[Clinical efficacy of sulbactam/cefoperazone for the treatment of geriatric patients with respiratory tract infections]

We performed clinical studies on sulbactam/cefoperazone (SBT/CPZ) for the treatment of geriatric patients with respiratory tract infections. Seven patients with pneumonia, 7 with acute bronchitis, 6 with chronic respiratory tract infections were treated with SBT/CPZ. The patients were administered with a daily dose of 2.0 g or 4.0 g for 4-14 days. The clinical responses were excellent in 3, good in 13, fair in 3, and poor in 1 patients. The efficacy rate was 80.0%. No side effects were observed in any patients, but elevations of GOT, GPT were observed in two cases. Causative organisms were E. coli (2 strains), P. aeruginosa (2), MSSA (1), MRSA (1), S. pneumoniae (1), H. influenzae (1), K. oxytoca (1), and E. aerogenes (1). The bacteriological effect rate was 60%. One strain of MRSA and one of two strains of P. aeruginosa persisted in 2 patients.

[A comparative study of imipenem/cilastatin sodium BID vs QID in the treatment of infections associated with hematopoietic disorders]

Using the envelope method, we allocated 125 patients with infections accompanied by hematopoietic disorders into two groups treated with imipenem/cilastatin sodium (IPM/CS) at a daily dose of 1 g/1 g b.i.d. (group BID) or 0.5 g/0.5 g q.i.d. (group QID), and obtained the following results. 1. In group BID, ANLL was observed in 25 patients; ALL in 6; and NHL in 12. In group QID, ANLL was observed in 27 patients; ALL in 7; and NHL in 13. 2. In group BID, efficacy rates were 54.5% (6/11) in sepsis, 63.0% (17/27) in fever of undetermined origin and 50.0% (4/8) in pneumonia, thus the overall efficacy was 61.8% (34/55). In group QID, efficacy rates were 66.7% (4/6) in sepsis, 76.0% (19/25) in fever of undetermined origin and 35.7% (5/14) in pneumonia, thus the over all was 61.1% (33/54). No significant difference in response rates were observed between the two groups. 3. Bacteriologically, 22 bacterial strains were isolated in group BID and 21 21 strains, in group QID. The eradication rates after treatment with IPM/CS was 100% in group BID and 66.7% in group QID. 4. Side effects were observed in 8 patients in group BID and 3 in group QID. Laboratory examination revealed abnormal values in 9 patients in group BID and 6 in group QID. However, all of the side effects disappeared after the suspension or discontinuation of IPM/CS. The efficacies of IPM/CS therapy for severe infections in patients with hematopoietic disease were similar between 1 g/1 g b.i.d. and 0.5 g/0.5 g q.i.d. groups.

Granulocyte colony-stimulating factor does not enhance phagocytosis or microbicidal activity of human mature polymorphonuclear neutrophils in vitro

The direct effects of human granulocyte colony-stimulating factor (hG-CSF) on mature polymorphonuclear neutrophils (PMNs) in vitro were studied with regard to chemotaxis, superoxide production, and phagocytosis and microbicidal activity against the following viable microorganisms: Staphylococcus aureus, serum-resistant Pseudomonas aeruginosa, and Candida albicans. Recombinant hG-CSF (rhG-CSF) acted as a chemoattractant for human PMNs in a dose-dependent manner. The chemotactic response of PMNs to N-formyl-methionyl-leucyl-phenylalanine (FMLP) was not enhanced by rhG-CSF at any of the concentrations used. rhG-CSF did not induce the generation of superoxide by itself. However, rhG-CSF was able to prime human PMNs and to enhance O2- release stimulated by FMLP in a dose-dependent manner. rhg-CSF did not enhance phagocytosis or killing of the three species of microorganisms by normal PMNs. With PMNs obtained from patients who had hematological disorders or solid tumors, no enhancement of the microbicidal activity was observed in most cases. Microbial killing mediated by PMNs depended on the ratio of PMNs to target organisms. We concluded from these facts that the most important effect of rhG-CSF was to increase the number of the peripheral PMNs and not to enhance the functions of mature PMNs.

Characterisation of the external surfaces of Pseudomonas aeruginosa isolated from human blood and respiratory tract

The surface structures of the cell envelopes of 16 clinical isolates of Pseudomonas aeruginosa were examined by electronmicroscopy with the new fixation technique of freeze-substitution. Two types of structures were observed among the organisms. In one group of strains, mostly isolated from blood, a dense fibrous layer c. 30 nm thick was found around the outer-membrane surface, whereas no such structure was observed in the other group of isolates, most of which were from sputum. Lipopolysaccharides extracted from the isolates with a dense fibrous layer were found by SDS-PAGE to have long O-polysaccharide chains, whereas strains without such a layer mostly had lipopolysaccharides that lacked high mol. wt. O-polysaccharide chains.

Purification of Pneumocystis carinii trophozoites and identification of their circulating antigens

We have developed a new method to isolate Pneumocystis carinii trophozoites from experimental rat bronchoalveolar lavage specimens by using a Percoll discontinuous gradient and have identified the circulating antigens in experimental rat P. carinii pneumonia. The antigenic components of the trophozoites were compared with those of cysts by immunoblotting. A major immunoreactive band of 90,000 Da and some others of lower molecular mass were found in trophozoites. On the other hand, bands of 110,000, 50,000, and 45,000 Da were observed in cysts. The band of 50,000 Da was not identified when antitrophozoite rabbit serum preabsorbed with P. carinii-infected rat serum was used for immunoblotting. These results suggest that the molecule of 50,000 Da is the major circulating antigen in P. carinii-infected rats.

Clinical features of patients suffering from Streptococcus milleri infections--a retrospective analysis

We examined the clinical records of patients from whom S. milleri was isolated at Kyushu University Hospital from January 1987 through December 1988. Sixty-one patients were treated in 64 episodes with drainage or antibiotics. Oral and nasopharyngeal infections were observed in 27 cases, intrathoracic infections in 13, urogenital infections in 8, intraabdominal infections in 6 and skin and subcutaneous infections in 6. Except for acute bronchitis and urogenital infections, all of them were suppurative. As to underlying diseases, 21 patients had malignancies and 6 had diabetes mellitus. Leukocytopenia was not observed in any of the patients. S. milleri can be eradicated by treatment but it is sometimes replaced by other organisms. However, considering its tendency to cause suppurative infections, its pathogenic significance should be taken into account and patients should undergo surgical drainage combined with antibiotic therapy.

The effect of humoral and cell-mediated immunity in resistance to systemic Serratia infection

Protection against experimental Serratia marcescens infection in mice was enhanced by prior injection of formalin-killed or viable bacteria of the same strain. From the first to the fourth week after vaccination, specific immunity was involved in the host defence against systemic serratia infection. The transfer of antiserum specific for S. marcescens increased bacterial clearance from the liver, but did not increase the survival of the mice. Bacterial clearance from the liver was also increased by the transfer of spleen cells from immunised mice, but, again, survival was not increased. However, the transfer of both antiserum and spleen cells from vaccinated mice increased both bacterial clearance from the liver and survival (p less than 0.01). These results suggest an additive effect of humoral immunity and T-cell-mediated immunity in protection against systemic serratia infection.

[Therapeutic evaluation of imipenem/cilastatin sodium for bacterial infections in patients with hematological diseases]

1. To evaluate the efficacy and tolerance of imipenem/cilastatin sodium (IPM/CS) in severe infections associated with hematopoietic disorders, IPM/CS was administered to a total of 105 patients. 2. Out of 96 patients evaluable for efficacy, clinical responses were excellent in 23 patients, good in 30, fair in 15, poor in 19 and unknown in 9, and the overall response rate was 60.9%. 3. The most common underlying hematopoietic disease was acute non-lymphocytic leukemia and the most common infections were sepsis and suspected sepsis. 4. Daily dose, severity of infection and neutrophil count had effects on the clinical response. 5. The overall eradication rate of bacteria was 83.7%. 6. Side effects were observed in 10 patients (9.5%) and abnormal laboratory test results in 12 (11.4%). From the above findings, we have concluded that IPM/CS is very useful for the treatment of severe infections in compromised patients with hematopoietic diseases.

[A case of remarkable effect of clindamycin in nasal septum abscess caused by Streptococcus milleri]

We encountered a 14-year-old male patient with a destructive abscess of nasal septum, caused by Streptococcus milleri. He was successfully treated with Clindamycin in combination with surgical intervention. We emphasized the significance of Streptococcus milleri as a causative agent for abscess formation, and clindamycin should be considered as a first choice of antibiotics against Streptococcus milleri infection.

[Ofloxacin in the treatment of infection caused by Salmonella paratyphi A]

We reported a case of salmonellosis treated with ofloxacin (OFLX) which showed excellent clinical and bacteriological effect in a 22 year-old Japanese male with Salmonellosis paratyphi A. He had stayed in India from Sept. 6, 1990 to Oct. 13, 1990. On Oct. 25, 1990, he complained of a high fever and headache. On Oct. 29, he was admitted to our hospital and was diagnosed as Salmonellosis paratyphi A by the blood culture. He was treated with 2.0 g/day of chloramphenicol (CP) for 7 days, but the clinical efficacy was not sufficient. Therefore, we added 900 mg/day of OFLX for 10 days. He was treated successfully with them, the temperature became on the 2nd day. No side effect and no changes of laboratory data were observed and no recurrence was observed clinically and bacteriologically for three months after his discharge.

Accumulation of phosphate-containing granules in the nucleoid area of Pseudomonas aeruginosa

Many electron-dense granules were found in the nucleoid area of Pseudomonas aeruginosa strain K by electron microscopy with the technique of the freeze-substitution method. These granules contained phosphorus and calcium as determined by X-ray microanalysis. The size and the numbers of the granules decreased when the bacteria was cultured in the medium from which phosphate-containing compounds were depleted. From these observations we concluded that the granule was a phosphate-containing granule and possibly a polyphosphate granule. The excellent preservation of the fine structures by the freeze-substitution technique enables us to show very small polyphosphate granules in the nucleoid area of the bacterial cells which cannot be revealed by the conventional chemical fixation method. As we could not see the granules in other bacteria cultured in nutrient medium such as Serratia, Escherichia, Bacillus and Vibrios, the accumulation of the phosphate granules in Ps. aeruginosa might be a unique character of this bacteria and might be related to the growing capability of this bacteria in extremely low nutrient supply.

[A case of Plasmodium vivax malaria with findings of DIC]

We reported a rare case of Plasmodium vivax malaria who showed findings of disseminated intravascular coagulation (DIC). A 50-year-old Japanese male was sent to our hospital with the diagnosis of Plasmodium vivax malaria on the 26th of April, 1990. He had stayed in the Solomon Islands from Oct. 1987 to Dec. 1989, and had febrile episodes during his stay in the island. On April 18, 1990, he complained of a high fever with chills, and showed the same episodes on the 20th, 22th and was diagnosed as malaria. He was treated successfully with the sulfadoxine 500 mg and pyrimethamine 25mg (Fansidar), following the normal temperature on the 4th day and disappearance of malarial parasites in the peripheral blood smear on the 6th day. Interestingly, he had thrombocytopenia and a high titer serum level of fibrin degradation product (FDP) supporting the questionable diagnosis of DIC. Even on the 12th day after improved thrombocytopenia by treatment with Gabexate (FOY), the serum level of FDP, D-dimer and thrombin-nati-thrombin (TAT)III complex still remained at high titer levels. One month later he was readmitted for a relapse of Plasmodium vivax malaria, when he showed thrombocytopenia but the serum level of FDP, D-dimer, TAT III complex and PM.alpha 2 PI complex were normal levels. We concluded that the thrombocytopenia and the high titer of FDP at his first admission was a manifestation of DIC.

Treatment of complicated urinary tract infections with ofloxacin following an aminoglycoside

In order to reduce the dosage of aminoglycoside in the treatment of patients with complicated urinary tract infections (UTI) in outpatient clinics and to improve cost benefits, we tried both ofloxacin (OFX) treatment and a combination treatment with OFX and a single dose of aminoglycoside (isepamicin). Both groups showed the same cure rate on day 5, but the bacteriuria elimination rate on day 1 was slightly higher in the isepamicin-OFX group. The recurrence rate on days 7-14 did not differ between the groups. This aminoglycoside-OFX treatment did not show significantly higher effectiveness against complicated UTI but resulted in earlier elimination of bacteriuria. These results suggest that this combination therapy may be cost effective in treating complicated UTI, because of the shorter treatment period required.

[Clinical studies on the utility of ofloxacin for lower respiratory infections]

One hundred and thirteen patients who were treated at the Kyushu University Hospital and other related hospitals were randomly assigned to 2 groups to compare the effect of twice daily administration of 200 mg each and that of 300 mg each of ofloxacin (OFLX). The patients included 41 cases with pneumonia, 18 with acute bronchitis, 33 with chronic bronchitis, 15 with bronchiectasis with infection, 3 with diffused panbronchiolitis, and 3 with other secondary infectious diseases. Fifty-five cases were administered 400 mg OFLX a day and 58 cases received 600 mg. The number of severe cases in the 600 mg group was greater than that in the 400 mg group. The ratios of general amelioration of clinical symptoms were 92.6% in the 400 mg group and 82.1% in the 600 mg group. Thus, the ratio of the 400 mg group was better than that of the 600 mg group. However, the ratio of significant amelioration in the 600 mg group was 35.7% which was better than that in the 400 mg group, 27.8%. For bacteriological effects the rate of disappearance and decrease in number of bacteria was 92% in the 400 mg group and was significantly better than that of the 600 mg group, 70%. The incidence of side effects in the 600 mg group was 22.4% and this was high in contrast to that in the 400 mg group, 3.6%. Most of the side effects in the 600 mg group involved symptoms of the central nervous system such as sleeplessness. No significant differences were observed in incidences of abnormalities of laboratory tests at 1.8% and 1.7%, respectively. Safety in the 400 mg group were 96.4% which was significantly higher in number than those in the 600 mg group, 77.6%. Efficacy rates of twice daily administrations each with 200 mg and 300 mg OFLX for lower respiratory infections were 94.4 and 79.3%, respectively. In conclusion, the daily dose of 400 mg was the most effective.

[An autopsied case of infective endocarditis with cardiac tamponade due to myocardial rupture]

Since it is very rare that cardiac tamponade due to myocardial rupture caused by infective endocarditis, occurs we are reporting this case. A 62 year old man, who had underlying diseases of pneumoconiosis and hypertensive heart disease, visited Chikuho Rosai Hospital complaining of chest oppression and general fatigue on Feb. 7, 1987. He was diagnosed as having ischemic heart disease by electrocardiogram. Two days later, he suddenly had chills and a fever, and the laboratory data showed leukocytosis and a positive C-reactive protein (CRP). The echo cardiogram showed mitral regurgitation (MR) and aortic regurgitation (AR), but neither vegetation nor pericardial effusion was observed. On Feb. 16, he was admitted with shock, and he died the next day. The blood cultures grew gram-positive cocci, respectively. From the clinical symptoms, chest roentgenogram and electrocardiogram, we suspected a cardiac tamponade. On autopsy findings, though coronary arteries were intact, the aortic valves had severe valvular adhesions, calcifications and hypertrophies. The rupture hole was observed in the left ventricles, which was just under the aortic valve through the pericardiac space. It seemed that he died of a cardiac tamponade due to the outflow of blood from this hole. On histopathologic findings of the cardiac wall, gram-positive cocci and many of neutrophils were observed.

[Clinical studies on mycosis especially deep-seated candidiasis in blood disorder patients]

Deep-seated mycosis is prominently increasing as a terminal infection in compromised hosts with malignant blood disorders or malignant tumors. Moreover, localized candidal abscess of visual organs has recently been reported in several laboratories. We investigated the occurrence of deep-seated mycosis in 105 autopsied cases with blood disorders in our clinic from 1980 to 1987. Forty-four of those cases had died of various infections, and 80% of them were fungal infections. More than half of the fungal infections were aspergillosis. Deep-seated candidiasis was recognized in 10 cases, 6 of which were systemic candidiasis, the average duration of neutropenia below 500/mm3 was 19.7 days that of lymphopenia was 36.5 days. Two cases were complicated with GI-tract ulcer, and involved with hepatic candidiasis. On the other hand, in the 4 cases of localized candidial abscess, the duration of neutropenia was 58.5 days and that of lymphopenia was 28.8 days. These four cases were complicated with GI-tract ulcer. Histologically, Candida spp. were recognized at the bottom of the ulcer and invasion by inflammatory cells or tumor cells was found in the portal vein. We surmised that GI-tract ulceration is a very important complication of hepatic candidiasis or liver abscess, and the occurrence of localized candidiasis seems to depend on the duration and severity of neutropenia.

Effects of vaccination against systemic Serratia infection

Host defense against Serratia marcescens in experimental infection in mice was enhanced by vaccination with formalin-killed bacteria of the same strain. The enhancement appeared within 24 hr after vaccination, reached a peak seven days later and lasted four weeks. The enhanced resistance to Serratia infection was also observed in the early phase (within seven days) after vaccination with killed Escherichia coli or other Gram-negative strains, but the efficacy on Day 7 was inferior to that with killed S. marcescens. Phagocytic activities of both circulating neutrophils and peritoneal macrophages were measured by the chemiluminescence (CL) response, and the activity of tissue macrophages was evaluated by the carbon clearance test. The activities were significantly elevated in the early phase, that is, within two or three days for neutrophils, seven days for peritoneal macrophages and at least 14 days for tissue macrophages, after vaccination with killed Gram-negative bacteria. These results suggest that the enhancement of host defense in the early phase is dependent on phagocytic functions that are non-specifically activated by dead bacteria. In the late phase after vaccination, specific immunity might have been involved in the defense mechanism. However, transfer of high titer specific antiserum, in itself, did not render mice resistant to Serratia infection.

Protective effect of recombinant murine granulocyte-macrophage colony-stimulating factor against Pseudomonas aeruginosa infection in leukocytopenic mice

The effects of recombinant murine granulocyte-macrophage colony-stimulating factor (rmGM-CSF) against Pseudomonas aeruginosa infection in ICR mice were investigated. Mice were treated with cyclophosphamide (CPA) and were then injected intraperitoneally with rmGM-CSF three times daily, beginning on the day after CPA treatment, for 7 days. The number of peripheral blood leukocytes in both CPA- and rmGM-CSF-treated mice and control CPA-treated mice reached a nadir on day 4, when P. aeruginosa was injected intraperitoneally. The administration of rmGM-CSF significantly increased the proportion of survivors among mice infected with a lethal dose of P. aeruginosa. This effect was further analyzed by monitoring sequential changes in leukocyte count and bacterial growth in various organs. The number of bacteria in the peritoneal cavities, peripheral blood samples, and livers of GM-CSF-treated mice decreased to an undetectable level after a transient increase, and the number was significantly lower than that in control mice. In GM-CSF-treated mice, the neutrophil levels in peripheral blood started to increase 5 days after CPA administration and were consistently higher than those in controls. Furthermore, the neutrophils in GM-CSF-treated mice were more mature morphologically. Thus, the prophylactic effect of rmGM-CSF against P. aeruginosa infection may result from a rapid recovery of myelopoiesis and a partial enhancement of mature neutrophil function.

Purulent pericarditis caused by Streptococcus milleri

Streptococcus milleri was isolated in pure culture from the pericardial fluid of a 42-year-old man with pulmonary tuberculosis. Pericardiectomy had to be done to cure the pericarditis.

[Laboratory and clinical study of intravenous miconazole]

Laboratory and clinical study was carried out on miconazole (MCZ), a new synthetic imidazole. The antifungal activity of MCZ was studied and expressed as MICs for clinical isolates. The drug proved to have the highest activity against Cryptococcus neoformans, with MICs of no more than 0.16 micrograms/ml for all isolates of this species. MICs of Torulopsis glabrata were 0.08-5 micrograms/ml for all isolates and those of Candida albicans and Candida tropicalis were 5-20 micrograms/ml for more than 90% of the isolates. Most of other strains were less than 10 micrograms/ml. When 3 healthy adult men were administered each with 200 mg of MCZ by intravenous drip infusion for 1.25 hours, the mean serum MCZ concentration was 1.39 micrograms/ml at the end of the infusion, then decreased rapidly to 0.49 microgram/ml in following 30 minutes, and then decreased gradually to 0.17 microgram/ml 6 hours later. The mean cumulative urinary excretion rate of the drug was as low as 3.0% at this stage. A total of 25 patients with ages of 30-78 years, comprising 17 men and 8 women, were treated with 200-1,800 mg of MCZ daily for 3-93 days. The clinical effectiveness was ascertained in 19 cases among the patients; 9 cases with candidiasis, 3 with cryptococcosis and 7 with aspergillosis. Clinical responses were excellent in 2, good in 9 and poor in 8 cases, and its efficacy rates was 58%. The efficacy rate of the combination therapy with other antifungal agents was 60% in comparison with 57% of MCZ alone. Adverse reactions to the drug such as nausea, vomiting and anorexia were observed in 3 cases (12%). Abnormal changes in laboratory parameters were also observed: 3 patients with elevations of GOT and GPT, and another with eosinophilia.