Word count (not including title, abstract, research in context, acknowledgment, references, tables, and figure legends): 5,077 RESEARCH IN CONTEXTEvidence before this study: Our PubMed search for articles matching the terms ("metagenomic" OR "cell-free DNA") and "infect*" in the title/abstract and using the "Human" species filter from inception to September 30, 2019 yielded 463 articles. Many proof-of-concept and validation studies illustrating how metagenomic sequencing can diagnose infections have been previously reviewed. Our search identified only nine studies which applied metagenomic shotgun sequencing to blood specimens, likely because there is a relatively low signal-to-noise ratio with this specimen type in this setting. In a study of 358 febrile sepsis patients, plasma cell-free DNA sequencing detected causative agents missed by standard-of-care testing in 15% of patients, but also detected bacterial organisms adjudicated as commensals in 10% of patients.Recently, a proof-of-concept study used machine learning to integrate metagenomic sequencing and transcriptional host response profiling to differentiate pathogens from commensal organisms in respiratory specimens, albeit with only a small derivation cohort to train host response signatures.Added value of this study: Our 200-patient study assessed the clinical utility of combining both metagenomic sequencing and a previously-defined host response assay to diagnose sepsis. We developed a rigorous chart review approach to measure whether our assays' results could change a physician's diagnostic decision-making, without having to commit the assays into patient care. Metagenomic sequencing revealed previously-undetected and clinically relevant organisms in 17 of 200 patients, and host response profiling led at least two of three physician chart reviewers to change SUMMARY Background: Current diagnostic techniques are inadequate for rapid microbial diagnosis and optimal management of patients with suspected sepsis. We assessed the impact of metagenomic sequencing and host response profiling individually and in combination on microbiological diagnosis in these patients. Methods:In this cohort study of 200 consecutive patients with suspected sepsis we evaluated three molecular diagnostic methods with blood specimens: 1) direct bacterial DNA detection and characterization with metagenomic shotgun next generation sequencing and contaminant sequence removal using Bayesian inference; 2) direct viral DNA and RNA enrichment and detection with viral capture sequencing; and 3) transcript-based host response profiling with a previously-defined 18-gene qRT-PCR assay. We then evaluated changes in diagnostic decision-making among three expert physicians in a chart review by unblinding our three molecular test results in a staged fashion.Findings: Metagenomic shotgun sequencing confirmed positive blood culture results in 14 of 26 patients. In 17 of 200 patients, metagenomic sequencing and viral capture sequencing revealed organisms that were 1) not detected by conventional...

Production of secretory protein in Gram-negative bacteria simplifies downstream processing in recombinant protein production, accelerates protein engineering, and advances synthetic biology. Signal peptides and secretory carrier proteins are commonly used to effect the secretion of heterologous recombinant protein in Gram-negative bacteria. The Escherichia coli osmotically-inducible protein Y (OsmY) is a carrier protein that secretes a target protein extracellularly, and we have successfully applied it in the Bacterial Extracellular Protein Secretion System (BENNY) to accelerate the directed evolution workflow. In this study, we applied directed evolution on OsmY to enhance its total secretory protein production. After just one round of directed evolution followed by combining the mutations found, OsmY(M3) (L6P, V43A, S154R, V191E) was identified as the best carrier protein. OsmY(M3) produced 3.1 ± 0.3 fold and 2.9 ± 0.8 fold more secretory Tfu0937 β-glucosidase than its wildtype counterpart in E. coli strains BL21(DE3) and C41(DE3), respectively. OsmY(M3) also produced more secretory Tfu0937 at different cultivation temperatures (37 °C, 30 °C and 25 °C). Subcellular fractionation of the expressed protein confirmed the essential role of OsmY in protein secretion. Up to 80.8 ± 12.2% of total soluble protein was secreted after 15 h of cultivation. When fused to a red fluorescent protein or a lipase from Bacillus subtillis, OsmY(M3) also produced more secretory protein compared to the wildtype. This is the first report of applying directed evolution on a carrier protein to enhance total secretory protein production. The methodology can be further extended to evolve other signal peptides or carrier proteins for secretory protein production in E. coli and other bacteria. In this study, OsmY(M3) improved the production of three proteins, originating from diverse organisms and with diverse properties, in secreted form, clearly demonstrating its wide-ranging applications.