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Figure 1. Rip2 mice develop a severe and chronic lung inflammation and manifest impaired early cytokine production in response to infection.

WT and Rip2 −/− mice were infected with C. pneumoniae (1×10 6 IFU/mouse). Lungs of infected mice were isolated on days 3, 5, 14, and 35 after infection. Lungs were fixed in 10% buffered formalin, sectioned, and stained with HE to determine the extent of inflammation (A). Histological analysis of inflammation in C. pneumoniae –infected lungs of WT and Rip2 −/− mice on days 3, 5, 14, and 35 post-infection (B). Statistical significance was determined by Student's t test (* p <0.05, ** p <0.01, *** p <0.001). At 3, 5, and 14 days post-infection, the levels of IL-6, IL-12p40, and IFN-γ in BALF and lung tissue homogenates were determined (C). Statistical significance was determined by Student's t test (* p <0.05, n = 8–14).

https://doi.org/10.1371/journal.ppat.1000379.g001

Rip2 deficiency impairs the production of inflammatory cytokines during infection by day 3

Innate immune responses, and particularly IFN-γ plays an important role in host defense against acute infection and in establishment of persistence of [10] . We, therefore, determined the production of cytokines such as IL-6, IL-12 p40 and IFN-γ levels in BALF and lung homogenates from infected Rip2 and WT mice on days 3, 5 and 14. Concentrations of IL-6, IL-12p40, and IFN-γ were significantly reduced in BALF of Rip2 mice at day 3 compared to WT mice ( DENIM Denim trousers Whop New XwGo9k
). However, by day 5 and day 14, IL-6, IL-12p40 and IFN-γ concentrations in the BALF and lung homogenates from Rip2 mice were significantly increased and exceeded levels in WT mice ( Womens Verona W Colors Trainers Pepe Jeans London Sale Limited Edition 3N2Vbkkmj3
). Thus, in addition to increased histopathological inflammation seen in Rip2 mice on days 5 and 14 and during the later stages, we observed an initial impaired and delayed kinetics in cytokine production in –infected Rip2 mice on day 3, which was also followed by a significant increased in cytokine production in the lungs on days 5 and 14 ( Leather and Fabric Sneakers with Transparent Covering Fall/winter Maison Martin Margiela Sale Latest Collections Deals Cheap Online 100% Guaranteed Cheap Price G2Mfx4w
). We next measured IL-6 and IFN-γ levels in the supernatant of infected bone marrow–derived macrophages (BMDM) and whole lung cells . infection-induced cytokine production (IL-6, and IFN-γ release) were significantly impaired in both Rip2 macrophages and whole lung cells compared to WT macrophages and whole lung cells ( Figure S1A–S1D ).

Our data show impaired cytokine production in Rip2 −/− mice infected with C. pneumoniae early on day 3 following infection but a significant reversal and increase in cytokines and more severe and persistent lung inflammation by day 5 and 14 compared to WT mice ( Figure 1 ). We hypothesized that this more severe and persistent lung inflammation was due to an inability of Rip2 −/− mice to clear bacteria, which would then be expected to continue to provoke inflammation and cause the delayed increase in cytokine production. To test this hypothesis, we performed quantitative bacterial cultures in the lungs of mice at days 3, 5, and 14 post-infection. As anticipated, we observed significantly higher numbers of C. pneumoniae IFU in the lungs of Rip2 −/− mice on days 5 and 14 compared to WT mice ( FOOTWEAR Toe post sandals Sebastian Free Shipping Inexpensive Outlet Prices f9MJvxDtkQ
). This could not be explained by higher baseline load of bacteria in Rip2 −/− mice, since on day 3, bacterial numbers in lungs were similar between WT and Rip2-deficient mice ( Figure 2A ). Consistent with the bacterial clearance data, virtually all WT mice survived the infectious challenge, while Rip2 −/− mice had significantly increased mortality, and less than half the Rip2 −/− mice survived until the end of the experiment at day 35 ( Figure 2B ). Furthermore, the lungs from the Rip2 −/− mice that succumbed to infection harbored an abundance of C. pneumoniae (data not shown), while those who survived cleared the bacteria but still manifested chronic lung inflammation at day 35 ( LUMY SLIDE FitFlop Pick A Best Cheap Price Free Shipping Online Sale Eastbay Low Shipping For Sale Collections For Sale hdJuC
). Collectively then, these data indicate that: 1) Rip2 importantly contributes to clearance of C. pneumoniae from the lungs; and 2) in the absence of Rip2, severe lung inflammation occurs and persists, but fails to effectively combat the infection.

Current recommendations for AOM are valid with the exception again of areas where BLNAR H. influenzae strains are found, where MIC 90 s of amoxicillin, cefaclor, cefpodoxime, and cefdinir against high-level BLNAR strains are above PK/PD breakpoints. The MIC 90 of cefditoren against high-level BLNAR strains is 0.25 μg/ml; however, the PK/PD breakpoint for this agent has not been established but is likely to be lower than the MIC 90 ( 82 , Sneakers for Women On Sale Gold Leather 2017 35 Philippe Model Clearance Low Price Free Shipping Wholesale Price Websites Cheap Online For Sale Top Quality Free Shipping Deals 8jFCwfE6y
). Cefixime and cefpodoxime may have clinically useful activity against high-BLNAR strains, but additional information is needed and use of quinolones should be considered ( 104 , Find Great Cheap Price Spencer slippers Black Jimmy Choo London Free Shipping Authentic ccpaNY
). Similarly, current recommendations for sinusitis are valid, with the exception of areas where BLNAR H. influenzae strains are found.

Recommendations for AECB for patients with baseline risk factors, amoxicillin-clavulanate, and respiratory quinolones are valid, as H. influenzae is the predominant pathogen and these agents are active based on PK/PD breakpoints. However, of the agents recommended for patients without baseline risk factors, azithromycin, clarithromycin, telithromycin, doxycycline, cefuroxime axetil, cefpodoxime, and cefdinir, only cefpodoxime is active against H. influenzae based on PK/PD breakpoints. The rationale for these latter recommendations of agents that will not be effective for the patient group with a high probability of spontaneous resolution is unclear.

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Haemophilus influenzae is a major pathogen causing significant morbidity and mortality in all parts of the world. Meningitis and bacteremia occur in areas where the Hib vaccine is not used, whereas community-acquired respiratory tract infections caused by nontypeable strains occur worldwide. Although it has previously been assumed that little development of drug resistance has occurred in this species, we have reviewed the evidence showing that this is not the case. Apart from β-lactamase production, BLNAR strains occur, especially in Japan and France, and BLPACR strains have also been described. The clinical utility of antimicrobial agents recommended for treating diseases associated with H. influenzae are reviewed, and the limitations of the macrolide, azalide, and ketolide group of agents, tetracyclines, and selected β-lactams against infections caused by this species are noted. Quinolone resistance, though currently rare, may increase in the future. Also, widespread use of the pediatric pneumococcal conjugated vaccine has led to a relative increase in nontypeable H. influenzae compared to pneumococci in community-acquired respiratory tract infections. For all of these reasons, continued epidemiological monitoring of the susceptibility status of these strains is required. New agents are also needed, especially for penicillin-allergic patients in both pediatric patients with otitis media and older patients with AECB.

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AHFS ® Patient Medication Information. © Copyright, 2018. The American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland. All Rights Reserved. Duplication for commercial use must be authorized by ASHP.

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