A prospective clinical trial of a real-time polymerase chain reaction assay for the diagnosis of candidemia in nonneutropenic, critically ill adults

Background. Invasive Candida infection among nonneutropenic, critically ill adults is a clinical problem that has received increasing attention in recent years. Poor performance of extant diagnostic modalities has promoted risk-based, preemptive prescribing in view of the poor outcomes associated with inadequate or delayed antifungal therapy; this risks unnecessary overtreatment. A rapid, reliable diagnostic test could have a substantial impact on therapeutic practice in this patient population.

Methods. Three TaqMan-based real-time polymerase chain reaction assays were developed that are capable of detecting the main medically important Candida species, categorized according to the likelihood of fluconazole susceptibility. Assay 1 detected Candida albicans, Candida parapsilosis, Candida tropicalis, and Candida dubliniensis. Assays 2 and 3 detected Candida glabrata and Candida krusei, respectively. The clinical performance of these assays, applied to serum, was evaluated in a prospective trial of nonneutropenic adults in a single intensive care unit.

Results. In all, 527 specimens were obtained from 157 participants. All 3 assays were run in parallel for each specimen; they could be completed within 1 working day. Of these, 23 specimens were obtained from 23 participants categorized as having proven Candida infection at the time of sampling. If a single episode of Candida famata candidemia was excluded, the estimated clinical sensitivity, specificity, and positive and negative predictive values of the assays in this trial were 90.9%, 100%, 100% and 99.8%, respectively.

Conclusions. These data suggest that the described assays perform well in this population for enhancing the diagnosis of candidemia. The extent to which they may affect clinical outcomes, prescribing practice, and cost-effectiveness of care remains to be ascertained.

An empirical study of green supply chain management practices amongst UK manufacturers

Purpose: The purpose of this paper is to examine the extent and nature of greening the supply chain (SC) in the UK manufacturing sector; and the factors that influence the breadth and depth of this activity.

Design/methodology/approach: Based on the findings from a sample of manufacturing organisations drawn from the membership of The Chartered Institute for Purchasing and Supply. Data are collected using a questionnaire, piloted and pre-tested before distribution with responses from 60 manufacturing companies.

Findings: On average manufacturers perceive the greatest pressure to improve environmental performance through legislation and internal drivers (IDs). The least influential pressures are related to societal drivers and SC pressures from individual customers. Green supply chain management (GSCM) practices amongst this “average” group of UK manufacturing organisations are focusing on internal, higher risk, descriptive activities, rather than proactive, external engagement processes. Environmental attitude (EA) is a key predictor of GSCM activity and those organisations that have a progressive attitude are also operationally very active. EA shows some relationship to legislative drivers but other factors are also influential. Operational activity may also be moderated by organisational contingencies such as risk, size, and nationality.

Research limitations/implications: The main limitation to this paper is the relatively small manufacturing sample.

Practical implications: This paper presents a series of constructs that identify GSCM operational activities companies to benchmark themselves against. It suggests which factors are driving these operational changes and how industry contingencies may be influential.

Originality/value: This paper explores what is driving environmental behaviour amongst an “average” sample of manufacturers, what specific management practices take place and the relationships between them.

Keywords: Manufacturing industries, Environmental management, Supply chain management, Sustainable development, United Kingdom
Paper type: Research paper

Rapid detection of health-care-associated bloodstream infection in critical care using multipathogen real-time polymerase chain reaction technology: a diagnostic accuracy study and systematic review

Background: There is growing interest in the potential utility of real-time polymerase chain reaction (PCR) in diagnosing bloodstream infection by detecting pathogen deoxyribonucleic acid (DNA) in blood samples within a few hours. SeptiFast (Roche Diagnostics GmBH, Mannheim, Germany) is a multipathogen probe-based system targeting ribosomal DNA sequences of bacteria and fungi. It detects and identifies the commonest pathogens causing bloodstream infection. As background to this study, we report a systematic review of Phase III diagnostic accuracy studies of SeptiFast, which reveals uncertainty about its likely clinical utility based on widespread evidence of deficiencies in study design and reporting with a high risk of bias. 

Objective: Determine the accuracy of SeptiFast real-time PCR for the detection of health-care-associated bloodstream infection, against standard microbiological culture. 

Design: Prospective multicentre Phase III clinical diagnostic accuracy study using the standards for the reporting of diagnostic accuracy studies criteria. 

Setting: Critical care departments within NHS hospitals in the north-west of England. 

Participants: Adult patients requiring blood culture (BC) when developing new signs of systemic inflammation. 

Main outcome measures: SeptiFast real-time PCR results at species/genus level compared with microbiological culture in association with independent adjudication of infection. Metrics of diagnostic accuracy were derived including sensitivity, specificity, likelihood ratios and predictive values, with their 95% confidence intervals (CIs). Latent class analysis was used to explore the diagnostic performance of culture as a reference standard. 

Results: Of 1006 new patient episodes of systemic inflammation in 853 patients, 922 (92%) met the inclusion criteria and provided sufficient information for analysis. Index test assay failure occurred on 69 (7%) occasions. Adult patients had been exposed to a median of 8 days (interquartile range 4–16 days) of hospital care, had high levels of organ support activities and recent antibiotic exposure. SeptiFast real-time PCR, when compared with culture-proven bloodstream infection at species/genus level, had better specificity (85.8%, 95% CI 83.3% to 88.1%) than sensitivity (50%, 95% CI 39.1% to 60.8%). When compared with pooled diagnostic metrics derived from our systematic review, our clinical study revealed lower test accuracy of SeptiFast real-time PCR, mainly as a result of low diagnostic sensitivity. There was a low prevalence of BC-proven pathogens in these patients (9.2%, 95% CI 7.4% to 11.2%) such that the post-test probabilities of both a positive (26.3%, 95% CI 19.8% to 33.7%) and a negative SeptiFast test (5.6%, 95% CI 4.1% to 7.4%) indicate the potential limitations of this technology in the diagnosis of bloodstream infection. However, latent class analysis indicates that BC has a low sensitivity, questioning its relevance as a reference test in this setting. Using this analysis approach, the sensitivity of the SeptiFast test was low but also appeared significantly better than BC. Blood samples identified as positive by either culture or SeptiFast real-time PCR were associated with a high probability (> 95%) of infection, indicating higher diagnostic rule-in utility than was apparent using conventional analyses of diagnostic accuracy. 

Conclusion: SeptiFast real-time PCR on blood samples may have rapid rule-in utility for the diagnosis of health-care-associated bloodstream infection but the lack of sensitivity is a significant limiting factor. Innovations aimed at improved diagnostic sensitivity of real-time PCR in this setting are urgently required. Future work recommendations include technology developments to improve the efficiency of pathogen DNA extraction and the capacity to detect a much broader range of pathogens and drug resistance genes and the application of new statistical approaches able to more reliably assess test performance in situation where the reference standard (e.g. blood culture in the setting of high antimicrobial use) is prone to error.

Short-chain fatty acids cause an IL-8 response in cystic fibrosis airways via increased GPR41

RATIONALE: Anaerobic bacteria are present in large numbers in the airways of people with cystic fibrosis (PWCF). In the gut, anaerobes produce short-chain fatty acids (SCFAs) that modulate immune/inflammatory processes.

OBJECTIVES: To investigate the capacity of anaerobes to contribute to CF airway pathogenesis via SCFAs.

METHODS: Samples from 109 PWCF were processed using anaerobic microbiological culture with bacteria present identified by 16S RNA sequencing. SCFAs levels in anaerobe supernatants and bronchoalveolar lavage (BAL) were determined by gas chromatography. The mRNA and/or protein expression of SCFAs receptors, GPR41 and GPR43, in CF and non-CF bronchial brushings, and 16HBE14o- and CFBE41o- cells were evaluated using RT-PCR, western blot, laser scanning cytometry and confocal microscopy. SCFAs-induced IL-8 secretion was monitored by ELISA.

MEASUREMENTS AND MAIN RESULTS: Fifty seven of 109 (52.3%) PWCF were anaerobe-positive. Prevalence increased with age, from 33.3% to 57.7% in PWCF under (n=24) and over 6 years (n=85). All evaluated anaerobes produced millimolar concentrations of SCFAs, including acetic, propionic and butyric acid. SCFAs levels were higher in BAL samples from adults than children. GPR41 levels were elevated in; CFBE41o- versus 16HBE14o- cells; CF versus non-CF bronchial brushings; 16HBE14o- cells after treatment with CFTR inhibitor CFTR(inh)-172, CF BAL, or inducers of endoplasmic reticulum stress. SCFAs induced a dose-dependent and pertussis toxin-sensitive IL-8 response in bronchial epithelial cells with a higher production of IL-8 in CFBE41o- than 16HBE14o- cells.

CONCLUSIONS: This study illustrates that SCFAs contribute to excessive production of IL-8 in CF airways colonized with anaerobes via upregulated GPR41.

SN2014J gamma rays from the 56Ni decay chain

Context. The detection and measurement of gamma-ray lines from the decaychain of 56Ni provides unique information about the explosionin supernovae. SN2014J at 3.3 Mpc is a sufficiently-nearby supernova oftype Ia so that such measurements have been feasible with the gamma-rayspectrometer SPI on ESA's INTEGRAL gamma-ray observatory.

Aims:The 56Ni freshly produced in the supernova is understood topower the optical light curve, because it emits gamma rays upon itsradioactive decay first to 56Co and then to 56Fe.Gamma-ray lines from 56Co decay are expected to becomedirectly visible through the white dwarf material several weeks afterthe explosion, as they progressively penetrate the overlying material ofthe supernova envelope, which is diluted as it expands. The lines areexpected to be Doppler-shifted or broadened from the kinematics of the56Ni ejecta. We aim to exploit high-resolution gamma-rayspectroscopy with the SPI spectrometer on INTEGRAL toward constrainingthe 56Ni distribution and kinematics in this supernova.

Methods: We use the observations with the SPI spectrometer onINTEGRAL, together with an improved instrumental background method.

Results: We detect the two main lines from 56Co decay at847 and 1238 keV, which are significantly Doppler-broadened, and atintensities (3.65 ± 1.21) × 10-4 and (2.27± 0.69) × 10-4 ph cm-2s-1, respectively, at their brightness maximum. We measuretheir rise toward a maximum after about 60-100 days and a declinethereafter. The intensity ratio of the two lines is found to beconsistent with expectations from 56Co decay (0.62 ±0.28 at brightness maximum, the expected ratio is 0.68). We find thatthe broad lines seen in the late, gamma-ray transparent phase are notrepresentative of the early gamma-ray emission, and notice instead thatthe emission spectrum is complex and irregular until the supernova isfully transparent to gamma rays, with progressive uncovering of the bulkof 56Ni. We infer that the explosion morphology is notspherically symmetric, both in the distribution of 56Ni andin the unburnt material which occults the 56Co emission.After we compare light curves from different plausible models, theresulting 56Ni mass is determined to be 0.49 ± 0.09M⊙.