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Eckhoff AM, Fletcher AA, Kelly MS, Dohlman A, McIntyre CA, Shen X, Iyer MK, Nussbaum DP, Allen PJ. Comprehensive Assessment of the Intrinsic Pancreatic Microbiome. Ann Surg 2024:00000658-990000000-00843. [PMID: 38623754 DOI: 10.1097/sla.0000000000006299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
OBJECTIVE We sought to comprehensively profile tissue and cyst fluid in patients with benign, precancerous, and cancerous conditions of the pancreas to characterize the intrinsic pancreatic microbiome. SUMMARY BACKGROUND DATA Small studies in pancreatic ductal adenocarcinoma (PDAC) and intraductal papillary mucinous neoplasm (IPMN) have suggested that intra-pancreatic microbial dysbiosis may drive malignant transformation. METHODS Pancreatic samples were collected at the time of resection from 109 patients. Samples included tumor tissue (control, n=20; IPMN, n=20; PDAC, n=19) and pancreatic cyst fluid (IPMN, n=30; SCA, n=10; MCN, n=10). Assessment of bacterial DNA by quantitative PCR and 16S ribosomal RNA gene sequencing was performed. Downstream analyses determined the relative abundances of individual taxa between groups and compared intergroup diversity. Whole-genome sequencing data from 140 patients with PDAC in the National Cancer Institute's Clinical Proteomic Tumor Analysis Consortium (CPTAC) were analyzed to validate findings. RESULTS Sequencing of pancreatic tissue yielded few microbial reads regardless of diagnosis, and analysis of pancreatic tissue showed no difference in the abundance and composition of bacterial taxa between normal pancreas, IPMN, or PDAC groups. Low-grade dysplasia (LGD) and high-grade dysplasia (HGD) IPMN were characterized by low bacterial abundances with no difference in tissue composition and a slight increase in Pseudomonas and Sediminibacterium in HGD cyst fluid. Decontamination analysis using the CPTAC database confirmed a low-biomass, low-diversity intrinsic pancreatic microbiome that did not differ by pathology. CONCLUSIONS Our analysis of the pancreatic microbiome demonstrated very low intrinsic biomass that is relatively conserved across diverse neoplastic conditions and thus unlikely to drive malignant transformation.
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Affiliation(s)
- Austin M Eckhoff
- Department of Surgery, Duke University; Durham, North Carolina, USA
| | | | - Matthew S Kelly
- Department of Pediatrics, Duke University; Durham, North Carolina, USA
- Department of Molecular Genetics and Microbiology; Durham, North Carolina, USA
| | - Anders Dohlman
- Department of Biomedical Engineering, Duke Microbiome Center, Duke University; Durham, North Carolina, USA
| | - Caitlin A McIntyre
- Department of Surgery, Memorial Sloan Kettering, New York, New York, USA
| | - Xiling Shen
- Department of Surgery, Memorial Sloan Kettering, New York, New York, USA
- Terasaki Institute, Los Angeles, California, USA
| | - Matthew K Iyer
- Department of Surgery, Duke University; Durham, North Carolina, USA
| | | | - Peter J Allen
- Department of Surgery, Duke University; Durham, North Carolina, USA
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Heston SM, Hurst JH, Kelly MS. Understanding the influence of the microbiome on childhood infections. Expert Rev Anti Infect Ther 2024:1-17. [PMID: 38605646 DOI: 10.1080/14787210.2024.2340664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 04/04/2024] [Indexed: 04/13/2024]
Abstract
INTRODUCTION The microbiome is known to have a substantial impact on human health and disease. However, the impacts of the microbiome on immune system development, susceptibility to infectious diseases, and vaccine-elicited immune responses are emerging areas of interest. AREAS COVERED In this review, we provide an overview of development of the microbiome during childhood. We highlight available data suggesting that the microbiome is critical to maturation of the immune system and modifies susceptibility to a variety of infections during childhood and adolescence, including respiratory tract infections, Clostridioides difficile infection, and sexually transmitted infections. We discuss currently available and investigational therapeutics that have the potential to modify the microbiome to prevent or treat infections among children. Finally, we review the accumulating evidence that the gut microbiome influences vaccine-elicited immune responses among children. EXPERT OPINION Recent advances in sequencing technologies have led to an explosion of studies associating the human microbiome with the risk and severity of infectious diseases. As our knowledge of the extent to which the microbiome influences childhood infections continues to grow, microbiome-based diagnostics and therapeutics will increasingly be incorporated into clinical practice to improve the prevention, diagnosis, and treatment of infectious diseases among children.
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Affiliation(s)
- Sarah M Heston
- Pediatrics, Duke University School of Medicine, Durham, NC, UK
| | - Jillian H Hurst
- Pediatrics, Duke University School of Medicine, Durham, NC, UK
| | - Matthew S Kelly
- Pediatrics, Duke University School of Medicine, Durham, NC, UK
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Elgarten CW, Margolis EB, Kelly MS. The Microbiome and Pediatric Transplantation. J Pediatric Infect Dis Soc 2024; 13:S80-S89. [PMID: 38417089 PMCID: PMC10901476 DOI: 10.1093/jpids/piad062] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 08/25/2023] [Indexed: 03/01/2024]
Abstract
The microbial communities that inhabit our bodies have been increasingly linked to host physiology and pathophysiology. This microbiome, through its role in colonization resistance, influences the risk of infections after transplantation, including those caused by multidrug-resistant organisms. In addition, through both direct interactions with the host immune system and via the production of metabolites that impact local and systemic immunity, the microbiome plays an important role in the establishment of immune tolerance after transplantation, and conversely, in the development of graft-versus-host disease and graft rejection. This review offers a comprehensive overview of the evidence for the role of the microbiome in hematopoietic cell and solid organ transplant complications, drivers of microbiome shift during transplantation, and the potential of microbiome-based therapies to improve pediatric transplantation outcomes.
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Affiliation(s)
- Caitlin W Elgarten
- Division of Oncology, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Department of Pediatrics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Elisa B Margolis
- Department of Infectious Diseases, St. Jude Children’s Research Hospital, Memphis, Tennessee, USA
- Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis, Tennessee, USA
| | - Matthew S Kelly
- Departments of Pediatrics and Molecular Genetics & Microbiology, Duke University School of Medicine, Durham, North Carolina, USA
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Stubbendieck RM, Hurst JH, Kelly MS. Dolosigranulum pigrum: A promising nasal probiotic candidate. PLoS Pathog 2024; 20:e1011955. [PMID: 38300905 PMCID: PMC10833571 DOI: 10.1371/journal.ppat.1011955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2024] Open
Affiliation(s)
- Reed M. Stubbendieck
- Department of Microbiology and Molecular Genetics, Oklahoma State University, Stillwater, Oklahoma, United States of America
| | - Jillian H. Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
- Children’s Health and Discovery Institute, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Matthew S. Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, United States of America
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Kelly MS, Cataldi JR, Schlaudecker EP, Shah SS, Vinci RJ, Myers AL. Child Health Needs and the Pediatric Infectious Diseases Workforce: 2020-2040. Pediatrics 2024; 153:e2023063678N. [PMID: 38300015 PMCID: PMC10852198 DOI: 10.1542/peds.2023-063678n] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/21/2023] [Indexed: 02/02/2024] Open
Abstract
Pediatric infectious diseases (PID) physicians prevent and treat childhood infections through clinical care, research, public health, education, antimicrobial stewardship, and infection prevention. This article is part of an American Board of Pediatrics Foundation-sponsored supplement investigating the future of the pediatric subspecialty workforce. The article offers context to findings from a modeling analysis estimating the supply of PID subspecialists in the United States between 2020 and 2040. It provides an overview of children cared for by PID subspecialists, reviews the current state of the PID workforce, and discusses the projected headcount and clinical workforce equivalents of PID subspecialists at the national, census region, and census division levels over this 2-decade period. The article concludes by discussing the education and training, clinical practice, policy, and research implications of the data presented. Adjusting for population growth, the PID workforce is projected to grow more slowly than most other pediatric subspecialties and geographic disparities in access to PID care are expected to worsen. In models considering alternative scenarios, decreases in the number of fellows and time spent in clinical care significantly affect the PID workforce. Notably, model assumptions may not adequately account for potential threats to the PID workforce, including a declining number of fellows entering training and the unknown impact of the COVID-19 pandemic and future emerging infections on workforce attrition. Changes to education and training, clinical care, and policy are needed to ensure the PID workforce can meet the future needs of US children.
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Affiliation(s)
- Matthew S. Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University, Durham, North Carolina
| | - Jessica R. Cataldi
- Department of Pediatrics, Section of Infectious Diseases, University of Colorado School of Medicine, Aurora, Colorado
| | - Elizabeth P. Schlaudecker
- Division of Infectious Diseases
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Samir S. Shah
- Division of Infectious Diseases
- Division of Hospital Medicine, Cincinnati Children’s Medical Center, Cincinnati, Ohio
- Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, Ohio
| | - Robert J. Vinci
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Angela L. Myers
- Division of Infectious Diseases, Children’s Mercy Kansas City, Kansas City, Missouri
- University of Missouri – Kansas City
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Heston SM, Young RR, Jenkins K, Martin PL, Stokhuyzen A, Ward DV, Bhattarai SK, Bucci V, Arshad M, Chao NJ, Seed PC, Kelly MS. The effects of antibiotic exposures on the gut resistome during hematopoietic cell transplantation in children. Gut Microbes 2024; 16:2333748. [PMID: 38555499 PMCID: PMC10984140 DOI: 10.1080/19490976.2024.2333748] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 03/19/2024] [Indexed: 04/02/2024] Open
Abstract
Antibiotic resistance is a global threat driven primarily by antibiotic use. We evaluated the effects of antibiotic exposures on the gut microbiomes and resistomes of children at high risk of colonization by antibiotic-resistant bacteria. We performed shotgun metagenomic sequencing of 691 serially collected fecal samples from 80 children (<18 years) undergoing hematopoietic cell transplantation. We evaluated the effects of aerobic (cefepime, vancomycin, fluoroquinolones, aminoglycosides, macrolides, and trimethoprim-sulfamethoxazole) and anaerobic (piperacillin-tazobactam, carbapenems, metronidazole, and clindamycin) antibiotic exposures on the diversity and composition of the gut microbiome and resistome. We identified 372 unique antibiotic resistance genes (ARGs); the most frequent ARGs identified encode resistance to tetracyclines (n = 88), beta-lactams (n = 84), and fluoroquinolones (n = 79). Both aerobic and anaerobic antibiotic exposures were associated with a decrease in the number of bacterial species (aerobic, β = 0.71, 95% CI: 0.64, 0.79; anaerobic, β = 0.66, 95% CI: 0.53, 0.82) and the number of unique ARGs (aerobic, β = 0.81, 95% CI: 0.74, 0.90; anaerobic, β = 0.73, 95% CI: 0.61, 0.88) within the gut metagenome. However, only antibiotic regimens that included anaerobic activity were associated with an increase in acquisition of new ARGs (anaerobic, β = 1.50; 95% CI: 1.12, 2.01) and an increase in the relative abundance of ARGs in the gut resistome (anaerobic, β = 1.62; 95% CI: 1.15, 2.27). Specific antibiotic exposures were associated with distinct changes in the number and abundance of ARGs for individual antibiotic classes. Our findings detail the impact of antibiotics on the gut microbiome and resistome and demonstrate that anaerobic antibiotics are particularly likely to promote acquisition and expansion of antibiotic-resistant bacteria.
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Affiliation(s)
- Sarah M. Heston
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Rebecca R. Young
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Insitute, Duke University School of Medicine, Durham, NC, USA
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Paul L. Martin
- Division of Pediatric Transplant and Cellular Therapy, Duke University School of Medicine, Durham, NC, USA
| | - Andre Stokhuyzen
- Division of Pediatric Transplant and Cellular Therapy, Duke University School of Medicine, Durham, NC, USA
| | - Doyle V. Ward
- Center for Microbiome Research, University of Massachusetts Medical School, Worcester, MA, USA
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Shakti K. Bhattarai
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Vanni Bucci
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, MA, USA
| | - Mehreen Arshad
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Nelson J. Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke University School of Medicine, Durham, NC, USA
| | - Patrick C. Seed
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children’s Hospital of Chicago, Chicago, IL, USA
| | - Matthew S. Kelly
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
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Bradley JS, Makieieva N, Tøndel C, Roilides E, Kelly MS, Patel M, Vaddady P, Maniar A, Zhang Y, Paschke A, Chen LF. Pharmacokinetics, Safety, and Tolerability of Imipenem/Cilastatin/Relebactam in Children with Confirmed or Suspected Gram-Negative Bacterial Infections: A Phase 1b, Open-Label, Single-Dose Clinical Trial. J Clin Pharmacol 2023; 63:1387-1397. [PMID: 37562063 DOI: 10.1002/jcph.2334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [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: 04/18/2023] [Accepted: 08/02/2023] [Indexed: 08/12/2023]
Abstract
Imipenem/cilastatin/relebactam is approved for the treatment of serious gram-negative bacterial infections in adults. This study assessed the pharmacokinetics (PK), safety, and tolerability of a single dose of imipenem/cilastatin/relebactam (with a fixed 2:1 ratio of imipenem/cilastatin to relebactam, and with a maximum dose of 15 mg/kg imipenem and 15 mg/kg cilastatin [≤500 mg imipenem and ≤500 mg cilastatin] and 7.5 mg/kg relebactam [≤250 mg relebactam]) in children with confirmed/suspected gram-negative bacterial infections receiving standard-of-care antibacterial therapy. In this phase 1, noncomparative study (ClinicalTrials.gov identifier, NCT03230916), PK parameters from 46 children were analyzed using both population modeling and noncompartmental analysis. The PK/pharmacodynamic (PD) target for imipenem was percent time of the dosing interval that unbound plasma concentration exceeded the minimum inhibitory concentration (%fT>MIC) of ≥30% (MIC = 2 mcg/mL). For relebactam, the PK/PD target was a free drug area under the plasma concentration-time curve (AUC) normalized to MIC (at 2 mcg/mL) of ≥8.0 (equivalent to an AUC from time zero extrapolated to infinity of ≥20.52 mcg·h/mL). Safety was assessed up to 14 days after drug infusion. For imipenem, the ranges for the geometric mean %fT>MIC and maximum concentration (Cmax ) across age cohorts were 56.5%-93.7% and 32.2-38.2 mcg/mL, respectively. For relebactam, the ranges of the geometric mean Cmax and AUC from 0 to 6 hours across age cohorts were 16.9-21.3 mcg/mL and 26.1-55.3 mcg·h/mL, respectively. In total, 8/46 (17%) children experienced ≥1 adverse events (AEs) and 2/46 (4%) children experienced nonserious AEs that were deemed drug related by the investigator. Imipenem and relebactam exceeded plasma PK/PD targets; single doses of imipenem/cilastatin/relebactam were well tolerated with no significant safety concerns identified. These results informed imipenem/cilastatin/relebactam dose selection for further pediatric clinical evaluation.
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Affiliation(s)
- John S Bradley
- Department of Pediatrics, University of California San Diego School of Medicine and Rady Children's Hospital of San Diego, San Diego, CA, USA
| | - Nataliia Makieieva
- Department of Pediatrics, Kharkiv National Medical University, Kharkiv, Ukraine
| | - Camilla Tøndel
- Department of Clinical Science, University of Bergen, and Department of Pediatrics, Haukeland University Hospital, Bergen, Norway
| | - Emmanuel Roilides
- Third Department of Pediatrics, Infectious Diseases Unit, School of Medicine, Aristotle University and Hippokration General Hospital, Thessaloniki, Greece
| | - Matthew S Kelly
- Department of Pediatrics, Duke University Medical Center, Durham, NC, USA
| | | | - Pavan Vaddady
- Merck & Co. Inc, Rahway, NJ, USA
- Daiichi Sankyo, Inc., Basking Ridge, NJ, USA
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Waters AR, Biddell CB, Killela M, Kasow KA, Page K, Wheeler SB, Drier SW, Kelly MS, Robles J, Spees LP. Financial burden and recommended multilevel solutions among caregivers of pediatric hematopoietic stem cell transplant recipients. Pediatr Blood Cancer 2023; 70:e30700. [PMID: 37776093 PMCID: PMC10615841 DOI: 10.1002/pbc.30700] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 09/18/2023] [Accepted: 09/20/2023] [Indexed: 10/01/2023]
Abstract
BACKGROUND The healthcare costs of patients who receive hematopoietic stem cell transplantation (HSCT) are substantial. At the same time, the increasing use of pediatric HSCT leaves more caregivers of pediatric HSCT recipients at risk for financial burden-an understudied area of research. METHODS Financial burden experienced by caregivers of recipients who received autologous or allogeneic transplants was assessed using an explanatory mixed-methods design including a one-time survey and semi-structured interviews. Financial burden was assessed through an adapted COmprehensive Score for financial Toxicity (COST) as well as questions about the types of out-of-pocket costs and cost-coping behaviors. Chi-squared or Fisher's exact tests were used to assess differences in costs incurred and coping behaviors by financial toxicity and financial toxicity by demographic factors. Interviews were audio recorded, transcribed, and analyzed using directed content analysis. RESULTS Of 99 survey participants, 64% experienced high financial toxicity (COST ≤ $ \le \;$ 22). Caregivers with high financial toxicity were more likely to report costs related to transportation and diet. High financial toxicity was associated with nearly all cost-coping behaviors (e.g., borrowed money). High financial toxicity was also associated with increased use of hospital financial support and transportation assistance. Qualitative analysis resulted in four categories that were integrated with quantitative findings: (1) care-related out-of-pocket costs incurred, (2) cost-coping behaviors, (3) financial support resources used, and (4) multilevel recommendations for reducing financial burden. CONCLUSIONS Considering the substantial, long-term financial burden among pediatric HSCT patients and their caregivers, this population would benefit from adapted and tailored financial burden interventions.
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Affiliation(s)
- Austin R Waters
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
| | - Caitlin B Biddell
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
| | - Mary Killela
- School of Nursing, UNC-CH, Chapel Hill, North Carolina, USA
| | - Kimberly A Kasow
- Department of Pediatrics, UNC-CH, Chapel Hill, North Carolina, USA
| | - Kristin Page
- Department of Pediatrics, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Stephanie B Wheeler
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
| | - Sarah W Drier
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
| | - Matthew S Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Joanna Robles
- Department of Pediatrics, Division of Pediatric Hematology-Oncology, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (UNC-CH), Chapel Hill, North Carolina, USA
- Lineberger Comprehensive Cancer Center, UNC-CH, Chapel Hill, North Carolina, USA
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Heston SM, Lim CSE, Ong C, Chua MC, Kelly MS, Yeo KT. Strain-resolved metagenomic analysis of the gut as a reservoir for bloodstream infection pathogens among premature infants in Singapore. Gut Pathog 2023; 15:55. [PMID: 37974294 PMCID: PMC10652614 DOI: 10.1186/s13099-023-00583-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Accepted: 11/08/2023] [Indexed: 11/19/2023] Open
Abstract
BACKGROUND Gut dysbiosis contributes to the high risk of bloodstream infection (BSI) among premature infants. Most prior studies of the premature infant gut microbiota were conducted in Western countries and prior to development of current tools for strain-resolved analysis. METHODS We performed metagenomic sequencing of weekly fecal samples from 75 premature infants at a single hospital in Singapore. We evaluated associations between clinical factors and gut microbiota composition using PERMANOVA and mixed effects linear regression. We used inStrain to perform strain-level analyses evaluating for gut colonization by BSI-causing strains. RESULTS Median (interquartile range) gestation was 27 (25, 29) weeks, and 63% of infants were born via Cesarean section. Antibiotic exposures (PERMANOVA; R2 = 0.017, p = 0.001) and postnatal age (R2 = 0.015, p = 0.001) accounted for the largest amount of variability in gut microbiota composition. Increasing postnatal age was associated with higher relative abundances of several common pathogens (Enterococcus faecalis: p < 0.0001; Escherichia coli: p < 0.0001; Klebsiella aerogenes: p < 0.0001; Klebsiella pneumoniae: p < 0.0001). Antibiotic exposures were generally associated with lower relative abundances of both frequently beneficial bacteria (e.g., Bifidobacterium species) and common enteric pathogens (e.g., Enterobacter, Klebsiella species). We identified strains identical to the blood culture isolate in fecal samples from 12 of 16 (75%) infants who developed BSI, including all infections caused by typical enteric bacteria. CONCLUSIONS Antibiotic exposures were the dominant modifiable factor affecting gut microbiota composition in a large cohort of premature infants from South-East Asia. Strain-resolved analyses indicate that the gut is an important reservoir for organisms causing BSI among premature infants.
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Affiliation(s)
- Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Charis Shu En Lim
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
| | - Chengsi Ong
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
- Department of Nutrition and Dietetics, KK Women's and Children's Hospital, Singapore, Singapore
| | - Mei Chien Chua
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Kee Thai Yeo
- Department of Neonatology, KK Women's and Children's Hospital, Singapore, Singapore.
- Duke-NUS Medical School, Singapore, Singapore.
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Hurst JH, Heston SM, Kelly MS. Host microbiome-pathogen interactions in pediatric infections. Curr Opin Infect Dis 2023; 36:399-404. [PMID: 37462955 PMCID: PMC10529085 DOI: 10.1097/qco.0000000000000949] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 09/12/2023]
Abstract
PURPOSE OF REVIEW In this review, we discuss recent research that has furthered our understanding of microbiome development during childhood, the role of the microbiome in infections during this life stage, and emerging opportunities for microbiome-based therapies for infection prevention or treatment in children. RECENT FINDINGS The microbiome is highly dynamic during childhood and shaped by a variety of host and environmental factors. In turn, the microbiome influences risk and severity of a broad range of infections during childhood, with recent studies highlighting potential roles in respiratory, gastrointestinal, and systemic infections. The microbiome exerts this influence through both direct interactions with potential pathogens and indirectly through modulation of host immune responses. The elucidation of some of these mechanisms by recent studies and the development of effective microbiome-based therapies for adults with recurrent Clostridioides difficile infection highlight the enormous promise that targeting the microbiome has for reducing the burden of infectious diseases during childhood. SUMMARY The microbiome has emerged as a key modifier of infection susceptibility and severity among children. Further research is needed to define the roles of microbes other than bacteria and to elucidate the mechanisms underlying microbiome-host and microbiome-pathogen interactions of importance to infectious diseases in children.
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Affiliation(s)
- Jillian H. Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
- Duke Microbiome Center, Duke University School of Medicine, Durham, NC
| | - Sarah M. Heston
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
- Duke Microbiome Center, Duke University School of Medicine, Durham, NC
| | - Matthew S. Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
- Duke Microbiome Center, Duke University School of Medicine, Durham, NC
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Hurst JH, Kelly MS. Leveraging the human microbiota to target bacterial respiratory pathogens: new paths toward an expanded antimicrobial armamentarium. mBio 2023; 14:e0085423. [PMID: 37338299 PMCID: PMC10470731 DOI: 10.1128/mbio.00854-23] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Indexed: 06/21/2023] Open
Abstract
Acute respiratory infections are the most frequent infections across the lifespan and are the leading infectious cause of death among children globally. Bacterial respiratory infections are routinely treated with antibiotics, nearly all of which are derived from microbial natural products. Unfortunately, antibiotic-resistant bacteria are an increasingly frequent cause of respiratory infections, and there are few new antibiotics in development that target these pathogens. In the article by Stubbendieck et al., the authors identified Rothia species that demonstrate in vitro and ex vivo growth inhibition of the respiratory pathobiont Moraxella catarrhalis. The authors present experiments suggesting that this activity is mediated at least in part through the secretion of a novel peptidoglycan endopeptidase that targets the M. catarrhalis cell wall. In this commentary, we discuss these findings in the context of the urgent threat of antimicrobial resistance and highlight the promise of the human respiratory microbiota as a source of novel biotherapeutics.
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Affiliation(s)
- Jillian H. Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Microbiome Center, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew S. Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Microbiome Center, Duke University School of Medicine, Durham, North Carolina, USA
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Hurst JH, Mohan AA, Dalapati T, George IA, Aquino JN, Lugo DJ, Pfeiffer TS, Rodriguez J, Rotta AT, Turner NA, Burke TW, McClain MT, Henao R, DeMarco CT, Louzao R, Denny TN, Walsh KM, Xu Z, Mejias A, Ramilo O, Woods CW, Kelly MS. Differential host responses within the upper respiratory tract and peripheral blood of children and adults with SARS-CoV-2 infection. medRxiv 2023:2023.07.31.23293337. [PMID: 37577568 PMCID: PMC10418569 DOI: 10.1101/2023.07.31.23293337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/15/2023]
Abstract
Age is among the strongest risk factors for severe outcomes from SARS-CoV-2 infection. We sought to evaluate associations between age and both mucosal and systemic host responses to SARS-CoV-2 infection. We profiled the upper respiratory tract (URT) and peripheral blood transcriptomes of 201 participants (age range of 1 week to 83 years), including 137 non-hospitalized individuals with mild SARS-CoV-2 infection and 64 uninfected individuals. Among uninfected children and adolescents, young age was associated with upregulation of innate and adaptive immune pathways within the URT, suggesting that young children are primed to mount robust mucosal immune responses to exogeneous respiratory pathogens. SARS-CoV-2 infection was associated with broad induction of innate and adaptive immune responses within the URT of children and adolescents. Peripheral blood responses among SARS-CoV-2-infected children and adolescents were dominated by interferon pathways, while upregulation of myeloid activation, inflammatory, and coagulation pathways was observed only in adults. Systemic symptoms among SARS-CoV-2-infected subjects were associated with blunted innate and adaptive immune responses in the URT and upregulation of many of these same pathways within peripheral blood. Finally, within individuals, robust URT immune responses were correlated with decreased peripheral immune activation, suggesting that effective immune responses in the URT may promote local viral control and limit systemic immune activation and symptoms. These findings demonstrate that there are differences in immune responses to SARS-CoV-2 across the lifespan, including between young children and adolescents, and suggest that these varied host responses contribute to observed differences in the clinical presentation of SARS-CoV-2 infection by age. One Sentence Summary Age is associated with distinct upper respiratory and peripheral blood transcriptional responses among children and adults with SARS-CoV-2 infection.
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Affiliation(s)
- Ashley A Fletcher
- Department of Surgery, Division of Surgical Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Associate Director of the Duke Microbiome Center, Duke University, Durham, NC, USA
| | - Austin M Eckhoff
- Department of Surgery, Division of Surgical Oncology, Duke University School of Medicine, Durham, NC, USA
| | - Peter J Allen
- Department of Surgery, Division of Surgical Oncology, Duke University School of Medicine, Durham, NC, USA.
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Tran TH, Roberts AQ, Escapa IF, Gao W, Segre JA, Kong HH, Conlan S, Kelly MS, Lemon KP. Metabolic capabilities are highly conserved among human nasal-associated Corynebacterium species in pangenomic analyses. bioRxiv 2023:2023.06.05.543719. [PMID: 37333201 PMCID: PMC10274666 DOI: 10.1101/2023.06.05.543719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/20/2023]
Abstract
Corynebacterium species are globally ubiquitous in human nasal microbiota across the lifespan. Moreover, nasal microbiota profiles typified by higher relative abundances of Corynebacterium are often positively associated with health. Among the most common human nasal Corynebacterium species are C. propinquum, C. pseudodiphtheriticum, C. accolens, and C. tuberculostearicum. Based on the prevalence of these species, at least two likely coexist in the nasal microbiota of 82% of adults. To gain insight into the functions of these four species, we identified genomic, phylogenomic, and pangenomic properties and estimated the functional protein repertoire and metabolic capabilities of 87 distinct human nasal Corynebacterium strain genomes: 31 from Botswana and 56 from the U.S. C. pseudodiphtheriticum had geographically distinct clades consistent with localized strain circulation, whereas some strains from the other species had wide geographic distribution across Africa and North America. All four species had similar genomic and pangenomic structures. Gene clusters assigned to all COG metabolic categories were overrepresented in the persistent (core) compared to the accessory genome of each species indicating limited strain-level variability in metabolic capacity. Moreover, core metabolic capabilities were highly conserved among the four species indicating limited species-level metabolic variation. Strikingly, strains in the U.S. clade of C. pseudodiphtheriticum lacked genes for assimilatory sulfate reduction present in the Botswanan clade and in the other studied species, indicating a recent, geographically related loss of assimilatory sulfate reduction. Overall, the minimal species and strain variability in metabolic capacity implies coexisting strains might have limited ability to occupy distinct metabolic niches.
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Affiliation(s)
- Tommy H. Tran
- Alkek Center for Metagenomics & Microbiome Research, Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Ari Q. Roberts
- Alkek Center for Metagenomics & Microbiome Research, Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Isabel F. Escapa
- Alkek Center for Metagenomics & Microbiome Research, Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas, USA
| | - Wei Gao
- The Forsyth Institute (Microbiology), Cambridge, MA, USA
- Department of Oral Medicine, Infection and Immunity, Harvard School of Dental Medicine, Boston, MA, USA
| | - Julie A. Segre
- Microbial Genomics Section, Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Heidi H. Kong
- Dermatology Branch, National Institute of Arthritis and Musculoskeletal and Skin Diseases, National Institutes of Health, Bethesda, MD, USA
| | - Sean Conlan
- Microbial Genomics Section, Translational and Functional Genomics Branch, National Human Genome Research Institute, National Institutes of Health, Bethesda, MD, USA
| | - Matthew S. Kelly
- Division of Pediatric Infectious Diseases, Duke University School of Medicine, Durham, NC, USA
| | - Katherine P. Lemon
- Alkek Center for Metagenomics & Microbiome Research, Department of Molecular Virology & Microbiology, Baylor College of Medicine, Houston, Texas, USA
- Division of Infectious Diseases, Texas Children’s Hospital, Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
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15
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Moorthy GS, Young RR, Smith MJ, White MJ, Hong H, Kelly MS. Racial Inequities in Sepsis Mortality Among Children in the United States. Pediatr Infect Dis J 2023; 42:361-367. [PMID: 36795560 PMCID: PMC10101919 DOI: 10.1097/inf.0000000000003842] [Citation(s) in RCA: 0] [Impact Index Per Article: 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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
Abstract
BACKGROUND Racial inequities influence health outcomes in the United States, but their impact on sepsis outcomes among children is understudied. We aimed to evaluate for racial inequities in sepsis mortality using a nationally representative sample of pediatric hospitalizations. METHODS This population-based, retrospective cohort study used the 2006, 2009, 2012 and 2016 Kids' Inpatient Database. Eligible children 1 month to 17 years old were identified using sepsis-related International Classification of Diseases, Ninth Revision or International Classification of Diseases, Tenth Revision codes. We used modified Poisson regression to evaluate the association between patient race and in-hospital mortality, clustering by hospital and adjusting for age, sex and year. We used Wald tests to assess for modification of associations between race and mortality by sociodemographic factors, geographic region and insurance status. RESULTS Among 38,234 children with sepsis, 2555 (6.7%) died in-hospital. Compared with White children, mortality was higher among Hispanic (adjusted relative risk: 1.09; 95% confidence interval: 1.05-1.14), Asian/Pacific Islander (1.17, 1.08-1.27) and children from other racial minority groups (1.27, 1.19-1.35). Black children had similar mortality to White children overall (1.02, 0.96-1.07), but higher mortality in the South (7.3% vs. 6.4%; P < 0.0001). Hispanic children had higher mortality than White children in the Midwest (6.9% vs. 5.4%; P < 0.0001), while Asian/Pacific Islander children had higher mortality than all other racial categories in the Midwest (12.6%) and South (12.0%). Mortality was higher among uninsured children than among privately insured children (1.24, 1.17-1.31). CONCLUSIONS Risk of in-hospital mortality among children with sepsis in the United States differs by patient race, geographic region and insurance status.
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Affiliation(s)
- Ganga S. Moorthy
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Rebecca R. Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
| | - Michael J. Smith
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Michelle J. White
- Division of Hospital Medicine, Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Matthew S. Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
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Hicks ED, Agada NO, Yates TR, Kelly MS, Tam JS, Ferdman RM, Dibernardo LR, Madden JF, Moody MA, Markert ML. Case Report: Nontuberculous mycobacterial infections in children with complete DiGeorge anomaly. Front Immunol 2023; 14:1078976. [PMID: 36860874 PMCID: PMC9969526 DOI: 10.3389/fimmu.2023.1078976] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Accepted: 01/25/2023] [Indexed: 02/16/2023] Open
Abstract
Children with complete DiGeorge anomaly (cDGA) have congenital athymia, resulting in severe T cell immunodeficiency and susceptibility to a broad range of infections. We report the clinical course, immunologic phenotypes, treatment, and outcomes of three cases of disseminated nontuberculous mycobacterial infections (NTM) in patients with cDGA who underwent cultured thymus tissue implantation (CTTI). Two patients were diagnosed with Mycobacterium avium complex (MAC) and one patient with Mycobacterium kansasii. All three patients required protracted therapy with multiple antimycobacterial agents. One patient, who was treated with steroids due to concern for immune reconstitution inflammatory syndrome (IRIS), died due to MAC infection. Two patients have completed therapy and are alive and well. T cell counts and cultured thymus tissue biopsies demonstrated good thymic function and thymopoiesis despite NTM infection. Based on our experience with these three patients, we recommend that providers strongly consider macrolide prophylaxis upon diagnosis of cDGA. We obtain mycobacterial blood cultures when cDGA patients have fevers without a localizing source. In cDGA patients with disseminated NTM, treatment should consist of at least two antimycobacterial medications and be provided in close consultation with an infectious diseases subspecialist. Therapy should be continued until T cell reconstitution is achieved.
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Affiliation(s)
- Elizabeth Daly Hicks
- Division of Pediatric Allergy, Immunology, and Pulmonology, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Noah O Agada
- Division of Pediatric Allergy, Immunology, and Pulmonology, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Tyler R Yates
- Division of Pediatric Allergy, Immunology, and Pulmonology, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Matthew S Kelly
- Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States
| | - Jonathan S Tam
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Ronald M Ferdman
- Division of Clinical Immunology and Allergy, Children's Hospital Los Angeles, Los Angeles, CA, United States
| | - Louis R Dibernardo
- Department of Pathology, Duke University Medical Center, Durham, NC, United States
| | - John F Madden
- Department of Pathology, Duke University Medical Center, Durham, NC, United States
| | - M Anthony Moody
- Division of Pediatric Allergy, Immunology, and Pulmonology, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States.,Division of Infectious Diseases, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States.,Department of Immunology, Duke University Medical Center, Durham, NC, United States
| | - Mary Louise Markert
- Division of Pediatric Allergy, Immunology, and Pulmonology, Department of Pediatrics, Duke University Medical Center, Durham, NC, United States.,Department of Immunology, Duke University Medical Center, Durham, NC, United States
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Cunningham CK, Karron RA, Muresan P, Kelly MS, McFarland EJ, Perlowski C, Libous J, Oliva J, Jean-Philippe P, Moye J, Schappell E, Barr E, Rexroad V, Johnston B, Chadwick EG, Cielo M, Paul M, Deville JG, Aziz M, Yang L, Luongo C, Collins PL, Buchholz UJ. Evaluation of Recombinant Live-Attenuated Respiratory Syncytial Virus (RSV) Vaccines RSV/ΔNS2/Δ1313/I1314L and RSV/276 in RSV-Seronegative Children. J Infect Dis 2022; 226:2069-2078. [PMID: 35732186 PMCID: PMC10205613 DOI: 10.1093/infdis/jiac253] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [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: 04/05/2022] [Revised: 06/14/2022] [Accepted: 06/20/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND This United States-based study compared 2 candidate vaccines: RSV/ΔNS2/Δ1313/I1314L, attenuated by NS2 gene-deletion and temperature-sensitivity mutation in the polymerase gene; and RSV/276, attenuated by M2-2 deletion. METHODS RSV-seronegative children aged 6-24 months received RSV/ΔNS2/Δ1313/I1314L (106 plaque-forming units [PFU]), RSV/276 (105 PFU), or placebo intranasally. Participants were monitored for vaccine shedding, reactogenicity, and RSV serum antibodies, and followed over the subsequent RSV season. RESULTS Enrollment occurred September 2017 to October 2019. During 28 days postinoculation, upper respiratory illness and/or fever occurred in 64% of RSV/ΔNS2/Δ1313/I1314L, 84% of RSV/276, and 58% of placebo recipients. Symptoms were generally mild. Cough was more common in RSV/276 recipients than RSV/ΔNS2/Δ1313/I1314L (48% vs 12%; P = .012) or placebo recipients (17%; P = .084). There were no lower respiratory illness or serious adverse events. Eighty-eight and 96% of RSV/ΔNS2/Δ1313/I1314L and RSV/276 recipients were infected with vaccine (shed vaccine and/or had ≥4-fold rises in RSV antibodies). Serum RSV-neutralizing titers and anti-RSV F IgG titers increased ≥4-fold in 60% and 92% of RSV/ΔNS2/Δ1313/I1314L and RSV/276 vaccinees, respectively. Exposure to community RSV during the subsequent winter was associated with strong anamnestic RSV-antibody responses. CONCLUSIONS Both vaccines had excellent infectivity and were well tolerated. RSV/276 induced an excess of mild cough. Both vaccines were immunogenic and primed for strong anamnestic responses. CLINICAL TRIALS REGISTRATION NCT03227029 and NCT03422237.
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Affiliation(s)
- Coleen K Cunningham
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
- Department of Pediatrics, University of California, Irvine, California, USA
- Children’s Hospital of Orange County, Orange, California, USA
| | - Ruth A Karron
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Petronella Muresan
- Statistical and Data Management Center/Frontier Science and Technology Research Foundation, Brookline, Massachusetts, USA
| | - Matthew S Kelly
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina, USA
| | - Elizabeth J McFarland
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
| | | | | | - Jennifer Oliva
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Patrick Jean-Philippe
- Maternal, Adolescent and Pediatric Research Branch, Division of AIDS, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Jack Moye
- Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Institutes of Health, Bethesda, Maryland, USA
| | - Elizabeth Schappell
- Center for Immunization Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
| | - Emily Barr
- Department of Pediatrics, University of Colorado Anschutz Medical Campus and Children’s Hospital Colorado, Aurora, Colorado, USA
| | - Vivian Rexroad
- Investigational Drug Service Pharmacy, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Benjamin Johnston
- Frontier Science and Technology Research Foundation, Buffalo, New York, USA
| | - Ellen G Chadwick
- Department of Pediatrics, Northwestern University Feinberg School of Medicine and Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Mikhaela Cielo
- Division of Infectious Diseases, Maternal Child and Adolescent Center, University of Southern California Keck School of Medicine, Los Angeles, California, USA
| | - Mary Paul
- Department of Pediatrics, Baylor College of Medicine, Houston, Texas, USA
| | - Jaime G Deville
- David Geffen School of Medicine at University of California, Los Angeles, California, USA
| | - Mariam Aziz
- Rush University Medical Center, Cook County Hospital, Chicago, Illinois, USA
| | - Lijuan Yang
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Cindy Luongo
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Peter L Collins
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
| | - Ursula J Buchholz
- Laboratory of Infectious Diseases, National Institute of Allergy and Infectious Diseases, National Institutes of Health, Bethesda, Maryland, USA
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Chang YC, Young RR, Mavis AM, Chambers ET, Kirmani S, Kelly MS, Kalu IC, Smith MJ, Lugo DJ. Epstein-Barr Virus DNAemia and post-transplant lymphoproliferative disorder in pediatric solid organ transplant recipients. PLoS One 2022; 17:e0269766. [PMID: 36256635 PMCID: PMC9578615 DOI: 10.1371/journal.pone.0269766] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 09/22/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Pediatric solid organ transplant (SOT) recipients commonly have Epstein-Barr virus (EBV) DNAemia and are at risk of developing post-transplant lymphoproliferative disorder (PTLD). EBV DNAemia has not been analyzed on a continuous scale in this population. METHODS All children ≤ 18 years of age who underwent SOT at a single center between January 1, 2007 and July 31, 2018 were included in this retrospective study. Transplant episodes in which PTLD occurred were compared to transplant episodes without PTLD. Multivariable logistic regression was used to identify factors associated with the development of EBV DNAemia and maximum height of EBV DNAemia. A Cox proportional hazards model was used to calculate hazard ratios for time to PTLD. RESULTS Of 275 total transplant recipients and 294 transplant episodes, there were 14 episodes of PTLD. Intestinal and multivisceral transplant were strongly associated with PTLD (p = 0.002). Risk factors for the development of EBV DNAemia include donor and recipient positive EBV serologies (p = 0.001) and older age (p = 0.001). Maximum level of EBV DNAemia was significantly associated with development of PTLD (p<0.0001). Every one log (log10) increase in the maximum level of EBV DNAemia was associated with a more than doubling of the hazard on developing PTLD (HR: 2.18, 95% CI 1.19-3.99). CONCLUSIONS Transplant type was strongly associated with development of PTLD in pediatric SOT recipients. EBV serologies and age were associated with the development of EBV DNAemia and height of DNAemia. High levels of EBV DNAemia were strongly associated with an increased hazard for PTLD.
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Affiliation(s)
- Yeh-Chung Chang
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
- * E-mail:
| | - Rebecca R. Young
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Alisha M. Mavis
- Department of Pediatrics, Division of Gastroenterology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Eileen T. Chambers
- Department of Pediatrics, Division of Nephrology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Sonya Kirmani
- Department of Pediatrics, Division of Cardiology, University of Wisconsin-Madison, Madison, Wisconsin, United States of America
| | - Matthew S. Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Ibukunoluwa C. Kalu
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Michael J. Smith
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Debra J. Lugo
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, United States of America
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Uffman EA, Li SH, Chen JL, Allen N, Boiditswe S, Fouda GG, Hurst JH, Patel MZ, Steenhoff AP, Cunningham CK, Qin E, Davenport CA, Kelly MS. Kinetics of pneumococcal antibodies among HIV-exposed, uninfected infants in Botswana. Vaccine 2022; 40:4764-4771. [PMID: 35773120 PMCID: PMC9912097 DOI: 10.1016/j.vaccine.2022.06.059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 06/17/2022] [Accepted: 06/21/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Streptococcus pneumoniae is a leading cause of severe infections among children. Despite vaccination, HIV-exposed, uninfected (HEU) children have a higher incidence of invasive pneumococcal disease than HIV-unexposed, uninfected (HUU) children. We sought to compare the immunogenicity of 13-valent pneumococcal conjugate vaccine (PCV-13) in HEU and HUU infants. METHODS We conducted a prospective cohort study of 134 mother-infant dyads in Botswana. Infants received PCV-13 doses at 2, 3, and 4 months through routine clinical care. We measured IgG antibodies specific to vaccine serotypes in sera collected from infants at 0, 5, and 12 months of age. We calculated the proportion of infants with protective IgG levels (≥0.35 µg/mL) to specific pneumococcal serotypes. RESULTS At birth, fewer than half of infants had protective IgG levels to serotypes 1 (38%), 3 (46%), 4 (33%), 5 (23%), 6B (40%), 7F (44%), 9 V (44%), and 23F (46%). Compared to HUU infants (n = 97), HEU infants (n = 37) had lower antibody concentrations at birth to serotypes 5 (p = 0.046) and 19A (p = 0.008) after adjustment for maternal age and infant birth weight. More than 80% of HEU and HUU infants developed protective antibody levels to each of the 13 vaccine serotypes following PCV-13 vaccination. Median concentrations of antibodies to pneumococcal serotypes declined by 55-93% between 5 and 12 months of age, with fewer than half of infants having protective antibody levels to serotypes 1 (47%), 3 (28%), 9 V (44%), 18C (24%), and 23F (49%) at 12 months of age. CONCLUSIONS Both HEU and HUU infants developed protective antibody responses to PCV-13 administered in a 3 + 0 schedule. However, antibody concentrations to many pneumococcal serotypes waned substantially by 12 months of age, suggesting that a PCV-13 booster dose in the second year of life may be needed to maintain protective pneumococcal antibody levels in older infants and young children.
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Affiliation(s)
- Emilie A. Uffman
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Shuk Hang Li
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA,Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, NC, USA
| | - Jui-Lin Chen
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA
| | - Noel Allen
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | | | - Genevieve G. Fouda
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, NC, USA,Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Jillian H. Hurst
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | | | - Andrew P. Steenhoff
- Botswana-UPenn Partnership, Gaborone, Botswana,Global Health Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Coleen K. Cunningham
- Division of Pediatric Infectious Diseases, University of California-Irvine and Children’s Hospital of Orange County, Orange, CA, USA
| | - Emily Qin
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Clemontina A. Davenport
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, NC, USA
| | - Matthew S. Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC, USA
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Rao S, Hurst JH, Zhao C, Goldstein BA, Thomas L, Lang JE, Kelly MS. Asthma and the Risk of SARS-CoV-2 Infection Among Children and Adolescents. Pediatrics 2022; 149:185387. [PMID: 35274143 PMCID: PMC9647583 DOI: 10.1542/peds.2021-056164] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/04/2022] [Indexed: 12/25/2022] Open
Abstract
OBJECTIVES Over 6 million pediatric severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infections have occurred in the United States, but risk factors for infection remain poorly defined. We sought to evaluate the association between asthma and SARS-CoV-2 infection risk among children. METHODS We conducted a retrospective cohort study of children 5 to 17 years of age receiving care through the Duke University Health System and who had a Durham County, North Carolina residential address. Children were classified as having asthma using previously validated electronic health record-based definitions. SARS-CoV-2 infections were identified based on positive polymerase chain reaction testing of respiratory samples collected between March 1, 2020, and September 30, 2021. We matched children with asthma 1:1 to children without asthma, using propensity scores and used Poisson regression to evaluate the association between asthma and SARS-CoV-2 infection risk. RESULTS Of 46 900 children, 6324 (13.5%) met criteria for asthma. Children with asthma were more likely to be tested for SARS-CoV-2 infection than children without asthma (33.0% vs 20.9%, P < .0001). In a propensity score-matched cohort of 12 648 children, 706 (5.6%) children tested positive for SARS-CoV-2 infection, including 350 (2.8%) children with asthma and 356 (2.8%) children without asthma (risk ratio: 0.98, 95% confidence interval: 0.85-1.13. There was no evidence of effect modification of this association by inhaled corticosteroid prescription, history of severe exacerbation, or comorbid atopic diseases. Only 1 child with asthma required hospitalization for SARS-CoV-2 infection. CONCLUSIONS After controlling for factors associated with SARS-CoV-2 testing, we found that children with asthma have a similar SARS-CoV-2 infection risk as children without asthma.
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Affiliation(s)
| | - Jillian H. Hurst
- Children’s Health & Discovery Initiative,Pediatrics, Divisions of Infectious Diseases
| | | | - Benjamin A. Goldstein
- Children’s Health & Discovery Initiative,Departments of Biostatistics and Bioinformatics,Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Laine Thomas
- Departments of Biostatistics and Bioinformatics,Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Jason E. Lang
- Pulmonary and Sleep Medicine,Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Matthew S. Kelly
- Pediatrics, Divisions of Infectious Diseases,Address correspondence to Matthew S. Kelly, MD, MPH, DUMC Box 3499, Durham, NC 27705. E-mail:
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21
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Pernica JM, Arscott-Mills T, Steenhoff AP, Mokomane M, Moorad B, Bapabi M, Lechiile K, Mangwegape O, Batisani B, Mawoko N, Muthoga C, Vanniyasingam T, Ewusie J, Lowe A, Bonsu JM, Gezmu AM, Smieja M, Mazhani L, Stordal K, Thabane L, Kelly MS, Goldfarb DM. Optimising the management of childhood acute diarrhoeal disease using a rapid test-and- treat strategy and/or Lactobacillus reuteri DSM 17938: a multicentre, randomised, controlled, factorial trial in Botswana. BMJ Glob Health 2022; 7:bmjgh-2021-007826. [PMID: 35418412 PMCID: PMC9014020 DOI: 10.1136/bmjgh-2021-007826] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 10/27/2021] [Accepted: 03/14/2022] [Indexed: 11/03/2022] Open
Abstract
INTRODUCTION The study aim was to determine if rapid enteric diagnostics followed by the provision of targeted antibiotic therapy ('test-and-treat') and/or Lactobacillus reuteri DSM 17938 would improve outcomes in children hospitalised in Botswana with acute gastroenteritis. METHODS This was a multicentre, randomised, factorial, controlled, trial. Children aged 2-60 months admitted for acute non-bloody diarrhoea to four hospitals in southern Botswana were eligible. Participants were assigned to treatment groups by web-based block randomisation. Test-and-treat results were not blinded, but participants and research staff were blinded to L. reuteri/placebo assignment; this was dosed as 1×108 cfu/mL by mouth daily and continued for 60 days. The primary outcome was 60-day age-standardised height (HAZ) adjusted for baseline HAZ. All analyses were by intention to treat. The trial was registered at Clinicaltrials.gov. RESULTS Recruitment began on 12 June 2016 and continued until 24 October 2018. There were 66 participants randomised to the test-and-treat plus L. reuteri group, 68 randomised to the test-and-treat plus placebo group, 69 to the standard care plus L. reuteri group and 69 to the standard care plus placebo group. There was no demonstrable impact of the test-and-treat intervention (mean increase of 0.01 SD, 95% CI -0.14 to 0.16 SD) or the L. reuteri intervention (mean decrease of 0.07 SD, 95% CI -0.22 to 0.08 SD) on adjusted HAZ at 60 days. CONCLUSIONS In children hospitalised for acute gastroenteritis in Botswana, neither a test-and-treat algorithm targeting enteropathogens, nor a 60-day course of L. reuteri DSM 17938, were found to markedly impact linear growth or other important outcomes. We cannot exclude the possibility that test-and-treat will improve the care of children with significant enteropathogens (such as Shigella) in their stool. TRIAL REGISTRATION NUMBER NCT02803827.
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Affiliation(s)
- Jeffrey M Pernica
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada .,Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Tonya Arscott-Mills
- Botswana-UPenn Partnership, Gaborone, Botswana.,The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA.,Global Health Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Andrew P Steenhoff
- Global Health Center, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Margaret Mokomane
- Department of Microbiology, University of Botswana, Gaborone, South-East District, Botswana
| | | | | | | | | | | | | | - Charles Muthoga
- Botswana-UPenn Partnership, Gaborone, Botswana.,Botswana-Harvard AIDS Institute Partnership, Gaborone, Gaborone, Botswana
| | - Thuvaraha Vanniyasingam
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Joycelyne Ewusie
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,The Research Institute-Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Amy Lowe
- Department of Global Health, McMaster University, Hamilton, Ontario, Canada
| | - Janice M Bonsu
- University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Alemayehu M Gezmu
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Marek Smieja
- Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,Department of Pathology and Molecular Medicine, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Loeto Mazhani
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Ketil Stordal
- Pediatric Research Institute, University of Oslo Faculty of Medicine, Oslo, Norway
| | - Lehana Thabane
- Department of Pediatrics, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,Department of Health Research Methods, Evidence, and Impact, McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada.,The Research Institute-Biostatistics Unit, St Joseph's Healthcare Hamilton, Hamilton, Ontario, Canada.,University of Johannesburg Faculty of Health Sciences, Johannesburg, South Africa
| | - Matthew S Kelly
- Department of Pediatrics, Duke University, Durham, North Carolina, USA
| | - David M Goldfarb
- Department of Pathology and Laboratory Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
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22
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Hurst JH, McCumber AW, Aquino JN, Rodriguez J, Heston SM, Lugo DJ, Rotta AT, Turner NA, Pfeiffer TS, Gurley TC, Moody MA, Denny TN, Rawls JF, Clark JS, Woods CW, Kelly MS. Age-Related Changes in the Nasopharyngeal Microbiome Are Associated With Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) Infection and Symptoms Among Children, Adolescents, and Young Adults. Clin Infect Dis 2022; 75:e928-e937. [PMID: 35247047 PMCID: PMC8903463 DOI: 10.1093/cid/ciac184] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [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: 11/14/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Children are less susceptible to SARS-CoV-2 infection and typically have milder illness courses than adults, but the factors underlying these age-associated differences are not well understood. The upper respiratory microbiome undergoes substantial shifts during childhood and is increasingly recognized to influence host defense against respiratory pathogens. Thus, we sought to identify upper respiratory microbiome features associated with SARS-CoV-2 infection susceptibility and illness severity. METHODS We collected clinical data and nasopharyngeal swabs from 285 children, adolescents, and young adults (<21 years) with documented SARS-CoV-2 exposure. We used 16S ribosomal RNA gene sequencing to characterize the nasopharyngeal microbiome and evaluated for age-adjusted associations between microbiome characteristics and SARS-CoV-2 infection status and respiratory symptoms. RESULTS Nasopharyngeal microbiome composition varied with age (PERMANOVA, P < .001; R2 = 0.06) and between SARS-CoV-2-infected individuals with and without respiratory symptoms (PERMANOVA, P = .002; R2 = 0.009). SARS-CoV-2-infected participants with Corynebacterium/Dolosigranulum-dominant microbiome profiles were less likely to have respiratory symptoms than infected participants with other nasopharyngeal microbiome profiles (OR: .38; 95% CI: .18-.81). Using generalized joint attributed modeling, we identified 9 bacterial taxa associated with SARS-CoV-2 infection and 6 taxa differentially abundant among SARS-CoV-2-infected participants with respiratory symptoms; the magnitude of these associations was strongly influenced by age. CONCLUSIONS We identified interactive relationships between age and specific nasopharyngeal microbiome features that are associated with SARS-CoV-2 infection susceptibility and symptoms in children, adolescents, and young adults. Our data suggest that the upper respiratory microbiome may be a mechanism by which age influences SARS-CoV-2 susceptibility and illness severity.
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Affiliation(s)
| | | | - Jhoanna N Aquino
- Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Javier Rodriguez
- Children’s Clinical Research Unit, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah M Heston
- Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Debra J Lugo
- Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alexandre T Rotta
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicholas A Turner
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Trevor S Pfeiffer
- Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thaddeus C Gurley
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - M Anthony Moody
- Division of Infectious Diseases, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA,Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas N Denny
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - John F Rawls
- Department of Molecular Genetics and Microbiology, Duke University School of Medicine, Durham, North Carolina, USA,Duke Microbiome Center, Duke University School of Medicine, Durham, North Carolina, USAand
| | - James S Clark
- Nicholas School of the Environment, Duke University, Durham, North Carolina, USA
| | - Christopher W Woods
- Division of Infectious Diseases, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA,Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew S Kelly
- Correspondence: M. S. Kelly, 2301 Erwin Road, Durham, NC 27710 USA ()
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23
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Kelly MS, Plunkett C, Yu Y, Aquino JN, Patel SM, Hurst JH, Young RR, Smieja M, Steenhoff AP, Arscott-Mills T, Feemster KA, Boiditswe S, Leburu T, Mazhani T, Patel MZ, Rawls JF, Jawahar J, Shah SS, Polage CR, Cunningham CK, Seed PC. Non-diphtheriae Corynebacterium species are associated with decreased risk of pneumococcal colonization during infancy. ISME J 2022; 16:655-665. [PMID: 34511605 PMCID: PMC8857224 DOI: 10.1038/s41396-021-01108-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Revised: 08/22/2021] [Accepted: 09/03/2021] [Indexed: 02/08/2023]
Abstract
Streptococcus pneumoniae (pneumococcus) is a leading cause of severe infections among children and adults. Interactions between commensal microbes in the upper respiratory tract and S. pneumoniae are poorly described. In this study, we sought to identify interspecies interactions that modify the risk of S. pneumoniae colonization during infancy and to describe development of the upper respiratory microbiome during infancy in a sub-Saharan African setting. We collected nasopharyngeal swabs monthly (0-6 months of age) or bimonthly (6-12 months of age) from 179 mother-infant dyads in Botswana. We used 16S ribosomal RNA gene sequencing to characterize the nasopharyngeal microbiome and identified S. pneumoniae colonization using a species-specific PCR assay. We detect S. pneumoniae colonization in 144 (80%) infants at a median age of 71 days and identify a strong negative association between the relative abundance of the bacterial genera Corynebacterium within the infant nasopharyngeal microbiome and the risk of S. pneumoniae colonization. Using in vitro cultivation experiments, we demonstrate growth inhibition of S. pneumoniae by secreted factors from strains of several Corynebacterium species isolated from these infants. Finally, we demonstrate that antibiotic exposures and the winter season are associated with a decline in the relative abundance of Corynebacterium within the nasopharyngeal microbiome, while breastfeeding is associated with an increase in the Corynebacterium relative abundance. Our findings provide novel insights into the interspecies interactions that contribute to colonization resistance to S. pneumoniae and suggest that the nasopharyngeal microbiome may be a previously unrecognized mechanism by which environmental factors influence the risk of pneumococcal infections during childhood. Moreover, this work lays the foundation for future studies seeking to use targeted manipulation of the nasopharyngeal microbiome to prevent infections caused by S. pneumoniae.
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Affiliation(s)
- Matthew S. Kelly
- grid.7621.20000 0004 0635 5486Botswana-University of Pennsylvania Partnership, Gaborone, Botswana ,grid.26009.3d0000 0004 1936 7961Division of Pediatric Infectious Diseases, Duke University, Durham, NC USA
| | - Catherine Plunkett
- grid.16753.360000 0001 2299 3507Division of Pediatric Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Yahe Yu
- grid.40803.3f0000 0001 2173 6074Department of Mathematics, North Carolina State University, Raleigh, NC USA
| | - Jhoanna N. Aquino
- grid.26009.3d0000 0004 1936 7961Division of Pediatric Infectious Diseases, Duke University, Durham, NC USA
| | - Sweta M. Patel
- grid.26009.3d0000 0004 1936 7961Division of Pulmonary Allergy, and Critical Care Medicine, Duke University, Durham, NC USA
| | - Jillian H. Hurst
- grid.26009.3d0000 0004 1936 7961Division of Pediatric Infectious Diseases, Duke University, Durham, NC USA
| | - Rebecca R. Young
- grid.26009.3d0000 0004 1936 7961Division of Pediatric Infectious Diseases, Duke University, Durham, NC USA
| | - Marek Smieja
- grid.25073.330000 0004 1936 8227Department of Pathology and Molecular Medicine, McMaster University, Hamilton, ON Canada
| | - Andrew P. Steenhoff
- grid.7621.20000 0004 0635 5486Botswana-University of Pennsylvania Partnership, Gaborone, Botswana ,grid.239552.a0000 0001 0680 8770Global Health Center, Children’s Hospital of Philadelphia, Philadelphia, PA USA ,grid.239552.a0000 0001 0680 8770Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Tonya Arscott-Mills
- grid.7621.20000 0004 0635 5486Botswana-University of Pennsylvania Partnership, Gaborone, Botswana ,grid.239552.a0000 0001 0680 8770Global Health Center, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Kristen A. Feemster
- grid.239552.a0000 0001 0680 8770Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA USA
| | - Sefelani Boiditswe
- grid.7621.20000 0004 0635 5486Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Tirayaone Leburu
- grid.7621.20000 0004 0635 5486Botswana-University of Pennsylvania Partnership, Gaborone, Botswana
| | - Tiny Mazhani
- grid.7621.20000 0004 0635 5486University of Botswana School of Medicine, Gaborone, Botswana
| | - Mohamed Z. Patel
- grid.7621.20000 0004 0635 5486University of Botswana School of Medicine, Gaborone, Botswana
| | - John F. Rawls
- grid.26009.3d0000 0004 1936 7961Department of Molecular Genetics and Microbiology, Duke University, Durham, NC USA
| | - Jayanth Jawahar
- grid.26009.3d0000 0004 1936 7961Department of Molecular Genetics and Microbiology, Duke University, Durham, NC USA
| | - Samir S. Shah
- grid.239573.90000 0000 9025 8099Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH USA
| | - Christopher R. Polage
- grid.26009.3d0000 0004 1936 7961Department of Pathology, Duke University, Durham, NC USA
| | - Coleen K. Cunningham
- grid.26009.3d0000 0004 1936 7961Division of Pediatric Infectious Diseases, Duke University, Durham, NC USA
| | - Patrick C. Seed
- grid.16753.360000 0001 2299 3507Division of Pediatric Infectious Diseases, Feinberg School of Medicine, Northwestern University, Chicago, IL USA
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24
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Patel SM, Shaik-Dasthagirisaheb YB, Congdon M, Young RR, Patel MZ, Mazhani T, Boiditswe S, Leburu T, Lechiile K, Arscott-Mills T, Steenhoff AP, Feemster KA, Shah SS, Cunningham CK, Pelton SI, Kelly MS. Evolution of pneumococcal serotype epidemiology in Botswana following introduction of 13-valent pneumococcal conjugate vaccine. PLoS One 2022; 17:e0262225. [PMID: 34986196 PMCID: PMC8730465 DOI: 10.1371/journal.pone.0262225] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [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: 06/27/2021] [Accepted: 12/20/2021] [Indexed: 11/30/2022] Open
Abstract
Pneumococcal conjugate vaccines reduce the burden of invasive pneumococcal disease, but the sustained effect of these vaccines can be diminished by an increase in disease caused by non-vaccine serotypes. To describe pneumococcal serotype epidemiology in Botswana following introduction of 13-valent pneumococcal conjugate vaccine (PCV-13) in July 2012, we performed molecular serotyping of 268 pneumococcal strains isolated from 221 children between 2012 and 2017. The median (interquartile range) age of the children included in this analysis was 6 (3,12) months. Fifty-nine percent of the children had received at least one dose of PCV-13 and 35% were fully vaccinated with PCV-13. While colonization by vaccine serotypes steadily declined following PCV-13 introduction, 25% of strains isolated more than 3 years after vaccine introduction were PCV-13 serotypes. We also observed an increase in colonization by non-vaccine serotypes 21 and 23B, which have been associated with invasive pneumococcal disease and antibiotic resistance in other settings.
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Affiliation(s)
- Sweta M. Patel
- Division of Pulmonary, Allergy and Critical Care Medicine, Duke University, Durham, NC, United States of America
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- * E-mail:
| | | | - Morgan Congdon
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Rebecca R. Young
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC, United States of America
| | - Mohamed Z. Patel
- Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Tiny Mazhani
- Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | | | - Tirayaone Leburu
- Botswana—University of Pennsylvania Partnership, Gaborone, Botswana
| | - Kwana Lechiile
- Botswana—University of Pennsylvania Partnership, Gaborone, Botswana
| | - Tonya Arscott-Mills
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
- Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Botswana—University of Pennsylvania Partnership, Gaborone, Botswana
| | - Andrew P. Steenhoff
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
- Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
- Division of Pediatric Infectious Diseases and Global Health Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Kristen A. Feemster
- Division of Pediatric Infectious Diseases and Global Health Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, United States of America
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Medical Center, Cincinnati, OH, United States of America
| | - Coleen K. Cunningham
- Department of Pediatrics, University of California, Irvine, Irvine, CA, United States of America
| | - Stephen I. Pelton
- Division of Pediatric Infectious Diseases, Boston University School of Medicine, Boston, MA, United States of America
| | - Matthew S. Kelly
- Duke Global Health Institute, Duke University, Durham, NC, United States of America
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC, United States of America
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25
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Broderick DTJ, Waite DW, Marsh RL, Camargo CA, Cardenas P, Chang AB, Cookson WOC, Cuthbertson L, Dai W, Everard ML, Gervaix A, Harris JK, Hasegawa K, Hoffman LR, Hong SJ, Josset L, Kelly MS, Kim BS, Kong Y, Li SC, Mansbach JM, Mejias A, O’Toole GA, Paalanen L, Pérez-Losada M, Pettigrew MM, Pichon M, Ramilo O, Ruokolainen L, Sakwinska O, Seed PC, van der Gast CJ, Wagner BD, Yi H, Zemanick ET, Zheng Y, Pillarisetti N, Taylor MW. Bacterial Signatures of Paediatric Respiratory Disease: An Individual Participant Data Meta-Analysis. Front Microbiol 2021; 12:711134. [PMID: 35002989 PMCID: PMC8733647 DOI: 10.3389/fmicb.2021.711134] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: The airway microbiota has been linked to specific paediatric respiratory diseases, but studies are often small. It remains unclear whether particular bacteria are associated with a given disease, or if a more general, non-specific microbiota association with disease exists, as suggested for the gut. We investigated overarching patterns of bacterial association with acute and chronic paediatric respiratory disease in an individual participant data (IPD) meta-analysis of 16S rRNA gene sequences from published respiratory microbiota studies. Methods: We obtained raw microbiota data from public repositories or via communication with corresponding authors. Cross-sectional analyses of the paediatric (<18 years) microbiota in acute and chronic respiratory conditions, with >10 case subjects were included. Sequence data were processed using a uniform bioinformatics pipeline, removing a potentially substantial source of variation. Microbiota differences across diagnoses were assessed using alpha- and beta-diversity approaches, machine learning, and biomarker analyses. Results: We ultimately included 20 studies containing individual data from 2624 children. Disease was associated with lower bacterial diversity in nasal and lower airway samples and higher relative abundances of specific nasal taxa including Streptococcus and Haemophilus. Machine learning success in assigning samples to diagnostic groupings varied with anatomical site, with positive predictive value and sensitivity ranging from 43 to 100 and 8 to 99%, respectively. Conclusion: IPD meta-analysis of the respiratory microbiota across multiple diseases allowed identification of a non-specific disease association which cannot be recognised by studying a single disease. Whilst imperfect, machine learning offers promise as a potential additional tool to aid clinical diagnosis.
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Affiliation(s)
| | - David W. Waite
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
| | - Robyn L. Marsh
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
| | - Carlos A. Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Paul Cardenas
- Colegio de Ciencias Biológicas y Ambientales, Instituto de Microbiología, Universidad San Francisco de Quito, Quito, Ecuador
| | - Anne B. Chang
- Child Health Division, Menzies School of Health Research, Charles Darwin University, Darwin, NT, Australia
- Department of Respiratory and Sleep Medicine, Queensland Children’s Hospital, Brisbane, QLD, Australia
- Australian Centre for Health Services Innovation, Queensland University of Technology, Brisbane, QLD, Australia
| | - William O. C. Cookson
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Leah Cuthbertson
- Royal Brompton and Harefield NHS Foundation Trust, London, United Kingdom
| | - Wenkui Dai
- Department of Obstetrics and Gynecology, Peking University Shenzhen Hospital, Shenzhen, China
| | - Mark L. Everard
- School of Medicine, University of Western Australia, Perth, WA, Australia
| | - Alain Gervaix
- Department of Pediatrics, Gynecology and Obstetrics, Faculty of Medicine, University Hospitals of Geneva, Geneva, Switzerland
| | - J. Kirk Harris
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, MA, United States
- Harvard Medical School, Boston, MA, United States
| | - Lucas R. Hoffman
- Seattle Children’s Hospital, Seattle, WA, United States
- Department of Pediatrics and Microbiology, University of Washington, Seattle, WA, United States
| | - Soo-Jong Hong
- Department of Pediatrics, Childhood Asthma Atopy Center, Humidifier Disinfectant Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, South Korea
| | | | - Matthew S. Kelly
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC, United States
| | - Bong-Soo Kim
- Department of Life Science, Multidisciplinary Genome Institute, Hallym University, Chuncheon, South Korea
| | - Yong Kong
- Department of Biostatistics, Yale School of Public Health, Yale University, New Haven, CT, United States
| | - Shuai C. Li
- Department of Computer Science, City University of Hong Kong, Kowloon, Hong Kong SAR, China
- Department of Biomedical Engineering, City University of Hong Kong, Kowloon, Hong Kong SAR, China
| | - Jonathan M. Mansbach
- Harvard Medical School, Boston, MA, United States
- Department of Pediatrics, Boston Children’s Hospital, Boston, MA, United States
| | - Asuncion Mejias
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Center for Vaccines and Immunity, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - George A. O’Toole
- Department of Microbiology and Immunology, Geisel School of Medicine at Dartmouth, Hanover, NH, United States
| | - Laura Paalanen
- Finnish Institute for Health and Welfare (THL), Helsinki, Finland
| | - Marcos Pérez-Losada
- Department of Biostatistics and Bioinformatics, Computational Biology Institute, Milken Institute School of Public Health, George Washington University, Washington, DC, United States
- CIBIO-InBIO, Centro de Investigação em Biodiversidade e Recursos Genéticos, Universidade do Porto, Campus Agrário de Vairão, Vairão, Portugal
| | - Melinda M. Pettigrew
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, CT, United States
| | - Maxime Pichon
- CHU Poitiers, Infectious Agents Department, Poitiers, France
- University of Poitiers, INSERM U1070, Poitiers, France
| | - Octavio Ramilo
- Division of Pediatric Infectious Diseases, Department of Pediatrics, Center for Vaccines and Immunity, Abigail Wexner Research Institute at Nationwide Children’s Hospital, The Ohio State University College of Medicine, Columbus, OH, United States
| | - Lasse Ruokolainen
- Department of Biosciences, University of Helsinki, Helsinki, Finland
| | | | - Patrick C. Seed
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, United States
| | | | - Brandie D. Wagner
- Department of Biostatistics and Informatics, Colorado School of Public Health, University of Colorado, Aurora, Aurora, CO, United States
| | - Hana Yi
- School of Biosystem and Biomedical Science, Korea University, Seoul, South Korea
| | - Edith T. Zemanick
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, United States
| | | | | | - Michael W. Taylor
- School of Biological Sciences, University of Auckland, Auckland, New Zealand
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26
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Heston SM, Young RR, Tanaka JS, Jenkins K, Vinesett R, Saccoccio FM, Martin PL, Chao NJ, Kelly MS. Risk Factors for CMV Viremia and Treatment-Associated Adverse Events Among Pediatric Hematopoietic Stem Cell Transplant Recipients. Open Forum Infect Dis 2021; 9:ofab639. [PMID: 35111869 PMCID: PMC8802801 DOI: 10.1093/ofid/ofab639] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [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: 11/05/2021] [Accepted: 12/13/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Cytomegalovirus (CMV) causes substantial morbidity and mortality after hematopoietic stem cell transplantation (HSCT). There are limited data on risk factors for CMV viremia and the safety of antiviral medications used to treat CMV in children. METHODS We conducted a single-center retrospective study of children who underwent HSCT between 2000 and 2016. We used log-logistic regression to evaluate associations between clinical characteristics and CMV-free survival at 100 days after HSCT. We compared the incidences of laboratory-defined adverse events (AEs) during treatment with ganciclovir and foscarnet. RESULTS Among 969 children, the median (interquartile range) age was 6.5 (3.1-11.5) years, and 80% underwent allogeneic HSCT. Two hundred forty-four (25%) children developed CMV viremia. Older age (odds ratio [OR], 0.95; 95% CI, 0.92-0.98), male sex (OR, 0.71; 95% CI, 0.51-0.99), non-Black, non-White race (OR, 0.56; 95% CI, 0.36-0.87), umbilical cord blood donor source (OR, 0.28; 95% CI, 0.08-0.97), and CMV seropositivity (R-/D+: OR, 0.17; 95% CI, 0.07-0.41; R+/D-: OR, 0.14; 95% CI, 0.09-0.21; R+/D+: OR, 0.08; 95% CI, 0.04-0.15) were associated with lower odds of 100-day CMV-free survival. Compared with foscarnet, ganciclovir was associated with lower incidences of thrombocytopenia (incidence rate ratio [IRR], 0.38; 95% CI, 0.15-0.97), electrolyte AEs (IRR, 0.42; 95% CI, 0.24-0.75), endocrine AEs (IRR, 0.52; 95% CI, 0.34-0.79), and renal AEs (IRR, 0.36; 95% CI, 0.19-0.65). CONCLUSIONS CMV viremia occurred commonly among children after HSCT, and ganciclovir and foscarnet were associated with distinct toxicity profiles among children with CMV infection. These findings should be considered when developing CMV prevention and treatment strategies for children after HSCT.
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Affiliation(s)
- Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA,Correspondence: Sarah Heston, MD, Duke Children’s Health Center, Box 102346, Durham, NC 27710 ()
| | - Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - John S Tanaka
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard Vinesett
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Frances M Saccoccio
- Division of Pediatric Infectious Diseases, University of Florida Shands Children’s Hospital, Gainesville, Florida, USA
| | - Paul L Martin
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Nelson J Chao
- Division of Hematologic Malignancies and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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Bradley JS, Makieieva N, Tøndel C, Roilides E, Kelly MS, Patel M, Vaddady P, Maniar A, Zhang Y, Paschke A, Butterton JR, Chen LF. 1159. Pharmacokinetics, Safety, and Tolerability of Imipenem/Cilastatin/Relebactam in Pediatric Participants With Confirmed or Suspected Gram-negative Bacterial Infections: A Phase 1b, Open-label, Single-Dose Clinical Trial. Open Forum Infect Dis 2021. [PMCID: PMC8643896 DOI: 10.1093/ofid/ofab466.1352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Background Imipenem/cilastatin/relebactam (IMI/REL) is approved for treating hospital-acquired/ventilator-associated bacterial pneumonia, complicated urinary tract infection, and complicated intra-abdominal infection in adults. This study assessed single-dose pharmacokinetics (PK), safety, and tolerability of IMI/REL in neonatal and pediatric participants with confirmed or suspected gram-negative bacterial infections. Methods This was a phase 1, open-label, non-comparative study (NCT03230916). Age- and weight-adjusted dosing is summarized in Table 1. The primary objective was to characterize the PK profiles for imipenem and relebactam after a single intravenous dose of IMI/REL. PK parameters were analyzed using population modeling. The PK target for imipenem was the percent time of the dosing interval that the unbound plasma concentration exceeded the minimum inhibitory concentration (%fT >MIC) of ≥30% (MIC used, 2 µg/mL). The PK target for relebactam was an area under the curve (AUC)/MIC ratio >8 (MIC used, 2 µg/mL), corresponding to AUC0-24h >58.88 μM∙h. Safety and tolerability were assessed for up to 14 days after drug infusion. ![]()
Results Of the 46 participants who received IMI/REL, 42 were included in the PK analysis. The mean plasma concentration-time profiles for imipenem and relebactam were generally comparable across age cohorts (Figure). For imipenem, the geometric mean %ƒT >MIC ranged from 50% to 94% and the mean maximum concentration (Cmax) ranged from 65 μM to 126 μM (Table 2). For relebactam, the geometric Cmax ranged from 33 μM to 87 μM and mean AUC0-6h ranged from 51 μM·h to 159 μM·h across the age cohorts (Table 2). IMI/REL was well tolerated with 8 (17.4%) participants experiencing ≥1 adverse events (AE) and 2 (4.3%) participants experiencing AE that were deemed drug related by the investigator. Drug-related AE were increased alanine aminotransferase, increased aspartate aminotransferase, anemia, and diarrhea, which were non-serious, mild in severity, and resolved within the follow-up period of 14 days. Figure 1 ![]()
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Conclusion Imipenem and relebactam exceeded the pediatric plasma PK targets across pediatric age cohorts in the study; the single doses of IMI/REL were well tolerated. These results will inform IMI/REL dose selection for further pediatric clinical evaluation. Disclosures Camilla Tøndel, MD, PhD, Merck & Co., Inc., (Grant/Research Support) Emmanuel Roilides, MD, PhD, FIDSA, FAAM, FESCMID, FECMM, FISAC, Merck Sharp & Dohme Corp. (Consultant, Grant/Research Support) Matthew S. Kelly, MD, MPH, Merck Sharp & Dohme Corp. (Consultant, Grant/Research Support) Munjal Patel, PhD, Merck Sharp & Dohme Corp. (Employee, Shareholder) Pavan Vaddady, PhD, Merck Sharp & Dohme Corp. (Employee) Alok Maniar, MD, MPH, Merck Sharp & Dohme Corp. (Employee, Shareholder) Ying Zhang, PhD, Merck & Co., Inc. (Employee, Shareholder) Amanda Paschke, MD MSCE, Merck Sharp & Dohme Corp. (Employee, Shareholder) Joan R. Butterton, MD, Merck Sharp & Dohme Corp. (Employee, Shareholder) Luke F. Chen, MBBS MPH MBA FRACP FSHEA FIDSA, Merck (Employee)
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Affiliation(s)
- John S Bradley
- University of California San Diego, San Diego, California
| | - Nataliia Makieieva
- Kharkiv National Medical University, Kharkiv, Kharkivs’ka Oblast’, Ukraine
| | - Camilla Tøndel
- Haukeland University Hospital, Bergen, Hordaland, Norway
| | - Emmanuel Roilides
- Aristotle University and Hippokration General Hospital, Thessaloniki, Thessaloniki, Greece
| | | | | | | | | | - Ying Zhang
- Merck & Co., Inc., Kenilworth, New Jersey
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Hurst JH, Heston SM, Chambers HN, Cunningham HM, Price MJ, Suarez L, Crew CG, Bose S, Aquino JN, Carr ST, Griffin SM, Smith SH, Jenkins K, Pfeiffer TS, Rodriguez J, DeMarco CT, De Naeyer NA, Gurley TC, Louzao R, Zhao C, Cunningham CK, Steinbach WJ, Denny TN, Lugo DJ, Moody MA, Permar SR, Rotta AT, Turner NA, Walter EB, Woods CW, Kelly MS. Severe Acute Respiratory Syndrome Coronavirus 2 Infections Among Children in the Biospecimens from Respiratory Virus-Exposed Kids (BRAVE Kids) Study. Clin Infect Dis 2021; 73:e2875-e2882. [PMID: 33141180 PMCID: PMC7665428 DOI: 10.1093/cid/ciaa1693] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 10/30/2020] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Child with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection typically have mild symptoms that do not require medical attention, leaving a gap in our understanding of the spectrum of SARS-CoV-2-related illnesses that the viruses causes in children. METHODS We conducted a prospective cohort study of children and adolescents (aged <21 years) with a SARS-CoV-2-infected close contact. We collected nasopharyngeal or nasal swabs at enrollment and tested for SARS-CoV-2 using a real-time polymerase chain reaction assay. RESULTS Of 382 children, 293 (77%) were SARS-CoV-2-infected. SARS-CoV-2-infected children were more likely to be Hispanic (P < .0001), less likely to have asthma (P = .005), and more likely to have an infected sibling contact (P = .001) than uninfected children. Children aged 6-13 years were frequently asymptomatic (39%) and had respiratory symptoms less often than younger children (29% vs 48%; P = .01) or adolescents (29% vs 60%; P < .001). Compared with children aged 6-13 years, adolescents more frequently reported influenza-like (61% vs 39%; P < .001) , and gastrointestinal (27% vs 9%; P = .002), and sensory symptoms (42% vs 9%; P < .0001) and had more prolonged illnesses (median [interquartile range] duration: 7 [4-12] vs 4 [3-8] days; P = 0.01). Despite the age-related variability in symptoms, wWe found no difference in nasopharyngeal viral load by age or between symptomatic and asymptomatic children. CONCLUSIONS Hispanic ethnicity and an infected sibling close contact are associated with increased SARS-CoV-2 infection risk among children, while asthma is associated with decreased risk. Age-related differences in clinical manifestations of SARS-CoV-2 infection must be considered when evaluating children for coronavirus disease 2019 and in developing screening strategies for schools and childcare settings.
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Affiliation(s)
- Jillian H Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Children’s Health and Discovery Institute, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah M Heston
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Meghan J Price
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Lilianna Suarez
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Carter G Crew
- Children’s Health and Discovery Institute, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Shree Bose
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Jhoanna N Aquino
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stuart T Carr
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - S Michelle Griffin
- Children’s Clinical Research Unit, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stephanie H Smith
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kirsten Jenkins
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Trevor S Pfeiffer
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Javier Rodriguez
- Children’s Clinical Research Unit, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - C Todd DeMarco
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicole A De Naeyer
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thaddeus C Gurley
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Raul Louzao
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Congwen Zhao
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Coleen K Cunningham
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - William J Steinbach
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas N Denny
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Debra J Lugo
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - M Anthony Moody
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sallie R Permar
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
- Children’s Health and Discovery Institute, Department of Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Alexandre T Rotta
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Nicholas A Turner
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Emmanuel B Walter
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, North Carolina, USA
- Department of Pediatrics, Division of Primary Care Pediatrics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Christopher W Woods
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
| | - Matthew S Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, North Carolina, USA
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Congdon M, Hong H, Young RR, Cunningham CK, Enane LA, Arscott-Mills T, Banda FM, Chise M, Motlhatlhedi K, Feemster K, Patel SM, Boiditswe S, Leburu T, Shah SS, Steenhoff AP, Kelly MS. Effect of Haemophilus influenzae Type b and 13-Valent Pneumococcal Conjugate Vaccines on Childhood Pneumonia Hospitalizations and Deaths in Botswana. Clin Infect Dis 2021; 73:e410-e416. [PMID: 32634831 PMCID: PMC8282259 DOI: 10.1093/cid/ciaa919] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 04/12/2020] [Accepted: 06/29/2020] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Globally, pneumonia is the leading cause of death among children. Few data exist regarding the effect of Haemophilus influenzae type b (Hib) vaccine and 13-valent pneumococcal conjugate vaccine (PCV-13) on the burden of childhood pneumonia in African settings. METHODS We collected data on children aged 1 to 59 months at 3 hospitals in Botswana. Hib vaccine and PCV-13 were introduced in Botswana in November 2010 and July 2012, respectively. We compared pneumonia hospitalizations and deaths prevaccine (January 2009 to October 2010) with postvaccine (January 2013 to December 2017) using seasonally adjusted, interrupted time-series analyses. RESULTS We identified 6943 pneumonia hospitalizations and 201 pneumonia deaths. In the prevaccine period, pneumonia hospitalizations and deaths increased by 24% (rate, 1.24; 95% CI, .94-1.64) and 59% (rate, 1.59; 95% CI, .87-2.90) per year, respectively. Vaccine introduction was associated with a 48% (95% CI, 29-62%) decrease in the number of pneumonia hospitalizations and a 50% (95% CI, 1-75%) decrease in the number of pneumonia deaths between the end of the prevaccine period (October 2010) and the beginning of the postvaccine period (January 2013). During the postvaccine period, pneumonia hospitalizations and deaths declined by 6% (rate, .94; 95% CI, .89-.99) and 22% (rate, .78; 95% CI, .67-.92) per year, respectively. CONCLUSIONS Pneumonia hospitalizations and deaths among children declined sharply following introduction of Hib vaccine and PCV-13 in Botswana. This effect was sustained for more than 5 years after vaccine introduction, supporting the long-term effectiveness of these vaccines in preventing childhood pneumonia in Botswana.
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Affiliation(s)
- Morgan Congdon
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Coleen K Cunningham
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA
| | - Leslie A Enane
- The Ryan White Center for Pediatric Infectious Disease and Global Health, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Tonya Arscott-Mills
- Division of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
- Botswana–UPenn Partnership, Gaborone, Botswana
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Francis M Banda
- Botswana–UPenn Partnership, Gaborone, Botswana
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
| | | | - Keneilwe Motlhatlhedi
- Department of Family Medicine and Public Health, University of Botswana, Gaborone, Botswana
| | - Kristen Feemster
- Division of Pediatric Infectious Diseases and Global Health Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Sweta M Patel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University, Durham, North Carolina, USA
| | | | | | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Medical Center, Cincinnati, Ohio, USA
| | - Andrew P Steenhoff
- Department of Pediatrics and Adolescent Health, University of Botswana, Gaborone, Botswana
- Division of Pediatric Infectious Diseases and Global Health Center, Department of Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina, USA
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30
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Garrido C, Hurst JH, Lorang CG, Aquino JN, Rodriguez J, Pfeiffer TS, Singh T, Semmes EC, Lugo DJ, Rotta AT, Turner NA, Burke TW, McClain MT, Petzold EA, Permar SR, Moody MA, Woods CW, Kelly MS, Fouda GG. Asymptomatic or mild symptomatic SARS-CoV-2 infection elicits durable neutralizing antibody responses in children and adolescents. JCI Insight 2021; 6:e150909. [PMID: 34228642 PMCID: PMC8492306 DOI: 10.1172/jci.insight.150909] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 06/30/2021] [Indexed: 11/17/2022] Open
Abstract
As SARS-CoV-2 continues to spread globally, questions have emerged regarding the strength and durability of immune responses in specific populations. In this study, we evaluated humoral immune responses in 69 children and adolescents with asymptomatic or mild symptomatic SARS-CoV-2 infection. We detected robust IgM, IgG, and IgA antibody responses to a broad array of SARS-CoV-2 antigens at the time of acute infection and 2 and 4 months after acute infection in all participants. Notably, these antibody responses were associated with virus-neutralizing activity that was still detectable 4 months after acute infection in 94% of children. Moreover, antibody responses and neutralizing activity in sera from children and adolescents were comparable or superior to those observed in sera from 24 adults with mild symptomatic infection. Taken together, these findings indicate that children and adolescents with mild or asymptomatic SARS-CoV-2 infection generate robust and durable humoral immune responses that can likely contribute to protection from reinfection.
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Affiliation(s)
- Carolina Garrido
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, United States of America
| | - Jillian H Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Cynthia G Lorang
- Duke Human Vaccine Institute, Duke Univeristy School of Medicine, Durham, United States of America
| | - Jhoanna N Aquino
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Javier Rodriguez
- Children's Clinical Research Unit, Department of Pediatrics, Duke University School of Medicine, Durham, United States of America
| | - Trevor S Pfeiffer
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Tulika Singh
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, United States of America
| | - Eleanor C Semmes
- Department of Molecular Genetics and Microbiology, Duke University, Durham, United States of America
| | - Debra J Lugo
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Alexandre T Rotta
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, United States of America
| | - Nicholas A Turner
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Thomas W Burke
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, United States of America
| | - Micah T McClain
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Elizabeth A Petzold
- Children's Clinical Research Unit, Department of Pediatrics, Duke University School of Medicine, Durham, United States of America
| | - Sallie R Permar
- Department of Pediatrics, Weill Cornell Medical College, New York, United States of America
| | - M Anthony Moody
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, United States of America
| | - Christopher W Woods
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Matthew S Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
| | - Genevieve G Fouda
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, United States of America
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Garrido C, Hurst JH, Lorang CG, Aquino JN, Rodriguez J, Pfeiffer TS, Singh T, Semmes EC, Lugo DJ, Rotta AT, Turner NA, Burke TW, McClain MT, Petzold EA, Permar SR, Moody MA, Woods CW, Kelly MS, Fouda GG. Asymptomatic or mild symptomatic SARS-CoV-2 infection elicits durable neutralizing antibody responses in children and adolescents. medRxiv 2021. [PMID: 33907760 DOI: 10.1101/2021.04.17.21255663] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
As SARS-CoV-2 continues to spread globally, questions have emerged regarding the strength and durability of immune responses in specific populations. In this study, we evaluated humoral immune responses in 69 children and adolescents with asymptomatic or mild symptomatic SARS-CoV-2 infection. We detected robust IgM, IgG, and IgA antibody responses to a broad array of SARS-CoV-2 antigens at the time of acute infection and 2 and 4 months after acute infection in all participants. Notably, these antibody responses were associated with virus neutralizing activity that was still detectable 4 months after acute infection in 94% of children. Moreover, antibody responses and neutralizing activity in sera from children and adolescents were comparable or superior to those observed in sera from 24 adults with mild symptomatic infection. Taken together, these findings indicate children and adolescents with mild or asymptomatic SARS-CoV-2 infection generate robust and durable humoral immune responses that are likely to protect from reinfection.
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Hurst JH, McCumber AW, Aquino JN, Rodriguez J, Heston SM, Lugo DJ, Rotta AT, Turner NA, Pfeiffer TS, Gurley TC, Moody MA, Denny TN, Rawls JF, Woods CW, Kelly MS. Age-related changes in the upper respiratory microbiome are associated with SARS-CoV-2 susceptibility and illness severity. medRxiv 2021:2021.03.20.21252680. [PMID: 33791716 PMCID: PMC8010748 DOI: 10.1101/2021.03.20.21252680] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Children are less susceptible to SARS-CoV-2 and typically have milder illness courses than adults. We studied the nasopharyngeal microbiomes of 274 children, adolescents, and young adults with SARS-CoV-2 exposure using 16S rRNA gene sequencing. We find that higher abundances of Corynebacterium species are associated with SARS-CoV-2 infection and SARS-CoV-2-associated respiratory symptoms, while higher abundances of Dolosigranulum pigrum are present in SARS-CoV-2-infected individuals without respiratory symptoms. We also demonstrate that the abundances of these bacteria are strongly, and independently, associated with age, suggesting that the nasopharyngeal microbiome may be a potentially modifiable mechanism by which age influences SARS-CoV-2 susceptibility and severity. SUMMARY Evaluation of nasopharyngeal microbiome profiles in children, adolescents, and young adults with a SARS-CoV-2-infected close contact identified specific bacterial species that vary in abundance with age and are associated with SARS-CoV-2 susceptibility and the presence of SARS-CoV-2-associated respiratory symptoms.
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Heston SM, Young RR, Arshad M, Jenkins K, Martin PL, Ward DV, Bhattarai S, Bucci V, Seed PC, Kelly MS. 174. Shotgun Metagenomics and Colonization by Antibiotic-resistant Bacteria in Pediatric Hematopoietic Stem Cell Transplant Recipients. Open Forum Infect Dis 2020. [PMCID: PMC7776648 DOI: 10.1093/ofid/ofaa439.484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Bacteremia in hematopoietic stem cell transplant (HSCT) recipients most frequently arises from gut bacterial translocation and is associated with a higher mortality if the organism is antibiotic-resistant. We sought to determine the impact of prior antibiotic exposure on antibiotic resistance genes (ARGs) in the gut metagenomes of HSCT recipients to inform future infection prevention strategies.
Methods
We performed shotgun metagenomic sequencing of fecal samples collected during the transplant hospitalization from children (< 18 years of age) undergoing HSCT at Duke University between 2015 and 2018. Host-decontaminated sequencing reads were aligned to the Comprehensive Antibiotic Resistance Database. We used a negative binomial regression model to determine the impact of recent therapeutic antibiotic exposure on the number of ARGs prior to HSCT.
Results
Median age of the 77 children included in these analyses was 4.8 years, and 58% were male. Hematological malignancy was the transplant indication for 42% of children, and 87% of transplants were allogeneic. In the 654 longitudinal samples, we identified 926 unique ARGs, conferring resistance to 31 classes of antibiotics. The median number of ARGs per sample was 24 (interquartile range: 13, 49). The most common ARGs detected were dfrF (conferring resistance to trimethoprim), tetO (tetracyclines), and tetW (tetracyclines), each detected in >65% of samples. Of the 66 children with fecal samples collected prior to HSCT, 70% of children received therapeutic antibiotics in the 2 weeks prior to enrollment. Accounting for transplant indication, sex, and age, the incidence of ARGs was 47% higher in children who received recent therapeutic antibiotics (incidence rate ratio 1.47; 95% CI (1.03–2.13); p=0.04).
Conclusion
ARGs are commonly found in the gut metagenomes of pediatric HSCT recipients prior to HSCT and are associated with recent receipt of therapeutic antibiotics. Future directions for this dataset include determining the ability of ARGs in the metagenome to predict clinical outcomes, including mortality and infections. Understanding the colonization and acquisition of ARGs could inform infection prevention strategies and empiric therapies and lead to improved infectious outcomes in these high-risk patients.
Disclosures
All Authors: No reported disclosures
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Affiliation(s)
| | | | - Mehreen Arshad
- Northwestern University/Lurie Children’s Hospital of Chicago, Chicago, Illinois
| | | | - Paul L Martin
- Duke University Medical Center, Durham, North Carolina
| | - Doyle V Ward
- University of Massachusetts Medical School, Worcester, Massachusetts
| | | | - Vanni Bucci
- University of Massachusetts, N.Dartmouth, Massachusetts
| | - Patrick C Seed
- Northwestern University Feinberg School of Medicine, Ann & Robert H. Lurie Children’s Hospital, Stanley Manne Children’s Research Institute, Chicago, Illinois
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Elgarten CW, Li Y, Getz KD, Hemmer M, Huang YSV, Hall M, Wang T, Kitko CL, Jagasia MH, Nishihori T, Murthy HS, Hashem H, Cairo MS, Sharma A, Hashmi SK, Askar M, Beitinjaneh A, Kelly MS, Auletta JJ, Badawy SM, Mavers M, Aplenc R, MacMillan ML, Spellman SR, Arora M, Fisher BT. Broad-Spectrum Antibiotics and Risk of Graft-versus-Host Disease in Pediatric Patients Undergoing Transplantation for Acute Leukemia: Association of Carbapenem Use with the Risk of Acute Graft-versus-Host Disease. Transplant Cell Ther 2020; 27:177.e1-177.e8. [PMID: 33718896 DOI: 10.1016/j.jtct.2020.10.012] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Variation in the gastrointestinal (GI) microbiota after hematopoietic cell transplantation (HCT) has been associated with acute graft-versus-host disease (aGVHD). Because antibiotics induce dysbiosis, we examined the association of broad-spectrum antibiotics with subsequent aGVHD risk in pediatric patients undergoing HCT for acute leukemia. We performed a retrospective analysis in a dataset merged from 2 sources: (1) the Center for International Blood and Marrow Transplant Research, an observational transplantation registry, and (2) the Pediatric Health Information Services, an administrative database from freestanding children's hospitals. We captured exposure to 3 classes of antibiotics used for empiric treatment of febrile neutropenia: (1) broad-spectrum cephalosporins, (2) antipseudomonal penicillins, and (3) carbapenems. The primary outcome was grade II-IV aGVHD; secondary outcomes were grade III-IV aGVHD and lower GI GVHD. The adjusted logistic regression model (full cohort) and time-to-event analysis (subcohort) included transplantation characteristics, GVHD risk factors, and adjunctive antibiotic exposures as covariates. The full cohort included 2550 patients at 36 centers; the subcohort included 1174 patients. In adjusted models, carbapenems were associated with an increased risk of grade II-IV aGVHD in the full cohort (adjusted odds ratio [aOR], 1.24; 95% confidence interval [CI], 1.02 to 1.51) and subcohort (sub hazard ratio [HR], 1.31; 95% CI, 0.99 to 1.72), as well as with an increased risk of grade III-IV aGVHD (subHR, 1.77; 95% CI, 1.25 to 2.52). Early carbapenem exposure (before day 0) especially impacted aGVHD risk. For antipseudomonal penicillins, the associations with aGVHD were in the direction of increased risk but were not statistically significant. There was no identified association between broad-spectrum cephalosporins and aGVHD. Carbapenems, more than other broad-spectrum antibiotics, should be used judiciously in pediatric HCT recipients to minimize aGVHD risk. Further research is needed to clarify the mechanism underlying this association.
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Affiliation(s)
- Caitlin W Elgarten
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Yimei Li
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Kelly D Getz
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | | | - Yuan-Shung V Huang
- Department of Biomedical and Health Informatics, Children's Hospital of Philadelphia, Philadelphia, PA
| | | | - Tao Wang
- Division of Biostatistics, Institute for Health and Equity, Medical College of Wisconsin, Milwaukee, WI
| | - Carrie L Kitko
- Division of Pediatric Hematology/Oncology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, TN
| | | | - Taiga Nishihori
- Department of Blood and Marrow Transplantation, H. Lee Moffitt Cancer Center, Tampa, FL
| | - Hemant S Murthy
- Division of Hematology-Oncology, Blood and Marrow Transplantation Program, Mayo Clinic, Jacksonville, FL
| | - Hasan Hashem
- Division of Pediatric Hematology/Oncology and Bone Marrow Transplantation, King Hussein Cancer Center, Amman, Jordan
| | - Mitchell S Cairo
- Division of Pediatric Hematology, Oncology and Stem Cell Transplantation, Department of Pediatrics, New York Medical College, Valhalla, NY
| | - Akshay Sharma
- Department of Bone Marrow Transplantation and Cellular Therapy, St. Jude Children's Research Hospital, Memphis, TN
| | - Shahrukh K Hashmi
- Department of Internal Medicine, Mayo Clinic, Rochester, MN.,Oncology Center, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | - Medhat Askar
- Department of Pathology and Laboratory Medicine, Baylor University Medical Center, Dallas, TX
| | - Amer Beitinjaneh
- Division of Transplantation and Cellular Therapy, University of Miami, Miami, FL
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Jeffery J Auletta
- Blood and Marrow Transplant Program and Host Defense Program, Divisions of Hematology/Oncology/Bone Marrow Transplant and Infectious Diseases, Nationwide Children's Hospital, Columbus, OH
| | - Sherif M Badawy
- Division of Hematology, Oncology and Stem Cell Transplant, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL.,Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Melissa Mavers
- Division of Stem Cell Transplantation and Regenerative Medicine, Department of Pediatrics, Bass Center for Childhood Cancer and Blood Diseases, Stanford University School of Medicine, Palo Alto, CA
| | - Richard Aplenc
- Division of Oncology, Children's Hospital of Philadelphia, Philadelphia, PA.,Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA
| | - Margaret L MacMillan
- Blood and Marrow Transplant Program, Department of Pediatrics, University of Minnesota, Minneapolis, MN
| | | | - Mukta Arora
- Division of Hematology, Oncology and Transplantation, Department of Medicine, University of Minnesota Medical Center, Minneapolis, MN
| | - Brian T Fisher
- Center for Pediatric Clinical Effectiveness, Children's Hospital of Philadelphia, Philadelphia, PA.,Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia PA.,Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA
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35
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Singh T, Heston SM, Langel SN, Blasi M, Hurst JH, Fouda GG, Kelly MS, Permar SR. Lessons From COVID-19 in Children: Key Hypotheses to Guide Preventative and Therapeutic Strategies. Clin Infect Dis 2020; 71:2006-2013. [PMID: 32382748 PMCID: PMC7239258 DOI: 10.1093/cid/ciaa547] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2020] [Accepted: 05/05/2020] [Indexed: 12/22/2022] Open
Abstract
The current pandemic of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the causative agent of coronavirus disease 2019 (COVID-19), reveals a peculiar trend of milder disease and lower case fatality in children compared with adults. Consistent epidemiologic evidence of reduced severity of infection in children across different populations and countries suggests there are underlying biological differences between children and adults that mediate differential disease pathogenesis. This presents a unique opportunity to learn about disease-modifying host factors from pediatric populations. Our review summarizes the current knowledge of pediatric clinical disease, role in transmission, risks for severe disease, protective immunity, as well as novel therapies and vaccine trials for children. We then define key hypotheses and areas for future research that can use the pediatric model of disease, transmission, and immunity to develop preventive and therapeutic strategies for people of all age groups.
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Affiliation(s)
- Tulika Singh
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA.,Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Stephanie N Langel
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA.,Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Maria Blasi
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA.,Division of Infectious Diseases, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
| | - Jillian H Hurst
- Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Genevieve G Fouda
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA.,Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Sallie R Permar
- Duke Human Vaccine Institute, Duke University Medical Center, Durham, North Carolina, USA.,Department of Molecular Genetics and Microbiology, Duke University, Durham, North Carolina, USA.,Duke Children's Health and Discovery Initiative, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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36
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Congdon M, Arscott-Mills T, Kelly MS. Reply to authors. Clin Infect Dis 2020; 73:e2835-e2836. [PMID: 33103198 DOI: 10.1093/cid/ciaa1628] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- Morgan Congdon
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA
| | - Tonya Arscott-Mills
- Division of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA.,Botswana-UPenn Partnership, Gaborone, Botswana.,Department of Paediatrics & Adolescent Health, University of Botswana, Gaborone, Botswana
| | - Matthew S Kelly
- Botswana-UPenn Partnership, Gaborone, Botswana.,Division of Pediatric Infectious Diseases, Duke University, Durham, NC
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Heston SM, Young RR, Hong H, Akinboyo IC, Tanaka JS, Martin PL, Vinesett R, Jenkins K, McGill LE, Hazen KC, Seed PC, Kelly MS. Microbiology of Bloodstream Infections in Children After Hematopoietic Stem Cell Transplantation: A Single-Center Experience Over Two Decades (1997-2017). Open Forum Infect Dis 2020; 7:ofaa465. [PMID: 33209953 PMCID: PMC7652097 DOI: 10.1093/ofid/ofaa465] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [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: 08/04/2020] [Accepted: 09/24/2020] [Indexed: 12/24/2022] Open
Abstract
Background Bloodstream infections (BSIs) occur frequently after hematopoietic stem cell transplantation (HSCT). We examined the microbiology of BSI in pediatric HSCT recipients over a 2-decade period at our institution to inform empirical antimicrobial prescribing and infection prevention strategies. Methods We conducted a retrospective cohort study of children (<18 years) who underwent HSCT at Duke University between 1997 and 2015. We used recurrent-event gap-time Cox proportional hazards models to determine the hazards of all-cause and cause-specific BSI according to HSCT year. We compared the median time to BSI by causative organism type and evaluated for temporal trends in the prevalence of antibiotic resistance among causative organisms. Results A total of 865 BSI occurred in 1311 children, including 412 (48%) Gram-positive bacterial, 196 (23%) Gram-negative bacterial, 56 (6%) fungal, 23 (3%) mycobacterial, and 178 (21%) polymicrobial BSI. The hazard of all BSIs did not change substantially over time during the study period, but the hazard of fungal BSIs declined over time during the study period (P = .04). Most fungal BSIs (82%) occurred in the first 100 days after HSCT, whereas mycobacterial BSIs occurred later after HSCT than BSIs caused by other organisms (P < .0001). The prevalence of vancomycin resistance among BSIs caused by Enterococcus faecium increased during the study period (P = .0007). The risk of 2-year mortality in children was increased with BSI (P = .02), Gram-negative bacterial BSI (P = .02), and fungal BSI (P < .0001). Conclusions Despite expanded practices for BSI prevention over the past several decades, the incidence of BSI remains high in pediatric HSCT recipients at our institution. Additional strategies are urgently needed to effectively prevent BSIs in this high-risk population.
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Affiliation(s)
- Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Hwanhee Hong
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ibukunoluwa C Akinboyo
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - John S Tanaka
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul L Martin
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Richard Vinesett
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Lauren E McGill
- Division of Pediatric Transplant and Cellular Therapy, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin C Hazen
- Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Patrick C Seed
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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38
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Hurst JH, Heston SM, Chambers HN, Cunningham HM, Price MJ, Suarez L, Crew CG, Bose S, Aquino JN, Carr ST, Griffin SM, Smith SH, Jenkins K, Pfeiffer TS, Rodriguez J, DeMarco CT, De Naeyer NA, Gurley TC, Louzao R, Cunningham CK, Steinbach WJ, Denny TN, Lugo DJ, Moody MA, Permar SR, Rotta AT, Turner NA, Walter EB, Woods CW, Kelly MS. SARS-CoV-2 Infections Among Children in the Biospecimens from Respiratory Virus-Exposed Kids (BRAVE Kids) Study. medRxiv 2020. [PMID: 32908992 PMCID: PMC7480040 DOI: 10.1101/2020.08.18.20166835] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND Children with SARS-CoV-2 infection typically have mild symptoms that do not require medical attention, leaving a gap in our understanding of the spectrum of illnesses that the virus causes in children. METHODS We conducted a prospective cohort study of children and adolescents (<21 years of age) with a SARS-CoV-2-infected close contact. We collected nasopharyngeal or nasal swabs at enrollment and tested for SARS-CoV-2 using a real-time PCR assay. RESULTS Of 382 children, 289 (76%) were SARS-CoV-2-infected. SARS-CoV-2-infected children were more likely to be Hispanic (p<0.0001), less likely to have a history of asthma (p=0.009), and more likely to have an infected sibling contact (p=0.0007) than uninfected children. Children ages 6-13 years were frequently asymptomatic (38%) and had respiratory symptoms less often than younger children (30% vs. 49%; p=0.008) or adolescents (30% vs. 59%; p<0.0001). Compared to children ages 6-13 years, adolescents more frequently reported influenza-like (61% vs. 39%; p=0.002), gastrointestinal (26% vs. 9%; p=0.003), and sensory symptoms (43% vs. 9%; p<0.0001), and had more prolonged illnesses [median (IQR) duration: 7 (4, 12) vs. 4 (3, 8) days; p=0.004]. Despite the age-related variability in symptoms, we found no differences in nasopharyngeal viral load by age or between symptomatic and asymptomatic children. CONCLUSIONS Hispanic ethnicity and an infected sibling close contact are associated with increased SARS-CoV-2 infection risk among children, while a history of asthma is associated with decreased risk. Age-related differences in the clinical manifestations of SARS-CoV-2 infection must be considered when evaluating children for COVID-19 and in developing screening strategies for schools and childcare settings.
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Affiliation(s)
- Jillian H Hurst
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC.,Children's Health and Discovery Institute, Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Sarah M Heston
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | | | | | | | | | - Carter G Crew
- Children's Health and Discovery Institute, Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Shree Bose
- Duke University School of Medicine, Durham, NC
| | - Jhoanna N Aquino
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Stuart T Carr
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - S Michelle Griffin
- Children's Clinical Research Unit, Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - Stephanie H Smith
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Kirsten Jenkins
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Trevor S Pfeiffer
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Javier Rodriguez
- Children's Clinical Research Unit, Department of Pediatrics, Duke University School of Medicine, Durham, NC
| | - C Todd DeMarco
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Nicole A De Naeyer
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Thaddeus C Gurley
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Raul Louzao
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Coleen K Cunningham
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - William J Steinbach
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Thomas N Denny
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Debra J Lugo
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - M Anthony Moody
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC.,Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Sallie R Permar
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC.,Children's Health and Discovery Institute, Department of Pediatrics, Duke University School of Medicine, Durham, NC.,Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC
| | - Alexandre T Rotta
- Department of Pediatrics, Division of Pediatric Critical Care Medicine, Duke University School of Medicine, Durham, NC
| | - Nicholas A Turner
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Emmanuel B Walter
- Duke Human Vaccine Institute, Duke University School of Medicine, Durham, NC.,Department of Pediatrics, Division of Primary Care Pediatrics, Duke University School of Medicine
| | - Christopher W Woods
- Department of Medicine, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
| | - Matthew S Kelly
- Department of Pediatrics, Division of Infectious Diseases, Duke University School of Medicine, Durham, NC
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McClain MT, Constantine FJ, Henao R, Liu Y, Tsalik EL, Burke TW, Steinbrink JM, Petzold E, Nicholson BP, Rolfe R, Kraft BD, Kelly MS, Sempowski GD, Denny TN, Ginsburg GS, Woods CW. Dysregulated transcriptional responses to SARS-CoV-2 in the periphery support novel diagnostic approaches. medRxiv 2020:2020.07.20.20155507. [PMID: 32743603 PMCID: PMC7386527 DOI: 10.1101/2020.07.20.20155507] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
In order to elucidate novel aspects of the host response to SARS-CoV-2 we performed RNA sequencing on peripheral blood samples across 77 timepoints from 46 subjects with COVID-19 and compared them to subjects with seasonal coronavirus, influenza, bacterial pneumonia, and healthy controls. Early SARS-CoV-2 infection triggers a conserved transcriptomic response in peripheral blood that is heavily interferon-driven but also marked by indicators of early B-cell activation and antibody production. Interferon responses during SARS-CoV-2 infection demonstrate unique patterns of dysregulated expression compared to other infectious and healthy states. Heterogeneous activation of coagulation and fibrinolytic pathways are present in early COVID-19, as are IL1 and JAK/STAT signaling pathways, that persist into late disease. Classifiers based on differentially expressed genes accurately distinguished SARS-CoV-2 infection from other acute illnesses (auROC 0.95). The transcriptome in peripheral blood reveals unique aspects of the immune response in COVID-19 and provides for novel biomarker-based approaches to diagnosis.
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Affiliation(s)
- Micah T McClain
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
- Durham Veterans Affairs Medical Center, Durham, NC
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
| | | | - Ricardo Henao
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
| | - Yiling Liu
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
| | - Ephraim L Tsalik
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
- Durham Veterans Affairs Medical Center, Durham, NC
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Thomas W Burke
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
| | - Julie M Steinbrink
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
| | - Elizabeth Petzold
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
| | | | - Robert Rolfe
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
| | - Bryan D Kraft
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, NC
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center
| | | | | | - Geoffrey S Ginsburg
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
| | - Christopher W Woods
- Center for Applied Genomics and Precision Medicine, Duke University, Durham, NC
- Durham Veterans Affairs Medical Center, Durham, NC
- Division of Infectious Diseases, Duke University Medical Center, Durham, NC
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40
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Tanaka JS, Young RR, Heston SM, Jenkins K, Spees LP, Sung AD, Corbet K, Thompson JC, Bohannon L, Martin PL, Stokhuyzen A, Vinesett R, Ward DV, Bhattarai SK, Bucci V, Arshad M, Seed PC, Kelly MS. Anaerobic Antibiotics and the Risk of Graft-versus-Host Disease after Allogeneic Hematopoietic Stem Cell Transplantation. Biol Blood Marrow Transplant 2020; 26:2053-2060. [PMID: 32682948 DOI: 10.1016/j.bbmt.2020.07.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 07/09/2020] [Accepted: 07/09/2020] [Indexed: 01/10/2023]
Abstract
Certain anaerobic bacteria are important for maintenance of gut barrier integrity and immune tolerance and may influence the risk of graft-versus-host disease (GVHD) after allogeneic hematopoietic stem cell transplantation (HSCT). We conducted a single-center retrospective cohort study of allogeneic HSCT recipients to evaluate associations between receipt of antibiotics with an anaerobic spectrum of activity and GVHD outcomes. We identified 1214 children and adults who developed febrile neutropenia between 7 days before and 28 days after HSCT and compared GVHD risk and mortality among patients who received anaerobic antibiotics (piperacillin-tazobactam or carbapenems; n = 491) to patients who received only antibiotics with minimal activity against anaerobes (aztreonam, cefepime, or ceftazidime; n = 723). We performed metagenomic sequencing of serial fecal samples from 36 pediatric patients to compare the effects of specific antibiotics on the gut metagenome. Receipt of anaerobic antibiotics was associated with higher hazards of acute gut/liver GVHD (hazard ratio [HR], 1.26; 95% confidence interval [CI], 1.03 to 1.54) and acute GVHD mortality (HR, 1.63; 95% CI, 1.08 to 2.46), but not chronic GVHD diagnosis (HR, 1.04; 95% CI: .84 to 1.28) or chronic GVHD mortality (HR, .88; 95% CI, .53 to 1.45). Anaerobic antibiotics resulted in decreased gut bacterial diversity, reduced abundances of Bifidobacteriales and Clostridiales, and loss of bacterial genes encoding butyrate biosynthesis enzymes from the gut metagenome. Acute gut/liver GVHD was preceded by a sharp decline in bacterial butyrate biosynthesis genes with antibiotic treatment. Our findings demonstrate that exposure to anaerobic antibiotics is associated with increased risks of acute gut/liver GVHD and acute GVHD mortality after allogeneic HSCT. Use of piperacillin-tazobactam or carbapenems should be reserved for febrile neutropenia cases in which anaerobic or multidrug-resistant infections are suspected.
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Affiliation(s)
- John S Tanaka
- Duke University School of Medicine, Durham, North Carolina
| | - Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Lisa P Spees
- Department of Health Policy and Management, University of North Carolina at Chapel Hill, Gillings School of Global Public Health, Chapel Hill, North Carolina; Lineberger Comprehensive Cancer Center, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Kelly Corbet
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Jillian C Thompson
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Lauren Bohannon
- Division of Hematologic Malignancies and Cellular Therapy, Duke University, Durham, North Carolina
| | - Paul L Martin
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Andre Stokhuyzen
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Richard Vinesett
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Doyle V Ward
- Center for Microbiome Research, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Shakti K Bhattarai
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Vanni Bucci
- Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Mehreen Arshad
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Patrick C Seed
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina.
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41
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Patel SM, Jallow S, Boiditswe S, Madhi SA, Feemster KA, Steenhoff AP, Arscott-Mills T, Muthoga C, Ajibola G, Shapiro R, Shah SS, Cunningham CK, Kelly MS. Placental Transfer of Respiratory Syncytial Virus Antibody Among HIV-Exposed, Uninfected Infants. J Pediatric Infect Dis Soc 2020; 9:349-356. [PMID: 31549157 PMCID: PMC7358043 DOI: 10.1093/jpids/piz056] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 07/08/2019] [Indexed: 01/07/2023]
Abstract
BACKGROUND Maternal human immunodeficiency virus (HIV) infection is associated with lower placental transfer of antibodies specific to several childhood pathogens. Our objective for this study was to evaluate the effect of maternal HIV infection on the placental transfer of respiratory syncytial virus (RSV)-neutralizing antibodies. METHODS We conducted a cross-sectional study of mothers and their newborn infants at a tertiary hospital in Gaborone, Botswana, between March 2015 and December 2015. We measured serum RSV antibody levels by using a microneutralization assay. We used multivariable linear regression to evaluate the effect of maternal HIV infection on maternal RSV antibody levels, placental transfer of RSV antibodies, and newborn RSV antibody levels. RESULTS Of 316 mothers, 154 (49%) were infected with HIV. The placental transfer ratios for RSV antibodies to HIV-exposed, uninfected (HEU) and HIV-unexposed, uninfected infants were 1.02 and 1.15, respectively. The geometric mean titer (95% confidence interval) of RSV-neutralizing antibodies was 2657 (2251-3136) among HEU newborns and 2911 (2543-3331) among HIV-unexposed, uninfected newborns. In multivariable analyses, maternal HIV infection was associated with lower placental transfer of RSV antibodies (P = .02) and a lower level of RSV antibodies among newborns (P = .002). Among HEU newborns, higher birth weight (P = .004) and an undetectable maternal antenatal viral load (P = .01) were associated with more effective placental transfer of RSV antibodies. CONCLUSIONS Maternal human immunodeficiency virus (HIV) infection is associated with lower mother-to-fetus transfer of serum RSV-neutralizing antibodies. HEU infants should be prioritized for preventive interventions for RSV. Maternal viral suppression through combination antiretroviral therapy has the potential to improve immunity to RSV among HIV-exposed infants.
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Affiliation(s)
- Sweta M Patel
- Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University, Durham, North Carolina
| | - Sabelle Jallow
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit
- Centre for Vaccines and Immunology, National Institute for Communicable Diseases of the National Health Laboratory Service, Johannesburg, South Africa
| | | | - Shabir A Madhi
- Medical Research Council, Respiratory and Meningeal Pathogens Research Unit
- Department of Science and Technology/National Research Foundation, Vaccine Preventable Diseases Research Chair, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Kristen A Feemster
- Global Health Center, Children’s Hospital of Philadelphia, Pennsylvania
- Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Pennsylvania
| | - Andrew P Steenhoff
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
- Global Health Center, Children’s Hospital of Philadelphia, Pennsylvania
- Division of Pediatric Infectious Diseases, Children’s Hospital of Philadelphia, Pennsylvania
| | - Tonya Arscott-Mills
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
- Global Health Center, Children’s Hospital of Philadelphia, Pennsylvania
| | - Charles Muthoga
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
| | | | - Roger Shapiro
- Botswana–Harvard AIDS Institute Partnership, Gaborone, Botswana
- Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Hospital Medical Center, Ohio
| | - Coleen K Cunningham
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University, Durham, North Carolina
- Botswana–University of Pennsylvania Partnership, Gaborone, Botswana
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Fawole OA, Kelly MS, Steenhoff AP, Feemster KA, Crotty EJ, Rattan MS, David T, Mazhani T, Shah SS, Andronikou S, Arscott-Mills T. Interpretation of pediatric chest radiographs by non-radiologist clinicians in Botswana using World Health Organization criteria for endpoint pneumonia. Pediatr Radiol 2020; 50:913-922. [PMID: 32524176 PMCID: PMC7539136 DOI: 10.1007/s00247-020-04625-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2019] [Revised: 12/16/2019] [Accepted: 01/21/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND In low- and middle-income countries, chest radiographs are most frequently interpreted by non-radiologist clinicians. OBJECTIVE We examined the reliability of chest radiograph interpretations performed by non-radiologist clinicians in Botswana and conducted an educational intervention aimed at improving chest radiograph interpretation accuracy among non-radiologist clinicians. MATERIALS AND METHODS We recruited non-radiologist clinicians at a referral hospital in Gaborone, Botswana, to interpret de-identified chest radiographs for children with clinical pneumonia. We compared their interpretations with those of two board-certified pediatric radiologists in the United States. We evaluated associations between level of medical training and the accuracy of chest radiograph findings between groups, using logistic regression and kappa statistics. We then developed an in-person training intervention led by a pediatric radiologist. We asked participants to interpret 20 radiographs before and immediately after the intervention, and we compared their responses to those of the facilitating radiologist. For both objectives, our primary outcome was the identification of primary endpoint pneumonia, defined by the World Health Organization as presence of endpoint consolidation or endpoint effusion. RESULTS Twenty-two clinicians interpreted chest radiographs in the primary objective; there were no significant associations between level of training and correct identification of endpoint pneumonia; concordance between respondents and radiologists was moderate (κ=0.43). After the training intervention, participants improved agreement with the facilitating radiologist for endpoint pneumonia from fair to moderate (κ=0.34 to κ=0.49). CONCLUSION Non-radiologist clinicians in Botswana do not consistently identify key chest radiographic findings of pneumonia. A targeted training intervention might improve non-radiologist clinicians' ability to interpret chest radiographs.
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Affiliation(s)
- Oluwatunmise A. Fawole
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,New York University School of Medicine, New York, NY, USA
| | - Matthew S. Kelly
- Botswana-UPenn Partnership, Gaborone, Botswana,Global Health Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Andrew P. Steenhoff
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Botswana-UPenn Partnership, Gaborone, Botswana,Global Health Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana,Department of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA
| | - Kristen A. Feemster
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA,Division of Infectious Diseases, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Global Health Center, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA, USA
| | - Eric J. Crotty
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Mantosh S. Rattan
- Department of Radiology and Medical Imaging, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Thuso David
- Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Tiny Mazhani
- Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Samir S. Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children’s Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Savvas Andronikou
- Department of General Pediatrics, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Radiology, Children’s Hospital of Philadelphia, Philadelphia, PA, USA,Department of Radiology, University of Cape Town, Cape Town, South Africa
| | - Tonya Arscott-Mills
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA. .,Botswana-UPenn Partnership, University of Botswana Main Campus, P.O. Box AC 157 ACH, Gaborone, Botswana. .,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA. .,Department of Pediatrics and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana. .,Department of General Pediatrics, Children's Hospital of Philadelphia, Philadelphia, PA, USA.
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Young RR, Jenkins K, Araujo-Perez F, Seed PC, Kelly MS. Long-term stability of microbiome diversity and composition in fecal samples stored in eNAT medium. Microbiologyopen 2020; 9:e1046. [PMID: 32390344 PMCID: PMC7349174 DOI: 10.1002/mbo3.1046] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [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: 02/06/2020] [Revised: 03/25/2020] [Accepted: 03/28/2020] [Indexed: 12/31/2022] Open
Abstract
Fecal samples collected for microbiome analyses are typically frozen to avoid postcollection changes in microbial composition. eNAT is a guanidine thiocyanate-based medium that stabilizes microbial DNA and allows safe specimen handling and shipping by inactivating microorganisms. We collected fecal samples (n = 50) from children undergoing hematopoietic stem cell transplantation. We divided samples into three aliquots: (a) stored in RNAlater and immediately transferred to -80°C; (b) stored in eNAT medium and immediately transferred to -80°C; and (c) stored in eNAT medium at ambient temperature (~20°C) for 30 days prior to transfer to -80°C. Mean (standard deviation) Shannon diversity and Chao1 indices in sample aliquots were 2.05 (0.62) and 23.8 (16.6), respectively. Comparing samples frozen immediately in RNAlater to samples frozen immediately in eNAT, there were no differences in Shannon diversity (p = .51), Chao1 richness (p = .66), and overall microbiome composition (p = .99). Comparing eNAT samples frozen immediately to samples stored at ambient temperature, we identified no differences in Shannon diversity (p = .65), Chao1 richness (p = .87), and overall microbiome composition (p = .99). Storage of fecal samples in eNAT at ambient temperature for 30 days did not alter microbiome richness, diversity, or composition. eNAT may be a useful medium for fecal microbiome studies, particularly when cold chain storage is unavailable.
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Affiliation(s)
- Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC, USA
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC, USA
| | - Felix Araujo-Perez
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Patrick C Seed
- Department of Pediatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC, USA
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Liang G, Zhao C, Zhang H, Mattei L, Sherrill-Mix S, Bittinger K, Kessler LR, Wu GD, Baldassano RN, DeRusso P, Ford E, Elovitz MA, Kelly MS, Patel MZ, Mazhani T, Gerber JS, Kelly A, Zemel BS, Bushman FD. The stepwise assembly of the neonatal virome is modulated by breastfeeding. Nature 2020; 581:470-474. [PMID: 32461640 PMCID: PMC7263352 DOI: 10.1038/s41586-020-2192-1] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Accepted: 02/14/2020] [Indexed: 01/01/2023]
Abstract
The gut of healthy human neonates is usually devoid of viruses at birth, but quickly becomes colonized, in some cases leading to gastrointestinal disorders1–4. Here we report that viral community assembly in neonates takes place in distinct steps. Fluorescent staining of virus-like particles purified from infant meconium/early stool samples show few or no particles, but by one month of life particle numbers achieve 109 per gram, and these numbers appear to persist through life5–7. We investigated the origin of these viral populations using shotgun metagenomic sequencing of viral-enriched preparations and whole microbial communities, and followed up with targeted microbiological analyses. Results indicate that, early after birth, pioneer bacteria colonize the infant gut, and by one month prophage induced from these bacteria provide the predominant population of virus-like particles. By four months of life, identifiable viruses that replicate in human cells become more prominent. Multiple human viruses were more abundant in stool samples from babies exclusively fed formula versus those fed partially or fully on breast milk, paralleling reports that breast milk can be protective against viral infections8–10. Phage populations also differed associated with breastfeeding. Evidently colonization of the infant gut is stepwise, first mainly by temperate bacteriophages induced from pioneer bacteria, and later by viruses that replicate in human cells, with the second phase modulated by breastfeeding.
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Affiliation(s)
- Guanxiang Liang
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Chunyu Zhao
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Huanjia Zhang
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lisa Mattei
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Scott Sherrill-Mix
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kyle Bittinger
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Lyanna R Kessler
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Gary D Wu
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Robert N Baldassano
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Patricia DeRusso
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Eileen Ford
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Michal A Elovitz
- Maternal and Child Health Research Center, Department of Obstetrics and Gynecology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University, Durham, NC, USA
| | - Mohamed Z Patel
- Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Tiny Mazhani
- Department of Paediatric and Adolescent Health, Faculty of Medicine, University of Botswana, Gaborone, Botswana
| | - Jeffrey S Gerber
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Andrea Kelly
- Division of Endocrinology and Diabetes, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Babette S Zemel
- Division of Gastroenterology, Hepatology, and Nutrition, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Frederic D Bushman
- Department of Microbiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Akinboyo IC, Young RR, Spees LP, Heston SM, Smith MJ, Chang YC, McGill LE, Martin PL, Jenkins K, Lugo DJ, Hazen KC, Seed PC, Kelly MS. Microbiology and Risk Factors for Hospital-Associated Bloodstream Infections Among Pediatric Hematopoietic Stem Cell Transplant Recipients. Open Forum Infect Dis 2020; 7:ofaa093. [PMID: 32284949 PMCID: PMC7141603 DOI: 10.1093/ofid/ofaa093] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 12/18/2019] [Accepted: 03/12/2020] [Indexed: 12/02/2022] Open
Abstract
Background Children undergoing hematopoietic stem cell transplantation (HSCT) are at high risk for hospital-associated bloodstream infections (HA-BSIs). This study aimed to describe the incidence, microbiology, and risk factors for HA-BSI in pediatric HSCT recipients. Methods We performed a single-center retrospective cohort study of children and adolescents (<18 years of age) who underwent HSCT over a 20-year period (1997–2016). We determined the incidence and case fatality rate of HA-BSI by causative organism. We used multivariable Poisson regression to identify risk factors for HA-BSI. Results Of 1294 patients, the majority (86%) received an allogeneic HSCT, most commonly with umbilical cord blood (63%). During the initial HSCT hospitalization, 334 HA-BSIs occurred among 261 (20%) patients. These were classified as gram-positive bacterial (46%), gram-negative bacterial (24%), fungal (12%), mycobacterial (<1%), or polymicrobial (19%). During the study period, there was a decline in the cumulative incidence of HA-BSI (P = .021) and, specifically, fungal HA-BSIs (P = .002). In multivariable analyses, older age (incidence rate ratio [IRR], 1.03; 95% confidence interval [CI], 1.01–1.06), umbilical cord blood donor source (vs bone marrow; IRR, 1.69; 95% CI, 1.19–2.40), and nonmyeloablative conditioning (vs myeloablative; IRR, 1.85; 95% CI, 1.21–2.82) were associated with a higher risk of HA-BSIs. The case fatality rate was higher for fungal HA-BSI than other HA-BSI categories (21% vs 6%; P = .002). Conclusions Over the past 2 decades, the incidence of HA-BSIs has declined among pediatric HSCT recipients at our institution. Older age, umbilical cord blood donor source, and nonmyeloablative conditioning regimens are independent risk factors for HA-BSI among children undergoing HSCT.
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Affiliation(s)
- Ibukunoluwa C Akinboyo
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Rebecca R Young
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Lisa P Spees
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina, Chapel Hill, North Carolina, USA.,Lineberger Comprehensive Cancer Center, University of North Carolina, Chapel Hill, North Carolina, USA
| | - Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Michael J Smith
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Yeh-Chung Chang
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Lauren E McGill
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA.,Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, North Carolina, USA
| | - Paul L Martin
- Division of Pediatric Blood and Marrow Transplantation, Duke University Medical Center, Durham, North Carolina, USA
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Debra J Lugo
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
| | - Kevin C Hazen
- Pathology, Duke University Medical Center, Durham, North Carolina, USA
| | - Patrick C Seed
- Division of Pediatric Infectious Diseases, Northwestern Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA
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Weimer KED, Kelly MS, Permar SR, Clark RH, Greenberg RG. Association of Adverse Hearing, Growth, and Discharge Age Outcomes With Postnatal Cytomegalovirus Infection in Infants With Very Low Birth Weight. JAMA Pediatr 2020; 174:133-140. [PMID: 31790557 PMCID: PMC6902194 DOI: 10.1001/jamapediatrics.2019.4532] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
IMPORTANCE Studies suggest that postnatal cytomegalovirus (CMV) infection can lead to long-term morbidity in infants with very low birth weight (VLBW; <1500 g), including bronchopulmonary dysplasia (BPD), necrotizing enterocolitis (NEC), and neurodevelopmental impairment. However, to date, the association of postnatal CMV with hearing, growth, and length of stay among VLBW infants is unknown. OBJECTIVES To determine the risk for failed hearing screen, increased postnatal age at discharge, or decreased growth at discharge in VLBW infants with postnatal CMV infection compared with CMV-uninfected infants and to compare the risk for other major outcomes of prematurity, including BPD and NEC, in infants with and without postnatal CMV infection. PARTICIPANTS This multicenter retrospective cohort study included VLBW infants from 302 neonatal intensive care units managed by the Pediatrix Medical Group from January 1, 2002, through December 31, 2016. Infants hospitalized on postnatal day 21 with a diagnosis of postnatal CMV and hearing screen results after a postmenstrual age of 34 weeks were included in the study population. Data were analyzed from December 11, 2017, to June 14, 2019. MAIN OUTCOMES AND MEASURES Infants with and without postnatal CMV infection were matched using propensity scores. Poisson and linear regression were used to examine the association between postnatal CMV and the risk of failed hearing screen, postnatal age at discharge, growth, BPD, and NEC. RESULTS A total of 304 infants with postnatal CMV were identified, and 273 of these infants (89.8%; 155 boys [56.8%]) were matched with 273 infants without postnatal CMV (148 boys [54.2%]). Hearing screen failure occurred in 45 of 273 infants (16.5%) with postnatal CMV compared with 25 of 273 infants (9.2%) without postnatal CMV (risk ratio [RR], 1.80; 95% CI, 1.14 to 2.85; P = .01). Postnatal CMV was also associated with an increased postnatal age at discharge of 11.89 days (95% CI, 6.72 to 17.06 days; P < .001) and lower weight-for-age z score (-0.23; 95% CI, -0.39 to -0.07; P = .005). Analysis confirmed an increased risk of BPD (RR, 1.30; 95% CI, 1.17 to 1.44; P < .001), previously reported on infants from this cohort from 1997 to 2012, but not an increased risk of NEC after postnatal day 21 (RR, 2.00; 95% CI, 0.18 to 22.06; P = .57). CONCLUSIONS AND RELEVANCE These data suggest that postnatal CMV infection is associated with lasting sequelae in the hearing and growth status of VLBW infants and with prolonged hospitalization. Prospective studies are needed to determine the full effects of postnatal CMV infection and whether antiviral treatment reduces the associated morbidity.
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Affiliation(s)
- Kristin E. D. Weimer
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Matthew S. Kelly
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | - Sallie R. Permar
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina
| | | | - Rachel G. Greenberg
- Department of Pediatrics, Duke University Medical Center, Durham, North Carolina,Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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Abu-Raya B, Goldfarb DM, Smieja M, Luinstra K, Richard-Greenblatt M, Steenhoff AP, Feemster KA, Arscott-Mills T, Cunningham CK, Shah SS, Patel MZ, Kelly MS, Sadarangani M. The prevalence and clinical characteristics of pertussis-associated pneumonia among infants in Botswana. BMC Pediatr 2019; 19:444. [PMID: 31733643 PMCID: PMC6858628 DOI: 10.1186/s12887-019-1820-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Accepted: 11/04/2019] [Indexed: 02/08/2023] Open
Abstract
Background There are scant data on the prevalence and clinical course of pertussis disease among infants with pneumonia in low- and middle-income countries. While pertussis vaccination coverage is high (≥90%) among infants in Botswana, human immunodeficiency virus (HIV) infection affects nearly one-third of pregnancies. We aimed to evaluate the prevalence and clinical course of pertussis disease in a cohort of HIV-unexposed uninfected (HUU), HIV-exposed uninfected (HEU), and HIV-infected infants with pneumonia in Botswana. Methods We recruited children 1–23 months of age with clinical pneumonia at a tertiary care hospital in Gaborone, Botswana between April 2012 and June 2016. We obtained nasopharyngeal swab specimens at enrollment and tested these samples using a previously validated in-house real-time PCR assay that detects a unique sequence of the porin gene of Bordetella pertussis. Results B. pertussis was identified in 1/248 (0.4%) HUU, 3/110 (2.7%) HEU, and 0/33 (0.0%) HIV-infected children. All pertussis-associated pneumonia cases occurred in infants 1–5 months of age (prevalence, 1.0% [1/103] in HUU and 4.8% [3/62] in HEU infants). No HEU infants with pertussis-associated pneumonia were taking cotrimoxazole prophylaxis at the time of hospital presentation. One HUU infant with pertussis-associated pneumonia required intensive care unit admission for mechanical ventilation, but there were no deaths. Conclusions The prevalence of pertussis was low among infants and young children with pneumonia in Botswana. Although vaccination against pertussis in pregnancy is designed to prevent classical pertussis disease, reduction of pertussis-associated pneumonia might be an important additional benefit.
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Affiliation(s)
- Bahaa Abu-Raya
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada. .,Division of Infectious Diseases, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.
| | - David M Goldfarb
- Division of Infectious Diseases, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada.,Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.,Department of Pathology and Laboratory Medicine, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Marek Smieja
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kathy Luinstra
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | | | - Andrew P Steenhoff
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.,Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kristen A Feemster
- Division of Infectious Diseases, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Division of Disease Control, Philadelphia Department of Public Health, Philadelphia, PA, USA
| | - Tonya Arscott-Mills
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Coleen K Cunningham
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Mohamed Zaakir Patel
- Department of Paediatrics and Adolescent Health, University of Botswana School of Medicine, Gaborone, Botswana
| | - Matthew S Kelly
- Botswana-University of Pennsylvania Partnership, Gaborone, Botswana.,Global Health Center, Children's Hospital of Philadelphia, Philadelphia, PA, USA.,Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, NC, USA
| | - Manish Sadarangani
- Vaccine Evaluation Center, BC Children's Hospital Research Institute, University of British Columbia, 950 West 28th Avenue, Vancouver, BC, V5Z 4H4, Canada.,Division of Infectious Diseases, Department of Pediatrics, University of British Columbia, Vancouver, BC, Canada
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Hurst JH, Barrett KJ, Kelly MS, Staples BB, McGann KA, Cunningham CK, Reed AM, Gbadegesin RA, Permar SR. Cultivating Research Skills During Clinical Training to Promote Pediatric-Scientist Development. Pediatrics 2019; 144:e20190745. [PMID: 31363070 PMCID: PMC6855830 DOI: 10.1542/peds.2019-0745] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/16/2019] [Indexed: 11/24/2022] Open
Abstract
Physician-scientists represent a critical component of the biomedical and health research workforce. However, the proportion of physicians who spend a significant amount of effort on scientific research has declined over the past 40 years. This trend has been particularly noticeable in pediatrics despite recent scientific work revealing that early life influences, exposures, and health status play a significant role in lifelong health and disease. To address this problem, the Duke University Department of Pediatrics developed the Duke Pediatric Research Scholars Program for Physician-Scientist Development (DPRS). The DPRS is focused on research training during pediatric residency and fellowship. We aim to provide sufficient research exposure and support to help scholars develop a research niche and scholarly products as well as identify the career pathways that will enable them to achieve their research goals. Herein, we describe the DPRS's organizational structure, core components, recruitment strategies, and initial results, and we discuss implementation challenges and solutions. Additionally, we detail the program's integration with the department's residency and fellowship training programs (with particular reference to the challenges of integrating research into small- to medium-sized residency programs) and describe the development and integration of related initiatives across Duke University School of Medicine. The program served as the basis for 2 successful National Institutes of Health Stimulating Access to Research in Residency (R38) applications, and we hope it will serve as a model to integrate formalized research training for residents and fellows who wish to pursue research careers in academic medicine.
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Affiliation(s)
- Jillian H. Hurst
- Duke Pediatric Research Scholars Program for Physician-Scientist Development and
- Clinical and Translational Sciences Institute
- Office of Physician-Scientist Development, Duke University, Durham, North Carolina; and
- Department of Pediatrics, Children’s Health and Discovery Institute, Durham, North Carolina
| | - Katherine J. Barrett
- Duke Pediatric Research Scholars Program for Physician-Scientist Development and
- Office of Physician-Scientist Development, Duke University, Durham, North Carolina; and
| | - Matthew S. Kelly
- Duke Pediatric Research Scholars Program for Physician-Scientist Development and
- Divisions of Infectious Diseases and
| | | | | | | | | | - Rasheed A. Gbadegesin
- Duke Pediatric Research Scholars Program for Physician-Scientist Development and
- Nephrology
- Duke Molecular Physiology Institute
- Office of Physician-Scientist Development, Duke University, Durham, North Carolina; and
| | - Sallie R. Permar
- Duke Pediatric Research Scholars Program for Physician-Scientist Development and
- Divisions of Infectious Diseases and
- Duke Human Vaccine Institute, and
- Office of Physician-Scientist Development, Duke University, Durham, North Carolina; and
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Kelly MS, Ward DV, Severyn CJ, Arshad M, Heston SM, Jenkins K, Martin PL, McGill L, Stokhuyzen A, Bhattarai SK, Bucci V, Seed PC. Gut Colonization Preceding Mucosal Barrier Injury Bloodstream Infection in Pediatric Hematopoietic Stem Cell Transplantation Recipients. Biol Blood Marrow Transplant 2019; 25:2274-2280. [PMID: 31326608 DOI: 10.1016/j.bbmt.2019.07.019] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/08/2019] [Accepted: 07/11/2019] [Indexed: 02/06/2023]
Abstract
The gastrointestinal tract is the predicted reservoir for most bloodstream infections (BSIs) after hematopoietic stem cell transplantation (HSCT). Whole-genome sequencing and comparative genomics have the potential to improve our understanding of the dynamics of gut colonization that precede BSI in HSCT recipients. Within a prospective cohort study of children (age <18 years) undergoing HSCT, 9 subjects met criteria for mucosal barrier injury BSI. We performed whole-genome sequencing of the blood culture isolate and weekly fecal samples preceding the BSI to compare the genetic similarity of BSI isolates to fecal strains. We evaluated temporal associations between antibiotic exposures and the abundances of BSI strains in the gut microbiota and correlated the detection of antibiotic resistance genes with the phenotypic antibiotic resistance of these strains. The median patient age was 2.6 years, and 78% were male. BSIs were caused by Escherichia coli (n = 5), Enterococcus faecium (n = 2), Enterobacter cloacae (n = 1), and Rothia mucilaginosa (n = 1). In the 6 BSI episodes with evaluable comparative genomics, the fecal strains were identical to the blood culture isolate (>99.99% genetic similarity). Gut domination by these strains preceded only 4 of 7 E. coli or E. faecium BSIs by a median of 17 days (range, 6 to 21 days). Increasing abundances of the resulting BSI strains in the gut microbiota were frequently associated with specific antibiotic exposures. E. cloacae and R. mucilaginosa were not highly abundant in fecal samples preceding BSIs caused by these species. The detection of antibiotic resistance genes for β-lactam antibiotics and vancomycin predicted phenotypic resistance in BSI strains. Bacterial strains causing mucosal barrier injury BSI in pediatric HSCT recipients were observed in the gut microbiota before BSI onset, and changes in the abundances of these strains within the gut preceded most BSI episodes. However, frequent sampling of the gut microbiota and sampling of other ecological niches is likely necessary to effectively predict BSI in HSCT recipients.
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Affiliation(s)
- Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina.
| | - Doyle V Ward
- Center for Microbiome Research, University of Massachusetts Medical School, Worcester, Massachusetts; Department of Microbiology and Physiological Systems, University of Massachusetts Medical School, Worcester, Massachusetts
| | - Christopher J Severyn
- Division of Pediatric Hematology and Oncology, Lucile Packard Children's Hospital, Palo Alto, California
| | - Mehreen Arshad
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Sarah M Heston
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Paul L Martin
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Lauren McGill
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Andre Stokhuyzen
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Shakti K Bhattarai
- Department of Biology, University of Massachusetts Dartmouth, North Dartmouth, Massachusetts
| | - Vanni Bucci
- Department of Biology, University of Massachusetts Dartmouth, North Dartmouth, Massachusetts
| | - Patrick C Seed
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital, Chicago, Illinois
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Spees LP, Martin PL, Kurtzberg J, Stokhuyzen A, McGill L, Prasad VK, Driscoll TA, Parikh SH, Page KM, Vinesett R, Severyn C, Sung AD, Proia AD, Jenkins K, Arshad M, Steinbach WJ, Seed PC, Kelly MS. Reduction in Mortality after Umbilical Cord Blood Transplantation in Children Over a 20-Year Period (1995-2014). Biol Blood Marrow Transplant 2018; 25:756-763. [PMID: 30481599 DOI: 10.1016/j.bbmt.2018.11.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [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: 09/11/2018] [Accepted: 11/15/2018] [Indexed: 12/16/2022]
Abstract
Infections and graft-versus-host disease (GVHD) have historically resulted in high mortality among children undergoing umbilical cord blood transplantation (UCBT). However, recent advances in clinical practice have likely improved outcomes of these patients. We conducted a retrospective cohort study of children (<18years of age) undergoing UCBT at Duke University between January 1, 1995 and December 31, 2014. We compared 2-year all-cause and cause-specific mortality during 3 time periods based on year of transplantation (1995 to 2001, 2002 to 2007, and 2008 to 2014). We used multivariable Cox regression to identify demographic and UCBT characteristics that were associated with all-cause mortality, transplantation-related mortality, and death from invasive aspergillosis after adjustment for time period. During the 20-year study period 824 children underwent UCBT. Two-year all-cause mortality declined from 48% in 1995 to 2001 to 30% in 2008 to 2014 (P = .0002). White race and nonmalignant UCBT indications were associated with lower mortality. Black children tended to have a higher risk of death for which GVHD (18% versus 11%; P = .06) or graft failure (9% versus 3%; P = .01) were contributory than white children. Comparing 2008 to 2014 with 1995 to 2001, more than half (59%) of the reduced mortality was attributable to a reduction in infectious mortality, with 45% specifically related to reduced mortality from invasive aspergillosis. Antifungal prophylaxis with voriconazole was associated with lower mortality from invasive aspergillosis than low-dose amphotericin B lipid complex (hazard ratio, .09; 95% confidence interval, .01 to .76). With the decline in mortality from invasive aspergillosis, adenovirus and cytomegalovirus have become the most frequentinfectious causes of death in children after UCBT. Advances in clinical practice over the past 20years improved survival of children after UCBT. Reduced mortality from infections, particularly invasive aspergillosis, accounted for the largest improvement in survival and was associated with use of voriconazole for antifungal prophylaxis.
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Affiliation(s)
- Lisa P Spees
- The Cecil G. Sheps Center for Health Services Research, University of North Carolina at Chapel Hill Gillings School of Global Public Health, Chapel Hill, North Carolina
| | - Paul L Martin
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Joanne Kurtzberg
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Andre Stokhuyzen
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Lauren McGill
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Vinod K Prasad
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Timothy A Driscoll
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Suhag H Parikh
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Kristin M Page
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Richard Vinesett
- Division of Pediatric Blood and Marrow Transplant, Duke University Medical Center, Durham, North Carolina
| | - Christopher Severyn
- Division of Pediatric Hematology-Oncology, Lucille Packard Children's Hospital, Stanford University, Palo Alto, California
| | - Anthony D Sung
- Division of Hematologic Malignancies and Cellular Therapy, Duke Cancer Institute, Duke University, Durham, North Carolina
| | - Alan D Proia
- Department of Pathology, Duke University Medical Center, Durham, North Carolina
| | - Kirsten Jenkins
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Mehreen Arshad
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - William J Steinbach
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina
| | - Patrick C Seed
- Division of Pediatric Infectious Diseases, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois
| | - Matthew S Kelly
- Division of Pediatric Infectious Diseases, Duke University Medical Center, Durham, North Carolina.
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