along with immune dysfunction and resistance to antiretroviral therapy. Neurocognitive impairment is more prevalent in HIV+ METH users than either HIV+ or METH+ alone. A common neurotoxic mechanism during HIV CNS infection is mitochondrial impairment leading to oxidative stress. METH directly and indirectly contributes to mitochondrial impairment; however, the mechanisms regulating mitochondrial homeostasis and overall oxidative burden in astrocytes are not well understood in the context of HIV-associated neuroinflammation and METH abuse. We have reported that astrocyte-trace amine associated receptor 1 (TAAR1) is induced by HAND-relevant stimuli and binds METH, leading to cAMP/calcium signaling and impaired glutamate clearance during HIV. We hypothesize that METH-abuse in HAND modulates astrocyte-TAAR1 levels and activity, regulating astrocyte-mediated neurotoxic outcomes, including mitochondrial damage and increased oxidative burden. Methods: TAAR1-mediated regulation was evaluated with siRNA or the selective inhibitor, EPPTB. Mitochondrial size was assessed by MitoTracker Red™ labeling and fluorescent microscopy. The effects of METH on oxygen consumption were measured by extracellular flux Seahorse assay, while changes in gene expression were measured by real-time PCR, western blotting and WES protein assays respectively. Results: Here we report METH-mediated impairment of astrocyte mitochondrial recycling during prolonged exposure in the context of HIV, including enlarged mitochondrial size, mitofusin recruitment, altered oxygen consumption and increased resulting oxidative burden. Further, astrocyte TAAR1 appears to regulate mitochondrial recycling. Conclusions: TAAR1 may be a valid therapeutic target to ameliorate astrocyte-mediated neurodegeneration in HAND and METH abuse.Item Translational Regulation and Expresion of HIV-1 Nef in the Central Nervous System(2017-03-14) He, Johnny; Wilson, KellySignificance: With over 36.7 million people infected today with Human Immunodeficiency Virus (HIV)and 2.1 million new infections each year, HIV presents a massive public health challenge. Introduction of antiretroviral therapies, such as cART, has led to increased life expectancy of HIV patients with a corresponding increase of AIDS induced neurological dysfunction known as HIV/NeuroAIDS. This is characterized by an increase in reactive astrocytes, with up to 20% of astrocytes becoming infected during severe cases. No specific treatment has been developed for HIV/NeuroAIDS, but It is known that astrocytes act as latent reservoirs for HIV-1. Understanding of this phenomenon is in need of expansion to improve treatment options. Purpose: We sought to provide insight into this matter, by focusing on one particular HIV-1 protein, the Negative Regulatory Factor. Nef protein is one of three completely spliced HIV-1 proteins and has been implicated in HIV latency and mutations in Nef have been associated with long-term non progressive HIV infections. This coupled with astrocytes being a site of restricted HIV replication lead to the question of how Nef expression is regulated in astrocytes when compared to regulation in T lymphocytes, which have less restricted HIV replication. Hypothesis: We hypothesized that translation of Nef is downregulated in astrocytes in the HIV infected central nervous system. Materials and Methods: Nef transfected SVGA (human astrocyte cell line) and 293t (SV40 large T antigen-expressing human embryonic kidney cells) were used for in-vitro studies. Western blot, Real-time PCR, and Luciferase assay were utilized to analyze protein expression, Nef mRNA levels, and transcriptional activity, respectively. Additionally, expression of Nef in astrocytes was visualized in iNef mice (Inducible Nef transgenic mice) brain tissue with immunohistochemistry(IHC). Results/Conclusions: Preliminary results show 293t cells expressing higher levels of Nef protein than SVGA cells. Analysis of mRNA levels, transcriptional activity, and IHC of iNef brain tissue are inconclusive. Further optimization of conditions is required to obtain consistent reproducible results.Item Actual Versus Perceived Use of Pharmacokinetic (Primarily Absorption) Influential OTC Agents and ART Tolerability in a Nationwide Matched Cohort of HIV Patients and Their Healthcare Providers(2017-03-14) Clay, Patrick; Perry, Richard; Hadfield, Anna; Liu, Jialiang; Suzuki, Sumihiro; Gehrig, MarkBackground: Antiretroviral therapy (ART) for HIV patients is lifelong. ART efficacy is clear, adverse effects (AE) severity has decreased yet still impact outcomes. This study obtained ‘real world’ data comparing healthcare providers' (HCP) perceptions and clinic records to their patients' perceptions of ART tolerability and self-management. Methods: Study utilized Adelphi's HIV Disease Specific Programme, a cross-sectional survey including provider interviews (n = 131) and matched HCP and patient self-completed surveys (n = 485), conducted among HIV patients and their HCPs. Similar questionnaires focused on disease symptoms, ART AEs, other AEs, compliance, impact and reasons for switching or discontinuing therapy. Results: A total of 131 HCPs were interviewed (n = 80 ID physicians) at 18 metro areas across the US. “Efficacy” was stated by 58% of HCPs as the most important attribute when selecting ART yet the top 5 attributes for ART selection in patient charts revealed criteria of “well tolerated by patients.” ID specialists perceived 32% of all patients are experiencing ART side effects and this increases with subsequent regimens. HCPs interviewed revealed diarrhea as one of the most common symptoms seen with 66% stating diarrhea was the most “most troublesome” AE. This agrees with patients, who recorded diarrhea as equal second “most problematic symptom.” ART changes are most frequently for lack of virologic control (36%) but secondarily (28%) due to GI AEs. HCPs and patients agree on proportion experiencing diarrhea and being treated for it, yet only about 1/3 of patients receive therapy. Finally, our results also reported a concerning discrepancy between prevalence of OTC drugs used by patients versus perceived use by HCPs. Conclusions: HIV patients experience and self-medicate GI symptoms disparate with HCPs knowledge, representing a potential major detrimental influence on outcomes.