The receptor for advanced glycation end products promotes bacterial growth at distant body sites in Staphylococcus aureus skin infection

The receptor for advanced glycation endproducts (RAGE) has been implicated in the regulation of skin inflammation. We here sought to study the role of RAGE in host defense during skin infection caused by Staphylococcus (S.) aureus, the most common pathogen in this condition. Wild-type (Wt) and RAGE deficient (rage(-/-)) mice were infected subcutaneously with S. aureus and bacterial loads and local inflammation were quantified at regular intervals up to 8 days after infection. While bacterial burdens were similar in both mouse strains at the primary site of infection, rage(-/-) mice had lower bacterial counts in lungs and liver. Skin cytokine and chemokine levels did not differ between groups. In accordance with the skin model, direct intravenous infection with S. aureus was associated with lower bacterial loads in lungs and liver of rage(-/-) mice. Together these data suggest that RAGE does not impact local host defense during S. aureus skin infection, but facilitates bacterial growth at distant body site

Limited role of the receptor for advanced glycation end products during Streptococcus pneumoniae bacteremia

Streptococcus pneumoniae is one of the most common causes of sepsis. Sepsis is associated with the release of 'damage-associated molecular patterns' (DAMPs). The receptor for advanced glycation end products (RAGE) is a multiligand receptor, abundantly expressed in the lungs, that recognizes several of these DAMPs. Triggering of RAGE leads to activation of the NF-κB pathway and perpetuation of inflammation. Earlier investigations have shown that the absence of RAGE reduces inflammation and bacterial dissemination and increases survival in sepsis caused by S. pneumoniae pneumonia. We hypothesized that the detrimental role of RAGE depends on the level of RAGE expression in the primary organ of infection. By directly injecting S. pneumoniae intravenously, thereby circumventing the extensive RAGE-expressing lung, we here determined whether RAGE contributes to an adverse outcome of bacteremia or whether its role is restricted to primary lung infection. During late-stage infection (48 h), rage(-/-) mice had an attenuated systemic inflammatory response, as reflected by lower plasma levels of proinflammatory cytokines, reduced endothelial cell activation (as measured by E-selectin levels) and less neutrophil accumulation in lung tissue. However, RAGE deficiency did not influence bacterial loads or survival in this model. In accordance, plasma markers for cell injury were similar in both mouse strains. These results demonstrate that while RAGE plays a harmful part in S. pneumoniae sepsis originating from the respiratory tract, this receptor has a limited role in the outcome of primary bloodstream infection by this pathoge

High-mobility group box 1 and the receptor for advanced glycation end products contribute to lung injury during Staphylococcus aureus pneumonia

Staphylococcus (S.) aureus has emerged as an important cause of necrotizing pneumonia. Lung injury during S. aureus pneumonia may be enhanced by local release of damage associated molecular patterns such as high-mobility group box 1 (HMGB1). In the current study we sought to determine the functional role of HMGB1 and its receptors, toll-like receptor 4 (TLR4) and the receptor for advanced glycation end products (RAGE), in the injurious host response to S. aureus pneumonia. Pneumonia was induced in wild type (Wt), TLR4 deficient (tlr4-/-) and RAGE deficient (rage-/-) mice by intranasal inoculation of 1 × 107 colony-forming units (CFU) of a USA300 S. aureus. In a separate set of experiments, Wt mice were injected intraperitoneally with a monoclonal anti-HMGB1 antibody or an isotype matched control antibody immediately before and every 24 hours after intranasal infection of S. aureus. Mice were sacrificed at 6, 24, 48 or 72 hours after infection for harvesting of blood and organs. S. aureus pneumonia was associated with HMGB1 release in the bronchoalveolar compartment peaking after 24 hours. Anti-HMGB1 attenuated lung pathology and protein leak and reduced interleukin-1β release 6 hours after infection, but not at later time points. RAGE deficiency more modestly attenuated lung pathology without influencing protein leak, while TLR4 deficiency did not impact on lung injury. These data suggest that HMGB1 and RAGE, but not TLR4, contribute to lung injury accompanying the early phase of S. aureus pneumoni

The Stability and Workload Index for Transfer score predicts unplanned intensive care unit patient readmission: initial development and validation

OBJECTIVE: Unplanned readmission of hospitalized patients to an intensive care unit (ICU) is associated with a worse outcome, but our ability to identify who is likely to deteriorate after ICU dismissal is limited. The objective of this study is to develop and validate a numerical index, named the Stability and Workload Index for Transfer, to predict ICU readmission. DESIGN: In this prospective cohort study, risk factors for ICU readmission were identified from a broad range of patients' admission and discharge characteristics, specific ICU interventions, and in-patient workload measurements. The prediction score was validated in two independent ICUs. SETTING: One medical and one mixed medical-surgical ICU in two tertiary centers. PATIENTS: Consecutive patients requiring >24 hrs of ICU care. INTERVENTIONS: None. MEASUREMENTS: Unplanned ICU readmission or unexpected death following ICU dismissal. RESULTS: In a derivation cohort of 1,131 medical ICU patients, 100 patients had unplanned readmissions, and five died unexpectedly in the hospital following ICU discharge. Predictors of readmission/unexpected death identified in a logistic regression analysis were ICU admission source, ICU length of stay, and day of discharge neurologic (Glasgow Coma Scale) and respiratory (hypoxemia, hypercapnia, or nursing requirements for complex respiratory care) impairment. The Stability and Workload Index for Transfer score predicted readmission more precisely (area under the curve [AUC], 0.75; 95% confidence interval [CI], 0.70-0.80) than the day of discharge Acute Physiology and Chronic Health Evaluation III score (AUC, 0.62; 95% CI, 0.56-0.68). In the two validation cohorts, the Stability and Workload Index for Transfer score predicted readmission similarly in a North American medical ICU (AUC, 0.74; 95% CI, 0.67-0.80) and a European medical-surgical ICU (AUC, 0.70; 95% CI, 0.64-0.76), but was less well calibrated in the medical-surgical ICU. CONCLUSION: The Stability and Workload Index for Transfer score is derived from information readily available at the time of ICU dismissal and acceptably predicts ICU readmission. It is not known if discharge decisions based on this prediction score will decrease the number of ICU readmissions and/or improve outcom

Mice Lacking the Lectin-Like Domain of Thrombomodulin Are Protected Against Melioidosis

Objective: Thrombomodulin is a multidomain receptor primarily expressed by vascular endothelium. The lectin-like domain of thrombomodulin has anti-inflammatory properties. In this study, we investigated the role of the thrombomodulin lectin-like domain in the host response to Gram-negative sepsis caused by Burkholderia pseudomallei, a Tier 1 biothreat agent and the causative agent of melioidosis, a common form of community-acquired sepsis in Southeast Asia. Design: Animal study. Setting: University research laboratory. Subjects: Wild-type mice and mice lacking the lectin-like domain of thrombomodulin. Interventions: Mice were intranasally infected with live B. pseudomallei and killed after 24, 48, or 72 hours for harvesting of lungs, liver, spleen, and blood. Additionally, survival studies were performed. Measurements and Main Results: Following exposure to B. pseudomallei, mice lacking the lectin-like domain of thrombomodulin showed a survival advantage, accompanied by decreased bacterial loads in the blood, lungs, liver, and spleen. Although lung histopathology did not differ between groups, mice lacking the lectin-like domain of thrombomodulin displayed strongly attenuated systemic inflammation, as reflected by lower plasma cytokine levels, maintenance of normal kidney and liver function, histologic evidence of reduced organ damage, and damage to the spleen. Conclusions: This study reveals for the first time a detrimental role for the thrombomodulin lectin-like domain in the host response to sepsis caused by a clinically relevant Gram-negative pathoge

Expression and Function of S100A8/A9 (Calprotectin) in Human Typhoid Fever and the Murine Salmonella Model

Background Typhoid fever, caused by the Gram-negative bacterium Salmonella enterica serovar Typhi, is a major cause of community-acquired bacteremia and death worldwide. S100A8 (MRP8) and S100A9 (MRP14) form bioactive antimicrobial heterodimers (calprotectin) that can activate Toll-like receptor 4, promoting lethal, endotoxin-induced shock and multi-organ failure. We aimed to characterize the expression and function of S100A8/A9 in patients with typhoid fever and in a murine invasive Salmonella model. Methods and principal findings S100A8/A9 protein levels were determined in acute phase plasma or feces from 28 Bangladeshi patients, and convalescent phase plasma from 60 Indonesian patients with blood culture or PCR-confirmed typhoid fever, and compared to 98 healthy control subjects. To functionally characterize the role of S100A8/A9, we challenged wildtype (WT) and S100A9-/- mice with S. Typhimurium and determined bacterial loads and inflammation 2- and 5- days post infection. We further assessed the antimicrobial function of recombinant S100A8/A9 on S. Typhimurium and S. Typhi replication in vitro. Typhoid fever patients demonstrated a marked increase of S100A8/A9 in acute phase plasma and feces and this increases correlated with duration of fever prior to admission. S100A8/A9 directly inhibited the growth of S. Typhimurium and S. Typhi in vitro in a dose and time dependent fashion. WT mice inoculated with S. Typhimurium showed increased levels of S100A8/A9 in both the liver and the systemic compartment but S100A9-/- mice were indistinguishable from WT mice with respect to bacterial growth, survival, and inflammatory responses, as determined by cytokine release, histopathology and organ injury. Conclusion S100A8/A9 is markedly elevated in human typhoid, correlates with duration of fever prior to admission and directly inhibits the growth of S. Typhimurium and S. Typhi in vitro. Despite elevated levels in the murine invasive Salmonella model, S100A8/A9 does not contribute to an effective host response against S. Typhimurium in mice

Receptor for Advanced Glycation End Products (RAGE) Serves a Protective Role during Klebsiella pneumoniae - Induced Pneumonia

Klebsiella species is the second most commonly isolated gram-negative organism in sepsis and a frequent causative pathogen in pneumonia. The receptor for advanced glycation end products (RAGE) is expressed on different cell types and plays a key role in diverse inflammatory responses. We here aimed to investigate the role of RAGE in the host response to Klebsiella (K.) pneumoniae pneumonia and intransally inoculated rage gene deficient (RAGE-/-) and normal wild-type (Wt) mice with K. pneumoniae. Klebsiella pneumonia resulted in an increased pulmonary expression of RAGE. Furthermore, the high-affinity RAGE ligand high mobility group box-1 was upregulated during K. pneumoniae pneumonia. RAGE deficiency impaired host defense as reflected by a worsened survival, increased bacterial outgrowth and dissemination in RAGE-/- mice. RAGE-/- neutrophils showed a diminished phagocytosing capacity of live K. pneumoniae in vitro. Relative to Wt mice, RAGE-/- mice demonstrated similar lung inflammation, and slightly elevated-if any-cytokine and chemokine levels and unchanged hepatocellular injury. In addition, RAGE-/- mice displayed an unaltered response to intranasally instilled Klebsiella lipopolysaccharide (LPS) with respect to pulmonary cell recruitment and local release of cytokines and chemokines. These data suggest that (endogenous) RAGE protects against K. pneumoniae pneumonia. Also, they demonstrate that RAGE contributes to an effective antibacterial defense during K. pneumoniae pneumonia, at least partly via its participation in the phagocytic properties of professional granulocytes. Additionally, our results indicate that RAGE is not essential for the induction of a local and systemic inflammatory response to either intact Klebsiella or Klebsiella LP

S100A12 and soluble receptor for advanced glycation end products levels during human severe sepsis

S100A12 is highly expressed, and serum levels correlate with individual disease activity in patients with inflammatory diseases. We here sought to determine the extent of S100A12 release and its soluble high-affinity receptor for advanced glycation end products (sRAGE) in patients with severe sepsis stratified to the three most common infectious sources (lungs, abdomen, and urinary tract) and to determine S100A12 and sRAGE concentrations at the site of infection during peritonitis. Two patient populations were studied: (a) 51 patients with sepsis due to (i) peritonitis (n = 12), (ii) pneumonia (n = 29), or (iii) urinary tract infection (n = 10); and (b) 17 patients with peritonitis. In addition, eight healthy humans were studied after intravenous injection of lipopolysaccharide (4 ng/kg). Compared with healthy volunteers, patients with severe sepsis displayed increased circulating S100A12 concentrations at day 0 (591.2 ± 101.0 vs. 106.2 ± 15.6 ng/mL [control subjects], P < 0.0001) and at day 3 (637.2 ± 111.2 vs. 106.2 ± 15.6 ng/mL [control subjects], P < 0.0001). All three severe sepsis subgroups had elevated serum S100A12 concentrations at both time points (sepsis due to [i] peritonitis [393.5 ± 89.9 at day 0 and 337.9 ± 97.2 at day 3 vs. 106.2 ± 15.6 ng/mL, control subjects, P < 0.005 and P < 0.05, respectively]; [ii] pneumonia [716.9 ± 167.0 at day 0 and 787.5 ± 164.7 at day 3 vs. 106.2 ± 15.6 ng/mL, control subjects, both P < 0.0001]; and [iii] urinary tract infection [464.2 ± 115.6 at day 0 and 545.6 ± 254.9 at day 3 vs. 106.2 ± 15.6 ng/mL, control subjects, P < 0.0001 and P < 0.05, respectively]). Remarkably, patients with sepsis due to pneumonia had the highest S100A12 levels (716.9 ± 167.0 and 787.5 ± 164.7 ng/mL at days 0 and 3, respectively). S100A12 levels were not correlated to either Acute Physiology and Chronic Health Evaluation II scores (r = -0.185, P = 0.19) or Sepsis-Related Organ Failure Assessment scores (r = -0.194, P = 0.17). Intravenous lipopolysaccharide injection in healthy humans elevated systemic S100A12 levels (peak levels at 3 h of 59.6 ± 22.0 vs. 12.4 ± 3.6 ng/mL; t = 0 h, P < 0.005). In contrast to S100A12, sRAGE concentrations did not change during severe sepsis or human endotoxemia. During peritonitis, S100A12 concentrations in abdominal fluid (12945.8 ± 4142.1 ng/mL) were more than 100-fold higher than in concurrently obtained plasma (121.2 ± 80.4 ng/mL, P < 0.0005), whereas sRAGE levels in abdominal fluid (148.8 ± 36.0 pg/mL) were lower than those in plasma (648.7 ± 145.6 pg/mL, P < 0.005) and did not increase. In conclusion, in severe sepsis, S100A12 is released systemically irrespective of the primary source of infection. During abdominal sepsis, S100A12 release likely predominantly occurs at the site of infection. Concentrations of its high-affinity sRAGE do not change during infection or human endotoxemia