We describe 9 patients at a medical center in Detroit, Michigan, USA, with severe acute respiratory syndrome coronavirus 2 and Clostridioides difficile . Both infections can manifest as digestive symptoms and merit screening when assessing patients with diarrhea during the coronavirus disease pandemic. These co-infections also highlight the continued importance of antimicrobial stewardship.

Virus IMPORTANCEThe development of vaccines for respiratory syncytial virus has been hampered by a lack of understanding of the requirements for eliciting high titers of neutralizing antibodies. The results of this study suggest that particle-associated RSV F protein containing mutations that stabilize the structure in a prefusion conformation may stimulate higher titers of protective antibodies than particles containing F protein in a wild-type or postfusion conformation. These findings indicate that the prefusion F protein assembled into VLPs has the potential to produce a successful RSV vaccine candidate.H uman respiratory syncytial virus (RSV) is the most significant cause of acute viral respiratory disease in infants and young children (1). There are from 34 to 65 million RSV infections resulting in acute lower respiratory disease requiring hospitalization and 160,000 to 199,000 deaths per year worldwide (2). Elderly populations are also at significant risk for serious RSV disease. In the United States, the virus accounts for 10,000 deaths and 14,000 to 60,000 hospitalizations per year among individuals more than 64 years of age (3-5). Indeed, RSV infection of this population is at least as significant as influenza virus infections. RSV infections result in high mortality rates in immunocompromised populations, particularly stem cell transplant recipients (6) and individuals with cardiopulmonary diseases (7). Despite the significance of RSV disease in different populations, there are no vaccines available.Failure to develop a licensed RSV vaccine is not due to lack of effort as numerous vaccine candidates have been characterized in preclinical and clinical studies spanning 5 decades (summarized in references 8 to 9). While many problems have uniquely hindered RSV vaccine development, a major hurdle has been a lack of understanding of requirements for generation of protective immunity to RSV infection. Many vaccine candidates are protective in animal models and, while stimulating antibody responses in humans, have failed to induce high levels of neutralizing antibodies and protection from virus challenge in human trials (reviewed in references 10 and 11). Although there are likely many reasons for these observations, one important issue has been a lack of clear understanding of the most effective form of the RSV antigens, particularly the F protein, for stimulating potent neutralizing antibodies.The paramyxovirus F protein is folded into a metastable conformation and upon fusion activation refolds, through a series of conformational intermediates, into the postfusion conformation, which is structurally very different from the prefusion form (12)(13)(14)(15)(16)(17)(18)(19). While it is logical to assume that the prefusion form of F protein should be more effective in stimulating optimally neutralizing antibodies, recent structural studies have shown that the postfusion form of the F protein contains at least some epitopes recognized by neutralizing monoclonal antibodies (17, 18). Thus, it has been a...

Efforts to develop a vaccine for respiratory syncytial virus (RSV) have primarily focused on the RSV fusion protein. The pre-fusion conformation of this protein induces the most potent neutralizing antibodies and is the focus of recent efforts in vaccine development. Following the first identification of mutations in the RSV F protein (DS-Cav1 mutant protein) that stabilized the pre-fusion conformation, other mutant stabilized pre-fusion F proteins have been described. To determine if there are differences in alternate versions of stabilized pre-fusion F proteins, we explored the use, as vaccine candidates, of virus-like particles (VLPs) containing five different pre-fusion F proteins, including the DS-Cav1 protein. The expression of these five pre-F proteins, their assembly into VLPs, their pre-fusion conformation stability in VLPs, their reactivity with anti-F monoclonal antibodies, and their induction of immune responses after the immunization of mice, were characterized, comparing VLPs containing the DS-Cav1 pre-F protein with VLPs containing four alternative pre-fusion F proteins. The concentrations of anti-F IgG induced by each VLP that blocked the binding of prototype monoclonal antibodies using two different soluble pre-fusion F proteins as targets were measured. Our results indicate that both the conformation and immunogenicity of alternative VLP associated stabilized pre-fusion RSV F proteins are different from those of DS-Cav1 VLPs.

Respiratory syncytial virus (RSV) is a significant respiratory pathogen but no vaccine is available. RSV infections present 2 major, unique problems. First, humans can experience repeated infections caused by the same virus sero-group indicating that protective memory responses to RSV infection are defective. Second, most people have been infected with RSV by age 5. Immune responses to these infections, while poorly protective, could impact the effectiveness of a vaccine. The goal of this study was to assess the generation of protective immune responses in mice previously infected with RSV by virus-like particle (VLP) vaccine candidates containing a stabilized pre-fusion form of the RSV F protein or a stabilized post-fusion F protein. We report that a single immunization of RSV-experienced animals with a stabilized pre-fusion F protein VLP stimulated high titers of neutralizing antibody while a single injection of a post-fusion F protein VLP or a second RSV infection only weakly stimulated neutralizing antibody titers. These results suggest that prior RSV infection can induce neutralizing antibody memory responses, which can be activated by pre-F protein VLPs but not by post-F protein VLPs or a subsequent infection. Thus the F protein conformation has a major impact on enhancing production of neutralizing antibodies in RSV-experienced animals. Furthermore, although both VLPs contained the same RSV G protein, the pre-F VLP stimulated significantly higher titers of total anti-G protein IgG than the post-F VLP in both naïve and RSV-experienced animals. Thus the F protein conformation also influences anti-G protein responses.

A comparative retrospective study to quantify the impact of Coronavirus Disease 2019 (COVID-19) on patient safety. We found a statistically significant increase in central line-associated blood stream infections and blood culture contamination rates during the pandemic. Increased length of stay and mortality was also observed during COVID-19.

BackgroundVirus-like particles (VLPs) based on Newcastle disease virus (NDV) core proteins, M and NP, and containing two chimera proteins, F/F and H/G, composed of the respiratory syncytial virus (RSV) fusion protein (F) and glycoprotein (G) ectodomains fused to the transmembrane and cytoplasmic domains of the NDV F and HN proteins, respectively, stimulate durable, protective anti-RSV neutralizing antibodies in mice. Furthermore, immunization of mice with a VLP containing a F/F chimera protein with modifications previously reported to stabilize the pre-fusion form of the RSV F protein resulted in significantly improved neutralizing antibody titers over VLPs containing the wild type F protein. The goal of this study was to determine if VLPs containing the pre-fusion form of the RSV F protein stimulated protective immune responses in cotton rats, a more RSV permissive animal model than mice.MethodsCotton rats were immunized intramuscularly with VLPs containing stabilized pre-fusion F/F chimera protein as well as the H/G chimera protein. The anti-RSV F and RSV G antibody responses were determined by ELISA. Neutralizing antibody titers in sera of immunized animals were determined in plaque reduction assays. Protection of the animals from RSV challenge was assessed. The safety of the VLP vaccine was determined by monitoring lung pathology upon RSV challenge of immunized animals.ResultsThe Pre-F/F VLP induced neutralizing titers that were well above minimum levels previously proposed to be required for a successful vaccine and titers significantly higher than those stimulated by RSV infection. In addition, Pre-F/F VLP immunization stimulated higher IgG titers to the soluble pre-fusion F protein than RSV infection. Cotton rats immunized with Pre-F/F VLPs were protected from RSV challenge, and, importantly, the VLP immunization did not result in enhanced respiratory disease upon RSV challenge.ConclusionsVLPs containing the pre-fusion RSV F protein have characteristics required for a safe, effective RSV vaccine.

Most individuals are infected with respiratory syncytial virus (RSV) by age two, but infection does not result in long-term protective immunity to subsequent infections. Previous RSV infection may, however, impact responses to an RSV vaccine. The goal of these studies was to explore the effect of previous RSV infection on murine antibody responses to RSV F and G protein-containing virus-like particles (VLP), comparing responses to those resulting from VLP immunization of RSV-naive animals. These studies showed that after RSV infection, immunization with a single dose of VLPs containing a conformation-stabilized prefusion F protein stimulated high titers of neutralizing antibodies (NA), while an immunization with post-F-containing VLPs or a second RSV infection only weakly stimulated NA, even though total anti-F protein IgG antibody levels in both VLP-immunized animals were similar. Furthermore, single pre-F or post-F VLP immunization of animals previously infected (primed) with RSV resulted in total anti-F antibody titers that were 10- to 12-fold higher than titers after a VLP prime and boost of RSV-naive animals or after two consecutive RSV infections. The avidities of serum antibodies as well as numbers of splenic B cells and bone marrow cells after different immunization protocols were also assessed. The combined results show that RSV infection can quite effectively prime animals for the production of protective antibodies that can be efficiently activated by a pre-F VLP boost but not by a post-F VLP boost or a second RSV infection.IMPORTANCEHumans may experience repeated infections caused by the same serotype of respiratory syncytial virus (RSV), in contrast to infections with most other viruses, indicating that immune memory responses to RSV are defective. However, the effects of any residual but nonprotective immunity on responses to RSV vaccines are not clear. This study demonstrates that a VLP vaccine candidate containing a stabilized prefusion F protein can robustly stimulate protective immunity in animals previously infected with RSV, while a second RSV infection or a postfusion F-containing VLP cannot. This result shows that a properly constructed immunogen can be an effective vaccine in animals previously infected with RSV. The results also suggest that the defect in RSV memory is not in the induction of that memory but rather in its activation by a subsequent RSV infection.

Respiratory syncytial virus (RSV) infection poses a significant risk for infants. Since the direct vaccination of infants is problematic, maternal vaccination may provide a safer, more effective approach to their protection. In the cotton rat (CR) model, we have compared the immunization of pregnant CR dams with virus-like particles assembled with the prototype mutation stabilized pre-fusion F protein, DS-Cav1, as well two alternative mutation stabilized pre-fusion proteins (UC-2 F, UC-3 F) and showed that the alternative pre-fusion F VLPs protected the offspring of immunized dams significantly better than DS-Cav1 F VLPs (Blanco, et al. J. Virol. 93: e00914). Here, we have addressed the reasons for this increased protection by characterizing the specificities of antibodies in the sera of both immunized dams and their offspring. The approach was to measure the levels of total anti-pre-F IgG serum antibodies that would block the binding of representative pre-fusion specific monoclonal antibodies to soluble pre-fusion F protein targets. Strikingly, we found that the sera in most offspring of DS-Cav1 F VLP-immunized dams had no mAb D25-blocking antibodies, although their dams had robust levels. In contrast, all offspring of UC-3 F VLP-immunized dams had robust levels of these D25-blocking antibodies. Both sets of pup sera had significant levels of mAb AM14-blocking antibodies, indicating that all pups received maternal antibodies. A lack of mAb D25-blocking antibodies in the offspring of DS-Cav1 F VLP-immunized dams may account for the lower protection of their pups from challenge compared to the offspring of UC-3 F VLP-immunized dams.Vaccines 2020, 8, 133 2 of 15 to infectious, attenuated, or vector viruses, since they do not contain a genome and do not produce a spreading infection. Our VLPs are based on the core proteins of Newcastle disease virus (NDV), NP and M proteins, and they are assembled with the RSV F and G protein ectodomains fused to the transmembane and cytoplasmic domains of the NDV F and HN proteins, respectively.There has been a resurgence of interest and activity in RSV vaccine development due to the ground-breaking studies of McLellan, et al. who succeeded in solving the crystal structure of the RSV pre-fusion F protein and identifying a set of mutations in the F protein, termed DS-Cav1, which stabilized the pre-fusion form of the F protein [20,21]. We have reported that VLPs assembled with the DS-Cav1 mutant F protein stimulate, in mice and in cotton rats, neutralizing antibody titers much higher than those induced by VLPs assembled with the post-fusion F protein or wild-type F protein [16,22]. Furthermore, the immunization of cotton rat dams with DS-Cav1 F VLPs protected their offspring from RSV challenge [14].Since the description of DS-Cav1 F protein, a number of other laboratories and companies have identified different sets of mutations that reportedly stabilize the pre-fusion F protein [23][24][25][26][27][28][29]. A very important question for vaccine development is whether the different m...