The dose at which neomycin and polymyxin B can be applied for selective decontamination of the digestive tract in mice

Prominent role of gut dysbiosis in the pathogenesis of cystic fibrosis-related liver disease in mice

BACKGROUND & AIMS

Cystic fibrosis-related liver disease (CFLD) is a chronic cholangiopathy that increases morbidity and mortality in patients with CF. Current treatments are unsatisfactory, and incomplete understanding of CFLD pathogenesis hampers therapeutic development. We have previously shown that mouse CF cholangiocytes respond to lipopolysaccharide with excessive inflammation. Thus, we investigated the role of the gut-liver axis in the pathogenesis of CFLD.

METHODS

Wild-type (WT), whole-body Cftr knockout (CFTR-KO) and gut-corrected (CFTR-KO-GC) mice were studied. Liver changes were assessed by immunohistochemistry and single-cell transcriptomics (single-cell RNA sequencing), inflammatory mediators were analysed by proteome array, faecal microbiota by 16S ribosomal RNA sequencing and gut permeability by FITC-dextran assay.

RESULTS

The livers of CFTR-KO mice showed ductular proliferation and periportal inflammation, whereas livers of CFTR-KO-GC mice had no evident pathology. Single-cell RNA sequencing analysis of periportal cells showed increased presence of neutrophils, macrophages and T cells, and activation of pro-inflammatory and pathogen-mediated immune pathways in CFTR-KO livers, consistent with a response to gut-derived stimuli. CFTR-KO mice exhibited gut dysbiosis with enrichment of Enterobacteriaceae and Enterococcus spp., which was associated with increased intestinal permeability and mucosal inflammation, whereas gut dysbiosis and inflammation were absent in CFTR-KO-GC mice. Treatment with nonabsorbable antibiotics ameliorated intestinal permeability and liver inflammation in CFTR-KO mice. Faecal microbiota transfer from CFTR-KO to germ-free WT mice did not result in dysbiosis nor liver pathology, indicating that defective intestinal CFTR is required to maintain dysbiosis.

CONCLUSION

Defective CFTR in the gut sustains a pathogenic microbiota, creates an inflammatory milieu, and alters intestinal permeability. These changes are necessary for the development of cholangiopathy. Restoring CFTR in the intestine or modulating the microbiota could be a promising strategy to prevent or attenuate liver disease.

IMPACT AND IMPLICATIONS

Severe cystic fibrosis-related liver disease (CFLD) affects 10% of patients with cystic fibrosis (CF) and contributes to increased morbidity and mortality. Treatment options remain limited due to a lack of understanding of disease pathophysiology. The cystic fibrosis transmembrane conductance regulator (CFTR) mediates Cl- and HCO3- secretion in the biliary epithelium and its defective function is thought to cause cholestasis and excessive inflammatory responses in CF. However, our study in Cftr-knockout mice demonstrates that microbial dysbiosis, combined with increased intestinal permeability caused by defective CFTR in the intestinal mucosa, acts as a necessary co-factor for the development of CFLD-like liver pathology in mice. These findings uncover a major role for the gut microbiota in CFLD pathogenesis and call for further investigation and clinical validation to develop targeted therapeutic strategies acting on the gut-liver axis in CF.

Gut microbial community differentially characterizes patients with nonalcoholic fatty liver disease

BACKGROUND AND AIM

Discordant reports of the signature gut microbes involved in nonalcoholic fatty liver disease (NAFLD) have hampered understanding of the pathogenesis of the disease, and thus its diagnosis. Thus, we investigated diagnostic factors and the potential mechanisms for heterogenous NAFLD based on the gut environment, including microbes and functional pathways.

METHODS

Stools from 16 biopsy-proven NAFLD patients were analyzed for bacterial taxonomy and functional pathways based on 16s rRNA gene sequencing. Data from the physical examination, serum biochemistry, and the gut environment were subjected to a decision tree classifier to identify diagnostic markers.

RESULTS

We identified two NAFLD subpopulations: those with and without a gut microbiota similar to health controls (HCs), defined as P_HC-like and P patients, respectively. Stools of P_HC-like patients were significantly populated with Enterobacteriaceae and were inferred to be rich in metabolites degraded from dicarboxylic acid sugars. Significant colonization of Prevotella was observed in the stools of P patients, in parallel with enrichment of metabolites from heme b biosynthesis and sulfate reduction. As a potential mechanism, we suggest that protoporphyrin IX and/or protoheme from Prevotella participates in hepatic injury, and that endogenous hydrogen sulfide increases serum IL-6 level in P patients. However, endotoxin-producing Enterobacteriaceae are thought to produce glycerate, triggering a peroxisome proliferator- activated receptor-alpha-mediated decrease in IL-6 level and fat accumulation in P_HC-like patients.

CONCLUSIONS

Heterogenous NAFLD subpopulations were identified, defined according to gut microbial composition and their potential underlying pathogenic mechanisms; our results raise the possibility of personalized treatment for NALFD patients.

Galectin-3 as a Therapeutic Target for NSAID-Induced Intestinal Ulcers

Non-steroidal anti-inflammatory drugs (NSAIDs) induce ulcers in the gastrointestinal tract, including the stomach and small intestine. NSAID-induced gastric ulcers can be prevented by taking acid-neutralizing/inhibitory drugs and cytoprotective agents. In contrast, there are no medicines to control NSAID-induced small intestinal ulcers, which are accompanied by a mucosal invasion of bacteria and subsequent activation of immune cells. Galectin-3 (Gal3), an endogenous lectin, has anti-microbial and pro-inflammatory functions. In the small intestine, since Gal3 is highly expressed in epithelial cells constitutively and macrophages inducibly, the Gal3 level can affect microbiota composition and macrophage activation. We hypothesized that the modulation of Gal3 expression could be beneficial in NSAID-induced intestinal ulcers. Using Gal3 knockout (Gal3KO) mice, we determined whether Gal3 could be a therapeutic target in NSAID-induced intestinal ulcers. Following the administration of indomethacin, an NSAID, we found that small intestinal ulcers were less severe in Gal3KO mice than in wild-type (WT) mice. We also found that the composition of intestinal microbiota was different between WT and Gal3KO mice and that bactericidal antibiotic polymyxin B treatment significantly suppressed NSAID-induced ulcers. Furthermore, clodronate, a macrophage modulator, attenuated NSAID-induced ulcers. Therefore, Gal3 could be an exacerbating factor in NSAID-induced intestinal ulcers by affecting the intestinal microbiota population and macrophage activity. Inhibition of Gal3 may be a therapeutic strategy in NSAID-induced intestinal ulcers.

CLINICAL TRIAL REGISTRATION

www.ClinicalTrials.gov, identifier NCT03832946.

Mesenteric lymph node CD4+ T lymphocytes migrate to liver and contribute to non-alcoholic fatty liver disease

Non-alcoholic fatty liver disease (NAFLD) is characterized by altered intestinal microbiota and intestinal immune disorder. Here we investigated the role of mesenteric lymph node (MLN) CD4⁺ T lymphocytes in NAFLD. In high fat diet (HFD)-fed mice, the percentage ratios of Th1 to Th2 cells and Th17 to Treg cells were imbalanced in MLNs. Co-culture assays showed MLN CD4⁺ T lymphocytes from HFD-fed mice tended to migrate to the liver and promoted hepatic inflammation. Adoptive transfer of MLN CD4⁺ T lymphocytes from NAFLD mice to HFD-fed mice resulted in higher transaminase, worse hepatic inflammation and lipid accumulation. Antibiotics and probiotics were administrated to regulate intestinal microbiota, and the restoration of MLN Th1/Th2 and Th17/Treg cells in alleviated NAFLD were found. In summary, MLNs CD4⁺ T subtype cells may involve in NAFLD, and the restoration of MLN CD4⁺ T subtype cells ratio by regulating intestinal bacteria could be the new strategies.

Trapping of Lipopolysaccharide to Promote Immunotherapy against Colorectal Cancer and Attenuate Liver Metastasis

The development and progression of colorectal cancer (CRC) is closely related to gut microbiome. Here, the impact of lipopolysaccharide (LPS), one of the most prevalent products in the gut microbiome, on CRC immunotherapy is investigated. It is found that LPS is abundant in orthotopic CRC tissue and is associated with low responses to anti-PD-L1 mAb therapy, and clearance of Gram-negative bacteria from the gut using polymyxin B (PmB) or blockade of Toll-like receptor 4 using TAK-242 will both relieve the immunosuppressive microenvironment and boost T-cell infiltration into the CRC tumor. Further, an engineered LPS-targeting fusion protein is designed and its coding sequence is loaded into a lipid-protamine-DNA (LPD) nanoparticle system for selective expression of LPS trap protein and blocking LPS inside the tumor, and this nanotrapping system significantly relieves the immunosuppressive microenvironment and boosts anti-PD-L1 mAb therapy against CRC tumors. This LPS trap system even attenuates CRC liver metastasis when applied, suggesting the importance of blocking LPS in the gut-liver axis. The strategy applied here may provide a useful new way for treating CRC as well as other epithelial cancers that interact with mucosa microbiome.

High Fat High Cholesterol Diet (Western Diet) Aggravates Atherosclerosis, Hyperglycemia and Renal Failure in Nephrectomized LDL Receptor Knockout Mice: Role of Intestine Derived Lipopolysaccharide

A high fat meal, frequently known as western diet (WD), exacerbates atherosclerosis and diabetes. Both these diseases are frequently associated with renal failure. Recent studies have shown that lipopolysaccharide (LPS) leaks into the circulation from the intestine in the setting of renal failure and after WD. However, it is not clear how renal function and associated disorders are affected by LPS. This study demonstrates that circulatory LPS exacerbates renal insufficiency, atherosclerosis and glucose intolerance. Renal insufficiency was induced by 2/3 nephrectomy in LDL receptor knockout mice. Nx animals were given normal diet (Nx) or WD (Nx+WD). The controls were sham operated animals on normal diet (control) and WD (WD). To verify if LPS plays a role in exaggerating renal insufficiency, polymyxin (PM), a known LPS antagonist, and curcumin (CU), a compound known to ameliorate chronic kidney disease (CKD), was given to Nx animals on western diet (Nx+WD+PM and Nx+WD+CU, respectively). Compared to control, all other groups displayed increased circulatory LPS. The Nx+WD cohort had the highest levels of LPS. Nx group had significant renal insufficiency and glucose intolerance but not atherosclerosis. WD had intense atherosclerosis and glucose intolerance but it did not show signs of renal insufficiency. Compared to other groups, Nx+WD had significantly higher cytokine expression, macrophage infiltration in the kidney, renal insufficiency, glucose intolerance and atherosclerosis. PM treatment blunted the expression of cytokines, deterioration of renal function and associated disorders, albeit not to the levels of Nx, and was significantly inferior to CU. PM is a non-absorbable antibiotic with LPS binding properties, hence its beneficial effect can only be due to its effect within the GI tract. We conclude that LPS may not cause renal insufficiency but can exaggerate kidney failure and associated disorders following renal insufficiency.

Loss of CFTR affects biliary epithelium innate immunity and causes TLR4-NF-κB-mediated inflammatory response in mice

BACKGROUND & AIMS

Loss of function of the cystic fibrosis transmembrane conductance regulator (CFTR) in the biliary epithelium reduces bile flow and alkalinization in patients with cystic fibrosis (CF). Liver damage is believed to result from ductal cholestasis, but only 30% of patients with CF develop liver defects, indicating that another factor is involved. We studied the effects of CFTR deficiency on Toll-like receptor 4 (TLR4)-mediated responses of the biliary epithelium to endotoxins.

METHODS

Dextran sodium sulfate (DSS) was used to induce colitis in C57BL/6J-Cftrtm1Unc (Cftr-KO) mice and their wild-type littermates. Ductular reaction and portal inflammation were quantified by keratin-19 and CD45 immunolabeling. Cholangiocytes isolated from wild-type and Cftr-KO mice were challenged with lipopolysaccharide (LPS); cytokine secretion was quantified. Activation of nuclear factor κB (NF-κB), phosphorylation of TLR4, and activity of Src were determined. HEK-293 that expressed the secreted alkaline phosphatase reporter and human TLR4 were transfected with CFTR complementary DNAs.

RESULTS

DSS-induced colitis caused biliary damage and portal inflammation only in Cftr-KO mice. Biliary damage and inflammation were not attenuated by restoring biliary secretion with 24-nor-ursodeoxycholic acid but were significantly reduced by oral neomycin and polymyxin B, indicating a pathogenetic role of gut-derived bacterial products. Cftr-KO cholangiocytes incubated with LPS secreted significantly higher levels of cytokines regulated by TLR4 and NF-κB. LPS-mediated activation of NF-κB was blocked by the TLR4 inhibitor TAK-242. TLR4 phosphorylation by Src was significantly increased in Cftr-KO cholangiocytes. Expression of wild-type CFTR in the HEK293 cells stimulated with LPS reduced activation of NF-κB.

CONCLUSIONS

CFTR deficiency alters the innate immunity of the biliary epithelium and reduces its tolerance to endotoxin, resulting in an Src-dependent inflammatory response mediated by TLR4 and NF-κB. These findings might be used to develop therapies for CF-associated cholangiopathy.

Antibiotics protect against fructose-induced hepatic lipid accumulation in mice: role of endotoxin

BACKGROUND/AIMS

Consumption of refined carbohydrates in soft drinks has been postulated to be a key factor in the development of non-alcoholic fatty liver disease (NAFLD). The aim of the present study was to test the effects of ad libitum access to different sugars consumed in drinking water on hepatic fat accumulation.

METHODS

For 8 weeks, C57BL/J6 mice had free access to solutions containing 30% glucose, fructose, sucrose, or water sweetened with artificial sweetener (AS) or plain water. Body weight, caloric intake, hepatic steatosis and lipid peroxidation were assessed.

RESULTS

Total caloric intake and weight gain were highest in mice exposed to glucose. In contrast, hepatic lipid accumulation was significantly higher in mice consuming fructose compared to all other groups. Moreover, endotoxin levels in portal blood and lipid peroxidation as well as TNFalpha expression were significantly higher in fructose fed mice than in all other groups. Concomitant treatment of fructose fed mice with antibiotics (e.g., polymyxin B and neomycin) markedly reduced hepatic lipid accumulation in fructose fed mice.

CONCLUSIONS

These data support the hypothesis that high fructose consumption may not only lead to liver damage through overfeeding but also may be directly pro-inflammatory by increasing intestinal translocation of endotoxin.

Reduced stem cell mobilization in mice receiving antibiotic modulation of the intestinal flora: involvement of endotoxins as cofactors in mobilization

Since endotoxins are potent inducers of stem cell mobilization, we hypothesized that their presence in the gut may play a role in cytokine-induced mobilization. To address this possibility we added ciprofloxacin and polymyxin B to the drinking water of Balb/c mice mobilized with either interleukin-8 (IL-8), granulocyte colony-stimulating factor (G-CSF), or flt3 ligand (FL). The yield of colony-forming units (CFUs) was significantly reduced in all mice treated with these antibiotics when compared with controls (IL-8: 192 +/- 61 vs 290 +/- 64, P <.05; G-CSF: 1925 +/- 1216 vs 3371 +/- 1214, P <.05; FL: 562 +/- 213 vs 1068 +/- 528, P <.05). Treatment with ciprofloxacin eliminated only aerobic Gram-negative bacteria from the feces without effect on mobilization. Polymyxin B treatment did not result in decontamination but significantly reduced the number of mobilized hematopoietic progenitor cells (HPCs) most likely due to the endotoxin binding capacity of polymyxin B. More than 90% of the gastrointestinal flora consists of anaerobic bacteria. Elimination of the anaerobic flora by metronidazol led to a significantly reduced number of mobilized HPCs when compared with controls (IL-8: 55 +/- 66 vs 538 +/- 216, P <.05). Germ-free OF1 mice showed a significantly reduced mobilization compared with their wild-type controls (IL-8 controls: 378 +/- 182, IL-8 germ free: 157 +/- 53, P <.05). Finally, we performed reconstitution experiments adding Escherichia coli-derived endotoxins to the drinking water of decontaminated mice. This resulted in partial restoration of the IL-8-induced mobilization (67 +/- 28 vs 190 +/- 98.1, P <.01). Our results indicate that endotoxins serve as cofactors in cytokine-induced mobilization. Modification of the endotoxin content by antibiotic treatment may affect the yield of cytokine-induced mobilization.

History of recognition and measurement of colonization resistance of the digestive tract as an introduction to selective gastrointestinal decontamination

Selective decontamination of the digestive tract was developed following the observation that the digestive tract normally has considerable resistance to colonization by newly ingested bacteria. The research that eventually led to selective decontamination was performed because in the late 1960s and early 1970s, the need for prophylaxis against Gram-negative infections in immuno-compromized patients became evident. At that time, the relatively small number of antibiotics available for therapy of serious infections often lead to treatment failure. To introduce the subject of selective decontamination, this paper, therefore, starts with a short historical overview of the kind of infectious agents as well as the antibiotics available in the 1960s; particularly regarding the type and treatment of infections in severely compromised patients. The fact that the possibilities in infectious diseases were limited was the reason for our experimental search for ways of successful prophylactic treatment with minimal risk of development of resistance.

Influence of high versus low intestinal concentration of gram-negative bacteria and endotoxin on the susceptibility of murine myelopoiesis in bone marrow and spleen to cytostatic treatment with Ara-C

The haematopoietic recovery after i.v. cytarabine was studied in C3H/Law mice as a measure for stem cell susceptibility in relation to the intestinal Gram-negative bacteria (GNB) and endotoxin. Reduction or elevation of GNB and endotoxin was induced by either polymyxin or bacitracin, both non-absorbable antibiotics. Bacitracin caused less suppression of the splenic cellularity after cytarabine, and an advancement of the recovery of femoral nucleated cells. The femoral recovery of CFU-GM exhibited a biphasic pattern. The speed and height of the rebound increase of CFU-GMs were significantly affected by the antibiotics. Thus, (modulation of) the murine intestinal microflora influences the haematopoietic recovery after cytostatic drugs. The mechanisms involved are complex; intestinal endotoxin seems to play a role.

Selective decontamination of the digestive tract in intensive care patients: review and commentary

OBJECTIVE

To evaluate the benefits, risks, and costs of antimicrobial regimens used for selective decontamination of the digestive tract (SDD) in intensive care unit (ICU) patients.

DATA SOURCES

Information was obtained from clinical trials, review articles, abstracts, and textbooks. Key indexing terms included antibiotics, selective decontamination, and infections.

STUDY SELECTION

Research articles describing controlled clinical trials of SDD in medical or surgical ICU patients were reviewed. Trials that investigated transplant, cirrhotic, leukemic, or oncology patient populations were excluded.

DATA EXTRACTION

The details of studies that evaluated nosocomial infection or nosocomial pneumonia rates were extracted. These included study design, demographics, SDD regimens, severity of illness scores, and colonization, infection, and mortality rates.

DATA SYNTHESIS

The use of SDD in mechanically ventilated surgical or trauma ICU patients reduces the incidence of colonization, nosocomial pneumonia, and overall infection rates, but does not change the overall mortality rate. Administration of antibiotic and antifungal agents in a nasogastric suspension is required for SDD. The addition of systemic prophylactic antibiotics or oropharyngeal paste was not required to decrease nosocomial infections. The most frequently studied SDD regimen (colistin/amphotericin B/tobramycin) is not feasible for use in the US because of exorbitant drug costs. Less expensive alternatives include norfloxacin/nystatin, or colistin/nystatin/gentamicin.

CONCLUSIONS

Additional research is required before SDD regimens can be routinely recommended in surgical and trauma ICU patients. A multicenter study is warranted to determine the long-range benefits, potential for resistance, and cost-effectiveness of SDD.

Colonization resistance of the digestive tract--mechanism and clinical consequences

Potentially pathogenic bacteria and yeasts meet a number of resistance factors. These colonization resistance (CR) determining factors control the growth density of potentially pathogenic microorganisms in the various parts of the alimentary canal. The CR of the digestive tract is to be seen partially of host origin but to a greater extent due to direct and indirect activity of the (anaerobic) indigenous microflora. This implies that the CR mechanism is vulnerable to antibiotics which affect the indigenous flora during treatment. A decreased CR enhances colonization by microorganisms that are resistant to the antibiotic(s) used for therapy. Increased population densities of potentially pathogenic bacteria ("overgrowth") may correlate with invasion of the mucosal tissues often followed by translocation to remote lymphatic organs. Overgrowth also may correlate with development or acquisition of resistance to the antibiotic applied. By screening in experimental animals antibiotics have been selected which do not affect the CR. Such antimicrobial drugs have successfully been used to selectively eliminate potentially pathogenic bacteria and yeast in neutropenic patients.

Experimental whole gut irrigation in the rat

An animal model of whole gut irrigation (WGI) in the rat was developed to study the effects of the irrigation procedure on the gastrointestinal microflora. Irrigation was performed with as well as without neomycin (1,000 mg/l) in the irrigation fluid. At the end of the irrigation procedure the animals were intragastrically contaminated with 2 neomycin-resistant Enterobacteriaceae strains (i.e. an Escherichia coli and a Klebsiella pneumoniae) to study the intestinal colonization by these strains. Although both contaminating strains persisted longer in the animals treated with irrigation fluid with neomycin than in those treated with mere irrigation fluid, persistence was only significantly longer with the E. coli strain (p less than 0.025). It seems likely that the condition of the--mainly anaerobic--mucosa-associated microflora after WGI was responsible for this difference in duration of colonization by the contaminating E. coli strain.

Oral administration of antibiotics and intestinal flora associated endotoxin in mice

The contribution of aerobic and anaerobic gram-negative intestinal bacteria to the release of endotoxin in the intestinal tract was investigated during oral administration of various nonabsorbable antimicrobial drugs to C3H/Law mice. The intestinal endotoxin release was studied by determination of the endotoxin concentration in faecal supernatants with the Limulus amebocyte lysate assay. Selective elimination of aerobic gram-negative bacteria by oral treatment with polymyxin, aztreonam or temocillin resulted in a reduction of the endotoxin concentration of faecal supernatants to 10% of the untreated control. Further decrease of the endotoxin concentration to 1% was achieved by total decontamination of the intestinal tract by oral cephalothin/neomycin treatment. Endotoxin determination with the Limulus amebocyte lysate assay appeared to be unaffected by the antibiotics present in the faecal supernatants after oral treatment. On basis of these experiments, it is concluded that in mice 90% of the faeces derived endotoxin can be ascribed to release of endotoxin by intestinal aerobic gram-negative bacteria.

Myelopoiesis in experimentally contaminated specific-pathogen-free and germfree mice during oral administration of polymyxin

Oral administration of polymyxin to specific-pathogen-free C3H/Law mice which with previously contaminated with gram-negative bacteria resulted in complete suppression of cecal gram-negative bacteria. Suppression of cecal gram-negative bacteria was accompanied by reduction of the cecal endotoxin concentration from 10 to 1 microgram/g of cecal content as measured with a microtechnique for the Limulus amebocyte lysate assay. Endotoxin determination by this assay appeared to be unaffected by the amount of polymyxin present in cecal preparations after oral administration of this antibiotic. In experimentally contaminated specific-pathogen-free mice, the femoral concentration of progenitor cells forming granulocyte-macrophage colonies in vitro (CFU-GM) decreased significantly (P less than 0.001) to 66% of the initial control after 4 days of polymyxin treatment. However, the femoral CFU-GM concentration in germfree mice and splenic CFU-GM concentration in experimentally contaminated specific-pathogen-free and germfree mice was not affected by polymyxin treatment. The kinetic behavior of femoral and splenic CFU-GM in experimentally contaminated specific-pathogen-free and germfree mice was expressed as the in vivo sensitivity to the S-phase-specific cytostatic drug hydroxyurea, i.e., the hydroxyurea kill. Administration of polymyxin to experimentally contaminated specific-pathogen-free mice significantly diminished the hydroxyurea kill of femoral CFU-GM from 29 to 13% (P less than 0.02) and of splenic CFU-GM from 53 to 27% (P less than 0.005). The hydroxyurea kill of femoral CFU-GM in germfree mice was not significantly affected by polymyxin treatment. On basis of these results we conclude that the effect of polymyxin treatment on myelopoiesis is most likely due to elimination of intestinal gram-negative bacteria and may indicate a significant role of intestinal gram-negative bacteria in the regulation of myelopoiesis.

Influence of temocillin on colonisation resistance and consequences for therapy

The influence of temocillin on the colonisation resistance of the digestive tract was studied in mice, with doses ranging from 0.062 to 1 mg/day administered orally and 0.25 to 4 mg/day administered subcutaneously. The effect on the colonisation resistance was measured by the concentration of resistant bacteria (either endogenous enterococci or an exogenous strain of Enterobacter cloacae) as well as by the relative caecal weight and the appearance of beta-aspartylglycine in the caecal contents. None of these parameters indicated a decreased colonisation resistance by any of the dosages investigated, meaning that, in the mouse the drug can be used safely without an increased risk of overgrowth by resistant bacteria causing superinfections. Both systemic and oral administration of 0.25mg of temocillin/mouse/day (10 mg/kg/day) appeared to completely suppress the sensitive Gram-negative bacilli from the digestive tract within 2 days. This selective decontamination of the digestive tract in mice was the reason for a subsequent study in man. It emerged that selective decontamination with parenterally administered temocillin was possible in 7 out of 10 volunteers. The remaining 3 however, did not respond to temocillin although their faecal Gram-negative bacilli were susceptible to the drug. In none of the volunteers did the colonisation resistance appear to be affected. The consequences of the use of temocillin for either prevention or therapy of infections are discussed.

The digestive tract in immunocompromised patients: importance of maintaining its resistance to colonization, especially in hospital in-patients and those taking antibiotics

The colonization resistance (CR) of the gastrointestinal tract to potential pathogens depends partly on factors within the host but to a greater extent on the normal (anaerobic) gut flora. Its strength varies between individuals. These individual differences in resistance to colonization by pathogenic microorganisms may explain differences in susceptibility to infection. CR is lowered by remission-inducing treatment (radiation and/or chemotherapy) in leukaemia, but more severely by certain antibiotics. Development (by selection or transfer) of resistance to these antibiotics may lead to overgrowth and penetration of the mucosal lining by the overgrowing (potentially) pathogenic bacteria. Other antibiotics however, if sufficiently dosed, have been found to eliminate (potential) pathogens selectively without decreasing CR. This selective decontamination of the gastrointestinal tract has been successfully used prophylactically in neutropenic patients but needs to be monitored bacteriologically. It should perhaps be used more widely in the hospital to control development and spread of antibiotic-resistant strains.

Selective decontamination and the anaerobic faecal flora

Selective decontamination with non-absorbable antibiotics of the gastrointestinal tract of patients with impaired host defense is increasingly applied to prevent infections with gram-negative facultatively anaerobic rods. In vivo experiments on the effect of antibiotics on the human intestinal flora were performed with (ex-germ-free) mice. The experiments have shown that the human obligately anaerobic flora did not change during selective decontamination with polymyxin B, but Enterobacteriaceae were eliminated. The magnitude of differences between the sensitivity to antibiotics of the human obligately anaerobic flora and the Enterobacteriaceae in vitro may be used as an index for the usefulness of the antibiotic for selective decontamination. Binding of the antibiotics to intestinal contents has been found to be important for the estimation of the daily dose. The release of the bound antibiotic could contribute to the maintenance of equable concentrations in the intestine.

Effect of antibiotics on the human intestinal flora in mice

Antibiotics used during selective decontamination were studied for their effect on the human intestinal flora in mice. Polymyxin B and neomycin were found to eliminate Escherichia coli from the gastrointestinal tract but did not alter total numbers of obligate anaerobes. Neomycin induced an increase of the percentage of gram-negative obligate anaerobes. Cephradine did not affect the numbers of obligate and facultative anaerobes but increased the percentage of gram-negative obligately anaerobic rods in the flora. The selective effect of polymyxin B and neomycin on the flora is accounted for by a relative insusceptibility of the anaerobic flora as compared with E. coli. Low concentrations of polymyxin B and neomycin were detected in caecal supernatants. This was found to be due to strong binding of both antibiotics to the solid fraction of intestinal contents.

Effect of twelve antimicrobial drugs on the colonization resistance of the digestive tract of mice and on endogenous potentially pathogenic bacteria

Twelve antimicrobial drugs were studied for their effect on the endogenous aerobic potentially pathogenic bacteria (Enterobacteriaceae, Streptococcus faecalis) in the intestines and on the colonization resistance (CR) of the digestive tract. Three subclasses of antimicrobial drugs could be recognized: (1) those which suppress the CR following low oral doses (rifamycin, penicillin V, cloxacillin, fenethicillin); (2) those in which the CR is suppressed only following relatively high oral doses (amoxycillin); and (3) those in which no obvious suppression of the CR was noticed even following substantial oral doses (nalidixic acid, cinoxacin, co-trimoxazole, oral cephalosporins, piv-mecillinam and doxycyclin). Some of the drugs in the third category were found to suppress endogenous Enterobacteriaceae (nalidixic acid, co-trimoxazole, piv-mecillinam and doxycyclin) and S. faecalis (doxycyclin) at dose levels at which they did not decrease CR.

The screening of four aminoglycosides in the selective decontamination of the digestive tract in mice

The suppressive effect of amikacin, gentamicin, tobramycin and paromomycin on the aerobic endogenous flora and on the colonization resistance of the digestive tract was tested by administering one of the antibiotics orally at five different dose levels. At a certain dose level, all antibiotics suppressed the endogenous Enterobacteriaceae species. Amikacin was particularly effective in this respect. Low doses of amikacin rapidly destroyed the colonization resistance. This resistance only remained unaffected in animals treated with tobramycin in doses that were still adequate to completely suppress the endogenous Enterobacteriaceae species. We concluded that of all the antibiotics tested in this study, only tobramycin may have a future in (clinical) application for the selective decontamination of the digestive tract. Selective decontamination can be considered an effective method for infection prevention in leukopenic patients.

Bacteriological aspects of selective decontamination of the digestive tract as a method of infection prevention in granulocytopenic patients

We describe the bacteriological results of a controlled clinical trial of selective decontamination of the digestive tract as a method of infection prevention in granulocytopenic patients. Selective elimination of Enterobacteriaceae and Pseudomonadaceae species was accomplished by the oral administration of nalidixic acid, co-trimoxazole, or polymyxin. Yeasts were eliminated selectively by amphotericin B or nystatin treatment. The drugs used in this study were chosen because of their capacities to selectively eliminate gram-negative rods and yeast without affecting the anaerobic part of the gut flora which is responsible for colonization resistance. Compared with the control group, the selectively decontaminated patients had significantly fewer (P less than 0.0005) gram-negative rods or yeasts or both in their throat swab cultures and in their feces. This reduction may explain the clinical effectiveness of selective decontamination.