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Krinsky N, Sizikov S, Nissim S, Dror A, Sas A, Prinz H, Pri-Or E, Perek S, Raz-Pasteur A, Lejbkowicz I, Cohen-Matsliah SI, Almog R, Chen N, Kurd R, Jarjou'i A, Rokach A, Ben-Chetrit E, Schroeder A, Caulin AF, Yost CC, Schiffman JD, Goldfeder M, Martinod K. NETosis induction reflects COVID-19 severity and long COVID: insights from a 2-center patient cohort study in Israel. J Thromb Haemost 2023; 21:2569-2584. [PMID: 37054916 PMCID: PMC10088279 DOI: 10.1016/j.jtha.2023.02.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2022] [Revised: 01/29/2023] [Accepted: 02/12/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND COVID-19 severity and its late complications continue to be poorly understood. Neutrophil extracellular traps (NETs) form in acute COVID-19, likely contributing to morbidity and mortality. OBJECTIVES This study evaluated immunothrombosis markers in a comprehensive cohort of acute and recovered COVID-19 patients, including the association of NETs with long COVID. METHODS One-hundred-seventy-seven patients were recruited from clinical cohorts at 2 Israeli centers: acute COVID-19 (mild/moderate, severe/critical), convalescent COVID-19 (recovered and long COVID), along with 54 non-COVID controls. Plasma was examined for markers of platelet activation, coagulation, and NETs. Ex vivo NETosis induction capability was evaluated after neutrophil incubation with patient plasma. RESULTS Soluble P-selectin, factor VIII, von Willebrand factor, and platelet factor 4 were significantly elevated in patients with COVID-19 versus controls. Myeloperoxidase (MPO)-DNA complex levels were increased only in severe COVID-19 and did not differentiate between COVID-19 severities or correlate with thrombotic markers. NETosis induction levels strongly correlated with illness severity/duration, platelet activation markers, and coagulation factors, and were significantly reduced upon dexamethasone treatment and recovery. Patients with long COVID maintained higher NETosis induction, but not NET fragments, compared to recovered convalescent patients. CONCLUSIONS Increased NETosis induction can be detected in patients with long COVID. NETosis induction appears to be a more sensitive NET measurement than MPO-DNA levels in COVID-19, differentiating between disease severity and patients with long COVID. Ongoing NETosis induction capability in long COVID may provide insights into pathogenesis and serve as a surrogate marker for persistent pathology. This study emphasizes the need to explore neutrophil-targeted therapies in acute and chronic COVID-19.
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Affiliation(s)
| | | | | | - Adi Dror
- Peel Therapeutics Israel, Ltd, Nesher, Israel
| | - Anna Sas
- Peel Therapeutics Israel, Ltd, Nesher, Israel
| | | | | | - Shay Perek
- Department of Internal Medicine A, Rambam Health Care Campus, The Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Ayelet Raz-Pasteur
- Department of Internal Medicine A, Rambam Health Care Campus, The Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Izabella Lejbkowicz
- Epidemiology Department and Biobank, Rambam Health Care Campus, Haifa, Israel
| | | | - Ronit Almog
- Epidemiology Department and Biobank, Rambam Health Care Campus, Haifa, Israel
| | - Nikanor Chen
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ramzi Kurd
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Amir Jarjou'i
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Ariel Rokach
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Eli Ben-Chetrit
- Department of Internal Medicine, Shaare Zedek Medical Center, Faculty of Medicine, The Hebrew University of Jerusalem, Jerusalem, Israel
| | - Avi Schroeder
- Laboratory for Targeted Drug Delivery and Personalized Medicine Technologies, Department of Chemical Engineering, Technion - Israel Institute of Technology, Haifa 32000, Israel
| | | | - Christian Con Yost
- Division of Neonatology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA; Molecular Medicine Program, University of Utah, Salt Lake City, Utah, USA
| | - Joshua D Schiffman
- Peel Therapeutics, Inc, Salt Lake City, Utah, USA; Division of Pediatric Hematology/Oncology, Department of Pediatrics, University of Utah, Salt Lake City, Utah, USA.
| | | | - Kimberly Martinod
- Center for Molecular and Vascular Biology, Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.
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Li Y, van Houten CB, Boers SA, Jansen R, Cohen A, Engelhard D, Kraaij R, Hiltemann SD, Ju J, Fernández D, Mankoc C, González E, de Waal WJ, de Winter-de Groot KM, Wolfs TFW, Meijers P, Luijk B, Oosterheert JJ, Sankatsing SUC, Bossink AWJ, Stein M, Klein A, Ashkar J, Bamberger E, Srugo I, Odeh M, Dotan Y, Boico O, Etshtein L, Paz M, Navon R, Friedman T, Simon E, Gottlieb TM, Pri-Or E, Kronenfeld G, Oved K, Eden E, Stubbs AP, Bont LJ, Hays JP. The diagnostic value of nasal microbiota and clinical parameters in a multi-parametric prediction model to differentiate bacterial versus viral infections in lower respiratory tract infections. PLoS One 2022; 17:e0267140. [PMID: 35436301 PMCID: PMC9015155 DOI: 10.1371/journal.pone.0267140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2021] [Accepted: 04/04/2022] [Indexed: 11/18/2022] Open
Abstract
Background The ability to accurately distinguish bacterial from viral infection would help clinicians better target antimicrobial therapy during suspected lower respiratory tract infections (LRTI). Although technological developments make it feasible to rapidly generate patient-specific microbiota profiles, evidence is required to show the clinical value of using microbiota data for infection diagnosis. In this study, we investigated whether adding nasal cavity microbiota profiles to readily available clinical information could improve machine learning classifiers to distinguish bacterial from viral infection in patients with LRTI. Results Various multi-parametric Random Forests classifiers were evaluated on the clinical and microbiota data of 293 LRTI patients for their prediction accuracies to differentiate bacterial from viral infection. The most predictive variable was C-reactive protein (CRP). We observed a marginal prediction improvement when 7 most prevalent nasal microbiota genera were added to the CRP model. In contrast, adding three clinical variables, absolute neutrophil count, consolidation on X-ray, and age group to the CRP model significantly improved the prediction. The best model correctly predicted 85% of the ‘bacterial’ patients and 82% of the ‘viral’ patients using 13 clinical and 3 nasal cavity microbiota genera (Staphylococcus, Moraxella, and Streptococcus). Conclusions We developed high-accuracy multi-parametric machine learning classifiers to differentiate bacterial from viral infections in LRTI patients of various ages. We demonstrated the predictive value of four easy-to-collect clinical variables which facilitate personalized and accurate clinical decision-making. We observed that nasal cavity microbiota correlate with the clinical variables and thus may not add significant value to diagnostic algorithms that aim to differentiate bacterial from viral infections.
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Affiliation(s)
- Yunlei Li
- Department of Pathology & Clinical Bioinformatics, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Chantal B. van Houten
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Stefan A. Boers
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | - Dan Engelhard
- Division of Paediatric Infectious Disease Unit, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - Robert Kraaij
- Department of Internal Medicine, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Saskia D. Hiltemann
- Department of Pathology & Clinical Bioinformatics, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Jie Ju
- Department of Pathology & Clinical Bioinformatics, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | | | | | | | - Wouter J. de Waal
- Department of Paediatrics, Diakonessenhuis, Utrecht, The Netherlands
| | - Karin M. de Winter-de Groot
- Department of Paediatric Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tom F. W. Wolfs
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Pieter Meijers
- Department of Paediatrics, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Bart Luijk
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Aik W. J. Bossink
- Department of Respiratory Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Michal Stein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Adi Klein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Jalal Ashkar
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Ellen Bamberger
- MeMed, Tirat Carmel, Israel
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Isaac Srugo
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Majed Odeh
- Department of Internal Medicine A, Bnai Zion Medical Centre, Haifa, Israel
| | - Yaniv Dotan
- Pulmonary Division, Rambam Health Care Campus, Haifa, Israel
| | | | | | | | | | | | | | | | | | | | | | | | - Andrew P. Stubbs
- Department of Pathology & Clinical Bioinformatics, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Louis J. Bont
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - John P. Hays
- Department of Medical Microbiology and Infectious Diseases, Erasmus MC Cancer Institute, University Medical Center Rotterdam, Rotterdam, The Netherlands
- * E-mail:
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van Houten CB, Cohen A, Engelhard D, Hays JP, Karlsson R, Moore E, Fernández D, Kreisberg R, Collins LV, de Waal W, de Winter-de Groot KM, Wolfs TFW, Meijers P, Luijk B, Oosterheert JJ, Heijligenberg R, Sankatsing SUC, Bossink AWJ, Stubbs A, Stein M, Reisfeld S, Klein A, Rachmilevitch R, Ashkar J, Braverman I, Kartun V, Chistyakov I, Bamberger E, Srugo I, Odeh M, Schiff E, Dotan Y, Boico O, Navon R, Friedman T, Etshtein L, Paz M, Gottlieb TM, Pri-Or E, Kronenfeld G, Simon E, Oved K, Eden E, Bont LJ. Antibiotic misuse in respiratory tract infections in children and adults-a prospective, multicentre study (TAILORED Treatment). Eur J Clin Microbiol Infect Dis 2019; 38:505-514. [PMID: 30707378 PMCID: PMC6394715 DOI: 10.1007/s10096-018-03454-2] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Accepted: 12/05/2018] [Indexed: 12/20/2022]
Abstract
Respiratory tract infections (RTI) are more commonly caused by viral pathogens in children than in adults. Surprisingly, little is known about antibiotic use in children as compared to adults with RTI. This prospective study aimed to determine antibiotic misuse in children and adults with RTI, using an expert panel reference standard, in order to prioritise the target age population for antibiotic stewardship interventions. We recruited children and adults who presented at the emergency department or were hospitalised with clinical presentation of RTI in The Netherlands and Israel. A panel of three experienced physicians adjudicated a reference standard diagnosis (i.e. bacterial or viral infection) for all the patients using all available clinical and laboratory information, including a 28-day follow-up assessment. The cohort included 284 children and 232 adults with RTI (median age, 1.3 years and 64.5 years, respectively). The proportion of viral infections was larger in children than in adults (209(74%) versus 89(38%), p < 0.001). In case of viral RTI, antibiotics were prescribed (i.e. overuse) less frequently in children than in adults (77/209 (37%) versus 74/89 (83%), p < 0.001). One (1%) child and three (2%) adults with bacterial infection were not treated with antibiotics (i.e. underuse); all were mild cases. This international, prospective study confirms major antibiotic overuse in patients with RTI. Viral infection is more common in children, but antibiotic overuse is more frequent in adults with viral RTI. Together, these findings support the need for effective interventions to decrease antibiotic overuse in RTI patients of all ages.
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Affiliation(s)
- Chantal B van Houten
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands
| | | | - Dan Engelhard
- Division of Paediatric Infectious Disease Unit, Hadassah-Hebrew University Medical Centre, Jerusalem, Israel
| | - John P Hays
- Department of Medical Microbiology and Infectious Diseases, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Roger Karlsson
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Edward Moore
- Department of Infectious Diseases, Institute of Biomedicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | | | - Wouter de Waal
- Department of Paediatrics, Diakonessenhuis, Utrecht, The Netherlands
| | - Karin M de Winter-de Groot
- Department of Paediatric Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tom F W Wolfs
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands
| | - Pieter Meijers
- Department of Paediatrics, Gelderse Vallei Hospital, Ede, The Netherlands
| | - Bart Luijk
- Department of Respiratory Medicine, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Jan Jelrik Oosterheert
- Department of Internal Medicine and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Rik Heijligenberg
- Department of Internal Medicine, Gelderse Vallei Hospital, Ede, The Netherlands
| | | | - Aik W J Bossink
- Department of Respiratory Medicine, Diakonessenhuis Utrecht, Utrecht, The Netherlands
| | - Andrew Stubbs
- Department of Bioinformatics, Erasmus University Medical Centre, Rotterdam, The Netherlands
| | - Michal Stein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Sharon Reisfeld
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Adi Klein
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | | | - Jalal Ashkar
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Itzhak Braverman
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Valery Kartun
- Department of Paediatrics, Hillel Yaffe Medical Centre, Hadera, Israel
| | - Irena Chistyakov
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Ellen Bamberger
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Isaac Srugo
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Majed Odeh
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Elad Schiff
- Department of Paediatrics, Bnai Zion Medical Centre, Haifa, Israel
| | - Yaniv Dotan
- Department of Internal Medicine, Bnai Zion Medical Centre, Haifa, Israel
| | | | | | | | | | | | | | | | | | | | | | | | - Louis J Bont
- Division of Paediatric Immunology and Infectious Diseases, University Medical Centre Utrecht, Utrecht University, P.O. Box 85090, Office KC.03.063.0, 3508 AB, Utrecht, The Netherlands.
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4
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Stein M, Lipman-Arens S, Oved K, Cohen A, Bamberger E, Navon R, Boico O, Friedman T, Etshtein L, Paz M, Gottlieb TM, Kriger O, Fonar Y, Pri-Or E, Yacobov R, Dotan Y, Hochberg A, Grupper M, Chistyakov I, Potasman I, Srugo I, Eden E, Klein A. A novel host-protein assay outperforms routine parameters for distinguishing between bacterial and viral lower respiratory tract infections. Diagn Microbiol Infect Dis 2017; 90:206-213. [PMID: 29273482 DOI: 10.1016/j.diagmicrobio.2017.11.011] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 11/16/2017] [Accepted: 11/18/2017] [Indexed: 01/12/2023]
Abstract
Bacterial and viral lower respiratory tract infections (LRTIs) are often clinically indistinguishable, leading to antibiotic overuse. We compared the diagnostic accuracy of a new assay that combines 3 host-biomarkers (TRAIL, IP-10, CRP) with parameters in routine use to distinguish bacterial from viral LRTIs. Study cohort included 184 potentially eligible pediatric and adult patients. Reference standard diagnosis was based on adjudication by an expert panel following comprehensive clinical and laboratory investigation (including respiratory PCRs). Experts were blinded to assay results and assay performers were blinded to reference standard outcomes. Evaluated cohort included 88 bacterial and 36 viral patients (23 did not fulfill inclusion criteria; 37 had indeterminate reference standard outcome). Assay distinguished bacterial from viral LRTI patients with sensitivity of 0.93±0.06 and specificity of 0.91±0.09, outperforming routine parameters, including WBC, CRP and chest x-ray signs. These findings support the assay's potential to help clinicians avoid missing bacterial LRTIs or overusing antibiotics.
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Affiliation(s)
- Michal Stein
- Infectious Diseases Unit, Hillel Yaffe Medical Center, Hadera, Israel.
| | | | - Kfir Oved
- MeMed Diagnostics, Tirat Carmel, Israel
| | - Asi Cohen
- MeMed Diagnostics, Tirat Carmel, Israel
| | - Ellen Bamberger
- MeMed Diagnostics, Tirat Carmel, Israel; Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Roy Navon
- MeMed Diagnostics, Tirat Carmel, Israel
| | | | - Tom Friedman
- MeMed Diagnostics, Tirat Carmel, Israel; Rambam Medical Center, Haifa, Israel
| | | | | | | | - Or Kriger
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yura Fonar
- Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Renata Yacobov
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Yaniv Dotan
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Amit Hochberg
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
| | - Moti Grupper
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Irina Chistyakov
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Israel Potasman
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Isaac Srugo
- Bnai Zion Medical Center, Haifa, Israel; Technion-Israel Institute of Technology, Haifa, Israel
| | - Eran Eden
- MeMed Diagnostics, Tirat Carmel, Israel
| | - Adi Klein
- Department of Pediatrics, Hillel Yaffe Medical Center, Hadera, Israel
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