INTRODUÇÃO: As infecções osteoarticulares permanecem como um grande desafio para os profissionais de saúde envolvidos no seu manejo, a despeito do sucesso obtido com a introdução dos antimicrobianos para o tratamento das doenças infectocontagiosas no final da década de 1930. O Staphylococcus aureus (S. aureus) é o agente mais frequentemente encontrado nestas infecções e também é o agente mais estudado, porém possuímos poucas informações disponíveis na literatura médica a respeito das osteomielites por bacilos Gram-negativos (BGN). OBJETIVOS: A caracterização clínica e microbiológica dos episódios de osteomielite causadas por bacilos Gram-negativos. A determinação das diferenças evolutivas e dos fatores de risco para a ocorrência de osteomielite por bacilos Gram-negativos, quando comparadas à osteomielite causada por S. aureus. MÉTODOS: Análise retrospectiva dos casos de osteomielite causadas por bacilos Gram-negativos atendidos no Instituto de Ortopedia e Traumatologia do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo no período de janeiro de 2007 a janeiro de 2009. Apenas amostras de osso ou aspirado de canal medular foram consideradas válidas. RESULTADOS: Foram incluídos 89 pacientes no grupo S. aureus e 101 pacientes no grupo BGN. Os pacientes do grupo BGN eram predominantemente do sexo masculino (63%), com mediana de 42 anos de idade. Apresentaram-se com osteomielite crônica (43%) e osteomielite aguda associada à fratura exposta (32%), nos membros inferiores (71%), cuja principal sintomatologia inicial foi a fistulização (69%). Quando comparado ao grupo S. aureus, o grupo BGN estava estatisticamente associado com o antecedente de fratura exposta (35% vs. 18%; p=0,0064), apresentando ainda um maior tempo de internação hospitalar (mediana 41 vs. 24 dias; p=0,0114), maior tempo para a obtenção da primeira cultura positiva (mediana 10 vs. 6,5 dias; p=0,0042), antibioticoterapia mais prolongada (mediana 40 vs. 24 dias; p=0,0329), maior número de procedimentos cirúrgicos (média 3,41 vs. 2,47; p=0,0173) e maior uso de reparo do revestimento cutâneo (31% vs. 9%; p=0,0005). O grupo S. aureus estava estatisticamente associado com as osteomielites da coluna vertebral (23,6% vs. 6,9%; p=0,0008). Foram isolados 121 agentes Gram-negativos de 101 amostras clínicas e os agentes mais frequentes foram Enterobacter spp. (24,7%), Acinetobacter baumannii (21,4%), Pseudomonas aeruginosa (19,8%) e Klebsiella pneumoniae (8,2%). CONCLUSÕES: Os 101 pacientes portadores de osteomielite por BGN eram na sua maioria jovens, do sexo masculino, vítimas de traumas nos membros inferiores e que desenvolveram osteomielite aguda e crônica associadas a fraturas expostas. Os pacientes do grupo BGN necessitaram de um número maior de procedimentos cirúrgicos, maior uso de reparo do revestimento cutâneo, permaneceram internados por mais tempo, necessitaram de um número de dias maior para o isolamento do agente infeccioso e utilizaram antibioticoterapia mais prolongada, quando comparados aos pacientes do grupo S. aureus. O antecedente de fratura exposta foi o principal fator de risco para o desenvolvimento de osteomielite por um BGN, quando comparado ao grupo S. aureus / INTRODUCTION: Bone and joint infection remains a serious therapeutic challenge, despite the high success rate observed with antibiotic therapy in most bacterial disease since the end of 1930 decade. Staphylococcus aureus (S. aureus) is the most studied and the most frequently isolated pathogen, but there is insufficient information in medical literature regarding Gram- negative bacilli (GNB) osteomyelitis. OBJECTIVES: Describe clinical and microbiological characteristics of Gram-negative bacilli osteomyelitis. Establish evolving differences and risk factors for the occurrence of GNB osteomyelitis, compared to S. aureus osteomyelitis. METHODS: Retrospective analysis of all patients with GNB osteomyelitis treated at Institute of Orthopedics and Traumatology, Hospital das Clínicas - School of Medicine, Universidade de São Paulo from january 2007 to january 2009. Only bone or bone marrow aspirate samples were included. RESULTS: 89 patients were included in S. aureus group and 101 patients were included in GNB group. Patients in GNB group were mostly male (63%), with median age of 42 years. At presentation, they had chronic osteomyelitis (43%) and acute open-fracture associated osteomyelitis (32%), in the lower limbs (71%), with a discharging sinus as the main clinical sign (69%). When compared to S. aureus group, GNB group was statistically associated with a previous history of open-fracture (35% vs. 18%; p=0.0064), showed a longer length of hospital stay (median 41 vs. 24 days; p=0.0114), a higher number of days to isolate the infective bacteria (median 10 vs. 6,5 days; p=0.0042), a longer use of antibiotics (median 40 vs. 24 days; p=0.0329), a higher number of surgical procedures (mean 3,41 vs. 2,47; p=0.0173) and a higher rate of soft- tissue reconstruction (31% vs. 9%; p=0.0005). S. aureus group was statistically associated with spine osteomyelitis (23,6% vs. 6.9%; p=0.0008). 121 Gram-negative pathogens were isolated from 101 clinical samples and the most frequent agents were Enterobacter spp. (24.7%), Acinetobacter baumannii (21.4%), Pseudomonas aeruginosa (19.8%) and Klebsiella pneumoniae (8.2%). CONCLUSIONS: Patients with GNB osteomyelitis were mainly young, male, with lower limb trauma and developed chronic and open- fracture associated osteomyelitis. Patients in GNB group had a higher number of surgical procedures, a higher rate of soft-tissue reconstruction, a longer length of hospitalization, a longer time to isolate the infective bacteria and a prolonged use of antibiotics, when compared to patients in S. aureus group. A previous history of open-fracture was the main risk factor to development of GNB osteomyelitis, compared to S. aureus group

A total of 49 patients were studied, using invasive hemodynamic techniques with systemic arterial, pulmonary artery and right atrial pressure recordings together with thermodilution cardiac output determinations. Sixteen of the patients were also subjected to cardiometabolic studies, using measurement of coronary sinus blood flow by the continuous thermodilution technique and analyses of oxygen content and lactate concentration in the systemic and coronary circulation. A common denominator in the five investigations was, that a distributive cardiovascular dysequilibrium was either induced (for surgical or anaesthesiological reasons) or already present due to a pathological condition. Thoracic epidural block from T 1 to T 12 induced marked decrease in systemic blood pressure due to vasodilation and impairment of cardiac performance. Prenalterol administration effectively abolished the low blood pressure by its marked inotropic action, having no effect on systemic vascular resistance. Myocardial oxygen consumption changed in parallel with the changes in cardiac work following both thoracic epidural block and prenalterol. Coronary vascular resistance was markedly decreased by the block and was not affected by prenalterol. It is suggested, that the critically low perfusion pressure is the main cause of the coronary vasodilation and that alpha-blockade induced by the thoracic epidural block is of less importance. The combination of a thoracic epidural block from T 1 to T 12 and selective ßi-stimulation with prenalterol was an effective way to modify the cardiovascular response to infrarenal aortic cross clamping. This treatment transferred the patients to a more favourable cardiac function curve and possibly facilitated the redistribution of blood flow in association with clamping. In association with declamping of the infrarenal aorta or the common iliac arteries, volume loading to a slightly elevated left ventricular filling pressure shortly before declamping was an effective way to counteract the expected blood pressure drop. A normal left ventricular filling pressure prior to declamping did not prevent the blood pressure drop following declamping. It is suggested, that mismatching between vascular volume and blood volume is the main cause of declamping hypotension. In patients with low resistance, distributive septic shock caused by gram negative bacteremias and signs of impaired cardiac function, prenalterol effectively reversed the hypotension and improved tissue perfusion by selectively increasing cardiac output. In parallel to the increased cardiac work, an increase in myocardial metabolic demand was demonstrated. / digitalisering@umu.se

La surexpression des pompes d’efflux (PE) appartenant à la famille Resistance-Nodulation-Division (RND) est l’un des contributeurs majeurs de la multirésistance (MDR) et la pathogénicité des bactéries Gram-négatives. Ces transporteurs sont capables d'expulser à l’extérieur de la cellule bactérienne différentes classes d'antibiotiques, ce qui contribue de manière significative à l'échec thérapeutique du traitement des maladies infectieuses. Dans ce contexte, les PEs sont des cibles intéressantes pour la découverte de nouveaux antimicrobiens. Afin de combattre ce mécanisme de résistance, des inhibiteurs des pompes d’efflux (EPIs) sont développés comme adjuvants d'antibiotiques dans le but de restaurer ou d'améliorer leur activité. L'archétype AcrAB-TolC est particulièrement répandu chez les espèces d’Enterobacter pertinentes en clinique (pathogènes « ESKAPE »). Cette étude décrit une stratégie basée sur des analogues des fluoroquinolones pour le drug design des EPIs, contre la pompe AcrB chez E. aerogenes. Ainsi, la synthèse et l'évaluation microbiologique des dérivés de quinazoline-4(3H)-one ont été effectuées. Les propriétés structurales et moléculaires des composés testés (i.e. rigidité et flexibilité) ont également été étudiées. Pour cela, de nouveaux scaffolds ont été évaluées. Plusieurs molécules ont montré une augmentation de la sensibilité des bactéries à la norfloxacine et au chloramphénicol. Les résultats obtenus, appuyés par la modélisation moléculaire, suggèrent que la flexibilité moléculaire et la nature des fonctions chimiques des EPIs jouent un rôle essentiel dans l'amélioration de l'activité et la sélectivité vis-à-vis des fluoroquinolones. / Overexpression of Resistance-Nodulation-Division (RND) efflux pumps (EP) is a major contributor in multidrug resistance (MDR) and pathogenicity in Gram-negative bacteria. These transporters are able to expel out of the bacterial cell clinically important antibiotic classes, contributing in a significant manner to the treatment failure of infectious diseases. With the worrying levels of bacterial resistance reported worldwide and the continuous spreading of MDR pathogens, EPs are interesting targets for the discovery of new antimicrobial drugs. Therefore, to overcome this mechanism, efflux pump inhibitors (EPIs) are being developed as adjuvants in order to restore or improve the activity of usual antibiotics. The AcrAB-TolC archetype is particularly widespread in Enterobacter spp. presenting clinical relevance (ESKAPE pathogens). In this study, we described the drug design strategy based on fluoroquinolone antibiotic analogs, against the AcrB pump of E. aerogenes. Thus, synthesis and microbiological evaluation of quinazolin-4(3H)-one derivatives were performed. The structural and molecular properties of the tested compounds (i. e. rigidity and flexibility) were also investigated. In this purpose, a scaffold hopping of the quinazolinone core to homologous benzoquinazolinones and precursors benzamides were carried out. Several molecules increased the bacterial susceptibility towards norfloxacin and chloramphenicol. The obtained results, supported by molecular modeling, suggest that molecular flexibility and the nature of chemical functions play a critical role to improve activity and selectivity on fluoroquinolone potentiation targeting AcrB efflux pump.

Escherichia coli enteropatogênica atípica (EPECa) é causadora de diarréia infantil e apresenta alta heterogeneidade quanto aos fatores de virulência. O objetivo deste trabalho foi estudar o comportamento de EPECa na interação com fagócitos profissionais. Duas amostras de EPECa sorotipo O55:H7 mostraram-se capazes de reduzir a fagocitose. Os sobrenadantes dos cultivos foram submetidos a SPE e HPLC e as frações com efeito antifagocítico foram submetidas a espectrometria de massas. A fração capaz de reduzir a fagocitose de bactérias reduziu também a fagocitose de Saccharomyces cerevisiae. Além de mostrar que EPECa é capaz de induzir a antifagocitose, mostrou-se também que o fator antifagocitico é secretado, solúvel em meio aquoso, termoestável, apresenta baixo peso molecular, não é microbicida ou citotóxico e, por último, há indicativos de que possa apresentar uma região glicosídica. Estes achados sugerem que o fator antifagocítico pode, embora não sozinho, exercer um papel importante na adaptabilidade e patogenicidade das EPECa. / Atypical enteropathogenic Escherichia coli (aEPEC) causes diarrhea mainly in children and presents a high heterogeneity of virulence factors. The objective of this work was to study the behavior of aEPEC regarding its interaction with professional phagocytes. Two samples of aEPEC serotype O55:H7 were able to reduce phagocytosis, The culture supernatants were submitted to SPE and HPLC and the active fractions were tested and analyzed by mass spectrometry. The results show that the fraction with bacterial antiphagocytic activity also reduces phagocytosis of Saccharomyces cerevisiae. In addition to demonstrating that aEPEC can induce antiphagocytosis, this work shows that it is due to a secreted antiphagocytic factor that is soluble in aqueous medium, is thermo-stable, has a low molecular weight, is not bactericide or cytotoxic and, finally, possibly presents a glycosidic region. These findings suggest that the antiphagocytic factor may, though maybe not alone, play an important role in the adaptability and pathogenicity of aEPEC.

A bacteria Pectobacterium carotovora causa danos a diferentes hospedeiros por meio da produção de enzimas pectinolíticas que degradam o pectato de cálcio da lamela media próximo a parede celular, causando extravasamento do conteúdo celular, sintomas da podridão mole. Bactérias do gênero Burkholderia tem se mostrado capazes em controlar a podridão mole em orquídeas, no entanto, os aspectos moleculares envolvidos neste controle ainda não foram estudados. Neste trabalho, foram avaliados 602 transformantes quanto a sua habilidade em inibir os sintomas da podridão mole, onde foram observados 16 mutantes defectivos no controle da doença. Destes, foram identificados sete diferentes genes inativados pelo transposon Tn5, e estes genes podem estar envolvidos em processos de síntese de aleloquímicos, competição por nutrientes, adaptação a condições ambientais, e na interação com o hospedeiro e/ou entre microrganismos. No entanto, o envolvimento destes genes na perda da capacidade em controlar a podridão mole deve ser melhor estudado. / The bacterium Pectobacterium carotovora cause damage to different hosts and by production of pectic enzymes that degrade calcium pectate of the middle lamella near of the cell wall, causing overflow of cell content and consequently the soft rot. Burkholderia genus has proven able to control the soft rot in Orchids, however, the molecular aspects involved in the control have not been studied. In this work, 602 transformants were characterized for their ability to inhibit soft rot caused by P. carotovora. We identified 16 mutants showing shifts in inhibition pattern or lost of the ablitity to inhibit soft rot symptoms. Among these mutants, we identified 7 genes related to disease inhibition,and this genes may be involved in process of allelochemicals synthesis, competition for nutrients, adapting to environmental conditions, and interaction between the host and microorganisms. However, the involvement of these genes in loss of ability to control the soft rot disease is being further studied in details.

Yersinia pestis, the gram-negative causative agent of plague, is a master of immune evasion. The bacterium possesses a type three secretion system which translocates Yop effector proteins into host immune cells to inhibit a number of immune and cell signaling cascades. Interestingly, this apparatus is not expressed at low temperatures such as those found within the flea vector and is therefore neither in place nor functional when the bacteria are first transmitted into a mammalian host. However, the bacterium is still able to avoid activating the immune system, even very early during infection. When grown at 37°C (human body temperature) Y. pestis produces a tetra-acyl lipid A molecule, which is antagonistic to the human Toll like receptor 4/MD2, the major lipopolysaccharide recognition receptor. Although tetra-acyl lipid A binds this receptor complex, it does not induce signaling, and in fact inhibits the receptors interaction with other stimulatory forms of lipid A. The work undertaken in this thesis seeks to determine if the production of tetra-acyl lipid A by Y. pestis is a key virulence determinant and was a critical factor in the evolution of Y. pestis from its ancestral parent Yersinia pseudotuberculosis. By examining the enzymes involved in the lipid A biosynthesis pathway, it has been determined that Y. pestis lacks LpxL, a key enzyme that adds a secondary acyl chain on to the tetra acyl lipid A molecule. In the absence of this enzyme, Y. pestis cannot produce a TLR4 stimulating form of lipid A, whereas Y. pseudotuberculosis does contain the gene for LpxL and produces a stimulatory hexa acyl lipid A. To determine if the absence of LpxL in Y. pestis is important for virulence, LpxL from E. coli and Y. pseudotuberculosis were introduced into Y. pestis. In both cases the addition of LpxL led to bacterium which produced a hexa-acylated lipid A molecule and TLR4/MD2 stimulatory LPS. To verify the LpxL phenotype, lpxL was deleted from Y. pseudotuberculosis, resulting in bacteria which produce tetra-acylated lipid A and nonstimulatory LPS. Mice challenged with LpxL expressing Y. pestis were found to be completely resistant to infection. This profound attenuation in virulence is TLR4 dependent, as mice deficient for this receptor rapidly succumb to disease. These altered strains of the bacterium also act as vaccines, as mice infected with Y. pestis expressing LpxL then challenged with wild type Y. pestis do not become ill. These data demonstrate that the production of tetra-acyl lipid A is a critical virulence determinant for Y. pestis, and that the loss of LpxL formed a major step in the evolution of Y. pestis from Y. pseudotuberculosis. These bacterial strains were also used as tools to determine the contributions of different innate immune receptors and adaptor molecules to the host response during Y. pestis infection. The use of LpxL expressing Y. pestis allowed identification of the innate immune pathways critical for protection during Y. pestis infection. This model also established that CD14 recognition of rough LPS is critical for protection from Y. pestisexpressing LpxL, and activation of the IL-1 receptor and the induction of IL-1β plays a major role in this infection as well. The lipid A acylation profile of gram negative bacteria can have a direct and profound effect on the pathogenesis of the organism. This work illustrates a previously unknown and critical aspect of Y. pestis pathogenesis, which can be extended to other gram-negative pathogens. The greater detail of the contributions which different host adaptor and receptor molecules make to the overall innate immune signaling pathway will allow a better insight into how gram negative infections progress and how they are counteracted by the immune system. Alterations of the lipid A profile of Y. pestis have important implications for the production of vaccines to Y. pestis and other gram negative pathogens. Taken together, this work describes a novel mechanism for immune evasion by gram negative bacteria with consequences for understanding the immune response and the creation of more effective vaccines, both of which will decrease the danger posed by this virulent pathogen.

No description available.

[pt] As infecções por bactérias Gram-negativas Resistentes aos Carbapenêmicos (CR-GNB) estão entre as maiores preocupações atuais da área da, especialmente em Unidades de Terapia Intensiva (UTI), e podem estar associadas ao aumento do tempo de hospitalização, morbidade, custos e mortalidade. Esta tese tem como objetivo desenvolver uma abordagem abrangente e sistemática aplicando técnicas de aprendizado de máquina para construir modelos para prever a aquisição de CR-GNB em UTIs de hospitais brasileiros. Propusemos modelos de triagem para detectar pacientes que não precisam ser testados e um modelo de risco que estima a probabilidade de pacientes de UTI adquirirem CR-GNB. Aplicamos métodos de seleção de características, técnicas de aprendizado de máquina e estratégias de balanceamento para construir e comparar os modelos. Os critérios de desempenho escolhidos para avaliação foram Negative Predictive Value (NPV) and Matthews Correlation Coefficient (MCC) para o modelo de triagem e Brier score e curvas de calibração para o modelo de risco de aquisição de CR-GNB. A estatística de Friedman e os testes post hoc de Nemenyi foram usados para testar a significância das diferenças entre as técnicas. O método de ganho de informações e a mineração de regras de associação avaliam a importância e a força entre os recursos. Nosso banco de dados reúne dados de pacientes, antibióticos e microbiologia de cinco hospitais brasileiros de 8 de maio de 2017 a 31 de agosto de 2019, envolvendo pacientes hospitalizados em 24 UTIs adultas. As informações do laboratório foram usadas para identificar todos os pacientes com teste positivo ou negativo para CR-GNB, A. baumannii, P. aeruginosa ou Enterobacteriaceae. Há um total de 539 testes positivos e 7.462 negativos, resultando em 3.604 pacientes com pelo menos um exame após 48 horas de hospitalização. Dois modelos de triagem foram propostos ao tomador de decisão do hospital. O modelo da floresta aleatória reduz aproximadamente 39 por cento dos testes desnecessários e prevê corretamente 92 por cento dos positivos. A rede neural evita testes desnecessários em 64 por cento dos casos, mas 24 por cento dos testes positivos são classificados incorretamente. Os resultados mostram que as estratégias de amostragem tradicional, SMOTEBagging e UnderBagging obtiveram melhores resultados. As técnicas lineares como Regressão Logística com regularização apresentam bom desempenho e são mais interpretáveis; elas não são significativamente diferentes dos classificadores mais complexos. Para o modelo de risco de aquisição, o Centroides Encolhidos Mais Próximos é o melhor modelo com um Brier score de 0,152 e um cinto de calibração aceitável. Desenvolvemos uma validação externa a partir de 624 pacientes de dois outros hospitais da mesma rede, encontrando bons valores de Brier score (0,128 and 0,079) em ambos. O uso de antibióticos e procedimentos invasivos, principalmente ventilação mecânica, são os atributos mais importantes e significativos para a colonização ou infecção de CR-GNB. Os modelos preditivos podem ajudar a evitar testes de rastreamento e tratamento inadequado em pacientes de baixo risco. Políticas de controle de infecção podem ser estabelecidas para controlar a propagação dessas bactérias. A identificação de pacientes que não precisam ser testados diminui os custos hospitalares e o tempo de espera do laboratório. Concluímos que nossos modelos apresentam bom desempenho e parecem suficientemente confiáveis para prever um paciente com esses patógenos. Esses modelos preditivos podem ser incluídos no sistema hospitalar. A metodologia proposta pode ser replicada em diferentes ambientes de saúde. / [en] Infections by Carbapenem-Resistant Gram-negative bacteria (CR-GNB) are among the most significant contemporary health concerns, especially in intensive care units (ICUs), and may be associated with increased hospitalization time, morbidity, costs, and mortality. This thesis aims to develop a comprehensive and systematic approach applying machine-learning techniques to build models to predict the CR-GNB acquisition in ICUs from Brazilian hospitals. We proposed screening models to detect ICU patients who do not need to be tested and a risk model that estimates ICU patients probability of acquiring CR-GNB. We applied feature selection methods, machine-learning techniques, and balancing strategies to build and compare the models. The performance criteria chosen to evaluate the models were Negative Predictive Value (NPV) and Matthews Correlation Coefficient (MCC) for the screening model and Brier score and calibration curves for the CR-GNB acquisition risk model. Friedman s statistic and Nemenyi post hoc tests are used to test the significance of differences among techniques. Information gain method and association rules mining assess the importance and strength among features. Our database gathers the patients, antibiotic, and microbiology data from five Brazilian hospitals from May 8th, 2017 to August 31st, 2019, involving hospitalized patients in 24 adult ICUs. Information from the laboratory was used to identify all patients with a positive or negative test for carbapenem-resistant GNB, A. baumannii, P. aeruginosa, or Enterobacteriaceae. We have a total of 539 positive and 7,462 negative tests, resulting in 3,604 patients with at least one exam after 48 hours hospitalized. We proposed to the hospital s decision-maker two screening models. The random forest s model would reduce approximately 39 percent of the unnecessary tests and correctly predict 92 percent of positives. The Neural Network model avoids unnecessary tests in 64 percent of the cases, but 24 percent of positive tests are misclassified as negatives. Our results show that the sampling, SMOTEBagging, and UnderBagging approaches obtain better results. The linear techniques such as Logistic Regression with regularization give a relatively good performance and are more interpretable; they are not significantly different from the more complex classifiers. For the acquisition risk model, the Nearest Shrunken Centroids is the best model with a Brier score of 0.152 and a calibration belt acceptable. We developed an external validation of 624 patients from two other hospitals in the same network, finding good Brier score (0.128 and 0.079) values in both. The antibiotic and invasive procedures used, especially mechanical ventilation, are the most important attributes for the colonization or infection of CR-GNB. The predictive models can help avoid screening tests and inappropriate treatment in patients at low risk. Infection control policies can be established to control these bacteria s spread. Identifying patients who do not need to be tested decreases hospital costs and laboratory waiting times. We concluded that our models present good performance and seem sufficiently reliable to predict a patient with these pathogens. These predictive models can be included in the hospital system. The proposed methodology can be replicated in different healthcare settings.

Gram-negative infection has been linked to hospital water although few studies have examined whether water systems are reservoirs of nosocomial pathogens. This study investigated longitudinal recovery of the opportunistic pathogens Pseudomonas aeruginosa, Stenotrophomonas maltophilia and Acinetobacter baumannii from water outlets of a haematology unit and evaluated Point-Of-Use Filtration (POU-F) as a control measure. In a two-year double cross-over trial, water samples and swabs were taken weekly from 39 showers/taps on the unit. Four study phases alternated between non-filtered (Phases 1 & 3), and filtered outlets (Phases 2 & 4) using Pall AquasafeTM 14-day filters. In Phases 1 & 3; 99% of 1396 samples yielded bacterial growth, with colonies generally too numerous to count. Target species were isolated from 22% of water samples (P. aeruginosa 14%; S. maltophilia 10%) and 10% of swabs. P. aeruginosa was particularly associated with handwash stations and S. maltophilia with showers. A. baumannii was not isolated. With POU-F; 22% of 1242 samples yielded bacterial growth (mean CFU/100ml ,4.6). S. maltophilia was isolated only once from water but never from outlet swabs. PCR typing identified clusters of isolates colonizing different outlets over time but no clear association between water and patient isolates was identified. The incidence of Gram negative infections remained low throughout the study. Without POU-F, water from taps/showers represented a source of bacteria including the target species. POU-F substantially reduced the frequency and number of target species from every outlet, and merits further investigation as an intervention to protect immunocompromised patients from opportunistic pathogens. / School of Life Sciences, University of Bradford and Pall Medical (Pall Europe Ltd)

<p dir="ltr">The obligate human pathogen, <i>Neisseria gonorrhoeae </i>(Ngo), has continued to acquire widespread antibiotic resistance. Ngo is the causative agent of the sexually transmitted disease gonorrhea, and can cause additional complications such as endocarditis, septicemia, and infertility if left untreated. The Centers for Disease Control and Prevention (CDC) now recommends a treatment option of a single drug of last resort, ceftriaxone, leaving a need for novel therapeutics against this pathogen.</p><p dir="ltr">Like many bacterial pathogens, Ngo is Gram-negative consisting of both an inner membrane (IM) and outer membrane (OM). The transmembrane proteins in the IM have primarily an α-helical fold, while the transmembrane proteins in the OM have a β-barrel fold. These β-barrel outer membrane proteins (OMPs) have essential functions in regulating the homeostasis and nutrient acquisition of the cell, in addition to promoting virulence in pathogenic strains. These OMPs are folded and inserted into the outer membrane by the β-barrel assembly machinery (BAM) complex. In <i>E. coli,</i> BAM consists of five proteins: BamA, an OMP itself, and four lipoproteins, BamB, C, D, and E.</p><p dir="ltr">Here we present our work toward the structural characterization of BAM from Ngo (<i>Ng</i>BAM) using cryo-EM. Ngo lack a homolog of BamB and may function as a four component complex. To better understand the mechanism for how <i>Ng</i>BAM is able to mediate OMP biogenesis despite lacking a component that is critical in <i>E. coli</i>, we determined the cryo-EM structure of <i>Ng</i>BAM, which revealed several distinct features including that the barrel domain of BamA being observed in the inward-open conformation. We also investigated <i>Ng</i>BAM as a therapeutic target, by studying its interaction with a novel broad spectrum antibiotic darobactin. We first showed darobactin is effective against the laboratory strains of NgoFA19 and ATCC-49226. We also show it is effective against the human isolate WHOX, with a comparable MIC to ceftriaxone. To structurally characterize the mechanism of inhibition by darobactin, we used cryo-EM to determine the structures of <i>Ng</i>BAM bound to two darobactin compounds. In these structures, darobactin binding was accompanied by large conformational changes in <i>Ng</i>BamA. To further probe the effects of darobactin on the conformational plasticity of <i>Ng</i>BAM we performed experiments using double electron-electron resonance spectroscopy, which showed distance changes between the engineered site labels consistent with the conformational changes observed in our structural observation. In addition, narrowing of the peak distributions indicated that darobactin binding was reducing the overall conformational heterogeneity of the complex. Taken together, the work presented here contributes to the understanding of how <i>Ng</i>BAM functions in folding and inserting OMPs and provides a foundation for future structure based drug design of darobactin and other potential compounds.</p>