Presence of IgE antibodies to staphylococcal exotoxins on the skin of patients with atopic dermatitis. Evidence for a new group of allergens.

In the current study, we investigated whether Staphylococcus aureus grown from affected skin of atopic dermatitis (AD) patients secreted identifiable toxins that could act as allergens to induce IgE-mediated basophil histamine release. The secreted toxins of S. aureus grown from AD patients were identified by ELISA using antibodies specific for staphylococcal enterotoxin (SE) exfoliative toxin (ET), or toxic shock syndrome toxin (TSST-1). S. aureus isolates from 24 of 42 AD patients secreted identifiable toxins with SEA, SEB, and TSST accounting for 92% of the isolates. 32 of 56 AD sera (57%) tested contained significant levels of IgE primarily to SEA, SEB, and/or TSST. In contrast, although SEA, SEB, or TSST secreting S. aureus could be recovered from the skin of psoriasis patients, their sera did not contain IgE antitoxins. Freshly isolated basophils from 10 AD patients released 5-59% of total histamine in response to SEA, SEB, or TSST-1 but only with toxins to which patients had specific IgE. Basophils from eight other AD patients and six normal controls who had no IgE antitoxin failed to demonstrate toxin-induced basophil histamine release. Stripped basophils sensitized with three AD sera containing IgE to toxin released 15-41% of total basophil histamine only when exposed to the relevant toxin, but not to other toxins. Sensitization of basophils with AD sera lacking IgE antitoxin did not result in release of histamine to any of the toxins tested. These data indicate that a subset of patients with AD mount an IgE response to SEs that can be grown from their skin. These toxins may exacerbate AD by activating mast cells, basophils, and/or other Fc epsilon-receptor bearing cells armed with the relevant IgE antitoxin.     

NVC-422 Inactivates Staphylococcus aureus Toxins

Bacterial pathogens have specific virulence factors (e.g., toxins) that contribute significantly to the virulence and infectivity of microorganisms within the human hosts. Virulence factors are molecules expressed by pathogens that enable colonization, immunoevasion, and immunosuppression, obtaining nutrients from the host or gaining entry into host cells. They can cause pathogenesis by inhibiting or stimulating certain host functions. For example, in systemic Staphylococcus aureus infections, virulence factors such as toxic shock syndrome toxin 1 (TSST-1), staphylococcal enterotoxin A (SEA), and staphylococcal enterotoxin B (SEB) cause sepsis or toxic shock by uncontrolled stimulation of T lymphocytes and by triggering a cytokine storm. In vitro, these superantigens stimulate the proliferation of human peripheral blood mononuclear cells (PBMC) and the release of many cytokines. NVC-422 (N,N-dichloro-2,2-dimethyltaurine) is a broad-spectrum, fast-acting topical anti-infective agent against microbial pathogens, including antibiotic-resistant microbes. Using mass spectrometry, we demonstrate here that NVC-422 oxidizes methionine residues of TSST-1, SEA, SEB, and exfoliative toxin A (ETA). Exposure of virulence factors to 0.1% NVC-422 for 1 h prevented TSST-1-, SEA-, SEB-, and ETA-induced cell proliferation and cytokine release. Moreover, NVC-422 also delayed and reduced the protein A- and clumping factor-associated agglutination of S. aureus cultures. These results show that, in addition to its well-described direct microbicidal activity, NVC-422 can inactivate S. aureus virulence factors through rapid oxidation of methionines.     

Human antibodies to bacterial superantigens and their ability to inhibit T-cell activation and lethality

Bacterial superantigens (BSAgs) cause massive stimulation of the immune system and are associated with various pathologies and diseases. To address the role of antibodies in protection against BSAgs, we screened the sera of 29 human volunteers for antibodies to the SAgs staphylococcal enterotoxin A (SEA), SEB, SEC1, and toxic shock syndrome toxin 1 (TSST-1). Although all volunteers had detectable levels of antibodies against SEB and SEC1, many (9 out of 29 volunteers) lacked detectable antibody to SEA or had minimal titers. Antibody titers to TSST-1 were well below those to SEB and SEC1, and three volunteers lacked detectable antibody to this BSAg. In addition, pooled immunoglobulin preparations obtained from different companies had antibody titers against SEs and TSST-1. There was a good correlation between antibody titers and inhibition of superantigenic effects of these toxins. Transfer of SEB-specific antibodies, obtained from pooled sera, suppressed in vitro T-cell proliferation and totally protected mice against SEB. These data suggest that the inhibitory activity of human sera was specific to antibodies directed against the toxins. Thus, it may be possible to counteract with specific antibodies BSAg-associated pathologies caused by stimulation of the immune system.     

Genotypic identification of staphylococcal enterotoxins and toxic shock syndrome toxin 1 by the enzymatic detection of polymerase chain reaction-amplified DNA

The enzymatic detection of a polymerase chain reaction product (ED-PCR), a new detection method of PCR-amplified DNA, was evaluated for the identification of staphylococcal enterotoxin (SE) and toxic shock syndrome toxin 1 (TSST-1) genes. A total of 61Staphylococcus aureus strains, including reference strains and strains isolated from clinical specimens and food poisoning outbreaks, were examined by ED-PCR and by reverse passive latex agglutination (RPLA) phenotypic identification. There was 100% agreement between the genotypic and phenotypic identification of SEA, SEB, SEC, SEE strains and TSST-1. In the case of SED, however, 4 strains were positive by ED-PCR and negative by RPLA. ED-PCR offers an accurate alternative to traditional immunoassays or conventional PCR using electrophoresis for the detection of SE and TSST-1 production yielding results that are more precise than with older techniques.     

Neutralization of staphylococcal exotoxins in vitro by human-origin intravenous immunoglobulin

Human-origin intravenous immunoglobulin (IVIG) collected from healthy individuals was tested for its neutralizing activity against the hemolysin, toxic shock syndrome toxin-1 (TSST-1), and enterotoxins, produced by laboratory strains of methicillin-resistant Staphylococcus aureus (MRSA). The hemolytic activity of the culture supernatant against sheep red blood cells was reduced from 100% to 5.5% relative hemolysis in the presence of 0.156 mg protein/ml of IVIG. The maximum dilution endpoint of the culture supernatant for TSST-1-mediated latex aggregation was 32-fold. This level of TSST-1 activity was reduced to eightfold dilution by 0.78 mg protein/ml of IVIG, and the latex aggregation activity of undiluted TSST-1 in the culture supernatant was inhibited by 1.56 mg protein/ml of IVIG. Similarly, the enterotoxin A-mediated latex aggregation titer appeared to be a 320-fold dilution. This toxin activity was reduced to an 80-fold dilution and below a tenfold dilution by 0.049 through 0.78 and 1.56 mg protein/ml, respectively, of IVIG. These results show that IVIG has powerful neutralizing activity against hemolysin, TSST-1, and enterotoxin A. Therefore, IVIG may be useful for passive immunization therapy in patients suffering from diseases caused by MRSA exotoxins.     

Transcytosis of Staphylococcal Superantigen Toxins

Staphylococcus aureus produces a set of proteins (e.g., staphylococcal enterotoxin A [SEA], SEB, toxic shock syndrome toxin 1 [TSST-1]) which act both as superantigens (SAgs) and toxins. Although their mode of action as SAgs is well understood, little is known about how they enter the body via the intestine and cause food poisoning. To examine this problem we used an in vitro culture system to study the capacity of class II MHC-negative human intestinal epithelial cells (Caco-2) to transcytose several staphylococcal toxins. We found that Caco-2 cells are capable of dosedependent, facilitated transcytosis of SEB and TSST-1, but not SEA. We extended these studies in vivo in mice by showing that ingested SEB appears in the blood more efficiently than SEA. Our data suggest that these toxins can cross the epithelium in an immunologically intact form. These results may have important implications for the pathogenesis of food poisoning. S taphylococcus aureus produces a set of exotoxins including staphylococcal enterotoxins (SEs)¹ and toxic shock syndrome toxin 1 (TSST-1) which cause food poisoning and toxic shock syndrome in human beings and other species (1–4). These toxins are intermediate molecular weight proteins (22–30 kD) that also act as superantigens (SAgs; 5–7), due to their ability to bind to MHC class II molecules on APCs, and stimulate all T cells bearing particular Vβs on their T cell receptors (5–11). For example, the mouse in SEA stimulates T cells bearing Vβs 1, 3, 11, 17, and the closely related SEB and SECs stimulate T cells bearing Vβ7 and members of the Vβ8 family (12). TSST-1 stimulates nearly all T cells bearing Vβ15 in the mouse or Vβ2 in human (13). Thus, an individual toxin can potentially activate a very high proportion of T cells (5–30%). The toxic shock associated with these toxins has been attributed to the flood of cytokines (TNF, IL-2, etc.) released during this massive T cell stimulation. For example, in mice SEB can cause a shock-like syndrome resulting in rapid weight loss and death (14). Nude mice or mice lacking T cells bearing the relevant Vβ elements are resistant to the toxic effects of SEB (14). A role for T cells in generation of shock is also suggested by the greatly elevated percentage of T cells bearing Vβ2 in patients with TSST-1–mediated toxic shock syndrome (13, 15).On the other hand, in toxin-mediated food poisoning, the symptoms of which include diarrhea and vomiting within about 4–6 h of ingesting contaminated food, pathogenesis is not so well understood. It is possible that these toxins stimulate intestinal lymphocytes to release cytokines which induce the symptoms by local inflammation. Alternatively, they may have an additional functional domain which can interact directly with receptors on the cells lining the intestine to cause the symptoms. Distinguishing between these possibilities has been difficult due to the lack of a rodent model for toxin-mediated food poisoning.To shed some light on the problem, we performed experiments to see if these toxins can cross the intestinal epithelium, since to stimulate T cells, ingested toxin must escape the intestine in an intact form that is capable of interacting with the host immune system. We performed two types of experiments. In the first we directly examined transepithelial transcytosis of toxins in vitro using a well-characterized human enterocytic cell line, Caco-2 (16, 17). In the second we used T cell stimulation/deletion assays to detect toxins in the blood of mice after they had been fed toxins. Our results show that these toxins cross epithelial membranes, in some cases by a facilitated mechanism. While our results do not rule out a direct effect of these toxins on intestinal epithelium, they show that the toxins can gain rapid access to the immune system after ingestion supporting a role for T cells in the pathogenesis of food poisoning.     

Bacterial superantigens induce T cell expression of the skin-selective homing receptor, the cutaneous lymphocyte-associated antigen, via stimulation of interleukin 12 production

T lymphocyte infiltration is a prominent feature of the skin inflammation associated with infections by toxin (superantigen)- secreting Staphylococcus aureus or Streptococcus bacteria. The cutaneous lymphocyte-associated antigen (CLA) has been hypothesized to be a homing receptor (HR) involved in selective migration of memory/effector T cells to the skin. Since the expression of this putative skin-selective HR is known to be under strict microenvironmental control, we sought to determine the effect of staphylococcal and streptococcal toxins on T cell expression of CLA. After in vitro stimulation of peripheral blood mononuclear cells with staphylococcal enterotoxin B, toxic shock syndrome toxin-1, and streptococcal pyrogenic exotoxins A and C, there was a significant increase in the numbers of CLA+ T cell blasts (p < 0.01), but not blasts bearing the mucosa-associated adhesion molecule alpha e beta 7- integrin, compared with T cells stimulated with phytohemaglutinin (PHA) or anti-CD3. Bacterial toxins were also found to specifically induce interleukin (IL) 12 production. More importantly, induction of toxin- induced CLA expression was blocked by anti-IL-12, and the addition of IL-12 to PHA-stimulated T cells induced CLA, but not alpha e beta 7- integrin, expression. These data suggest that bacterial toxins induce the expansion of skin-homing CLA+ T cells in an IL-12-dependent manner, and thus may contribute to the development of skin rashes in superantigen-mediated diseases.     

Linezolid Effects on Bacterial Toxin Production and Host Immune Response: Review of the Evidence

BackgroundLinezolid is active against a broad range of gram-positive pathogens and has the potential to also affect production of bacterial toxins and host immune function.ObjectiveTo assess the evidence for direct effects of linezolid on bacterial toxin synthesis and modulation of host immune responses.MethodsLiterature searches were performed of the PubMed and OVID databases. Reviews and non–English language articles were excluded. Articles with information on the effect of linezolid on bacterial toxin synthesis and immune responses were selected for further review, and data were summarized.ResultsSubstantial in vitro evidence supports effects of linezolid on bacterial toxin production; however, the strength of the evidence and the nature of the effects are mixed. In the case of Staphylococcus aureus, repeated observations support the inhibition of production of certain staphylococcal toxins (Panton-Valentine leukocidin, protein A, and α- and β-hemolysin) by linezolid, whereas only solitary reports indicate inhibition (toxic shock syndrome toxin-1, coagulase, autolysins, and enterotoxins A and B) or stimulation (phenol-soluble modulins) of toxin production by linezolid. In the case of Streptococcus pyogenes, there are solitary reports of linezolid inhibition (protein M, deoxyribonuclease, and streptococcal pyrogenic exotoxins A, B, and F) or stimulation (immunogenic secreted protein 2 and streptococcal inhibitor of complement-mediated lysis) of toxin production, whereas published evidence for effects on streptolysin O production is conflicting. In vitro data are limited, but suggest that linezolid might also have indirect effects on host cytokine expression through inhibition of bacterial production of toxins. In vivo data from preclinical animal studies and a single clinical study in humans are limited and equivocal insofar as a potential role for linezolid in modulating the host inflammatory response; this is due in part to the difficulty in isolating antimicrobial effects and toxin synthesis inhibitory effects of linezolid from any secondary effects on host inflammatory response.ConclusionsAvailable evidence supports the possibility that linezolid can inhibit, and in some cases stimulate, toxin production in clinically relevant pathogens. However, more research will be needed to determine the potential clinical relevance of those findings for linezolid.     

Chocs toxiques dans les infections à cocci à Gram positif

Although Gram-positive cocci are implicated in half of the documented causes of sepsis, toxic shock syndrome (TSS) due to these organisms is rare. By definition, TSS, whether related to staphylococcus (staph-TSS) or streptococcus (strep-TSS), is characterized by the production of superantigen exotoxins, alone or in association with other virulence factors, inducing an excessive production of pro-inflammatory cytokines. Staph-TSS may be menstrual (colonisation of an absorbent tampon or intrauterine device [IUD]: production of TSS toxin-1 (TSST-1), negative blood culture, low mortality) or non-menstrual (usually postsurgical colonisation or local infection: production of TSST-1 or enterotoxin, positive blood culture in 50% of the cases, 20-25% mortality rate). Strep-TSS is usually associated with necrosing fasciitis (60% positive blood culture, mortality up to 80% in the case with associated myositis). Organ failure is managed like septic shock. Mechanical eradication of the toxin source is mandatory (removal of tampon or IUD in menstrual staph-TSS, surgical revision even without signs of local inflammation in post-surgical non-menstrual staph-TSS, and aggressive surgery in strep-TSS with necrosing fasciitis). Antibiotic treatment should be bactericidal (high-dose ??-lactam). In addition, it is recommended to add an antimicrobial with antitoxinic activity such as clindamycin (a large majority of Staphylococcus aureus and Streptococcus pyogenes strains implicated in TSS in France are susceptible to clindamycin) or polyvalent immunoglobulins, especially in case of shock with refractory hypotension.     

Destructive pulmonary embolism in a patient with community-acquired staphylococcal bacteremia

We report a 17-year-old man with destructive pulmonary embolism caused by Staphylococcus aureus bacteremia. The patient was not immunocompromised and had neither underlying diseases nor risk factors, such as concomitant influenza viral infection, which exacerbate staphylococcal infections. The rapid and extensive progression of pulmonary involvement in all lung fields make this a rare case; there have been few reports in the literature describing a similar radiographic appearance in patients with community-acquired staphylococcal bacteremia. In-vitro studies did not demonstrate the production of enterotoxins or toxic shock syndrome toxin 1 (TSST-1) by the isolated strain, but genetic analysis detected Panton-Valentine leukocidine gene from the strain. Subsequent empyema with bilateral pneumothorax was prolonged because of superinfection with both methicillin-resistant Staphylococcus aureus and Pseudomonas aeruginosa. Optional surgical treatments, including thoracostomy and thoracopneumoplasty, finally improved his condition. Received: February 22, 2001 / Accepted: July 25, 2001     

Injury primes the immune system for an enhanced and lethal T-cell response against bacterial superantigen.

We previously reported the high lethality of CD4+ T-cell activation in burn-injured T-cell receptor (TCR) transgenic mice. This suggested to us that T-cells may play a role in the development of the systemic inflammatory response syndrome (SIRS) which can occur after severe injury. In this study, we sought a more clinically relevant model to test the hypothesis that naturally produced bacterial toxins that are known to act as potent polyclonal T-cell activating agents may induce a similar lethal shock-like response in injured, non-TCR transgenic mice. Accordingly, sham- or burn-injured mice were treated with various doses of staphylococcal enterotoxin A (SEA), then observed for 48-hour mortality. We observed 94% and 56% 48-h mortality when burn-injured mice were given 15 microg and 10 microg of SEA, respectively, while neither SEA dose caused mortality in sham-injured mice. The assessment of serum cytokine levels demonstrated significantly elevated interleukin 2 (IL-2) and tumor necrosis factor alpha (TNFalpha) levels when compared to sham mice (P < 0.01). In vitro studies confirmed our in vivo results and also demonstrated elevated levels of interferon gamma (IFNgamma) (P < 0.01). We also observed a novel injury-dependent switch from CD4+ to CD8+ T-cells as the dominant T-cell type producing TNFalpha and IFNgamma in response to SEA stimulation in vitro. Taken together, our findings indicate that injury primes the immune system for an augmented early T-cell response that can result in a lethal shock-like syndrome.     

Identification of Staphylococcus aureus enterotoxins A and B genes by PCR-ELISA

We developed PCR-enzyme linked immunosorbent (ELISA) assays to detect Staphylococcus aureus enterotoxins A and B genes. The assays use internal biotin-labelled oligonucleotides as capture probes for immobilizing and subsequently detecting target sequences on microtiter plates. The detection limits of the PCR-ELISAs were approximately 250 gene copies, versus 2500 gene copies by agarose gel analysis. The sensitivity of the assays, as determined from a reference panel of 46 coded samples that included DNA purified from 31 different bacterial species and strains, SEA and SEB plasmid controls, and no-template controls was 100%. No cross-reactivity was observed with DNA from non-staphylococcal species. Using 27 clinical isolates of S. aureus, the SEA PCR-ELISA identified the enterotoxin A (sea) gene in 26 samples, and the SEB PCR-ELISA identified the enterotoxin B (seb) gene in all 27 samples. Compared with conventional antigen capture ELISAs for SEA and SEB toxins, the PCR-ELISAs showed overall superior detection limits. The sensitivity and specificity levels of the SEA PCR-ELISA and the SEA toxin ELISA were comparable within their respective detection thresholds, but the sensitivity and specificity of the SEB PCR-ELISA was much greater than that of SEB toxin ELISA.     

Superantigenic toxin genes coexist with specific staphylococcal cassette chromosome mec genes in methicillin-resistant Staphylococcus aureus

Staphylococcus aureus is a leading cause of human disease in the hospital setting and the community. Superantigenic toxin-producing methicillin-resistant Staphylococcus aureus (MRSA) is currently important for nosocomial infections and food-borne diseases worldwide because of its global spreading and difficulty in therapy. Superantigenic toxins can bypass normal antigen presentation and have strong T cell mitogenic activity, leading to massive release of proinflammatory cytokines and contributing to the severity of S. aureus sepsis. In this study, a total of 131 MRSA isolates from patients in the University Hospital were searched for staphylococcal cassette chromosome mec (SCCmec) genes and the staphylococcal superantigenic toxin genes by multiplex polymerase chain reactions. The MRSA isolates were classified into SCCmec type II (74.8%), type I (13.0%), type IV (3.8%), type V (2.3%), and type I and type II (3.8%). MRSA isolates (102/131) also carried a number of superantigenic toxin genes including staphylococcal enterotoxin (se) and toxic shock syndrome toxin-1 (tst-1) genes. The most frequent superantigen gene profile (55/131, 42.0%) of the MRSA isolates includes staphylococcal enterotoxin C (sec), seg, sei, staphylococcal enterotoxin-like L (sell), selm, seln, selo, and tst-1. Furthermore, SCCmec type I or type II MRSA isolates more frequently harbor sec, seg, sei, sell, selm, seln, selo, and tst-1 genes, compared to other types of MRSA. These results indicate that the selected superantigenic toxin genes are linked to SCCmec type I and type II. The coexistence of these toxins and the SCCmec genes in S. aureus may contribute to the biological fitness and pathogenicity of MRSA.     

Glutamine administration reduces Gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control.

OBJECTIVE: To determine the effect of intravenous glutamine supplementation vs. an isonitrogenous control on infectious morbidity in severely burned patients. Previous clinical studies in seriously ill patients suggest a beneficial effect of glutamine on infectious morbidity, but no trials have examined possible clinical benefits in severely burned patients. DESIGN: Prospective, double-blind, randomized trial. SETTING: Burn intensive care unit of a university hospital. PATIENTS: Twenty-six severe burn patients with total burn surface area of 25% to 90% and presence of full-thickness burns. Patients were evaluated for occurrence of bacteremia and antibiotic use during the first 30 days of their burn unit admission. Nutritional status and overall inflammation were also measured. INTERVENTION: Either intravenous glutamine or an isonitrogenous control amino acid solution was administered as a continuous infusion during burn intensive care unit stay. MEASUREMENTS AND MAIN RESULTS: The incidence of Gram-negative bacteremia was significantly reduced in the glutamine-supplemented group (8%) vs. control (43%; p <.04). No difference was seen in the incidence of Gram-positive bacteremia or fungemia. Average number of positive blood cultures, antibiotic usage, and mortality rates also were reduced but did not reach statistical significance. Significant improvements in serum transferrin and prealbumin were observed in glutamine-supplemented patients at 14 days after burn injury (p <.01 and.04, respectively). C-reactive protein was also significantly reduced at 14 days after burn injury in the glutamine group (p <.01). CONCLUSIONS: Significantly fewer bacteremic episodes with Gram-negative organisms occurred in the glutamine-supplemented patients. Glutamine supplementation improved measures of nutrition and decreased measures of overall inflammation. In addition, a trend toward lower mortality rate, decreased overall bacteremia incidence, and antibiotic usage in the glutamine group was observed. Glutamine's beneficial effects may be a result of improved gut integrity or immune function, but the precise mechanism of glutamine's protection is unknown.     

Increased mortality with accessory gene regulator (agr) dysfunction in Staphylococcus aureus among bacteremic patients

Accessory gene regulator (agr) dysfunction in Staphylococcus aureus has been associated with a longer duration of bacteremia. We aimed to assess the independent association between agr dysfunction in S. aureus bacteremia and 30-day in-hospital mortality. This retrospective cohort study included all adult inpatients with S. aureus bacteremia admitted between 1 January 2003 and 30 June 2007. Severity of illness prior to culture collection was measured using the modified acute physiology score (APS). agr dysfunction in S. aureus was identified semiquantitatively by using a δ-hemolysin production assay. Cox proportional hazard models were used to measure the association between agr dysfunction and 30-day in-hospital mortality, statistically adjusting for patient and pathogen characteristics. Among 814 patient admissions complicated by S. aureus bacteremia, 181 (22%) patients were infected with S. aureus isolates with agr dysfunction. Overall, 18% of patients with agr dysfunction in S. aureus died, compared to 12% of those with functional agr in S. aureus (P = 0.03). There was a trend toward higher mortality among patients with S. aureus with agr dysfunction (adjusted hazard ratio [HR], 1.34; 95% confidence interval [CI], 0.87 to 2.06). Among patients with the highest APS (scores of >28), agr dysfunction in S. aureus was significantly associated with mortality (adjusted HR, 1.82; 95% CI, 1.03 to 3.21). This is the first study to demonstrate an independent association between agr dysfunction and mortality among severely ill patients. The δ-hemolysin assay examining agr function may be a simple and inexpensive approach to predicting patient outcomes and potentially optimizing antibiotic therapy.     

Epidermal HLA-DR and the enhancement of cutaneous reactivity to superantigenic toxins in psoriasis

Streptococcal and staphylococcal superantigens (SAg's) have been implicated in the pathogenesis of inflammatory skin diseases, but the mechanisms by which these toxins act are unknown. The present study assessed the ability of nanogram quantities of topically applied purified toxic shock syndrome toxin-1 (TSST-1), staphylococcal enterotoxin type B, and streptococcal pyrogenic enterotoxin types A and C to induce inflammatory reactions in clinically uninvolved skin of normal controls and subjects with psoriasis, atopic dermatitis, and lichen planus. These SAg's triggered a significantly greater inflammatory skin response in psoriatics than in normal control subjects or in subjects with atopic dermatitis or lichen planus. Surprisingly, skin biopsies did not exhibit the T-cell receptor Vbeta stimulatory properties predicted for SAg-induced skin reactions. By 6 hours after patch testing with SAg's, TNF-alpha mRNA had increased in the epidermis (but not the dermis) in biopsies from psoriatics, compared with controls. Immunohistochemical studies revealed significantly higher HLA-DR expression in keratinocytes from psoriatics than from controls. However, a mutant TSST-1 protein that fails to bind HLA-DR did not elicit an inflammatory skin reaction. These results indicate that keratinocyte expression of HLA-DR enhances inflammatory skin responses to SAg's. They may also account for previous studies failing to demonstrate selective expansion of T-cell receptor Vbetas in psoriatics colonized with SAg-producing Staphylococcus aureus, and they identify a novel T cell-independent mechanism by which SAg's contribute to the pathogenesis of inflammatory skin diseases.     

Symmetry requirements for effective blocking of pore-forming toxins: comparative study with alpha-, beta-, and gamma-cyclodextrin derivatives

We compared the abilities of structurally related cationic cyclodextrins to inhibit Bacillus anthracis lethal toxin and Staphylococcus aureus α-hemolysin. We found that both β- and γ-cyclodextrin derivatives effectively inhibited anthrax toxin action by blocking the transmembrane oligomeric pores formed by the protective antigen (PA) subunit of the toxin, whereas α-cyclodextrins were ineffective. In contrast, α-hemolysin was selectively blocked only by β-cyclodextrin derivatives, demonstrating that both symmetry and size of the inhibitor and the pore are important.     

Panton-valentine leukocidin-positive and toxic shock syndrome toxin 1-positive methicillin-resistant Staphylococcus aureus: a French multicenter prospective study in 2008

The epidemiology of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) differs from country to country. We assess the features of the ST80 European clone, which is the most prevalent PVL-positive CA-MRSA clone in Europe, and the TSST-1 ST5 clone that was recently described in France. In 2008, all MRSA strains susceptible to fluoroquinolones and gentamicin and resistant to fusidic acid that were isolated in 104 French laboratories were characterized using agr alleles, spa typing, and the staphylococcal cassette chromosome mec element and PCR profiling of 21 toxin genes. Three phenotypes were defined: (i) kanamycin resistant, associated with the ST80 clone; (ii) kanamycin and tobramycin resistant, associated with the ST5 clone; and (iii) aminoglycoside susceptible, which was less frequently associated with the ST5 clone. Among the 7,253 MRSA strains isolated, 91 (1.3%) were ST80 CA-MRSA (89 phenotype 1) and 190 (2.6%) were ST5 CA-MRSA (146 phenotype 2, 42 phenotype 3). Compared to the latter, ST80 CA-MRSAs were more likely to be community acquired (80% versus 46%) and found in young patients (median age, 26.0 years versus 49.5 years) with deep cutaneous infections (48% versus 6%). They were less likely to be tetracycline susceptible (22% versus 85%) and to be isolated from respiratory infections (6% versus 27%). The TSST-1 ST5 clone has rapidly emerged in France and has become even more prevalent than the ST80 European clone, whose prevalence has remained stable. The epidemiological and clinical patterns of the two clones differ drastically. Given the low prevalence of both among all staphylococcal infections, no modification of antibiotic recommendations is required yet.     

Outcomes in patients tested for Clostridium difficile toxins

Clostridium difficile testing is shifting from toxin detection to C. difficile detection. Yet, up to 60% of patients with C. difficile by culture test negative for toxins and it is unclear whether they are infected or carriers. We reviewed medical records for 7046 inpatients with a C. difficile toxin test from 2005 to 2009 to determine the duration of diarrhea and rate of complications and mortality among toxin-positive (toxin+) and toxin− patients. Overall, toxin− patients had less severe diarrhea, fewer diarrhea days, and lower mortality (P < 0.001, all comparisons) than toxin+ patients. One toxin− patient (n = 1/6121; 0.02%) was diagnosed with pseudomembranous colitis, but there were no complications such as megacolon or colectomy for fulminant CDI among toxin− patients. These data suggest that C. difficile–attributable complications are rare among patients testing negative for C. difficile toxins. More studies are needed to evaluate the clinical significance of C. difficile detection in toxin− patients.     

Superantigens from Staphylococcus aureus induce procoagulant activity and monocyte tissue factor expression in whole blood and mononuclear cells via IL-1β

Summary.  Background :  Staphylococcus aureus is one of the most common bacteria in human sepsis, a condition in which the activation of blood coagulation plays a critical pathophysiological role. During severe sepsis and septic shock microthrombi and multiorgan dysfunction are observed as a result of bacterial interference with the host defense and coagulation systems. Objectives : In the present study, staphylococcal superantigens were tested for their ability to induce procoagulant activity and tissue factor (TF) expression in human whole blood and in peripheral blood mononuclear cells. Methods and results : Determination of clotting time showed that enterotoxin A, B and toxic shock syndrome toxin 1 from S. aureus induce procoagulant activity in whole blood and in mononuclear cells. The procoagulant activity was dependent on the expression of TF in monocytes since antibodies to TF inhibited the effect of the toxins and TF was detected on the surface of monocytes by flow cytometry. In the supernatants from staphylococcal toxin-stimulated mononuclear cells, interleukin (IL)-1β was detected by ELISA. Furthermore, the increased procoagulant activity and TF expression in monocytes induced by the staphylococcal toxins were inhibited in the presence of IL-1 receptor antagonist, a natural inhibitor of IL-1β. Conclusions : The present study shows that superantigens from S. aureus activate the extrinsic coagulation pathway by inducing expression of TF in monocytes, and that the expression is mainly triggered by superantigen-induced IL-1β release.