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tony_breu's profile
Tony Breu
Tony Breu
Tony Breu
@tony_breu

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Tony Breu

@tony_breu

Hospitalist and Director of Resident Education, VA Boston. Faculty, @HMSbioethics. Mets fan. Usually at #AMreport and thinking about #TWDFNR. Views are my own.

Boston, MA
connects.catalyst.harvard.edu/Profiles/displ…
Joined April 2012

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    Tony Breu‏ @tony_breu Jan 31
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    1/14 Why does E. coli clear from the blood faster than S. aureus? I've heard this repeatedly but never fully understood the difference. One answer helps explain why cirrhosis is a risk factor for infection and introduced me to a Trojan horse of the immune system. Read on!

    12:52 PM - 31 Jan 2020
    • 622 Retweets
    • 1,802 Likes
    • Pashna Munshi Ralph Wendt Hasan Kent Saarenas Rajeevalochana Susan Lou Kevin Keller carms Julian Barbosa
    35 replies 622 retweets 1,802 likes
      1. New conversation
      2. Tony Breu‏ @tony_breu Jan 31
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        2/ Let's start with some data showing that there IS a difference in how well E. coli and S. aureus are cleared from the blood. The SCRIBE study reported the following rates of persistent bacteremia: 🔹E. Coli 7% 🔹S. aureus: 33% https://www.ncbi.nlm.nih.gov/pubmed/27296858 pic.twitter.com/rZXV6GUjwT

        1 reply 4 retweets 54 likes
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      3. Tony Breu‏ @tony_breu Jan 31
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        3/ To understand this difference, we need to explore WHERE bacteria are cleared from the blood. One of the first sites is the reticuloendothelial system (aka the mononuculear phagocyte system or MPS). 🔹One key organ of the MPS: liver 🔹One key cell in the liver: Kupffer cell

        1 reply 4 retweets 57 likes
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      4. Tony Breu‏ @tony_breu Jan 31
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        4/ Kupffer cells (KC) phagocytose bacteria as they enter the sinusoids of the liver. In fact, some have described the liver as a "firewall" against bloodstream bacteria (KC make up >50% of the cells in the MPS). https://www.ncbi.nlm.nih.gov/pubmed/24848256 pic.twitter.com/cC172aYHV8

        1 reply 5 retweets 50 likes
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      5. Tony Breu‏ @tony_breu Jan 31
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        5/ An understanding of the role of the MPS (and KC within the liver, more specifically) sheds light on a fact we all know: 💥Cirrhosis is a risk factor for infection💥 Cirrhosis was associated with a HR of 5.8 for treatment failure after GNR bacteremia. https://www.ncbi.nlm.nih.gov/pubmed/28478600 pic.twitter.com/xtbVzSzAbk

        1 reply 5 retweets 60 likes
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      6. Tony Breu‏ @tony_breu Jan 31
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        6/ Though the infection risk ascribed to cirrhosis is multifactorial, the role of MPS dysfunction seems clear. In one study of 41 patients with cirrhosis, it was those with reduced MPS function had an increased risk of bacteremia. Kupffer cells matter! https://www.ncbi.nlm.nih.gov/pubmed/6693068 pic.twitter.com/jCs8QDgsGp

        1 reply 2 retweets 45 likes
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      7. Tony Breu‏ @tony_breu Jan 31
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        7/ Key point #1 🔑The mononuclear phagocyte system (MPS) is important for the clearance of bacteria from the blood. This leads to a POLL question. Which bacteria do you suspect is cleared more rapidly by the MPS?

        1 reply 2 retweets 25 likes
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      8. Tony Breu‏ @tony_breu Jan 31
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        8/ It turns out that MPS clearance may be FASTER with S. aureus. This is NOT what I expected to find when I began reading about this topic. https://www.ncbi.nlm.nih.gov/pubmed/13664867 pic.twitter.com/p5AeY8wqLN

        1 reply 2 retweets 43 likes
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      9. Tony Breu‏ @tony_breu Jan 31
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        9/ These results (i.e., that S. aureus is cleared by the MPS more quickly than E. coli) run counter to what I have understood. Another study demonstrates that although S. aureus counts drop more quickly, it levels off. Clearance of E. coli continues. https://www.ncbi.nlm.nih.gov/pubmed/14438353 pic.twitter.com/li9SaszB2w

        1 reply 4 retweets 36 likes
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      10. Tony Breu‏ @tony_breu Jan 31
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        10/ One proposed explanation for late/persistent bacteremia: S. aureus hides inside neutrophils. Evidence for S. aureus survival within neutrophils has been around for decades. In 1952, Rogers and Tompsett observed viable bacteria in the cytoplasm. https://www.ncbi.nlm.nih.gov/pubmed/14907971 pic.twitter.com/SnMXR0Bv02

        2 replies 16 retweets 93 likes
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      11. Tony Breu‏ @tony_breu Jan 31
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        11/ There are contemporary data suggesting that neutrophils act as Trojan horses for S. aureus. One prospective study of adults with cancer found LOWER rates of S. aureus bacteremia in those who were NEUTROPENIC: 🔹Neutropenic: 12% 🔹Not neutropenic: 35% https://www.ncbi.nlm.nih.gov/pubmed/16424972 

        3 replies 16 retweets 134 likes
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      12. Tony Breu‏ @tony_breu Jan 31
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        12/ Key points #2-3 🔑It appears that the MPS deals with S. aureus and E. coli in slightly different ways. 🔑Neutrophils may harbor viable S. aureus, allowing for their re-emergence in the blood.

        1 reply 2 retweets 64 likes
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      13. Tony Breu‏ @tony_breu Jan 31
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        13/ There are undoubtedly other factors at play. Differences in... 🔹Organisms (e.g., S. aureus is more likely to create metastatic foci) 🔹Treatments (i.e., antibiotic efficacy varies for E. coli and S. aureus) 🔹Immune response (e.g., there are variable cytokine responses)

        4 replies 6 retweets 61 likes
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      14. Tony Breu‏ @tony_breu Jan 31
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        14/14 - SUMMARY 🔑The MPS is important for the clearance of bacteria from the blood. 🔑It appears that the MPS deals with S. aureus and E. coli in slightly different ways. 🔑Neutrophils may harbor viable S. aureus, allowing for their re-emergence in the blood.

        7 replies 18 retweets 210 likes
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      15. End of conversation

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