Multicenter trial of single-dose azithromycin vs. ceftriaxone in the treatment of uncomplicated gonorrhea. Azithromycin Gonorrhea Study Group

BACKGROUND AND OBJECTIVES

Azithromycin is a new, long-acting azalide antibiotic that is active against Neisseria gonorrhoeae. A single oral dose of 1.0 g is effective against uncomplicated genital infection with Chlamydia trachomatis.

GOAL OF THIS STUDY

To compare the efficacy and tolerance of single-dose treatment of uncomplicated gonorrhea with azithromycin, 2.0 g orally, and ceftriaxone, 250 mg intramuscularly.

STUDY DESIGN

Seven hundred twenty-four men and women with presumptive, uncomplicated gonorrhea were treated with azithromycin 2.0 g orally or ceftriaxone 250 mg intramuscularly in a 2:1 ratio in a multicenter, open, randomized control trial in 10 public sexually transmitted disease clinics in the United States. Patients were followed up in 5 to 9 days and, for a subset of patients, 12 to 18 days after treatment. The main outcome measures were the isolation of N. gonorrhoeae and C. trachomatis and patient-reported side effects.

RESULTS

Among infected patients who returned for follow-up, N. gonorrhoeae was eradicated from all anatomic sites in 370 of 374 (98.9%; 95% confidence interval [95%CI] 97.9%-100%) treated with azithromycin and 171 of 175 (97.7%; 95%CI 95.5%-99.9%) given ceftriaxone. Treatment with either drug was effective in all 73 patients infected with beta-lactamase-producing N. gonorrhoeae. Chlamydial infection was eradicated in all 17 patients given azithromycin who returned and were recultured at follow-up and in two of seven patients given ceftriaxone (P < 0.001). Gastrointestinal side effects occurred in 35.3% (95%CI 30.7%-39.8%) of patients given azithromycin; of those with symptoms, these were moderate in 10.1% and severe in 2.9%.

CONCLUSIONS

Azithromycin 2.0 g and ceftriaxone 250 mg are equally effective in the treatment of uncomplicated gonorrhea. Azithromycin was associated with a relatively high frequency of gastrointestinal side effects and is expensive, but it has the advantages of oral administration and efficacy against concomitant chlamydial infection.

Coordinate regulation of multiple human lymphokine genes by Oct-1 and potentially novel 45 and 43 kDa polypeptides

The hematologic response to inflammation is critically dependent on the release of a family of glycoproteins termed CSFs. Central to this process is the coordinated T lymphocyte production of three of these proteins, granulocyte macrophage-CSF (GM-CSF), IL-3, and IL-5. In the course of our studies of the transcriptional regulation of IL-3 expression we noted that the same or similar proteins that bound to the downstream-activating region of the human IL-3 gene were also captured using DNA probes derived from sequences present in the GM-CSF and IL-5 genes. In this study, DNA-protein cross-linking techniques and reporter gene analyses were used to define the nuclear proteins that mediate transcriptional enhancement of these genes at one cis-acting site. These studies establish that Oct-1, a member of the POU family of transcription factors, binds to regions of the GM-CSF, IL-3, and IL-5 promoters and contributes to basal T cell gene transcription. In addition, although the c-jun proto-oncogene product was detected in stimulated human T cells, two additional T cell-specific proteins (45 and 43 kDa) bind to the GM-CSF, IL-3, and IL-5 promoters and are functionally and immunologically distinct from c-jun or OAP40 (jun-D). These proteins contribute to transcriptional enhancement of the IL-3 and GM-CSF genes in stimulated T cells. Together, these data suggest that the coordinate regulation of several lymphokine genes is based on responses to shared proteins. These studies further our understanding of the networks of transcriptionally active proteins responsible for the host response to inflammatory stimuli.

Coordinate regulation of multiple human lymphokine genes by Oct-1 and potentially novel 45 and 43 kDa polypeptides

The hematologic response to inflammation is critically dependent on the release of a family of glycoproteins termed CSFs. Central to this process is the coordinated T lymphocyte production of three of these proteins, granulocyte macrophage-CSF (GM-CSF), IL-3, and IL-5. In the course of our studies of the transcriptional regulation of IL-3 expression we noted that the same or similar proteins that bound to the downstream-activating region of the human IL-3 gene were also captured using DNA probes derived from sequences present in the GM-CSF and IL-5 genes. In this study, DNA-protein cross-linking techniques and reporter gene analyses were used to define the nuclear proteins that mediate transcriptional enhancement of these genes at one cis-acting site. These studies establish that Oct-1, a member of the POU family of transcription factors, binds to regions of the GM-CSF, IL-3, and IL-5 promoters and contributes to basal T cell gene transcription. In addition, although the c-jun proto-oncogene product was detected in stimulated human T cells, two additional T cell-specific proteins (45 and 43 kDa) bind to the GM-CSF, IL-3, and IL-5 promoters and are functionally and immunologically distinct from c-jun or OAP40 (jun-D). These proteins contribute to transcriptional enhancement of the IL-3 and GM-CSF genes in stimulated T cells. Together, these data suggest that the coordinate regulation of several lymphokine genes is based on responses to shared proteins. These studies further our understanding of the networks of transcriptionally active proteins responsible for the host response to inflammatory stimuli.

Comparative safety and efficacy of clarithromycin and amoxicillin/clavulanate in the treatment of acute otitis media in children

Clarithromycin is a new macrolide antibiotic with a wide spectrum of activity that includes the pathogens commonly causing pediatric otitis media. This randomized, investigator-blinded, multicenter trial compared the safety and efficacy of clarithromycin and amoxicillin/clavulanate in the treatment of acute otitis media in patients ages 6 months to 12 years. A total of 338 patients with acute otitis media diagnosed by otoscopy were randomized to receive clarithromycin 7.5 mg/kg twice daily, maximum 500 mg twice daily (n = 161), or amoxicillin/clavulanate 13.3 mg/kg three times daily, maximum 500 mg three times daily (n = 177), for 10 days. Treatment groups were comparable with respect to demographics, severity of infection and number of previous episodes. Efficacy was assessed by clinical examination performed within 48 hours of finishing study medication. A successful clinical response was seen in 90% (121 of 135) of evaluable clarithromycin patients vs. 92% (133 of 145) of evaluable amoxicillin/clavulanate patients (P = 0.681). Clinical failure or relapse (Posttreatment Days 0 to 4) occurred in 10% (14 of 135) of clarithromycin-treated patients vs. 8% (12 of 145) of amoxicillin/clavulanate-treated patients. Gastrointestinal adverse events were the most commonly reported in both groups. Of these events diarrhea was the most frequent, occurring in 12% (19 of 161) of clarithromycin and 32% (57 of 177) of amoxicillin/clavulanate-treated patients (P < 0.001). These results indicate that the efficacy of clarithromycin oral suspension was comparable with amoxicillin/clavulanate oral suspension in the treatment of acute otitis media in children. Clarithromycin was better tolerated than amoxicillin/clavulanate with a lower incidence of gastrointestinal side effects.

Expression of vascular cell adhesion molecule-1 in kidney allograft rejection

VCAM-1, a leukocyte adhesion molecule expressed by cytokine-activated endothelial cells in culture, may mediate mononuclear leukocyte infiltration in vessels and interstitium in solid organ allograft rejection. Using the avidin-biotin immunoperoxidase technique and an affinity-purified rabbit polyclonal antisera to recombinant human VCAM (rVCAM Ab) which works in methyl Carnoy's fixed tissues, we studied the expression of this molecule in biopsies of transplanted kidneys (N = 34) with and without features of rejection and allograft nephrectomies (N = 17) as well as nontransplanted control tissues (N = 26). The rVCAM Ab showed a population of reactive endothelial cells limited to sites of prominent subendothelial leukocytic cell infiltration in arteries and veins, and occasional peritubular capillaries (PTC) in rejecting allografts. Endothelial expression of VCAM was rarely identified in biopsies showing interstitial rejection only or cyclosporine toxicity, usually in PTC, and was only rarely encountered in nontransplanted control tissues. Apparent de novo expression of VCAM-1 by arterial smooth muscle cells and mesangial cells was present in cases of severe rejection. In addition, a population of cells (DC) with dendritic morphology was identified by rVCAM Ab within sites of lymphoid cell aggregation in rejecting allografts. Further evidence that these cells represent true DC was obtained by identification of VCAM-1 positive, morphologically similar cells in both germinal centers and interfollicular areas of all seven reactive lymph nodes tested; and by similar staining of these cells in the allografts and lymph nodes by antibodies to nerve growth factor receptor and the complement receptor CR1, previously shown to recognize DC. DCs were generally not seen in uninflamed normal control organs or portions of allografts uninvolved by lymphoid aggregates. Enhanced tubular epithelial cell expression of VCAM-1 was also present in rejecting allografts. All staining could be abolished by absorption of the antisera with VCAM-1 transfected, but not ICAM-1 or ELAM-1 transfected, CHO cells. In situ hybridization studies utilizing a cDNA probe to human VCAM-1 demonstrated mRNA production by glomerular, tubular and vascular cells corresponding to sites where the protein was immunohistochemically localized.(ABSTRACT TRUNCATED AT 400 WORDS)

Treatment of pharyngitis and tonsillitis with cefprozil: review of three multicenter trials

Cefprozil is a new oral cephalosporin with an in vitro spectrum of activity that includes group A beta-hemolytic streptococci (Streptococcus pyogenes). Three multicenter, randomized trials were conducted for comparing the clinical efficacy and safety of cefprozil administered once or twice daily with that of cefaclor, penicillin, or erythromycin ethylsuccinate administered three or four times daily in the treatment of mild-to-moderate tonsillopharyngitis. In the cefprozil-cefaclor trial, the pathogen eradication rate for evaluable patients receiving cefprozil was 83%, which was significantly better than that for patients receiving cefaclor (76%) (P = .035). The rate of satisfactory clinical response was similar with cefprozil (89%) and cefaclor (84%). The overall response rate was significantly better with cefprozil (80%) than with cefaclor (72%, P = .018). Differences in response rates were not noted when analyzing only patients 2-12 years of age. In the cefprozil-penicillin trial, the eradication rate of bacteriologic pathogens was similar in patients receiving cefprozil (91%) and in patients receiving penicillin (87%). A satisfactory clinical response was seen in 95% of the evaluable cefprozil-treated patients, which was significantly better than the rate of satisfactory clinical response seen in the penicillin-treated patients (88%; P = .023). In addition, during-therapy cultures for penicillin-treated patients yielded a significantly higher rate of beta-lactamase-producing Staphylococcus aureus than did those for the group of cefprozil-treated patients (13% vs. 4.5%, respectively; P = .046). Significantly more clinically symptomatic bacteriologic failures occurred in the penicillin group (P = .037).(ABSTRACT TRUNCATED AT 250 WORDS)

Gangliography

The authors present a technique for imaging ganglions. The principal uses, techniques, and complications of gangliography are discussed. A case study is presented to illustrate the significance of using gangliography as part of the preoperative assessment.

Catheter-related bacteremia caused by Oerskovia turbata

A case of Broviac catheter-related bacteremia in a 3-year-old boy infected with Oerskovia turbata is discussed. The blood cultures of the patient remained positive despite antibiotic therapy, and only with catheter removal was his blood sterilized. The microbiology and antimicrobial susceptibilities of this organism are described.

Comparison of piperacillin alone versus piperacillin plus tobramycin for treatment of respiratory infections in children with cystic fibrosis

Seventeen patients with cystic fibrosis (CF) and pulmonary exacerbations were randomly assigned to two treatment groups: piperacillin 600 mg/kg/day (P), and piperacillin 600 mg/kg/day plus tobramycin (PT), in order to determine the safety and pharmacokinetics of high-dose piperacillin and whether piperacillin alone was effective for the treatment of Pseudomonas infections. The mean half-life of piperacillin was 0.54 hours, with a peak concentration of 232 micrograms/ml. No differences between P and PT groups were noted in clinical assessment, as judged by Shwachman scores, pulmonary function testing, or weight gain. However, during the course of treatment, quantitative sputum cultures decreased by greater than 10(2) colony-forming units in only 5 out of 19 Pseudomonas isolates from the P group, compared with 12 of 19 isolates from the PT group (P less than 0.03, Chi-square). Although emergence of resistance was not seen, one isolate had an increase in minimum inhibitory concentration from 8 to 128 micrograms/ml. There were no serious adverse reactions to piperacillin; only one patient developed fever possibly related to piperacillin. Therapy with high-dose piperacillin was safe in children with CF. Treatment with piperacillin alone was less effective than combination therapy with gentamicin for reduction in titer of Pseudomonas in sputum. However, the role of antimicrobial agents in the treatment of CF remains undefined. A double-blind placebo-controlled trial is indicated.

Group B streptococcal soft tissue infections beyond the neonatal period

In one year sporadic soft tissue infections due to group B streptococci were identified in 37 patients beyond the neonatal period. Serious underlying conditions were present in 25 patients (68%), including 17 (46%) who had diabetes mellitus and 4 (11%) with paraplegia. Unlike previous reports, 12 patients (32%) were previously healthy. Infection developed in 8 persons as a result of minor trauma. The mean age of the normal hosts was 20.9 years, whereas the mean age of patients with underlying disease was 44.2 years (P<.0005). The clinical spectrum was varied and included abscess formation in 17 patients (46%). All patients required treatment with antibiotics and 28 (76%) required admission to hospital. Complete recovery occurred in 33 patients (89%) while 4 with diabetes required amputation of infected extremities. Group B Streptococcus was the only organism identified in 22 patients (59%) while mixed organisms were cultured in 15 (41%), including Staphylococcus aureus in 12 and gram-negative enteropathogens in 4. Group B streptococcal soft tissue infections beyond the neonatal period are common and may even involve normal hosts.

Feline cytotoxic immune mechanisms against virus-associated leukemia and fibrosarcoma

Humoral and cellular cytotoxic immune mechanisms of cats were compared against feline leukemia virus (FeLV)- and feline sarcoma virus (FeSV)-transformed cells. The groups of animals studied were nonexposed control cats; FeLV-infected immune or viremic tumor-bearing cats; FeSV-inoculated tumor progressor or regressor cats, and cats immunized with FeSV-transformed autochthonous fibroblasts (ATF). Sera containing complement-dependent antibodies (CDA), which lysed FeLV-producer lymphoma lines, had no cytotoxic effects when tested against FeLV-producer FeSV-transformed fibroblasts. Sera with lytic CDA activity were also tested for antibody-dependent cellular cytotoxic (ADCC) effects with peripheral blood lymphocytes (PBL) from nonimmune cats. No ADCC activity was detected against either lymphoid or fibroblast target lines. To demonstrate that cat PBL contained ADCC effector cells, antibody-coated murine target cells were employed and positive results obtained. Natural killer (NK) assays were performed using PBL from normal and tumor-bearing cats. Cytotoxic effects were only detectable to FeLV-producer lymphomas, and comparable levels of NK activity were found in normal and lymphoid tumor-bearing animals. In cats immunized with ATF, a population of effector cells was found in peripheral blood which had functional characteristics of cytotoxic T lymphocytes (CTL). The killing of ATF by CTL-like cells was not inhibited by FeLV/FeSV immune sera or by sera from autochthonous immune cats. The comparative importance of humoral and cellular cytotoxic mechanisms against FeLV- and FeSV-induced tumors is discussed.

Cellular immune response in the blood of cats is restricted to autochthonous feline sarcoma virus-transformed cells

The blood-borne cytotoxic cellular immune response of cats to autochthonous fibroblasts transformed with feline sarcoma virus (FeSV) was examined. Peripheral blood lymphocytes (PBL) from immune animals were assayed for cytotoxic activity using a 51Cr release microcytotoxicity assay. The time courses for appearance of cytotoxic cells were similar for all cats: effector lymphocytes appeared in the blood 7 days after immunization; peak activity occurred about day 16, and cytotoxic PBL were no longer detectable by 35 days. The specificity of cytotoxic lymphocytes was studied using autochthonous and allogeneic targets. PBL from each of five immunized cats killed autochthonous transformed fibroblast (ATF) targets, but the immune lymphocytes were not cytotoxic for non-transformed autochthonous fibroblasts, for allogeneic fibroblasts transformed with FeSV, or for an allogeneic lymphoma cell line which produces feline leukemia virus (FeLV). Specific restriction of target-cell killing to the ATF occurred at all effector:target-cell ratios tested, and was maintained throughout prolonged assay incubation periods. The results suggest that for cytotoxicity to occur it is necessary for the immune lymphocytes to recognize a combination of virus-associated antigens and "self" antigens on the ATF. The similarities between this restricted killing and that caused by cytotoxic T lymphocytes in other mammalian systems are discussed.

Benign giant cell tumor of the foot

Presented is a brief discussion of benign giant cell tumors, and a case report of this lesion originating from the lateral aspect of the calcaneocuboid articulation is discussed. The lesion reported is unique in that it is not associated with a tendon sheath. Computerized tomographic and magnetic resonance imaging failed to isolate the soft tissue mass.