Antimicrobial Stewardship Opportunities in Patients with Bacteremia Not Identified by BioFire FilmArray.

A subset of bacteremia cases are caused by organisms not detected by a rapid-diagnostics platform, BioFire blood culture identification (BCID), with unknown clinical characteristics and outcomes. Patients with ≥1 positive blood culture over a 15-month period were grouped by negative (NB-PC) versus positive (PB-PC) BioFire BCID results and compared with respect to demographics, infection characteristics, antibiotic therapy, and outcomes (length of hospital stay [LOS] and in-hospital mortality). Six percent of 1,044 positive blood cultures were NB-PC. The overall mean age was 65 ± 22 years, 54% of the patients were male, and most were admitted from home; fewer NB-PC had diabetes (19% versus 31%, P = 0.0469), although the intensive care unit admission data were similar. Anaerobes were identified in 57% of the bacteremia cases from the NB-PC group by conventional methods: Bacteroides spp. (30%), Clostridium (11%), and Fusobacterium spp. (8%). Final identification of the NB-PC pathogen was delayed by 2 days (P < 0.01) versus the PB-PC group. The sources of bacteremia were more frequently unknown for the NB-PC group (32% versus 11%, P < 0.01) and of pelvic origin (5% versus 0.1%, P < 0.01) compared to urine (31% versus 9%, P < 0.01) for the PB-PC patients. Fewer NB-PC patients received effective treatment before (68% versus 84%, P = 0.017) and after BCID results (82% versus 96%, P = 0.0048). The median LOS was similar (7 days), but more NB-PC patients died from infection (26% versus 8%, P < 0.01). Our findings affirm the need for the inclusion of anaerobes in BioFire BCID or other rapid diagnostic platforms to facilitate the prompt initiation of effective therapy for bacteremia.

Emergency Department Urinary Antibiograms Differ by Specific Patient Group.

Patients presenting to the emergency department (ED) represent a heterogeneous population comprised of all ages, various backgrounds, such as from the community and skilled-nursing facilities (SNFs), and at various risks for resistant pathogens. The aim of this study was to compare patient group-specific urinary antibiograms in the ED. Adults presented to the ED with an ICD 9/10 code urinary tract infection (UTI) diagnosis during July 2015 to June 2016 were randomly selected (n = 500) to extract relevant demographic, laboratory, and clinical data from the medical record. Urinary Escherichia coli antibiograms were compared between institutional versus ED and among ED patients (male versus female; age of 18 to 64 years versus ≥65 years; female aged 18 to 50 years versus >50 years; home versus SNF; and admitted versus discharged). E. coli grew from 56% (145/259) of the positive urine cultures. Overall ciprofloxacin (CIP), trimethoprim-sulfamethoxazole (SXT), and cefazolin (CFZ) susceptibilities were <71%. Differences in antibiograms were the following: lower CFZ and SXT susceptibilities in ED versus institutional (CFZ, 67% versus 86% [P = 0.001]; SXT, 66% versus 74% [P = 0.02]), lower ampicillin and gentamicin susceptibilities in females aged 18 to 50 years versus >50 years (32% versus 52% [P = 0.04]; 78% versus 93% [P = 0.02]), lower CIP susceptibilities in the elderly (64% versus 81%; P = 0.03), SNF versus home (35% versus 77%; P < 0.001), admitted versus discharged (63% versus 78%; P = 0.04), and lower SXT susceptibilities in patients aged <65 years versus the elderly (58% versus 71%; P = 0.01). Nitrofurantoin showed >80% susceptibility in all groups. Patient group-specific urinary antibiograms revealed distinct differences in E. coli susceptibility and should be developed to better inform empirical UTI therapy selection in the ED.

Ryanodine induces maturation of embryonic acetylcholinesterase forms in cultured quail myotubes.

[3H]Ryanodine is shown to specifically bind to cultured myotubes from 10 day quail embryo pectoralis. The binding of [3H]ryanodine increases in a time-dependent manner reaching 38 +/- 3 fmol/mg protein at 4 h. A level of theophylline (THEO; 5mM) that induces propagated wave-like contractures, doubles the capacity of the myotubes to bind [3H]ryanodine (78 +/- 7 fmol/mg protein at 4 h). Polycationic ruthenium red (100 microM) only partially inhibits (56%) [3H]ryanodine-binding, whereas the membrane permeable channel antagonist [2,6-dichloro-4-dimethyl-amino-phenyl]-isopropylamine (20 microM) inhibits occupancy > 80%. Ryanodine (10 microM) interferes with THEO-induced contractures. Pretreatment with micromolar ryanodine for 48 h, followed by washout for 48 h, causes a persistent decrease in [3H]ryanodine-binding sites. Persistent [3H]ryanodine receptor blockade coincides with a dramatic shift in AChE forms found in the myotubes. A transition from the embryonic 4S and 7S globular forms to the 20S collagen-tailed (adult) form is evident within 12 hr exposure to ryanodine and progresses after removal of the alkaloid from the culture medium, mimicking the transition that normally occurs during myocyte maturation in vivo. These results suggest that SR Ca++ movements and excitation-contraction coupling may, at least in part, contribute to AChE maturation.

Turkey muscle growth and focal myopathy.

Muscle structure and blood enzyme activity were studied to 16 wk of age in lines of turkeys selected for rapid growth. The body and carcass weights were measured, frozen sections of breast and leg muscles examined, and plasma creatine kinase (CK) levels determined. Muscle weights were usually proportional to BW except for the relatively larger superficial pectoralis (SP) muscles in the most rapidly growing line. Damaged muscle fibers were found in all muscles examined, especially in the SP of the breast, the gastrocnemius (GA), and other muscles of the leg; these damages became more common from 10 to 16 wk of age. There were more degenerating muscle fibers and higher levels of plasma CK in the rapidly growing lines than in a slower growing unselected line. The findings support the idea that a focal myopathy, unrelated to deep pectoral myopathy or to inherited muscular dystrophy of the chicken, is associated with rapid growth of turkeys.

Inbred crosses and inherited muscular dystrophy of the chicken.

Inbred normal and genetically dystrophic chickens of New Hampshire and White Leghorn backgrounds, respectively, have been crossed to yield hybrids of normal and dystrophic genotypes in order to provide genetically homogeneous but heterozygous experimental animals. This study examined carcass and pectoral muscle weights, pectoral muscle fiber diameters, serum creatine kinase (CK) levels, muscle acetylcholinesterase (AChE), lactic dehydrogenase (LDH), and creatine kinase, and response to daily injections of corticosterone-21-acetate (C21A) of these hybrid chickens and their inbred parental lines. With the exception of pectoral muscle weight, dystrophic hybrids exhibited symptoms of dystrophy: high serum CK and high muscle AChE and low LDH levels. The results support the hypothesis that neither early muscle fiber hypertrophy nor atrophy is invariably associated with expression of the dystrophic gene; both are the result of secondary gene interactions. One experiment showed that muscle AChE levels decreased and LDH levels rose after C21A treatments.

Recovery of acetylcholinesterase forms in quail muscle cultures after intoxication with diisopropylfluorophosphate.

Studies of recovery of acetylcholinesterase (AChE, EC 3.1.1.7) after inhibition by organophosphates (OPs) have been hampered by the low number of in vitro systems with large collagen-tailed forms of AChE characteristic of motor end plates. Pectoral muscle cultures from Japanese quail with high levels of a large 20S form of AChE were used to study recovery of cells from acute treatment with diisopropylfluorophosphate (DFP), an irreversible AChE inhibitor. Low molecular weight AChE forms were synthesized more rapidly than the large 20S form following a 15-min treatment with 10(-4)M DFP. Most of the activities of the small forms, but only part of the activity of the 20S form, disappeared within 48 hr after cycloheximide was added to block protein synthesis. To the contrary, virtually all the activity of the 20S AChE that was newly synthesized after DFP treatment was lost within 24 hr after cycloheximide treatment. The results were generally consistent with the idea that the 20S AChE form is assembled inside the cell near to its surface and then is released to bind to its outside.

Regulation of acetylcholinesterase forms in quail and chicken muscle cultures.

High molecular forms of acetylcholinesterase (AChE) have been difficult to obtain in primary cultures of muscle from mammals and birds. This research used pectoral muscle cultures from Japanese quail and chick embryos grown in medium containing embryo extract and horse serum to study the growth and extraction conditions necessary for study of high molecular weight 20S AChE forms found in these birds. The results confirmed the presence of a 20S AChE form in quail muscle cultures and showed that its extraction from the cells was considerably improved by using a Mg-cholate extraction buffer rather than the more commonly used NaCl-Triton X buffer. A striking finding was that removal of serum from the medium for 1-2 days caused the preferential increase in a 20S form in the quail and the resolution of one from background activity in chick muscle cultures. Removal of embryo extract had no effect on levels of the AChE forms. The results suggest that serum factors inhibit the formation of the high molecular weight, motor end plate associated form of AChE in aneural cultures of avian muscle, and that effects of factors such as neural extracts and nerves on AChE forms in cultured muscle should be examined using a defined basal media.

Ultrastructural localization of acetylcholinesterase in cultured cells. III. DFP treated embryo muscle.

Brief treatment with 10(-4)M diisopropylfluorophosphate (DEP) irreversibly inactivates acetylcholinesterase (E.C.3.1.1.7; acetylcholine hydrolase) (AChE) activity in 10 day old chick embryonic muscle cultures. Electron microscopic cytochemistry was employed to follow the distribution of new AChE during recovery from DEP treatment. In normal 10 day cultures of embryo pectoralis muscles AChE is localized in the nuclear envelope, perinuclear sarcoplasm, sarcotubular system, subsurface vesicles and bound outside the cells. Immediately after DFP treatment AChE activity is absent in large myotubes. Within 15 min, activity is randomly present in small amounts in the sarcotubular system and nuclear envelope. There is a dramatic increase in activitv in the nuclear envelope during the 1st hr of recovery, and connections between the nuclear envelope and sarcotubular system are often seen. The next few hr of recovery show increased AChE activity. By 4 hr activity approaches that of controls. Six to 8 hr after treatment, AChE activity can be detected spectrophotometrically in the medium and can be seen bound outside the cells with the electron microscope. The spatial and temporal patterns of AChE activity demonstrate that the recovery of AChE and its mobilization and release from DFP-treated cells are not governed solely by the levels attained by the enzyme in the cultured embryo muscle.

Ultrastructural localization of acetylcholinesterase in cultured cells. II. Cycloheximide-treated embryo muscle.

The acetylcholinesterase activity (AChE) of cultured chick embryo muscle fibers that remains after the cells have been treated with the protein synthesis inhibitor cycloheximide was examined with cytochemical stains and the electron microscope. AChE activity that decreased rapidly after addition of the inhibitor was associated with enzyme within the cells, and AChE activity that was relatively insensitive to the inhibitor was associated with AChE outside of the cells. The results support the view that there are at least two fractions of AChE in developing muscle fibers, one intracellular and labile, the other extracelullar and stable.

Ultrastructural localization of acetylcholinesterase in cultured cells. I. Embryo muscle.

Several techniques were employed to examine the localization of acetylcholinesterase (EC 3.1.1.7, AChE) in cultured chick embryonic skeletal muscle. Glutaraldehyde produced the best cellular preservation but less enzyme activity was lost when the cells were fixed in paraformaldehyde. Two staining methods were examined: in one (Karnovsky MJ, Roots L: J Histochem Cytochem 12:219, 1964) potassium ferricyanide was added with the primary reactants, and in the other (Tsuji S: Histochemistry 42:99, 1974) the potassium ferricyanide was added at the end of the staining procedure. Localizations of AChE were similar with both stains; activity was present in the nuclear envelope, the perinuclear sarcoplasm, the sarcoplasmic reticulum, subsurface vesicles and bound outside the cells. /owever, a granular artifact was found with the method of Karnovsky and Roots that did not appear with the method of Tsuji. The localization of AChE are consistent with kinetic data that AchE binds, moves and is released from cultured muscle fibers.

Acetylcholinesterase in abnormal human muscle.

Fifty human muscle biopsies were examined for histochemical localization of acetylcholinesterase (AChE) activity. Six normal muscle samples had AChE at the myoneural junctions and around the periphery of many fibers. The AChE within the sarcoplasm itself was found in only a few atrophied fibers. However, 21 of 44 biopsies of abnormal muscles had sarcoplasmic AChE in more than 10% of their fibers. Such cases included Duchenne, limb-girdle and facio-scapulo-humeral dystrophy, neurogenic and spinal muscle atrophy, spinal cord injury, peripheral nerve injury, Schwartz-Jampel syndrome and myasthenic syndrome. Sarcoplasmic AChE is found in embryo muscle and usually declines after birth. It appears after denervation in the chicken but not the rat and remains in muscles of chickens with an inherited muscular dystrophy. The results of the human muscle study support the idea that in the human, as in the chicken, interruption of a neurally-mediated regulation of AChE results in the reappearance of high AChE activity in the sarcoplasm of the muscle fibers.

Incidence of acetylcholinesterase in the sarcoplasm of human and chicken muscles.

Fifty-nine biopsies of human muscle, 53 of them abnormal, 6 normal, were studied for the histochemical localization of acetylcholinesterase (AChE) using frozen sections and light microscopy. In addition to AChE which was found at the myoneural and myotendon junction, specific staining was found around the periphery of many fibers from normal and abnormal muscles. Moreover, AChE activity was found to be high in the sarcoplasm of more than 10% of the fibers from 28 biopsies of abnormal muscle including cases of hemiplegia, spinal cord injury, denervation and neuropathy, infantile spinal muscle atrophy, Duchenne, limb-girdle and facioscapulohumeral dystrophies, Schwartz-Jampel syndrome and a myasthenic syndrome. Of the muscles from experimental animals examined, only the Rhesus monkey exhibited AChE around the periphery of the fibers, and only the dystrophic chicken and not the dystrophic mouse or hamster, showed extensive sarcoplasmic AChE. Histograms of muscle fiber diameters indicated that AChE in the sarcoplasm was associated with fibers of all sizes, depending on the nature of the disorder examined. Fibers containing AChE were smaller than unstained fibers in dystrophic chicken muscle. The results suggest that in the human, sarcoplasmic AChE is reversibly repressed during muscle maturation and that its mode of regulation by motor neurons is similar to that found in the chicken.