Antimycobacterial synergism of clarithromycin and rifabutin

Clarithromycin and rifabutin are among the most promising drugs for the therapy of infections caused by Mycobacterium avium or other atypical mycobacteria. Since synergism of combined drugs is important in order to achieve strong antimycobacterial activity, the combined inhibitory effects of antibacterial agents should also be investigated when agents are evaluated for possible use in antimycobacterial drug therapy. In the present study we examined the antimycobacterial activity of clarithromycin, rifabutin, and their combination against 51 clinical isolates of the M. avium complex from patients with acquired immune deficiency syndrome (AIDS) with disseminated mycobacteriosis. A concentration-dependent inhibition was seen for each drug. The antibacterial effect was significantly more pronounced for the combined drugs than for the agents tested separately. Synergism, against up to 88% of the strains tested, was seen for the tested drugs combined at different concentrations. All 51 M. avium strains were susceptible to the combination of 4 mg/l clarithromycin and 2 mg/l rifabutin.

Antituberculosis activity of clarithromycin

Antituberculosis activity of clarithromycin (CLA), a macrolide antibiotic, was investigated in vitro, in macrophages, and in C57BL/6 mice, CLA showed high in vitro MICs (4 to > 16 micrograms/ml) for several strains of Mycobacterium tuberculosis and caused slight enhancement of activity of rifampin (RIF) against H37Rv but failed to increase the activity of either RIF or isoniazid (INH) against other strains. However, inside J774A.1 macrophages, CLA showed high activity and was synergistic with RIF against some strains of tubercle bacilli susceptible or resistant to INH and RIF. In the in vivo studies with a drug-susceptible strain (H37Rv), CLA protected mice from mortality due to tuberculosis for up to 8 weeks of observation. The CFU data for lungs and spleens revealed that the antituberculosis activity of CLA is inferior to those of INH and streptomycin. However, the activity of CLA when used alone or in combination was comparable to that of thiacetazone, indicating its potential usefulness as a secondary drug for the treatment of tuberculosis.

The absence of genetic markers for streptomycin and rifampicin resistance in Mycobacterium avium complex strains

Mycobacterium avium, Mycobacterium intracellulare complex (MAC) bacilli are an important cause of bacteraemia in AIDS patients but treatment is complicated by their resistance to the usual antimycobacterial agents. In this study of 20 strains of MAC none was found to have the mutations associated with resistance to rifampicin and streptomycin in M. tuberculosis suggesting that MAC have unique mechanisms for resistance to these agents.

In-vitro activity of commonly used antifungal agents in the presence of rifampin, polymyxin B and norfloxacin against Candida albicans

This study assessed the in-vitro antifungal activity against Candida albicans of amphotericin B, ketoconazole and miconazole, each in the presence of rifampin, polymyxin B and norfloxacin. Evaluation of drug interactions was estimated by the checkerboard pattern broth dilution method and by time-kill studies. Rifampin reduced the activity of the three antifungal agents used, with the reduction being more pronounced with amphotericin B. Synergy was observed when polymyxin B was combined with any of the antifungal agents used. The addition of norfloxacin resulted in minimal, if any, change in the activity.

Determination of the in vivo post-antibiotic effects of ciprofloxacin and rifampicin

A modified rabbit meningitis model is described for determining the PAE in vivo, which utilised a self-standing device for repeatedly sampling pure CSF. The model allowed the PAEs of ciprofloxacin and rifampicin on Escherichia coli ATCC 25922 to be determined following PAE induction in vitro, or in vivo in CSF after intrathecal injection or during the last 1.5 h of a 7 h iv continuous infusion. The estimated volumes of distribution of ciprofloxacin and rifampicin in CSF were 0.68 +/- 0.24 mL and 0.74 +/- 0.04 mL, respectively, and the terminal elimination half lives were 1.8 +/- 0.5 h and 2.2 +/- 0.3 h, respectively. PAEs of approximately 2 h were obtained in vivo and in vitro after exposing E. coli to 3 x MIC of ciprofloxacin in vitro and to 1 x MIC of drug in vivo. When the organism was exposed to rapidly declining concentrations in vivo, only a minimal PAE was observed for both antibiotics. Moreover, a PAE of 3.1 +/- 1.3 h of rifampicin was obtained in vivo, being smaller than the 4.8 h PAE observed in vitro, which might be explained by the binding of 45 +/- 6.5% rifampicin to proteins in the CSF.

A new genetic assay for rifampicin susceptibility of Mycobacterium tuberculosis

A new method for testing rifampicin (RFP) susceptibility of Mycobacterium tuberculosis was developed. This method is based on detection of the internal sequence derived from 71-kDa heat shock protein mRNA in tubercle bacilli heat-treated in the presence of RFP. The target sequence was amplified by reverse transcription and PCR, followed by agarose gel electrophoretic analysis. No amplification occurred in one RFP-susceptible strain by exposure to 45 degrees C for 45 min in Middlebrook 7H9 broth containing RFP (10 micrograms/ml) after overnight incubation at 37 degrees C. On the other hand, an amplified 275-bp product was obtained from the RFP-resistant strain MY-129. In a subsequent trial using 65 clinical isolates, this method defined their RFP susceptibility levels as well as the verification of the MICs obtained by the conventional agar dilution method, with the exception of one RFP-susceptible strain. Thus, this method provides a rapid and practical system to determine RFP susceptibility in M. tuberculosis.

Antimicrobial agent resistance in mycobacteria: molecular genetic insights

The primary theme emerging from molecular genetic work conducted with Mycobacterium tuberculosis and several other mycobacterial species is that resistance is commonly associated with simple nucleotide alterations in target chromosomal genes rather than with acquisition of new genetic elements encoding antibiotic-altering enzymes. Mutations in an 81-bp region of the gene (rpoB) encoding the beta subunit of RNA polymerase account for rifampin resistance in 96% of M. tuberculosis and many Mycobacterium leprae isolates. Streptomycin resistance in about one-half of M. tuberculosis isolates is associated with missense mutations in the rpsL gene coding for ribosomal protein S12 or nucleotide substitutions in the 16S rRNA gene (rrs). Mutations in the katG gene resulting in catalase-peroxidase amino acid alterations nad nucleotide substitutions in the presumed regulatory region of the inhA locus are repeatedly associated with isoniazid-resistant M. tuberculosis isolates. A majority of fluoroquinolone-resistant M. tuberculosis isolates have amino acid substitutions in a region of the DNA gyrase A subunit homologous to a conserved fluoroquinolone resistance-determining region. Multidrug-resistant isolates of M. tuberculosis arise as a consequence of sequential accumulation of mutations conferring resistance to single therapeutic agents. Molecular strategies show considerable promise for rapid detection of mutations associated with antimicrobial resistance. These approaches are now amenable to utilization in an appropriately equipped clinical microbiology laboratory.

Antimycobacterial activity of a new rifamycin derivative, 3-(4-cinnamylpiperazinyl iminomethyl) rifamycin SV (T9)

The antimycobacterial activities of a new rifampin (RIF) derivative, 3-(4-cinnamylpiperazinyl iminomethyl) rifamycin SV (To), against 20 susceptible and multidrug-resistant strains of Mycobacterium tuberculosis and 20 Mycobacterium avium complex (MAC) strains were investigated. The radiometric MICs of T9 for M. tuberculosis were significantly lower than those of RIF. The MICs of T9 and RIF at which 90% of the RIF-susceptible strains were inhibited were < or = 0.25 and < or = 0.5 micrograms/ml, respectively. Interestingly, T9 had lower MICs against some RIF-resistant M. tuberculosis strains. T9 had better activity against MAC strains, and the MIC at which 90% of the MAC strains were inhibited was < or = 0.125 micrograms/ml, and that of RIF was < or = 2.0 micrograms/ml. T9 also showed high in vitro bactericidal and intracellular activities which were significantly superior to those of RIF against both M. tuberculosis, and MAC strains. More importantly, T9 showed excellent in vivo activity against M. tuberculosis H37Rv compared with that of RIF in both the lungs and spleens of C57BL/6 mice, indicating the potential therapeutic value of T9 in the treatment of mycobacterial infections.

Evaluation of cycloserine in the treatment of Alzheimer's disease

This multicenter study evaluated the efficacy and safety of cycloserine and measured its effects on explicit and implicit memory tests in patients with Alzheimer's disease (AD). Four hundred ten patients with AD, aged 50 years or older, were enrolled in this parallel-group, double-blind, placebo-controlled, randomized trial of 5, 15, or 50 mg cycloserine or placebo twice daily, and 403 entered the double-blind treatment phase. Two hundred sixty-five patients completed the entire 26-week treatment phase. There were no baseline differences among the four treatment groups. Cognitive Drug Research (CDR) efficacy assessments showed no differences between active treatments and placebo from baseline to study weeks 2, 6, 14, or 26. Patients receiving 15 mg of cycloserine improved significantly on one section of an implicit memory test. No differences among treatments were observed for any other assessment scales evaluated. The incidence and severity of adverse events were similar across treatment groups. Cycloserine was well tolerated but did not demonstrate consistent evidence of efficacy during the course of therapy. Higher doses may be necessary to achieve efficacy in the AD population and do not appear to be precluded by the adverse event profile seen in this study.

In vitro and in vivo activities of the benzoxazinorifamycin KRM-1648 against Mycobacterium tuberculosis

The in vitro and in vivo activities of a new benzoxazinorifamycin, KRM-1648 (KRM), against Mycobacterium tuberculosis were studied. The MIC at which 50% of the isolates are inhibited (MIC50) and the MIC90 of KRM for 30 fresh isolates of M. tuberculosis measured by the BACTEC 460 TB System were 0.016 and 2 micrograms/ml, respectively. These values were much lower than those for rifampin (RMP), which were 4 and >128 micrograms/ml, respectively, and considerably lower than those for rifabutin (RBT), which were 0.125 and 8 micrograms/ml, respectively. A correlational analysis of the MICs of these drugs for the clinical isolates revealed the presence of cross-resistance of the organisms to KRM and either RMP or RBT although the MICs of KRM were distributed over a much lower range than were those of the other two drugs. KRM and RMP at concentrations of 1 to 10 micrograms/ml almost completely inhibited the bacterial growth of RMP-sensitive strains (H37Rv, Kurono, and Fujii) of M. tuberculosis phagocytosed in macrophage-derived J774.1 cells. KRM was more active than RMP in inhibiting the growth of the RMP-resistant (MIC = 8 micrograms/ml) Kurata strain but failed to show such an effect against the RMP-resistant (MIC >128 micrograms/ml) Watanabe stain. When KRM was given to M. tuberculosis-infected mice at dosages of 5 to 20 mg/kg of body weight by gavage, one daily six times per week from day 1 after infection, it was much more efficacious than RMP against infections induced in mice by the RMP-sensitive Kurono strain, as measured by a reduction of rates of mortality, a reduction of the frequency and extent of gross lung lesions, histopathological changes in lung tissues, and a decrease in the bacterial loads in the lungs and spleens of infected mice. KRM also displayed significant therapeutic efficacy against infection induced by the RMP-resistant Kurata strain, while neither KRM nor RMP was efficacious against infection by the RMP-resistant Watanabe strain. In the case of infection with the Kurono strain, the efficacy of the drugs in prolonging the time of survival was in the order KRM, RBT, RMP. KRM was much more efficacious than RMP, when given at 1- to 4-week intervals. These findings suggest that KRM may be useful for the clinical treatment of tuberculosis contracted through RMP-sensitive strains, even when it is administered at long intervals.

Colorimetric method for determining MICs of antimicrobial agents for Mycobacterium tuberculosis

A colorimetric method for quantitative measurement of the susceptibility of Mycobacterium tuberculosis to antimicrobial agents is described. The method utilizes an oxidation-reduction dye, Alamar blue, as an indicator of growth. By this method, MICs of isoniazid, rifampin, streptomycin, and ethambutol were determined for 50 strains of M. tuberculosis. Colorimetric MIC results were available on the 7th, 10th, or 14th day of incubation for 29 (58%), 14 (28%), and 7 (14%) of the 50 strains, respectively. When MIC susceptibility results were compared with results obtained by the agar proportion method, increased levels of resistance detected by agar proportion were associated with higher MICs obtained by the colorimetric method. Tentative interpretive criteria for colorimetric MIC results which showed good agreement with results obtained by the agar proportion method were established. Interpretive agreement between the two methods was 98% for isoniazid, rifampin, and ethambutol and 94% for streptomycin. Overall, there was agreement between the two methods for 194 of 200 test results (97%). The colorimetric method is a rapid, quantitative, nonradiometric method for determining the antimicrobial susceptibility of M. tuberculosis.

A rifampicin-induced hepatic microsomal enzyme system for the generation of cyclosporine metabolites

A drug-induced rabbit hepatic microsomal enzyme system has been developed to produce milligram quantities of cyclosporine metabolites (CMs). Using a rifampicin-induced microsomal preparation in the presence of a NADPH regenerating system, 60% of the cyclosporine (CsA) was converted to CMs in 2 h. The CMs were recovered by solid phase extraction, and separated by gradient high performance liquid chromatography with two Ultrasphere Ocyl (C8) columns connected in tandem. More than 20 CMs were resolved. The quantities of major CMs produced by 45 mg of microsomal proteins were established by comparing peak areas with known concentrations of authentic CM standards. These major CMs included AM1, AM9, AM19, AM4N, AM1c and the aldehydic isomers (AM1cAL plus AM1AL). Other CMs that were not quantified included AM14N, AM4N9, AM1A, AM1c9, and AM1D1. Several CMs remained to be identified. All CMs were detected by radioimmunoassay using a non-specific CsA antiserum. The purity of the CMs were confirmed by fast atomic bombardment mass spectrometry. Similar findings were observed when erythromycin or trolandomycin was used to induce the hepatic microsomal enzymes. The procedure used to generate CMs was simple. With the enzyme fraction derived from one rabbit liver, 90 to 100 mg of CMs can be obtained. In this study, the metabolite patterns of CsA produced by rabbit liver microsomes were shown to resemble those observed for humans. These results indicate the possibility of using rabbit models to predict CsA biotransformation in man. The CMs generated by this enzyme system can be used to acquire information relevant to the situation in man.

Primary drug resistance to Mycobacterium tuberculosis in renal transplant recipients

BACKGROUND

After renal transplantation, patients have an up to 5% chance of being infected with Mycobacterium tuberculosis and there are reports from western countries of a 24% mortality if the infection is drug resistant. We investigated primary drug resistance in renal transplant recipients in Vellore, Tamil Nadu.

METHODS

Between January 1987 and December 1993 we studied 695 patients (who had received 717 renal allografts) for evidence of tuberculosis, and performed drug sensitivity tests.

RESULTS

Forty-three patients had culture-proven infection with Mycobacterium tuberculosis of whom 40 had drug sensitivity tests done. Initial drug resistance was seen from 1991. Rifampicin resistance was seen in 2, 1 and 4 patients and isoniazid resistance in 1, 2 and 2 patients in 1991, 1992 and 1993, respectively of the 23 isolates tested for drug susceptibility. Multi-drug resistance was seen in 1 and 2 patients in 1992 and 1993.

CONCLUSIONS

This is probably the first report in India of primary drug resistance of Mycobacterium tuberculosis in renal allograft recipients. It is a cause for concern as it may indicate a large reservoir of drug-resistant patients in the community.

In-vitro and intracellular activity of rifabutin on drug-susceptible and multiple drug-resistant (MDR) tubercle bacilli

Rifabutin, a spiropiperidyl derivative of rifampicin, is approved for the prophylaxis of Mycobacterium avium infections in AIDS patients in the US, and for the treatment of M. avium infections, tuberculosis and multiple drug resistant tuberculosis in many countries. In the present study, rifabutin was compared with rifampicin for its activity against drug susceptible and multi-drug resistant tubercle bacilli by several in-vitro and macrophage studies. Rifabutin exhibited similar or greater in-vitro activity than rifampicin as judged by the minimal inhibitory concentration (MIC), minimal bactericidal concentration (MBC) and MBC/MIC ratios, as well as continuous exposure and post-antibiotic effect studies. Rifabutin has been shown to be active against some multiple drug resistant strains which were resistant to rifampicin. In macrophage studies with continuous exposure to the drug or when the drug had been removed after 24 h, rifabutin also demonstrated high activity which was better than RMP against intracellular tubercle bacilli. This long-acting intracellular anti-mycobacterial activity may explain, in part, the clinical efficacy of rifabutin.

Inhibitory and bactericidal activities of levofloxacin, ofloxacin, erythromycin, and rifampin used singly and in combination against Legionella pneumophila

The susceptibilities of 56 Legionella pneumophila isolates (43 clinical and 15 environmental isolates) to levofloxacin, ofloxacin, erythromycin, and rifampin were studied with buffered charcoal yeast extract (BCYE) agar (inoculum, 10(4) CFU per spot), and the susceptibilities of five isolates were studied with buffered yeast extract (BYE) broth (inoculum, 10(5) CFU/ml). The MICs inhibiting 90% of strains tested on BCYE agar were 0.125, 0.25, 1.0, and < or = 0.004 micrograms/ml for levofloxacin, ofloxacin, erythromycin, and rifampin, respectively. The MICs by the BYE broth dilution method were 1 to 3, 2, 1 to 2, and 1 tube lower than those by the agar dilution method for levofloxacin, ofloxacin, erythromycin, and rifampin, respectively. The MBCs were 1 to 2 tubes higher than the broth dilution MICs for levofloxacin, 1 to 3 tubes higher than the broth dilution MICs for ofloxacin, 1 to 3 tubes higher than the broth dilution MICs for erythromycin, and the same as the broth dilution MICs for rifampin. In kinetic time-kill curve studies, at drug concentrations of 1.0 and 2.0 times the MIC, the most active drugs were levofloxacin and rifampin. At 72 h, concentrations of levofloxacin and rifampin of 2.0 times the MIC demonstrated a bactericidal effect against L. pneumophila. In contrast, at concentrations of 1.0 and 2.0 times the MICs regrowth was observed with ofloxacin and only a gradual decrease in the numbers of CFU per milliliter was observed with erythromycin. Only a minor inhibitory effect was observed with 0.25 or 0.5 time the MICs of all drugs at 24 to 48 h, with regrowth occurring at 72 h. In contrast to erythromycin or ofloxacin plus rifampin at 0.25 time the MICs, only levofloxacin plus rifampin demonstrated synergy. Thus, levofloxacin demonstrated the best inhibitory and bactericidal effects against L. pneumophila when it was studied alone or in a combination with rifampin.

Parthenogenesis-inducing microorganisms in Aphytis (Hymenoptera: Aphelinidae)

Production of males in uniparental lines of two species in the parasitic wasp genus Aphytis was induced by rifampicin, and male sexual functioning was determined. Wolbachia-specific 16S rDNA primers were used in a PCR in order to: (1) assess correlation between thelytokous reproduction and the presence of Wolbachia; (2) detect the loss of Wolbachia DNA in uniparental A. lingnanensis following antibiotic treatments, with or without the presence of a host; and (3) clone and sequence part of the Wolbachia 16S rDNA from the uniparental Aphytis species for phylogenetic studies. Males produced viable sperm that was transferred to the female spermatheca following mating. However, sperm failure to effect egg fertilization resulted in all-male progeny. Wolbachia were found in the two uniparental (A. lingnanensis and A. diaspidis) but not in the two biparental (A. lingnanensis and A. melinus) Aphytis lines tested. They can be detected in wasps up to 7 days following antibiotic treatments, regardless of the presence of host. The 16S rDNA for the symbionts in the two Aphytis species is virtually identical, and is most closely related to the Wolbachia found in Muscidifurax uniraptor (Pteromalidae).

Activity of sparfloxacin on Staphylococcus epidermidis attached to plastic catheters

The activity of sparfloxacin on Staphylococcus epidermidis biofilms on different plastic catheters was evaluated. Sparfloxacin showed high bactericidal activity against S. epidermidis biofilms on Vialon and polyvinylchloride catheters. The combination of sparfloxacin with amikacin or rifampicin significantly increased its activity against bacterial biofilms on polyurethane and Teflon catheters.

Susceptibilities of nontuberculosis mycobacterial species to amoxicillin-clavulanic acid alone and in combination with antimycobacterial agents

Neither amoxicillin nor clavulanic acid used alone was active at the highest level tested, i.e., 256.0 micrograms/ml, in vitro against 24 isolates of Mycobacterium fortuitum, Mycobacterium kansasii, and Mycobacterium marinum. However, the MIC of an amoxicillin-clavulanic acid combination of 2:1 was < or = 8.0/4.0 micrograms/ml for 50 percent of the isolates tested, with all isolates being inhibited in the range of 4.0/2.0 to 32.0/16.0 micrograms/ml, respectively. Titration of amoxicillin-clavulanic acid with a fixed 2-micrograms/ml concentration of ethambutol resulted in synergistic activity against 3 of 9 isolates of M. fortuitum, 10 of 10 isolates of M. kansasii, and 5 of 5 isolates of M. marinum. This observation was confirmed in a checkerboard analysis in which fractional inhibitory concentrations were < or = 0.5 for 20 of the 24 isolates. Synergistic activity was observed against the other four isolates in one of two trials. On the other hand, titration of amoxicillin-clavulanic acid in the presence of either one or two fixed concentrations of isoniazid, rifampin, cycloserine, tetracycline, or amikacin failed to result in synergism.

Tsukamurella inchonensis sp. nov

Chemotaxonomic and genomic 16S ribosomal DNA sequence analyses of two isolates obtained from two different clinical materials clearly delineated a new species of the genus Tsukamurella. This new species can be identified by its 16S ribosomal DNA similarity values, as well as its physiological characteristics. The name Tsukamurella inchonensis sp. nov. is proposed for these isolates, which are represented by strain IMMIB D-771T (= DSM 44067T) (T = type strain). This strain exhibits only 45% DNA relatedness to Tsukamurella paurometabola.

Effect on Pseudomonas aeruginosa alginate expression of direct plating and culture of fresh cystic fibrosis sputum on to pseudomonas isolation agar containing subinhibitory concentrations of roxithromycin and rifampicin

The effects of subinhibitory concentrations of roxithromycin (16 mg/L) or rifampicin (16 mg/L) on alginate production by Pseudomanas aeruginosa were investigated. The weight of purified alginate from antibiotic-free cultures was significantly greater (52.5 +/- 24.0 mg, range 22.4-109.5), compared with alginate from cultures bacteria exposed to sub-MIC of roxithromycin (21.9 +/- 17.0, 0.0-42.1 (P < or = 0.037)) and to sub-MIC of rifampicin (28.6 +/- 15.0, 2.9-47.5 (P < or = 0.038)). Chromatographic analysis of hydrolysed and chemically transformed sub-units of alginate revealed that the presence and the molar ratio of D-mannuronic acid and L-guluronic acid were not affected in the remnant alginate exposed to sub-MIC of roxithromycin in contrast to that in the remnant alginate exposed to sub-MIC of rifampicin.