Mounting evidence indicates that broad-spectrum antibiotic overuse is widespread in the management of suspected sepsis and leads to harms. Clinicians lack timely diagnostic tools to guide when broad empiric gram-negative (GN) coverage is needed. To address this gap, we aimed to identify a host-based signature of GN infection as a proof-of-concept for development of a future rapid diagnostic assay.Table 1.Participant and pathogen characteristics in classified discovery/cross-validation dataseta. “Systemic infections” refers to processes without a primary anatomic site of infection, such as dengue, but not to cases where bacteremia complicated a primary site of infection. b. Participants who presented with suspected sepsis and met enrollment criteria but were ultimately adjudicated as having a confirmed non-infectious disease, e.g. congestive heart failure or diabetic ketoacidosis. c. All were cases of disease caused by Mycobacterium tuberculosis. d. Other pathogens included Streptococcal spp. (n=5), Staphylococcus aureus (n=4), Mycobacterium tuberculosis (n=4), dengue virus (n=2), among other pathogens.Performance of host transcript- and protein-based signatures of gram negative infection in cross-validationArea under the receiver operating characteristic curves for gram-negative signatures compared to adjudicated diagnoses, based on stratified 5-fold cross-validation with 5 repeats. This analysis utilized RNASeq and a 29-analyte proteomics dataset derived from blood collected from participants at time of enrollment into a longitudinal study of sepsis conducted by the Austere environments Consortium for Enhanced Sepsis Outcomes (ACESO). Enrollment criteria in the original study were based on sepsis-2 definitions. Participants from sites in Kumasi, Ghana and Takéo Province, Cambodia who had confirmed, independently adjudicated diagnoses were included in this analysis. The dataset was classified into participants with laboratory confirmed GN infection and participants with any other non-GN confirmed diagnosis. We performed t-tests with False Discovery Rate correction, followed by an exhaustive search of transcript and protein combinations using logistic regression with a stratified 5-fold cross-validation with 5 repeats. The discovery/cross-validation dataset included 31 GN infections and 37 other cases. A transcriptomics exhaustive search yielded a signature featuring SMARCD3, EIF4G1, and IER5 with an area under the receiver operating characteristic (AUROC) curve of 0.891. A protein-based signature (features: IL17A, IL1RA, and MMP8) had an AUROC of 0.795. The approach used in this exploratory analysis shows promise for development of a rapid test to guide empiric antibiotics for sepsis while culture-based diagnostics are pending. This rapid test would provide critical benefit to patients in limited-resource settings, including in low- and middle-income countries, pandemic and mass-casualty scenarios, and prolonged field care during military operations. Further work is needed, first to expand the discovery dataset to ensure selection of features that will perform robustly across epidemiologic settings, and second to formally validate the signature in a separate test set. All Authors: No reported disclosures

In resource-scarce settings, melioidosis is associated with up to 80% mortality. Studies of melioidosis in Cambodia report primarily on pediatric populations with localized infection; however, literature describing Cambodian adults with severe melioidosis is lacking. We present a case series of 35 adults with sequence-confirmed Burkholderia pseudomallei bacteremia presenting to a provincial referral hospital in rural Cambodia. More than 90% of the patients had diabetes, an important risk factor for developing melioidosis. Inappropriate antimicrobial therapy was significantly associated with lower odds of survival. Improved diagnostic testing and greater access to first-line antibiotics for acute melioidosis treatment present potential targets for intervention to reduce mortality associated with this disease in resource-limited settings.

Abstract Background Sepsis from infection is a global health priority and clinical trials have failed to deliver effective therapeutic interventions. To address complicating heterogeneity in sepsis pathobiology, and improve outcomes, promising precision medicine approaches are helping identify disease endotypes, however, they require a more complete definition of sepsis subgroups. Methods Here, we use RNA sequencing from peripheral blood to interrogate the host response to sepsis from participants in a global observational study carried out in West Africa, Southeast Asia, and North America (N = 494). Results We identify four sepsis subtypes differentiated by 28-day mortality. A low mortality immunocompetent group is specified by features that describe the adaptive immune system. In contrast, the three high mortality groups show elevated clinical severity consistent with multiple organ dysfunction. The immunosuppressed group members show signs of a dysfunctional immune response, the acute-inflammation group is set apart by molecular features of the innate immune response, while the immunometabolic group is characterized by metabolic pathways such as heme biosynthesis. Conclusions Our analysis reveals details of molecular endotypes in sepsis that support immunotherapeutic interventions and identifies biomarkers that predict outcomes in these groups.

This article contains an experimental dataset related to the mechanical properties of Canadian small clear spruce-pine-fir wood. Motivated by the necessity of shading light on the orthotropic mechanical behavior of clear specimens of two of the most common wooden grades used for the manufacturing of cross-laminated timber panels in North America, a comprehensive experimental campaign on small clear spruce-pine-fir wood specimens, based on ASTM D143-22, has been conducted in the Department of Wood Science of the University of British Columbia. A total of 690 specimens from both visually-graded number 2 and machine-stress rated 2100fb 1.8E spruce-pine-fir wood were tested in compression, tension, and shear, following the directions parallel- and perpendicular-to-the-grain. For each test, the force and the deformation were recorded on-line through an MTS software before being stored in a hard drive disk unit as text files at the end of the test. Text files were then post-processed using a MATLAB routine to generate stress-strain data points, ultimate strength, and modulus of elasticity. Additionally, probability distributions of ultimate strength and modulus of elasticity of specimens were plotted. A Kolmogorov-Smirnov goodness-of-fit test was used to fit these data using either Burr, Gumbel, or Weibull distribution. In overall, the dataset presented in this work can be used in the finite-elements modelling of the structural behavior of timber connections or the local mechanical behavior of timber elements. This dataset can also be used to get a grasp and asses the variability in the mechanical properties of Canadian small clear spruce-pine-fir wood.

This article contains an experimental dataset related to the mechanical properties of Canadian small clear spruce-pine-fir wood. Motivated by the necessity of shading light on the orthotropic mechanical behavior of clear specimens of two of the most common wooden grades used for the manufacturing of cross-laminated timber panels in North America, a comprehensive experimental campaign on small clear spruce-pine-fir wood specimens, based on ASTM D143-22, has been conducted in the Department of Wood Science of the University of British Columbia. A total of 690 specimens from both visually-graded number 2 and machine-stress rated 2100fb 1.8E spruce-pine-fir wood were tested in compression, tension, and shear, following the directions parallel- and perpendicular-to-the-grain. For each test, the force and the deformation were recorded on-line through an MTS software before being stored in a hard drive disk unit as text files at the end of the test. Text files were then post-processed using a MATLAB routine to generate stress-strain data points, ultimate strength, and modulus of elasticity. Additionally, probability distributions of ultimate strength and modulus of elasticity of specimens were plotted. A Kolmogorov-Smirnov goodness-of-fit test was used to fit these data using either Burr, Gumbel, or Weibull distribution. In overall, the dataset presented in this work can be used in the finite-elements modelling of the structural behavior of timber connections or the local mechanical behavior of timber elements. This dataset can also be used to get a grasp and asses the variability in the mechanical properties of Canadian small clear spruce-pine-fir wood.

OBJECTIVES:We evaluated the performance of commonly used sepsis screening tools across prospective sepsis cohorts in the USA, Cambodia and Ghana.DESIGN:Prospective cohort studies.SETTING AND PARTICIPANTS:From 2014 to 2021, participants with two or more SIRS (Systemic Inflammatory Response Syndrome) criteria and suspected infection were enrolled in emergency departments and medical wards at hospitals in Cambodia and Ghana and hospitalised participants with suspected infection were enrolled in the USA. Cox proportional hazards regression was performed, and Harrell's C-statistic calculated to determine 28-day mortality prediction performance of the quick Sequential Organ Failure Assessment (qSOFA) score ≥2, SIRS score ≥3, National Early Warning Score (NEWS) ≥5, Modified Early Warning Score (MEWS) ≥5 or Universal Vital Assessment (UVA) score ≥2. Screening tools were compared with baseline risk (age and sex) with the Wald test.RESULTS:The cohorts included 567 participants (42.9% women) including 187 participants from Kumasi, Ghana, 200 participants from Takeo, Cambodia and 180 participants from Durham, North Carolina in the USA. The pooled mortality was 16.4% at 28 days. The mortality prediction accuracy increased from baseline risk with the MEWS (C-statistic: 0.63, 95% CI 0.58 to 0.68; p=0.002), NEWS (C-statistic: 0.68; 95% CI 0.64 to 0.73; p<0.001), qSOFA (C-statistic: 0.70, 95% CI 0.64 to 0.75; p<0.001), UVA score (C-statistic: 0.73, 95% CI 0.69 to 0.78; p<0.001), but not with SIRS (0.60; 95% CI 0.54 to 0.65; p=0.13). Within individual cohorts, only the UVA score in Ghana performed better than baseline risk (C-statistic: 0.77; 95% CI 0.71 to 0.83; p<0.001).CONCLUSIONS:Among the cohorts, MEWS, NEWS, qSOFA and UVA scores performed better than baseline risk, largely driven by accuracy improvements in Ghana, while SIRS scores did not improve prognostication accuracy. Prognostication scores should be validated within the target population prior to clinical use.

Abstract Background Survival prediction models have largely been derived and validated only in high-resource Western countries or in single center studies. We sought to create a prediction model for 28-day mortality using laboratory and physiologic parameters from 3 international sepsis cohorts and externally validated the model. Methods During 2014 to 2021, adult hospitalized patients with suspected infection were enrolled in Durham, United States (N=180) and those with suspected infection and ≥2 SIRS (Systemic Inflammatory Response Syndrome) criteria in Takeo, Cambodia (N=200), and Kumasi, Ghana (N=187). Twenty-five clinical laboratory and physiologic parameters were candidate covariates and sepsis screening scores included as comparators. First, bivariate Cox regression models were performed to determine risk of individual parameters. Then, a 10-fold cross-validated forward stepwise model selection technique was used to eliminate nonsignificant variables using a p-value < 0.10 and the cross-validated C-statistic was estimated. Lastly, this model was applied to an external cohort of hospitalized adults with suspected infection and ≥2 SIRS in Fort Portal, Uganda (N=331 with 9.3% 28-day mortality). Results Among 567 participants, overall mortality was 16.4% at 28-days. Mortality rate highest in Ghana (31.0%), followed by Cambodia (11.0%) and the United States (7.2%). Bivariate analyses identified hypernatremia ( >145 mEq/L) being associated with the highest risk of death (hazard ratio: 7.42; 95% CI: 3.65 to 15.10; Figure 1). On multivariable analysis, a 28-day mortality model including mean arterial pressure, Glasgow Coma score, blood sodium, lactate, and blood urea nitrogen (Table 1) resulted in a 10-fold cross-validated C-statistic of 0.80 (95% CI: 0.61 to 0.88). This model predicted mortality accurately in the validation cohort with a C-statistic of 0.74 (95%CI: 0.69 to 0.79). Figure 1.Forest plot for bivariate analyses for one month survival across United States, Cambodia, and Ghana cohorts. Conclusion Hypotension, altered mental status, serum sodium, serum BUN, and plasma lactate accurately identified risk of death by 28-days among those with suspected sepsis in 3 international derivation cohorts and in a validation cohort in Uganda. Our findings emphasize the importance of clinical laboratory results for sepsis risk stratification. Disclosures Ephraim L. Tsalik, MD PhD, Danaher Diagnostics, Predigen, and Biomeme: In the past 3 years, I have had held equity and consulted for Predigen and Biomeme. Currently, I am an employee of Danaher Diagnostics. Christopher W. Woods, MD MPH, Predigen, Inc: Co-founder.

Background Direct comparisons of sepsis screening tools for prognostication have largely been limited to single-centre or high-income countries despite a disproportionately high burden of sepsis in low- and middle-income countries (LMICs). We evaluated the performance of commonly used sepsis screening tools across prospective sepsis cohorts in the United States, Cambodia, and Ghana.Methods From 2014 to 2021, participants with 2 or more SIRS (Systemic Inflammatory Response Syndrome) criteria and suspected infection were enrolled in emergency departments and medical wards at hospitals in the Cambodia and Ghana and hospitalized participants with suspected infection were enrolled in the United States. Cox proportional hazards regression was performed, and Harrell’s C-statistic calculated to determine 28-day mortality prediction performance of the qSOFA score ≥2, SIRS score ≥3, NEWS ≥5, MEWS ≥5, or UVA score ≥2, Screening tools were compared to baseline risk (age and sex) with the Wald test.Results The cohorts included 567 participants (42.9% female) including 187 participants from Kumasi, Ghana, 200 participants from Takeo, Cambodia, and 180 participants from Durham, North Carolina in the United States. The pooled mortality was 16.4% at 28-days. The mortality prediction accuracy increased from baseline risk with the MEWS (C-statistic: 0.63, 95% CI: 0.58, 0.68; p=0.002), NEWS (C-statistic: 0.68; 95% confidence interval [CI]: 0.64, 0.73; p<0.001), qSOFA (C-statistic: 0.70, 95% CI: 0.64, 0.75; p<0.001), UVA score (C-statistic: 0.73, 95% CI: 0.69, 0.78; p<0.001), but not with SIRS (0.60; 95% CI: 0.54, 0.65; p=0.13). Within individual cohorts, only the UVA score in Ghana performed better than baseline risk (C-statistic: 0.77; 95% CI: 0.71, 0.83; p<0.001).Conclusions Among the cohorts, MEWS, NEWS, qSOFA, and UVA scores performed better than baseline risk, largely driven by accuracy improvements in Ghana, while SIRS scores did not improve prognostication accuracy. Prognostication scores should be validated within the target population prior to clinical use.Key questions What is already known on this topic – While single-centre cohorts and retrospective analyses have been performed, the optimal sepsis screening tool for prognostication in low- and middle-income countries is unknown.What this study adds – The MEWS, NEWS, qSOFA scores, but not SIRS, were additive over baseline risk for prognostication in prospective hospitalized infection cohorts, but with variable additive performance within each cohort.How this study might affect research, practice or policy - Prognostication scores should be validated within the target population prior to clinical use.### Competing Interest StatementELT has held equity and consulted for Predigen and Biomeme, and he is an employee of Danaher Diagnostics.### Funding StatementFunding: Defense Threat Reduction Agency (JSTO-CBA) to Naval Medical Research Center (NMRC) (HDTRA1516108), Defense Health Bureau of Medicine & Surgery to NMRC for Combating Antibiotic Resistance Bacteria (FY1819 0130.1832), Naval Medical Logistics Command Cooperative Agreement (N626451920001).### Author DeclarationsI confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained.YesThe details of the IRB/oversight body that provided approval or exemption for the research described are given below:Study protocols were approved by the Naval Medical Research Center (NMRC) Institutional Review Board (IRB) (Cambodia sepsis study # NMRC.2013.0019; Ghana sepsis study # NMRC.2016.0004-GHA; Duke sepsis study Duke#PRO00054849) in compliance with all applicable Federal regulations governing the protection of human subjects as well as host country IRBs. The study protocol in Cambodia was approved by the Cambodian National Ethics Committee for Health Research (NECHR). The protocol in Ghana was approved by the Committee on Human Research, Publication and Ethics (CHRPE) at Kwame Nkrumah University of Science & Technology. All procedures were in accordance with the ethical standards of the Helsinki Declaration of the World Medical Association. All patients, or their legally authorized representatives, provided written informed consent.I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals.YesI understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance).YesI have followed all appropriate research reporting guidelines and uploaded the relevant EQUATOR Network research reporting checklist(s) and other pertinent material as supplementary files, if applicable.YesAll data produced in the present study are available upon reasonable request to the authors.

The world’s most consequential pathogens occur in regions with the fewest diagnostic resources, leaving the true burden of these diseases largely under-represented. During a prospective observational study of sepsis in Takeo Province Cambodia, we enrolled 200 patients over an 18-month period. By coupling traditional diagnostic methods such as culture, serology, and PCR to Next Generation Sequencing (NGS) and advanced statistical analyses, we successfully identified a pathogenic cause in 46.5% of our cohort. In all, we detected 25 infectious agents in 93 patients, including severe threat pathogens such as Burkholderia pseudomallei and viral pathogens such as Dengue virus. Approximately half of our cohort remained undiagnosed; however, an independent panel of clinical adjudicators determined that 81% of those patients had infectious causes of their hospitalization, further underscoring the difficulty of diagnosing severe infections in resource-limited settings. We garnered greater insight as to the clinical features of severe infection in Cambodia through analysis of a robust set of clinical data.

Neonatal sepsis is the second most prevalent cause of neonatal deaths in low- and middle-income countries, and many countries lack epidemiologic data on the local causes of neonatal sepsis. During April 2015-November 2016, we prospectively collected 128 blood cultures from neonates admitted with clinical sepsis to the provincial hospital in Takeo, Cambodia, to describe the local epidemiology. Two percent (n = 3) of positive blood cultures identified were Gram-negative bacilli (GNB) and were presumed pathogens, whereas 10% (n = 13) of positive blood cultures identified were likely contaminants, consistent with findings in other published studies. No group B Streptococcus was identified in any positive cultures. The presence of GNB as the primary pathogens could help influence local treatment guidelines.

Abstract Background In Western settings, community-acquired pneumonia (CAP) due to Gram-negative bacilli (GNB) is relatively rare. Previous studies from Asia, however, indicate a higher prevalence of GNB in CAP, but data, particularly from Southeast Asia, are limited. Methods This is a prospective observational study of 1451 patients ≥15 y of age with CAP from two hospitals in Cambodia between 2007 and 2010. The proportion of GNB was estimated. Risk factors and clinical characteristics of CAP due to GNB were assessed using logistic regression models. Results The prevalence of GNB was 8.6% in all CAP patients and 15.8% among those with a valid respiratory sample. GNB infection was independently associated with diabetes, higher leucocyte count and CAP severity. Mortality was higher in patients with CAP due to GNB. Conclusions We found a high proportion of GNB in a population hospitalized for CAP in Cambodia. Given the complex antimicrobial sensitivity patterns of certain GNBs and the rapid emergence of multidrug-resistant GNB, microbiological laboratory capacity should be strengthened and prospective clinical trials comparing empiric treatment algorithms according to the severity of CAP are needed.

Melioidosis is a severe infectious disease caused by the gram-negative soil bacterium Burkholderia pseudomallei. Melioidosis is well known to be a major cause of morbidity and mortality in Southeast Asia, particularly in Thailand. However, melioidosis remains underreported in surrounding areas such as Cambodia. We report a case series of melioidosis in seven patients from Takeo Province, Cambodia. The patients, aged 24-65 years, were enrolled from May 2014 to May 2015 during a one year prospective study of sepsis at Takeo Provincial Hospital. They presented with fever, rigors, dyspnea, fatigue, diaphoresis, productive cough, and skin abscesses. Six of the seven patients were also hyponatremic. B. pseudomallei was cultured from the blood of six patients and the sputum of one patient. In this manuscript, we provide a detailed description of the clinical presentation, case management and laboratory confirmation of B. pseudomallei, as well as discuss the difficulties of identifying and treating melioidosis in low resource settings.

Background: Little is known about post-infectious pulmonary sequelae in countries like Cambodia where tuberculosis is hyper-endemic and childhood pulmonary infections are highly frequent. We describe the characteristics of hospitalized Cambodian patients presenting with community-acquired acute lower respiratory infections (ALRI) on post-infectious pulmonary sequelae (ALRIPS).Methods: Between 2007 and 2010, inpatients >= 15 years with ALRI were prospectively recruited. Clinical, biological, radiological and microbiological data were collected. Chest radiographs were re-interpreted by experts to compare patients with ALRIPS, on previously healthy lungs (ALRIHL) and active pulmonary tuberculosis (TB). Patients without chest radiograph abnormality or with abnormality suggestive as other chronic respiratory diseases were excluded from this analysis.Results: Among the 2351 inpatients with community-acquired ALRI, 1800 were eligible: 426 (18%) ALRIPS, 878 (37%) ALRIHL and 496 (21%) TB. ALRIPS patients had less frequent fever than other ALRI (p < 0.001) and more productive cough than ALRIHL (p < 0.001). Streptococcus pneumoniae, Haemophilus influenzae, and Pseudomonas aeruginosa accounted for 83% of ALRIPS group positive cultures. H. influenzae and P. aeruginosa were significantly associated with ALRIPS compared with ALRIHL. Treatment was appropriate in 58% of ALRIPS patients. Finally, 79% of ALRIPS were not recognized by local clinicians. In-hospital mortality was low (1%) but probably underestimated in the ALRIPS group.Conclusion: ALRIPS remains often misdiagnosed as TB with inappropriate treatment in low-income countries. Better-targeted training programs would help reduce the morbidity burden and financial costs. (C) 2013 Elsevier Ltd. All rights reserved.

Few data exist on viral and bacterial etiology of acute lower respiratory infections (ALRI) in ≥5 year –old persons in the tropics.