Emerging Options for the Prevention and Management of Clostridioides difficile Infection.

Agents in development for the prevention or treatment of Clostridioides difficile infection can be split into three broad categories: antibiotics, microbiome restoration, and vaccines. Given the extensive list of agents currently in development, this narrative review will focus on agents that have progressed into late-stage clinical trials, defined as having a Phase III clinical trial registered on ClinicalTrials.gov. These agents include one antibiotic (ridinilazole), three live biotherapeutic products (LBPs) (CP101, RBX2660, and SER109), and two toxoid vaccines (PF06425090 and a second toxoid vaccine). As new prevention and treatment strategies enter the market, clinicians and administrators will need knowledge of these products to make rational decisions on how best to adopt them into clinical practice.

[Approaches to vaccine prevention in multiple sclerosis]. / Vaktsinoprofilaktika pri rasseyannom skleroze.

The article presents an overview of modern approaches to vaccine prevention in multiple sclerosis (MS). Compared with the general population, patients with MS have been shown to have an increased risk of morbidity, a tendency to have a more severe course, and a greater mortality from vaccine-preventable infections. At the same time, in Russia, until recently, traditionally adhered to a conservative tactic of limiting vaccination in patients with autoimmune diseases, including MS. The use of various disease-modifying therapies (DMT) may also affect the susceptibility to infections and the severity of their course. Screening for latent infections, determination of immune status, collection of history of past infections and development of a vaccination plan based on these data are an important part of the preparation before the appointment of DMT to control the occurrence or reactivation of infections. The use of inactivated, subunit, conjugate, and toxoid-based vaccines are preferable for MS patients. When developing a vaccination plan, avoid live-attenuated vaccines whenever possible. There are no restrictions on vaccination during first line DMT intake. In case of vaccination in MS patients while using immunosuppressants, including drugs for immune reconstitution therapy, an individual risk assessment and timing are required. The available data on the awareness of patients about vaccine prophylaxis are significantly limited and require mass information events.

A phase 1, placebo-controlled, randomized study of the safety, tolerability, and immunogenicity of a Clostridium difficile vaccine administered with or without aluminum hydroxide in healthy adults.

INTRODUCTION: Clostridium difficile is a significant cause of morbidity and mortality in hospitals, nursing homes, and long-term care facilities. The bacteria can produce 3 toxins, of which the C. difficile toxin A and C. difficile toxin B are the principal virulence factors for C. difficile-associated disease. METHODS: A phase 1, first-in-human, placebo-controlled, dose-escalation study was performed to assess the safety and immunogenicity of an investigational vaccine candidate consisting of genetically and chemically detoxified, purified toxins A and B. The toxoids, either alone or in combination with aluminum hydroxide (Al(OH)3), were administered to healthy adults 50-85 years of age at antigen dose levels of 50, 100, or 200 µg in a 3-dose regimen administered at 0, 1, and 6 months. RESULTS: Overall, the C. difficile vaccine formulations and doses administered were generally well tolerated. Local reactions and systemic events were predominantly mild to moderate, were more common in the 50-64-year age cohort, and comprised mostly injection site pain, headache, and fatigue. In subjects who received the vaccine formulations, both the toxin A- and toxin B-specific neutralizing antibody geometric mean concentrations increased substantially at 1 month after Dose 2 and after Dose 3 compared to baseline. In the 50-64-year age cohort, geometric mean fold rises (GMFRs) in toxin A-specific neutralizing antibodies from baseline at Month 7 ranged from 59.19 to 149.23 in the vaccine groups compared to 2.47 in the control group. For toxin-B specific neutralizing antibodies, the GMFRs from baseline at Month 7 ranged from 116.67 to 2503.75 in the vaccine groups compared to 2.48 in the control group. In the 65-85-year age cohort, GMFRs in toxin A-specific neutralizing antibodies from baseline at Month 7 ranged from 42.73 to 254.77 in the vaccine groups compared to 2.03 in the control group. For toxin-B specific neutralizing antibodies, the GMFRs from baseline at Month 7 ranged from 136.12 to 4922.80 in the vaccine groups compared to 1.58 in the control group. Potent antitoxin neutralizing responses were still evident in immunized subjects in both age groups at Month 12. Although there was no clear dose-level response pattern, the data suggest that both the antitoxin A- and B-specific neutralizing responses were trending higher in the toxoid-only groups compared to the toxoid+Al(OH)3 groups. Furthermore, the magnitude of the immune response was similar in the 2 age cohorts. CONCLUSION: The vaccine formulations studied in this phase 1 study were immunogenic and well tolerated. The results presented support further development of the C. difficile vaccine candidate in a larger population of subjects to determine the optimal dose and immunization schedule. CLINICAL TRIAL REGISTRY: NCT01706367.

Engineered nanoparticles mimicking cell membranes for toxin neutralization.

Protein toxins secreted from pathogenic bacteria and venomous animals rely on multiple mechanisms to overcome the cell membrane barrier to inflict their virulence effect. A promising therapeutic concept toward developing a broadly applicable anti-toxin platform is to administer cell membrane mimics as decoys to sequester these virulence factors. As such, lipid membrane-based nanoparticulates are an ideal candidate given their structural similarity to cellular membranes. This article reviews the virulence mechanisms employed by toxins at the cell membrane interface and highlights the application of cell-membrane mimicking nanoparticles as toxin decoys for systemic detoxification. In addition, the implication of particle/toxin nanocomplexes in the development of toxoid vaccines is discussed.

Vacunaciones en pcientes con inmunodeficiencias graves / No disponible

No disponible

Vaccination of turkeys with Clostridium septicum bacterin-toxoid: evaluation of protection against clostridial dermatitis.

Clostridial dermatitis is an acute disease causing high mortality in turkeys. Both Clostridium septicum and Clostridium pefringens have been isolated from these cases; however, reports from several diagnostic laboratories indicate an increased isolation rate of C septicum compared with C. perfringens from cases of clostridial dermatitis in recent years. Previous studies suggested C. septicum was more potent than C. perfringens in causing clostridial dermatitis in turkeys. The objective of this study was to develop and evaluate the use of a C. septicum bacterin-toxoid to control clostridial dermatitis in turkeys. A C. septicum bacterin-toxoid was prepared and was initially tested in 6-wk-old commercial turkeys under laboratory conditions for its safety and efficacy. Subsequently, the bacterin-toxoid was evaluated for use in commercial turkey farms with a consistent history of clostridial dermatitis. Birds in the field were vaccinated subcutaneously once at 6 wk of age with C. septicum bacterin-toxoid, and then mortality in both vaccinated and unvaccinated groups was recorded and compared. Blood samples from birds in both groups were examined using ELISA to detect antibody response to the C. septicum toxoid. The C. septicum bacterin-toxoid was found to be safe and to elicit antibodies against the toxoid. In vaccinated commercial turkeys, control of clostridial dermatitis was achieved via antibiotic use and clostridial dermatitis mortality was significantly reduced compared with that of birds in the unvaccinated group. The C. septicum bacterin-toxoid seems to be a valuable tool for the turkey industry to reduce losses due to clostridial dermatitis.

Neutralizing antibodies to Shiga toxin type 2 (Stx2) reduce colonization of mice by Stx2-expressing Escherichia coli O157:H7.

Previously, we showed that the Shiga toxin type 2 (Stx2)-expressing Escherichia coli O157:H7 strain 86-24 colonized mice better than did its isogenic stx(2) negative mutant. Here, we confirmed that finding by demonstrating that Stx2 given orally to mice increased the levels of the 86-24 stx(2) mutant shed in feces. Then we assessed the impact of Stx2-neutralizing antibodies, administered passively or generated by immunization with an Stx2 toxoid, on E. coli O157:H7 colonization of mice. We found that such antibodies reduced the E. coli O157:H7 burden in infected mice and, as anticipated, also protected them from weight loss and death.

Pertussis vaccine: a critique.

A critical level of serum IgG pertussis toxin antibody is both essential and sufficient to confer individual and herd immunity to pertussis. Monocomponent pertussis toxoid conferred such immunity in Sweden and in Denmark. We refute the notion that filamentous hemagglutinin, pertactin, and fimbriae add to the immunity conferred by pertussis toxoid and describe the artifact created when efficacy is estimated for multicomponent pertussis vaccines. Lastly, the genetically-inactivated mutant pertussis toxoid is safer, more immunogenic, and should be more effective than the current chemically-inactivated pertussis toxin.

The rise in pertussis cases urges replacement of chemically-inactivated with genetically-inactivated toxoid for DTP.

The number of pertussis cases reported to the CDC increased from 5158 in 1995 to 21,503 in 2005. Most of the increase was in individuals greater than 10 years of age. This increase occurred also in other developed nations despite high coverage of infants and young children with the acellular pertussis vaccine. In Goteborg Sweden, virtual elimination of pertussis occurred following immunization of 70% of the children less than 10 years old with monocomponent pertussis toxoid (PTx). Immunity following disease or vaccination with either the cellular or acellular pertussis vaccine wanes gradually so that older children and adults may again become susceptible. Currently, PTx is made from chemically-inactivated pertussis toxin (PT). The most immunogenic PTx is made from genetically-inactivated mutant PT that induces higher levels of IgG anti-PT at all ages. Because of its greater immunogenicity, the genetically-inactivated PTx can be expected to be more protective on an individual and on a community basis for a longer duration than the current product. Manufacturers have declined to produce the genetically-inactivated PTx because of the expense required to change to the improved vaccine and not because of scientific issues.

Clostridium difficile toxoid vaccine in recurrent C. difficile-associated diarrhea.

BACKGROUND & AIMS: Recurrent C difficile -associated diarrhea (CDAD) is associated with a lack of protective immunity to C difficile toxins. A parenteral C difficile vaccine containing toxoid A and toxoid B was reported previously to be safe and immunogenic in healthy volunteers. Our aim was to examine whether the vaccine is also well tolerated and immunogenic in patients with recurrent CDAD. METHODS: Subjects received 4, 50-microg intramuscular inoculations of the C difficile vaccine over an 8-week period. Serum antitoxin antibodies were measured by ELISA, and toxin neutralizing activity was evaluated using the tissue culture cytotoxin assay. RESULTS: Three patients with multiple episodes of recurrent CDAD were vaccinated. Two of the 3 showed an increase in serum IgG antitoxin A antibodies (3-fold and 4-fold increases, respectively) and in serum IgG antitoxin B antibodies (52-fold and 20-fold, respectively). Both also developed cytotoxin neutralizing activity against toxin A and toxin B. Prior to vaccination, the subjects had required nearly continuous treatment with oral vancomycin for 7, 9, and 22 months, respectively, to treat recurrent episodes of CDAD. After vaccination, all 3 subjects discontinued treatment with oral vancomycin without any further recurrence. CONCLUSIONS: A C difficile toxoid vaccine induced immune responses to toxins A and B in patients with CDAD and was associated with resolution of recurrent diarrhea. The results of this study support the feasibility of active vaccination against C difficile and its toxins in high-risk individuals but must be validated in larger, randomized, controlled trials.

The use of vaccines in pregnancy.

Adult immunization rates in the United States lag behind pediatric immunization rates. Healthcare providers in all settings should discuss immunization with their patients. There are concerns regarding the use of vaccine in women who are pregnant or breastfeeding. This article reviews selected vaccines and the use of vaccines in women who are pregnant or breastfeeding. Basic principles of vaccine administration are discussed as well as standards for immunization practice. Concerns regarding vaccine safety in any population are reviewed.

Impact of routine vaccination with a pertussis toxoid vaccine in Denmark.

In many countries, acellular pertussis vaccines have replaced whole-cell vaccines. We evaluated the impact of a pertussis toxoid vaccine on pertussis in Denmark. We calculated incidence rates for pertussis before and after pertussis toxoid vaccine was introduced, and estimated vaccination effectiveness (VE). We found that routine vaccination with pertussis toxoid vaccine was effective against both hospitalisation with pertussis (VE, 93% for three doses) and non-hospitalised pertussis (VE, 78% for three doses). However, after the introduction we found an increase in pertussis among the youngest infants, a direct result of the new schedule (ages 3, 5 and 12 months) where the youngest infants are unvaccinated for a longer time-period compared with the prior schedule (ages 5, 9 weeks and 10 months).

[New drugs that prevent cytotoxicity of Shiga toxins].

Shiga toxin(Stx) produced by enterohemorrhagic E. coli is the virulence factor that causes not only enterohemorrhagic colitis but also fatal complications, such as hemolytic uremic syndrome. To prevent the complications, new strategies targeted to Stx have been tested, mostly using mimics of the trisaccharide structure of neutral lipid Gb3, the receptor for Stx. One group of such new drugs are agents that can bind to Stx in gastrointestinal tract and prevent its spread to extraintestinal sites, and the other group are water-soluble neutralizers that suppress Stx cytotoxicity in the circulation. Although most of these are now under the laboratory investigations, one of these drugs may hopefully be utilized clinically to prevent hemolytic uremic syndrome in future.

Potential of Klebsiella pneumoniae cytotoxin toxoid as vaccine against klebsiellosis in rabbits and mice.

The protective efficacy of toxoids prepared from crude cytotoxin (polymyxin-B extract, PBE) and purified Klebsiella cytotoxins (KCTs) was studied in rabbits and mice. The toxoids of KCT-I and PBE were found to be protective against homologous as well as heterologous Klebsiella challenges, while toxoids of KCT-II and KCT-III afforded protection in mice against homologous Klebsiella infections. KCT-I and PBE toxoids also induced good humoral anti-Klebsiella response in rabbits with ELISA titres ranging from 20480 to 81480. Immunized female rabbits passed protective anti-Klebsiella immunoglobulins to their offsprings through colostra. Baby rabbits fed on colostrum of immunized rabbits withstood lethal Klebsiella infection up to 1 month of age, but not on the 50th day. Baby rabbits having an anti-Klebsiella IgG titre > or =1280 were fully protected against lethal dose of Klebsiella. The study revealed a significant protective efficacy of KCT-I and PBE toxoids against klebsiellosis in mice and rabbits.

Local and systemic responses against ricin toxin promoted by toxoid or peptide vaccines alone or in liposomal formulations.

The objective of this study was to develop a vaccine which would ultimately protect man from the lethal effects of inhaled ricin toxin. Porton rats have previously been protected from lethal quantities of inhaled ricin by subcutaneous (s.c.) ricin toxoid vaccine, but not without lung damage. This situation might be improved by an alternative vaccine such as the A chain of ricin, already known to protect against inhaled ricin. Another option would be to improve respiratory tract immunity by local vaccination in conjunction with liposomal formulation with a view to enhancing lung secretion of immune IgA. While boosted s.c. doses of ricin toxoid or A chain produced indistinguishable systemic immune responses 3 weeks later, when delivered by the intratracheal (i.t.) route, the A chain failed to elicit a specific immune response, unlike ricin toxoid. This situation was overcome by liposomal formulations and although ricin toxoid was readily encapsulated in liposomes, A chain was not. However, by simply mixing A chain and liposomes in the same weight ratio determined for liposomal toxoid, systemic immune responses for each formulation were indistinguishable 1 week after boosting. Ricin antibody responses in lung fluid monitored 1, 3, 7 and 14 days after i.t. challenge with ricin were statistically indistinguishable, but the group vaccinated with liposomal toxoid secreted 28.7% IgA compared with 0.9-14.9% for the A chain liposomal group. From this, it might be anticipated that the lungs would be better protected by liposomally-encapsulated ricin toxoid than by the A chain-liposome mixture.

A prophylactic and therapeutic AIDS vaccine containing as a component the innocuous Tat toxoid.

Extracellular Tat can act as a viral toxin on uninfected cells of different tissues, including the CNS and the immune system, thus in order to immunize humans against Tat we have prepared a biologically inactivated but immunogenic Tat (Tat Toxoid). Tat Toxoid is not toxic in mice even at high doses. It triggers high levels of specific Tat Abs in the mouse and rabbit. Furthermore, in humans Tat Toxoid immunization was safe and induced in seronegatives persistent high levels of Tat Abs and in immunodeficient patients a significant rise of these specific Abs. Facing acute HIV-1 infection, the presence of high level of circulating Tat Abs promoted by Tat Toxoid vaccine should prevent Tat-induced immunosuppression and allow anti-HIV-1 cellular response to develop. As a consequence, early release of beta-chemokines could enhance host resistance towards HIV-1, and, in infected people, inhibit viral replication and evolution towards AIDS.

A cholera toxoid-insulin conjugate as an oral vaccine against spontaneous autoimmune diabetes.

Mucosally induced immunological tolerance is an attractive strategy for preventing or treating illnesses resulting from untoward inflammatory immune reactions against self- or non-self-antigens. Oral administration of relevant autoantigens and allergens has been reported to delay or suppress onset of clinical disease in a number of experimental autoimmune and allergic disorders. However, the approach often requires repeated feeding of large amounts of tolerogens over long periods and is only partly effective in animals already systemically sensitized to the ingested antigen such as in animals already harboring autoreactive T cells, and thus presumably also in humans with an autoimmune disease. We have recently shown that oral administration of microgram amounts of antigen coupled to cholera toxin B subunit (CTB), can effectively suppress systemic T cell reactivity in naive as well as in immune animals. We now report that feeding small amounts (2-20 microg) of human insulin conjugated to CTB can effectively suppress beta cell destruction and clinical diabetes in adult nonobese diabetic (NOD) mice. The protective effect could be transferred by T cells from CTB-insulin-treated animals and was associated with reduced lesions of insulitis. Furthermore, adoptive co-transfer experiments involving injection of Thy-1,2 recipients with diabetogenic T cells from syngeneic mice and T cells from congenic Thy-1,1 mice fed with CTB-insulin demonstrated a selective recruitment of Thy-1,1 donor cells in the peripancreatic lymph nodes concomitant with reduced islet cell infiltration. These results suggest that protection against autoimmune diabetes can be achieved by feeding minute amounts of a pancreas islet cell autoantigen linked to CTB and appears to involve the selective migration and retention of protective T cells into lymphoid tissues draining the site of organ injury.

[The experimental validation of methods for the emergency immunoprophylaxis of gas gangrene]. / Eksperimental'noe obosnovanie metodov ékstrennoi immunoprofilaktiki gazovoi gangreny.

The effectiveness, both immunological (by an increase in the titers of antitoxins) and protective (by resistance to the inoculation of the absolute lethal dose of infective agents), of the regional (wound) revaccination with tetratoxoid (Clostridium perfringens, C. oedematiens, C. septicum, C. histolyticum) was demonstrated on the experimental model of wound infection (gas gangrene) of guinea pigs. The schedule of rapid immunization with tetratoxoid was developed, which made it possible to create good immunological preparedness (basic immunity) for subsequent revaccination in case of traumas within 6 days. The effectiveness of rapid immunization by the application of tetratoxoid on the wound was shown. This immunization ensured a considered increase in the titers of antitoxins within the first 6 days, which increased the protection of the animals from infection with each of the four causative agents of gas gangrene.

Protection against inhalation toxicity of ricin and abrin by immunisation.

1. Abrin and ricin are highly toxic plant proteins which are very similar in structure and function and inhibit protein synthesis in eukaryotes. 2. Rats have been immunised against either toxin using formaldehyde-toxoids by three subcutaneous injections at intervals of 3 weeks. For abrin, serum titres in 14 out of 15 rats were raised to between 1:12800 and 1:51200 after two injections, 6 weeks from the start of the experiment. Titres of between 1:256 and 1:1024 were also measured in lung washes after challenge with active abrin toxin. 3. The three major antibody classes, IgG, IgM and IgA were present in the immune sera but IgG and IgA only were detected in lung washes. The proportion of IgA to IgG was higher in the lung fluid than in sera. Rats immunised by abrin toxoid were protected against 5 LCt50's of abrin by inhalation but others exposed to ricin were not. 4. For ricin, serum titres ranged from 1:800 to 1:25600 after two injections and after a third injection the titre range was the same but population samples were weighted towards the higher titres. All rats immunised with ricin toxoid survived the challenge of 5 LCt50's of ricin toxin by inhalation over the observation period of 28 days post-challenge. 5. Representative immunised rats (abrin toxoid) were taken at various times post-exposure, humanely killed and tissues were examined for pathological changes. It was concluded that an apparently severe lung lesion occurred at a later time than in non-immunised, toxin challenged rats. This damage was not lethal over the experimental observation periods. 6. Immunisation by the sub-cutaneous route therefore protects against lethality from challenge by inhalation of ricin or abrin toxins but does not prevent significant lung damage.