Listeria monocytogenes infections--therapeutic possibilities and problems

Comparison of the in vitro activity of ampicillin and moxifloxacin against Listeria monocytogenes at achievable concentrations in the central nervous system

PURPOSE

The aim of this study was to compare the in vitro activity of ampicillin and moxifloxacin against six isolates selected from 154 invasive clinical isolates of Listeria monocytogenes and evaluate their intra- and extracellular activities with achievable central nervous system concentrations obtained using Monte Carlo simulations with conventional and unconventional dosages.

METHODOLOGY

The MICs and minimal bactericidal concentrations (MBCs) of ampicillin and moxifloxacin were determined by using the broth microdilution method. The intra- and extracellular activities were compared using time-kill curves and inhibition of intracellular growth assays.

RESULTS

The MICs50/90 of ampicillin were 0.125/0.5 mg l-1 and the MBC50/90 was ≥16 mg l-1, while the moxifloxacin MICs50/90 were 0.25/0.5 mg l-1 and the MBC50/90 was 0.5 mg l-1. Ampicillin did not show any extracellular bactericidal activity at 24 h, although bactericidal activity was detected at 48 h. For moxifloxacin, the bactericidal effect was evident after 6 h of incubation. Both antibiotics achieved significant reductions in intracellular inoculum after 1-24 h of incubation; however, moxifloxacin becomes bactericidal more rapidly, producing a much greater reduction in the inoculum in the first hour than ampicillin. There were no differences among the MIC and MBC values of moxifloxacin and ampicillin among the strains belonging to different serotypes and/or epidemic clones. This fact was also found in the intra- and extracellular studies.

CONCLUSION

The results of this study demonstrated the faster bactericidal activity of moxifloxacin at achievable central nervous system concentrations against intra- and extracellular forms of L. monocytogenes in comparison with ampicillin.

Listeria septicemia accompanied by central nervous system involvement in a patient with multiple myeloma and secondary diabetes

Patient: Female, 58

Final Diagnosis: Listeria septicemia

Symptoms: Nausea • vomitting • high fever • apathetic intelligence • repeated convulsion

Medication: Levofloxacin

Clinical Procedure: —

Specialty: Hematology

Objective: Rare disease

Results of a two-center, before and after study of piperacillin-tazobactam versus ampicillin and gentamicin as empiric therapy for suspected sepsis at birth in neonates ≤ 1500 g

OBJECTIVE

We changed from ampicillin and gentamicin (AG) to piperacillin-tazobactam (PT) for routine treatment of suspected early-onset sepsis. The rationale for this change included ototoxic and renal toxic effects of gentamicin, resistance to gentamicin in late-onset infections and emergence of ampicillin resistant Escherichia coli. A before and after study was designed before the start of PT administration to monitor whether PT was associated with altered outcomes within the 501 to 1500 g birth weight (Very Low Birth Weight) population.

METHOD

Both unmatched and matched comparisons of AG (2007 to 2009) and PT (2010 to 2011) exposed infants are reported. Cohorts were evaluated for initial effectiveness for congenital infections, subsequent morbidities and mortality.

RESULTS

Data from 714 patients were collected (499 AG and 215 PT in the unmatched and 301 AG and 183 PT in the matched cohorts). No significant differences in demographics or initial Apgar scores were noted in the unmatched or matched comparisons. There were significant differences in many of the outcomes of interest in both the matched and unmatched comparisons including less necrotizing enterocolitis (NEC) and less diaper rash with PT versus AG. The only adverse finding with PT was a small, but statistically significant elevation in alkaline phosphatase.

CONCLUSIONS

Use of PT as the initial empiric antibiotic for very low birth weight infants was not associated with adverse microbiological outcomes. There was no increase in major morbidities. Although outcomes were superior in ≤ 1500 g infants treated with PT when compared with AG, the study design does not allow us to conclude that others will see a reduction in NEC or diaper rash if they implement this alternative.

Listeriosis

Listeria monocytogenes, a small, facultative anaerobic, Gram-positive motile bacillus, is an important cause of foodborne illness which disproportionately affects pregnant women and their newborns. Listeria infects many types of animals and contaminates numerous foods including vegetables, milk, chicken and beef. This organism has a unique proclivity to infect the fetoplacental unit with the ability to invade cells, multiply intracellularly and be transmitted cell-to-cell. The organism possesses several virulence factors, including internalin A and internalin B, which facilitate the direct invasion of cells. Cell-to-cell transmission is promoted by the bacterial surface protein ActA which is regulated by a transcriptional activator known as positive regulatory factor A. Both innate and adaptive immune responses enable the host to eliminate this pathogen. Clinical manifestations of infection in the newborn fall into the traditional categories of early- and late-onset sepsis. Therapeutic recommendations include ampicillin and gentamicin for 14-21 days.

Rapid eradication of Listeria monocytogenes by moxifloxacin in a murine model of central nervous system listeriosis

Listeriosis is a rare but life-threatening infection. A favorable outcome is greatly aided by early administration of antibiotics with rapid bactericidal activity against Listeria monocytogenes. Moxifloxacin, a new-generation fluoroquinolone with extended activity against gram-positive bacteria, has proved its effectiveness in vitro against intracellular reservoirs of bacteria. The efficacies of moxifloxacin and amoxicillin were compared in vivo by survival curve assays and by studying the kinetics of bacterial growth in blood and organs in a murine model of central nervous system (CNS) listeriosis. We combined pharmacokinetic and pharmacodynamic approaches to correlate the observed efficacy in vivo with plasma and tissue moxifloxacin concentrations. Death was significantly delayed for animals treated with a single dose of moxifloxacin compared to a single dose of amoxicillin. We observed rapid bacterial clearance from blood and organs of animals treated with moxifloxacin. The decrease in the bacterial counts in blood and brain correlated with plasma and cerebral concentrations of antibiotic. Moxifloxacin peaked in the brain at 1.92 +/- 0.32 microg/g 1 hour after intraperitoneal injection. This suggests that moxifloxacin rapidly crosses the blood-brain barrier and diffuses into the cerebral parenchyma. Moreover, no resistant strains were selected during in vivo experiments. Our results indicate that moxifloxacin combines useful pharmacokinetic properties and rapid bactericidal activity and that it may be a valuable alternative for the treatment of CNS listeriosis.

Comparative efficacies of antibiotics in a rat model of meningoencephalitis due to Listeria monocytogenes

The antibacterial activities of amoxicillin-gentamicin, trovafloxacin, trimethoprim-sulfamethoxazole (TMP-SMX) and the combination of trovafloxacin with TMP-SMX were compared in a model of meningoencephalitis due to Listeria monocytogenes in infant rats. At 22 h after intracisternal infection, the cerebrospinal fluid was cultured to document meningitis, and the treatment was started. Treatment was instituted for 48 h, and efficacy was evaluated 24 h after administration of the last dose. All tested treatment regimens exhibited significant activities in brain, liver, and blood compared to infected rats receiving saline (P < 0.001). In the brain, amoxicillin plus gentamicin was more active than all of the other regimens, and trovafloxacin was more active than TMP-SMX (bacterial titers of 4.1 +/- 0.5 log10 CFU/ml for amoxicillin-gentamicin, 5.0 +/- 0.4 log10 CFU/ml for trovafloxacin, and 5.8 +/- 0.5 log10 CFU/ml for TMP-SMX; P < 0.05). In liver, amoxicillin-gentamicin and trovafloxacin were similarly active (2.8 +/- 0.8 and 2.7 +/- 0.8 log10 CFU/ml, respectively) but more active than TMP-SMX (4.4 +/- 0. 6 log10 CFU/ml; P < 0.05). The combination of trovafloxacin with TMP-SMX did not alter the antibacterial effect in the brain, but it did reduce the effect of trovafloxacin in the liver. Amoxicillin-gentamicin was the most active therapy in this study, but the activity of trovafloxacin suggests that further studies with this drug for the treatment of Listeria infections may be warranted.

Central nervous system infection with Listeria monocytogenes. 33 years' experience at a general hospital and review of 776 episodes from the literature

We reviewed 776 previously reported and 44 new cases of CNS listeriosis outside of pregnancy and the neonatal period, and evaluated the epidemiologic, diagnostic, and therapeutic characteristics of this infection. Among patients with Listeria meningitis/meningoencephalitis, hematologic malignancy and kidney transplantation were the leading predisposing factors, but 36% of patients had no underlying diseases recognized. The infection occurred throughout life, with a higher incidence before the age of 3 and after the age of 45-50 years. Fever, altered sensorium, and headache were the most common symptoms, but 42% of patients had no meningeal signs on admission. Compared with patients with acute meningitis due to other bacterial pathogens, patients with Listeria infection had a significantly lower incidence of meningeal signs, and the CSF profile was significantly less likely to have a high WBC count or a high protein concentration. Gram stain of CSF was negative in two-thirds of cases of CNS listeriosis. One-third of patients had focal neurologic findings, and approximately one-fourth developed seizures over their course. Mortality was 26% overall, and was higher among patients with seizures and those older than 65 years of age. Relapse occurred in 7% of episodes. Ampicillin for a minimum of 15-21 days (with an aminoglycoside for at least the first 7-10 days) remains the treatment of choice. Cerebritis/abscess due to L. monocytogenes, without meningeal involvement, is less common but may be diagnosed by blood cultures and CNS imaging, or by stereotactic biopsy. Longer antibiotic therapy (at least 5-6 weeks) is needed in the presence of localized CNS involvement.

In vitro extracellular and intracellular activity of two newer and two earlier fluoroquinolones against Listeria monocytogenes

Two new fluoroquinolones (trovafloxacin and sparfloxacin) with enhanced activity against gram-positive pathogens and two earlier compounds (ciprofloxacin and ofloxacin) were tested for their in vitro inhibitory and bactericidal activity against 80 strains of Listeria monocytogenes. All strains were uniformly highly susceptible to trovafloxacin, the MIC90 being 0.25 mg/l. Resistance to sparfloxacin was not detected, however the MIC90 of sparfloxacin was eight times that of trovafloxacin. A few strains were resistant to ciprofloxacin and ofloxacin (MIC90 4 mg/l for both drugs). MBCs usually exceeded MICs by 2 to 4 times. The MBC90 of trovafloxacin (1 mg/l) was lower than that of the other three drugs (8 mg/l). After checking their ability to enter and grow within human enterocyte-like Caco-2 cells, four strains were used to study the intracellular activity and eradicating power of the four quinolones. Trovafloxacin was more active than sparfloxacin and the earlier fluoroquinolones in terms of both intracellular killing and inhibition of a cytopathogenic effect. The uniform high-level activity of trovafloxacin against Listeria monocytogenes isolates in conventional in vitro assays and its extracellular and intracellular killing of invasive strains suggest that this and maybe other new fluoroquinolones should be further investigated as possible anti-listerial agents.

Antimicrobial chemotherapy of human infection due to Listeria monocytogenes

Listeriosis is an uncommon infection, but when it occurs it carries a high mortality rate. Early diagnosis is essential and thereafter appropriate antimicrobial chemotherapy. Ampicillin or penicillin plus gentamicin remains the treatment of choice for most manifestations of listeriosis, and adequate doses must be given, i.e. greater than 6g/day of ampicillin or penicillin. Co-trimoxazole appears to be an excellent alternative agent with good penetration into the cerebrospinal fluid. Vancomycin is an appropriate agent for the treatment of primary bacteraemia but does not cross the blood-brain barrier sufficiently well to be useful in meningitis, while erythromycin may be used to treat listeriosis in cases of pregnancy. Treatment of bacteraemia requires one to two weeks' therapy, while meningitis cases may need to be treated for longer; for example, it has been found that most patients with acute meningitis in the UK were treated for 20 days. Infective endocarditis needs treatment for six to eight weeks. Doses should be varied with patients' altered organ function and antimicrobial serum monitoring performed when appropriate.

Genetic characterization of plasmid-encoded multiple antibiotic resistance in a strain of Listeria monocytogenes causing endocarditis

One susceptible and two multiply resistant isolates of Listeria monocytogenes from a patient suffering from prosthetic valve endocarditis are described. They could not be distinguished by several typing methods. Two isolates were resistant to chloramphenicol, macrolide/lincosamide/streptogramin antibiotics and tetracycline. The resistance determinants were located on a 39 kb plasmid pWDB100 that was transferable by filter mating to several gram-positive bacteria. Evidence was obtained to support the hypothesis that the resistant variant had primarily infected the patient's blood and prosthetic valve, and later lost the resistance plasmid. The three resistance determinants showed homology to other known markers, cat221/cat223, ermB and tetM, which are frequently found in different gram-positive genera. Plasmid pWDB100 showed extensive homology to the Streptococcus agalactiae broad-host-range plasmid pIP501. It was also very similar to two listerial plasmids found in France. Thus, plasmid pWDB100 and the homologous plasmids from France, although isolated in geographically distant regions, may illustrate spread of a plasmid and its relatives.

Precise prediction of a dominant class I MHC-restricted epitope of Listeria monocytogenes

Listeria monocytogenes is a Gram-positive bacterium which grows in the cytoplasm of eukaryotic cells and can cause severe disease in immunocompromised individuals. In murine systems CD8+ T lymphocytes have been shown to be important effectors of acquired protective immunity against L. monocytogenes. Class I MHC-restricted CD8+ cytotoxic T lymphocytes (CTL), which lyse J774 macrophage-like targets infected with L. monocytogenes, are induced following in vivo injection of live organisms. Natural peptide epitopes derived from L. monocytogenes can be acid-extracted from heavily infected BALB/c spleens and detected by CTL. A CTL clone, B9, derived from a (BALB/c x C57BL/6)F1 (H-2dxb) mouse, recognizes one of these natural epitopes in an H-2Kd-restricted fashion. B9 also recognizes P815 (H-2d) mastocytoma cells transfected with the listeriolysin gene. To identify the region of the listeriolysin recognized by CTL we used the H-2Kd peptide-binding motif described by Rammensee and colleagues to synthesize 11 nonamer peptides. One of these peptides, listeriolysin 91-99, was recognized very efficiently by B9. This represents the first identified class I MHC-restricted epitope of bacteria and demonstrates the utility of the allele-specific motif for predicting CTL epitopes.

Effect of various antibiotics on Listeria monocytogenes multiplying in L 929 cells

Various antibiotics were evaluated as to their effect on Listeria monocytogenes SLCC 4013 multiplying within L 929 mouse fibroblast cells. Antibiotics were employed in concentrations above the MIC value. However, there was no measurable effect of some drugs on intracellular listeriae (azlocillin, mezlocillin, cephalothin, ciprofloxacin, chloramphenicol). With other drugs an inhibition of intracellular growth was observed (penicillin, ampicillin, rifampicin, rifapentine, erythromycin, doxycycline, co-trimoxazole, coumermycin). Notably, with none of the antibiotics a complete eradication of the listeriae was achieved. There is a good correlation of these results with animal experiments. Therefore, the cell culture system might be useful for the screening of new antibiotics.

Therapeutic activities of antibiotics in listeriosis

In vitro practically all common antibiotics except cephalosporins are active against nearly all natural isolates of Listeria monocytogenes; the therapeutic efficacy of antibiotic treatment is, however, rather limited, since up to 30% listeriosis patients will succumb to this infection. At least one reason for this low in vivo efficiency is the intracellular habitat of L. monocytogenes. In animal experiments ampicillin or amoxicillin, respectively, are still the most active drugs. In addition, rifampicin also has pronounced protective activity. Coumermycin, which unfortunately cannot be given to humans, is the most reliable drug in animals.

Studies on the pathogenicity of Listeria monocytogenes

The characterization of mutants of Listeria monocytogenes with reduced virulence properties is described. Reduction in the amount of the extracellular protein p60 (encoded by the ipa gene) leads to cell filaments with impaired invasiveness. Mutants which cannot synthesize listeriolysin are still invasive but unable to survive within phagocytic cells. One type of listeriolysin-negative mutants is defective in the synthesis of a positive regulatory element PrfA which coordinately regulates the listeriolysin gene (lisA) together with several other genes, including those for a phosphatidylinositol-specific phospholipase and a metalloprotease.

Detection of a gene encoding a phosphatidylinositol-specific phospholipase C that is co-ordinately expressed with listeriolysin in Listeria monocytogenes

A phosphatidylinositol-specific phospholipase C (PI-PLC) that is unique to the pathogenic Listeria species L. monocytogenes and L. ivanovii has been detected. Deletion analysis performed with Escherichia coli recombinants expressing PI-PLC activity together with maxicell analysis showed that a 34 kDa polypeptide was responsible for this activity. Nucleotide sequencing revealed that the gene encoding this polypeptide comprises 317 amino acid residues with a 22-amino-acid signal peptide. This gene, designated pic for phosphatidylinositol-specific phospholipase C, is located back to back with the listeriolysin gene on the chromosome of L. monocytogenes where these genes are transcribed by divergent non-overlapping promoters. Expression of the pic gene is dependent on the product of the prfA gene, which also regulates expression of the listeriolysin gene in L. monocytogenes.

Molecular cloning, sequencing, and identification of a metalloprotease gene from Listeria monocytogenes that is species specific and physically linked to the listeriolysin gene

The entire nucleotide sequence of an open reading frame located immediately downstream of the listeriolysin gene from a virulent Listeria monocytogenes serotype 1/2a strain was determined. The product of the open reading frame was 510 amino acids with a predicted molecular weight of 57,400. The deduced amino acid sequence of this open reading frame is highly similar to that of a family of secreted metalloproteases produced by various members of the genus Bacillus, of which thermolysin is the prototype. Immunoblots performed with specific antisera raised against thermolysin from Bacillus stearothermophilus allowed the detection of a 60-kDa polypeptide, corresponding to the pro-form of the protease, in culture supernatants of L. monocytogenes strains. In maxicell experiments, Escherichia coli recombinants harboring this open reading frame also specifically directed production of a 60-kDa protein. Protease activity was low to undetectable in both Listeria strains and E. coli recombinants. This is due to lack of processing of the inactive pro-form of the protease to its mature active form in both species. We have designated this gene mpl for metalloprotease of L. monocytogenes. The gene was present only in pathogenic L. monocytogenes strains, in which it was physically linked to the listeriolysin gene.

Listeria brainstem encephalitis: two own cases and literature review

We analysed two of our own and 21 patients described in the literature with listeria brainstem encephalitis. The disease was characterised by a prodromal state with fever, nausea and headache followed by severe brainstem dysfunction with multiple cranial nerve palsies, ataxia, respiratory insufficiency and coma. The diagnosis was established by isolation of Listeria monocytogenes from CSF and/or serum. Serological tests are without diagnostic evidence. Cerebrospinal fluid examination may not initially point to a bacterial infection. Computed tomography and magnetic resonance imaging technique might supply evidence of brainstem involvement and contribute to an early diagnosis. There is a high percentage of lethal outcome without early antibiotic therapy.