Effect of pooled human cerebrospinal fluid on the postantibiotic effects of cefotaxime, ciprofloxacin, and gentamicin against Escherichia coli

Protein Binding in Translational Antimicrobial Development-Focus on Interspecies Differences

Background/Introduction: Plasma protein binding (PPB) continues to be a key aspect of antibiotic development and clinical use. PPB is essential to understand several properties of drug candidates, including antimicrobial activity, drug-drug interaction, drug clearance, volume of distribution, and therapeutic index. Focus areas of the review: In this review, we discuss the basics of PPB, including the main drug binding proteins i.e., Albumin and α-1-acid glycoprotein (AAG). Furthermore, we present the effects of PPB on the antimicrobial activity of antibiotics and the current role of PPB in in vitro pharmacodynamic (PD) models of antibiotics. Moreover, the effect of PPB on the PK/PD of antibiotics has been discussed in this review. A key aspect of this paper is a concise evaluation of PPB between animal species (dog, rat, mouse, rabbit and monkey) and humans. Our statistical analysis of the data available in the literature suggests a significant difference between antibiotic binding in humans and that of dogs or mice, with the majority of measurements from the pre-clinical species falling within five-fold of the human plasma value. Conversely, no significant difference in binding was found between humans and rats, rabbits, or monkeys. This information may be helpful for drug researchers to select the most relevant animal species in which the metabolism of a compound can be studied for extrapolating the results to humans. Furthermore, state-of-the-art methods for determining PPB such as equilibrium dialysis, ultracentrifugation, microdialysis, gel filtration, chromatographic methods and fluorescence spectroscopy are highlighted with their advantages and disadvantages.

Use of Supplemented or Human Material to Simulate PD Behavior of Antibiotics at the Target Site In Vitro

In antimicrobial drug development, in vitro antibiotic susceptibility testing is conducted in standard growth media, such as Mueller–Hinton broth (MHB). These growth media provide optimal bacterial growth, but do not consider certain host factors that would be necessary to mimic the in vivo bacterial environment in the human body. The present review aimed to include relevant data published between 1986 and 2019. A database search (PubMed) was done with text keywords, such as “MIC” (minimal inhibitory concentration), “TKC” (time kill curve), “blood”, “body fluid”, “PD” (pharmacodynamic), and “in vitro”, and 53 papers were ultimately selected. Additionally, a literature search for physiologic characteristics of body fluids was conducted. This review gives an excerpt of the complexity of human compartments with their physiologic composition. Furthermore, we present an update of currently available in vitro models operated either with adapted growth media or body fluids themselves. Moreover, the feasibility of testing the activity of antimicrobials in such settings is discussed, and pro and cons for standard practice methods are given. The impact on bacterial killing varies between individual adapted microbiological media, as well as direct pharmacodynamic simulations in body fluids, between bacterial strains, antimicrobial agents, and the compositions of the adjuvants or the biological fluid itself.

Proline-rich antimicrobial peptides show a long-lasting post-antibiotic effect on Enterobacteriaceae and Pseudomonas aeruginosa

Background

Proline-rich antimicrobial peptides (PrAMPs) represent a promising class of potential therapeutics to treat multiresistant infections. They inhibit bacterial protein translation at the 70S ribosome by either blocking the peptide-exit tunnel (oncocin type) or trapping release factors (apidaecin type).

Objectives

Besides direct concentration-dependent antibacterial effects, the post-antibiotic effect (PAE) is the second most important criterion of antimicrobial pharmacodynamics to be determined in vitro. Here, PAEs of 10 PrAMPs and three antibiotics against three Escherichia coli strains, Klebsiella pneumoniae ATCC 10031 and Pseudomonas aeruginosa ATCC 27853 were studied after 1 h of exposure.

Methods

A robust high-throughput screening to determine PAEs was established, i.e. liquid handling by a 96-channel pipetting system and continuous incubation and absorbance measurement in a microplate reader.

Results

Prolonged PAEs (≥4 h) were detected for all peptides at their MIC values against all strains; PAEs were even >10 h for Api88, Api137, Bac7(1-60) and A3-APO. The PAEs increased further at 4 × MIC. Aminoglycosides gentamicin and kanamycin usually showed lower PAEs (≤4 h) at MIC, but PAEs increased to > 10 h at 4 × MIC. Bacteriostatic chloramphenicol exhibited the shortest PAEs (<4 h).

Conclusions

The PAEs of PrAMPs studied against Enterobacteriaceae and P. aeruginosa for the first time were typically 4-fold stronger than for conventional antibiotics. Together with their fast and irreversible uptake by bacteria, the observed prolonged PAE of PrAMPs helps to explain their high in vivo efficacy despite unfavourable pharmacokinetics.

Proteomic Analysis to Elucidate the Antibacterial Action of Silver Ions Against Bovine Mastitis Pathogens

Silver ions act as a powerful, broad-spectrum antimicrobial agent and are known to kill over 650 different kinds of pathogens. We investigated the protein expression pattern and identity after silver ion treatment in Escherichia coli and Staphylococcus aureus, which are primarily responsible for the majority of bovine mastitis cases using proteomics. Two-dimensional electrophoresis showed that silver ion treatment significantly reduced 5 spot's density in E. coli and S. aureus, respectively. We identified 10 proteins (alkyl hydroperoxide reductase C22 subunit, phosphoglucomutase, fructose-1-phosphate kinase, putative carbamoyl transferase, alpha-galactosidase, carbamate kinase, ornithine transcarbamoylase, fumarate hydratase class II, alcohol dehydrogenase, and conserved hypothetical protein) by matrix-assisted laser desorption ionization time of flight (MALDI-TOF). These results demonstrated that silver ions have bactericidal effects through energy deprivation, inhibition of DNA replication, and accumulation of oxidants in bovine mastitis pathogens and suggested that silver ions can be applied for the treatment of bovine mastitis.

Clinical pharmacokinetics of antibacterials in cerebrospinal fluid

In the past 20 years, an increased discrepancy between new available antibacterials and the emergence of multidrug-resistant strains has been observed. This condition concerns physicians involved in the treatment of central nervous system (CNS) infections, for which clinical and microbiological success depends on the rapid achievement of bactericidal concentrations. In order to accomplish this aim, the choice of drugs is based on their disposition toward the cerebrospinal fluid (CSF), which is influenced by the physicochemical characteristics of antibacterials. A reduced distribution into CSF has been documented for beta-lactams, especially cephalosporins and carbapenems, on the basis of their hydrophilic nature. However, they represent a cornerstone of the majority of combined therapeutic schemes for their ability to achieve bactericidal concentrations, especially in the presence of inflamed meninges. The good tolerability of beta-lactams makes possible high daily dose intensities, which may be associated with increased probability of cure. Furthermore, the adoption of continuous infusion seems to be a fruitful option. Fluoroquinolones, namely moxifloxacin, and antituberculosis drugs, together with the agents such as linezolid, reach the highest CSF/plasma concentration ratio, which is greater than 0.8, and for most of these drugs it is near 1. For all drugs that are currently used for the treatment of CNS infections, the evaluation of pharmacokinetic/pharmacodynamic parameters, on the basis of dosing regimens and their time-dependent or concentration-dependent pattern of bacterial killing, remains an important aspect of clinical investigation and medical practice.

Enhanced activity of linezolid against Staphylococcus aureus in cerebrospinal fluid

Linezolid is considered for treatment of central nervous system (CNS) infections caused by multidrug-resistant Gram-positive bacteria. Therefore, the influence of cerebrospinal fluid (CSF) on the antimicrobial activity of linezolid was evaluated in vitro. Time-kill curves were conducted in CSF and Mueller-Hinton broth (MHB) using Staphylococcus aureus (ATCC 29213) and Staphylococcus epidermidis (ATCC 12228) strains. In CSF lower linezolid concentrations were needed against S. aureus (1× MIC) and S. epidermidis (0.5× MIC) to achieve bacteriostasis than in MHB (4× MIC for both strains). Good activity of linezolid in CSF supports performance of clinical trials evaluating its potential for treatment of CNS infections.

Principles of antimicrobial therapy

We have discussed important factors involved in choosing appropriate antimicrobial regimens for the treatment of bacterial meningitis and brain abscess to illustrate common themes relevant to the treatment of these diseases. We have limited this review to these conditions for two main reasons: (1) the principles involved in optimal antimicrobial therapy for these diseases likely apply to others CNS infections, such as viral and fungal diseases; and (2) little pharmacological information is currently available for other types of CNS infections. Many of the studies addressing the relevant pharmacological and microbiological aspects of antimicrobial therapy for CNS infections have been performed in experimental animal models and, as a result, the information derived from these studies may be different when examined in appropriate human studies. Our current understanding of appropriate antimicrobial therapy for CNS infections may be summarized as follows: 1. Choose bactericidal antimicrobials that effectively cross the BBB to achieve CSF concentrations well above the MBC (≥ 10-fold) for the suspected bacterial pathogen(s). 2. Take into consideration the relevant PD parameters the bactericidal activity of the antimicrobials used to treat bacterial meningitis, such as t > MBC or AUC/MBC. 3. Tailor the antimicrobial regimen based on microbiological information, once available. However, with respect to brain abscess therapy, keep in mind that anaerobes are commonly involved, but difficult to culture, and consider including antianaerobic therapy even if the bacterial cultures do not grow anaerobes. 4. Treat bacterial meningitis caused by nonmeningococcal pathogens for 7-10 days, but monitor clinical progress to determine whether the patient should continue on a more prolonged antimicrobial course. Meningococcal meningitis may be treated with 3-4 days of effective antimicrobial therapy, again with the caveat that the patients clinical course should dictate duration of therapy. 5. Treat brain abscess, preferably after aspiration/drainage, for at least 6 weeks with intravenous antimicrobials for brain abscess on the clinical response (e.g., improved symptoms, lack of new neurological findings) and radiographic changes (e.g., reduction in cavity size).

Cerebrospinal fluid impairs antimicrobial activity of fosfomycin in vitro

OBJECTIVES

Fosfomycin penetrates well into cerebrospinal fluid (CSF) and is considered for treatment of infections of the central nervous system (CNS). This study evaluated the influence of human CSF on the antimicrobial activity of fosfomycin.

METHODS

Time-kill curves were performed in Mueller-Hinton broth (MHB) and in pooled human CSF using fosfomycin concentrations ranging from 0.25x to 8x MIC for a clinical Staphylococcus aureus isolate. To estimate the activity of fosfomycin at the target site, the concentration-time curve measured in CSF of a patient at steady state was simulated in vitro in human CSF using two S. aureus isolates.

RESULTS

In CSF a higher fosfomycin concentration (8x MIC) was required to achieve sustained bacterial killing than in MHB (1x MIC). In vitro simulation of the pharmacokinetic profile measured in CSF of the selected patient showed initial killing, but terminal re-growth of both test strains.

CONCLUSIONS

The antibacterial activity of fosfomycin is lower in CSF than in MHB, and drug concentrations slightly exceeding the MIC may not be sufficient to achieve bactericidal effects in the CNS.

Antimicrobial activity of cefepime and rifampicin in cerebrospinal fluid in vitro

OBJECTIVES

Though used for infections of the central nervous system, the pharmacodynamics of antimicrobial agents is commonly evaluated only in commercially available bacterial growth media. In the present study, the effects of cerebrospinal fluid (CSF) on bacterial killing by cefepime and rifampicin were investigated.

METHODS

CSF was collected from patients who did not receive antibiotics. Time-kill curves were performed over 24 h using drug concentrations of 0.25-, 0.5-, 1-, 2-, 4- and 8-fold the respective MIC for the Staphylococcus aureus test strain. Killing curves were performed in Mueller-Hinton broth (MHB), in CSF incubated in ambient air (CSF(AIR)) and in CSF in air with 5% CO(2) (CSF(CO(2))). CO(2) served to adjust the pH of CSF to physiological values.

RESULTS

Sustained bacterial killing was achieved by cefepime at lower drug concentrations in CSF(CO(2)) than in MHB. In contrast, rifampicin concentrations above the MIC were required to exert sustained killing in CSF(CO(2)). Both drugs were least effective in CSF(AIR).

CONCLUSIONS

Standard susceptibility tests may lead to over- or underestimation of the activity of distinct antibiotics in CSF. Evaluation of the antimicrobial activity in pH-adjusted CSF can provide useful information on drugs considered for the treatment of bacterial infections residing in CSF.

Influence of dose on the disposition kinetics of netilmicin in the isolated kidney of the rat

The disposition of Netilmicin in the isolated rat kidney was studied in order to determine the influence of dose on the drug profile in this tissue. Doses of 50, 200, 800 or 10000 mg were injected through an afferent cannula into the isolated kidney as a bolus injection and outflow perfusate samples were collected. Statistical moments (AUC, MTT, VTT) were estimated from raw outflow curve data. Unit disposition function (UDF) was obtained by mass balance for each studied dose. The results of control assays addressing the viability of the isolated kidney preparations point to a high reproducibility for this preparation under the experimental conditions used, together with an acceptable viability. Comparison of statistical moments and derived parameters such as the extraction coefficient, distribution volume and drug renal clearance (E, Vd, ClE) suggest the existence of modifications in the distribution process with the dose, while elimination seems to remain unvariable; accordingly, the unit disposition function profiles were not superimposed for the different doses but differences during the early and final phases were observed.

Pharmacokinetics and pharmacodynamics of cephalosporins in cerebrospinal fluid

Largely because of their low lipophilicity, cephalosporins poorly penetrate through the blood-brain barrier, achieving relatively low cerebrospinal fluid (CSF) concentrations. However, the minimum bactericidal concentrations (MBCs) of the extended spectrum cephalosporins for common meningeal pathogens are generally low; thus, therapeutic CSF drug concentrations several-fold greater than the MBC can be achieved with currently recommended dosage regimens. However, the effectiveness of cephalosporin therapy is unreliable in patients with meningitis caused by highly penicillin-resistant pneumococci. As in other body sites, the bactericidal activity of cephalosporins in CSF predominantly depends on the time their concentrations exceed the MBC of infecting organisms (t>MBC). Experimental studies show that, for maximal efficacy, t>MBC values greater than 90% of the dosage interval are required in meningitis. Such values are usually achieved in humans with currently recommended dosage regimens because the half-lives of cephalosporins are 2- to 3-fold longer in CSF than in serum. Several advanced generation cephalosporins have shown equal efficacy in clinical trials, but only cefotaxime, ceftriaxone and ceftazidime are currently approved for the treatment of patients with bacterial meningitis.

Postantibiotic effects and postantibiotic sub-MIC effects of amoxicillin on Streptococcus gordonii and Streptococcus sanguis

Amoxicillin is one of the most frequently recommended antibiotics for prophylaxis of infective endocarditis in dental/oral procedures. In this study, the postantibiotic effect (PAE), postantibiotic sub-MIC (PASME) and sub-MIC effect (SME) of amoxicillin on oral streptococci, Streptococcus gordonii and Streptococcus sanguis, which are two of the major etiological agents in infective endocarditis, were investigated. The PAE was induced by 10 x MIC of amoxicillin for 2 h and the antibiotic was eliminated by washing. The PASMEs were studied by addition of 0.1, 0.2 and 0.3 x MICs during the postantibiotic phase of the bacteria, and the SMEs were studied by exposing bacteria to amoxicillin at the sub-MICs only. The PAE of amoxicillin was 2.0 h with S. gordonii DL1 and 0.7 h with S. sanguis MPC1. The PASME and SME of amoxicillin were observed both for S. gordonii DL1 and for S. sanguis MPC1. However, the durations of effects for S. sanguis MPC1 were shorter than those for S. gordonii DL1. The PASME values for both strains increased as the concentration of amoxicillin increased. The PASME values for both strains were substantially longer than the SME values. The present study illustrates the existence of PAE, PASME and SME for amoxicillin against S. gordonii and S. sanguis, thereby extending the pharmacodynamic advantages of amoxicillin for these bacteria in the prophylaxis procedures of infective endocarditis.

Postantibiotic effect of trovafloxacin against Streptococcus pneumoniae, Haemophilus influenzae, and Neisseria meningitidis in cerebrospinal fluid and broth culture media

Trovafloxacin displays exceptional antimicrobial potency against pathogens associated with community-acquired meningitis. The postantibiotic effect (PAE) of trovafloxacin was assessed against two clinical strains each of Streptococcus pneumoniae, Haemophilus influenzae Type B, and Neisseria meningitidis Group B. Testing was performed simultaneously in broth culture media (broth) and pooled CSF at concentrations equivalent to 0.5X and 4X MIC. Mean PAEs in broth at 0.5X and 4X MIC ranged between 0.07 to 1.10 and 0.57 to 5. 83 h and between 0.07 to 1.67 and 0.47 to 6.00 h in CSF for all organisms. Overall, the incorporation of CSF did not augment or diminish the duration of the trovafloxacin-induced PAE. These data, together with its pharmacokinetic profile in CSF and antimicrobial potency against these isolates, make trovafloxacin an agent of interest for the treatment of meningitis.

Pharmacokinetics and pharmacodynamics of antibiotics in meningitis

The penetration of antimicrobials into the CSF is dependent on lipid solubility, molecular size, capillary and choroid plexus efflux pumps, protein binding, and the degree of inflammation. Penicillins, certain cephalosporins, carbapenems, fluoroquinolones, vancomycin, and rifampin provide the highest ratios of CSF levels to the MBC for common infecting organisms. For beta-lactam antibiotics, it is the duration of time that CSF concentrations exceed the MBC that determines the rate of bactericidal activity. It appears that levels should exceed the MBC for more than 50% of the dosing interval. The peak/MBC and AUC/MBC ratios are important determinants of efficacy for aminoglycosides and fluoroquinolones. Once-daily dosing of aminoglycosides is as effective as multiple-daily dosing regimens in experimental meningitis, probably because of drug-induced prolonged persistent effects. Fluoroquinolones do not produce as prolonged persistent effects and are slightly less effective when administered once daily. Although steroid use can reduce the penetration and decrease the bactericidal activity of some antimicrobials, such as vancomycin, in experimental meningitis, the clinical impact of steroid use in human meningitis is still unclear.

Influence of human serum on pharmacodynamic properties of an investigational glycopeptide, LY333328, and comparator agents against Staphylococcus aureus

The MICs and MBCs of 15 antibiotics for two strains of Staphylococcus aureus were determined in Mueller-Hinton broth (MHB) and 90% serum-10% MHB. Subsequent experiments established that highly protein-bound antibiotics (>/=80%), such as LY333328, demonstrated higher MICs and MBCs, less killing over an 8-h interval, and shorter postantibiotic effects in 90% serum-10% MHB than in MHB alone. Albumin was demonstrated to be almost solely responsible for changes in the aforementioned pharmacodynamic parameters of LY333328.

Postantibiotic effects of imipenem and enoxacin against S. typhimurium and S. enteritidis and the influence on their surface hydrophobicity

The influence of the postantibiotic effect (PAE) and the postantibiotic sub-MICs effect (PA SME) of imipenem and enoxacin on the surface hydrophobicity of S. typhimurium and S. enteritidis strains were studied by evaluating Congo red binding and the aggregation in molar solutions of ammonium sulfate (SAT). A PAE was induced by 2x and 4 x MIC of antibiotics tested for 0.5 h. Suprainhibitory concentrations of imipenem against S. typhimurium induced a short PAE (0.3-0.6 h) compared to S. enteritidis (6.0-9.7 h). Suprasubinhibitory concentrations of imipenem did not allow a regrowth of S. enteritidis. Similar results were also found for enoxacin. Evaluation of surface hydrophobic properties of the salmonellas after affecting both PAEs and PA SMEs has shown that imipenem at concentrations 4 x MIC and 4 x MIC + 0.3 x MIC partially influenced the hydrophobicity of S. typhimurium. S. enteritidis was more susceptible toward both antibiotics tested.

Postexposure factors influencing the duration of postantibiotic effect: significance of temperature, pH, cations, and oxygen tension

The purpose of the present study was to assess and compare the impacts of various postexposure conditions on postantibiotic effect (PAE). PAEs were induced in Staphylococcus aureus and Escherichia coli by exposing the organisms to different antibiotics (penicillin G, ampicillin, erythromycin, ciprofloxacin, and gentamicin) at 5 or 10 times the MIC in plain Mueller-Hinton broth for 1 h at 35 degrees C. Regrowth was determined by measuring the viable counts after drug removal by a 10(-3) or 10(-4) dilution procedure under various postexposure conditions (incubation temperatures at 20, 25, 30, or 35 degrees C; growth under shaken, unshaken, anaerobic conditions; pH 6.0, 7.4, or 9.0; and with sodium chloride concentrations at 0, 1, 3, or 6%). PAE increased in response to a decrease in incubation temperature from 35 to 20 degrees C, and a significant correlation between bacterial generation times and duration of PAEs (r2, 0.82 to 0.97) was demonstrated. The duration of PAE was also modified by the pH in the regrowth medium. PAE increased considerably for S. aureus at pH 6.0 and 9.0 compared to that at pH 7.4 after induction with penicillin G, and with gentamicin the PAE against S. aureus recovering at pH 6.0 also increased considerably. A high concentration of sodium chloride in the regrowth medium produced the most extensive changes in PAE except for that against E. coli induced by ampicillin. PAE increased significantly in response to increased salinity. No recovery even after overnight incubation was detected for S. aureus after preexposure to penicillin, ciprofloxacin, or gentamicin. Only minor changes in the duration of PAE were observed in relation to recovery oxygen tension. It is concluded that many postexposure factors have a profound effect on the duration of PAE.

Pharmacokinetic contributions to postantibiotic effects. Focus on aminoglycosides

The postantibiotic effect (PAE) refers to a period of time after complete removal of an antimicrobial during which there is no growth of the target organism. The PAE appears to be a feature of most antimicrobial agents and has been documented with a variety of common bacterial pathogens. Various factors influence the presence or duration of the PAE including the type of organism, type of antimicrobial, concentration of antimicrobial, duration of antimicrobial exposure, antimicrobial combinations, and inoculum and medium used. beta-Lactams demonstrate a PAE against Gram-positive cocci, but produce only a short PAE with Gram-negative bacilli. Antimicrobial agents that inhibit RNA or protein synthesis have a PAE against Gram-positive cocci and Gram-negative bacilli. In vivo studies of aminoglycosides suggest that area under the plasma concentration-time curve is the pharmacokinetic parameter that best correlates with clinical efficacy. This is thought to be due to the concentration-dependent killing and PAE possessed by these antimicrobials. Animal and human studies have reported that once-daily administration of aminoglycoside is as effective as, or more effective than, and possibly less toxic than traditional multiple daily administration.

The postantibiotic effect of selected antibiotics on Staphylococcus aureus Newbould 305 from bovine intramammary infection

The postantibiotic effect (PAE) was determined for selected antibiotics against Staphylococcus aureus Newbould 305 originating in vivo from mastitic milk and compared with the PAE for the same S. aureus strain cultured in vitro. The PAE was measured at 2 and 4 times the MIC for 1 and 2 h of exposure. The PAE of penicillin, pirlimycin, and tilmicosin were reduced against S. aureus 305 originating in vivo compared with S. aureus 305 grown in vitro. The PAE of cephapirin was increased against S. aureus originating in vivo. Minimal effect on PAE was noted for novobiocin. The PAE for rifampicin extended beyond the limits of the test parameters (> 180 min) for all antibiotic concentrations, media, and exposure times tested, except at 2 times the MIC and at 1 h exposure when the PAE was reduced to 60 min for S. aureus 305 originating in vivo. The PAE of an antibiotic may be an important consideration in determining therapy intervals and antibiotic concentrations for treatment of bovine mastitis.

In vitro postantibiotic effects following multiple exposures of cefotaxime, ciprofloxacin, and gentamicin against Escherichia coli in pooled human cerebrospinal fluid and Mueller-Hinton broth

Multiple exposures with cefotaxime in either Mueller-Hinton broth or cerebrospinal fluid had no effect on killing or the duration of postantibiotic effect (PAE) in Escherichia coli strains tested. However, upon multiple exposures in Mueller-Hinton broth, ciprofloxacin and gentamicin PAEs significantly decreased with a concomitant reduction in bacterial killing. A reduction in bacterial killing following multiple ciprofloxacin and gentamicin exposures was also seen with cerebrospinal fluid; however, the PAE was maintained.

Modification in penicillin-binding proteins during in vivo development of genetic competence of Haemophilus influenzae is associated with a rapid change in the physiological state of cells

By using whole-cell labeling assay with 125I-penicillin V, we observed a reduction in the binding of the radiolabeled beta-lactam to four or five penicillin-binding proteins (PBPs) in Haemophilus influenzae cells cultivated under specific conditions. PBPs 3A, 3B, 4, and 6 were altered after the growth of bacteria in diffusion chambers implanted in the peritoneal cavity of rats. PBP 2 was also modified when cells were cultivated in human cerebrospinal fluids. Because this observation may have important consequences on the efficacy of beta-lactams during antibiotic therapy, we characterized the physiological state of bacteria cultivated in animals in the hope of explaining how such important changes in cell properties develop in vivo. Since the development of natural genetic competence occurs at the stationary phase of growth in H. influenzae, we used a DNA transformation assay to evaluate the physiological state of bacteria grown in diffusion chambers implanted in rats. Chromosomal DNA isolated from an antibiotic-resistant donor strain was mixed with bacteria in diffusion chambers. At different times during a 5-h incubation period, recipient bacteria were collected from the chambers, CFU were determined by plate counting, and antibiotic-resistant transformants were isolated on selective plates. Genetic competence rapidly developed in cells grown in rats, and the frequency of transformation by test DNA was elevated. Electron microscopy revealed an irregular cell shape and blebs at the surface of bacteria cultivated in animals and in cerebrospinal fluids. In an attempt to induce a similar physiological state in vitro, we supplemented broth cultures with cyclic AMP or synchronized cultures by a nutritional upshift. No changes in PBPs were observed with supplemental cyclic AMP or during a single cell cycle. Finally, a reduction in the affinity of PBPs for 125I-penicillin V identical to that observed in bacteria grown in rats was observed in cells isolated from the stationary phase of growth in vitro. These results clearly indicate that H. influenzae cells grown in animals undergo a rapid change to a physiological state similar to that found in late-stationary-phase cultures in vitro. This observation indicates that the rational design of future and improved antibiotic therapy of H. influenzae infections should consider cell properties of slow-growing or latent bacteria.