Proteinases release mucin from airways goblet cells

The mucin-release effect of proteinases on airways epithelium was assessed in vitro. Using explants of rabbit tracheal mucosa-submucosa we determined that elastase and alkaline proteinase from Pseudomonas aeruginosa, pancreatic trypsin and elastase and the microbial proteinases subtilisin, thermolysin and pronase, all stimulate mucin release from goblet cells. On the other hand Streptomyces caespitosus proteinase pancreatic chymotrypsin and collagenase fail to trigger mucin release. Bovine trachea and human nasal polyp epithelium also release mucins in response to proteinases. Mucin release activity is dependent on proteolytic activity of enzymes which have a fairly broad, but generally similar, substrate specificity. The cellular mechanism of action is not known. We propose that mucin secretion in response to proteinases represents a useful defence mechanism but also forms the basis for hypersecretory states and airways obstruction in chronic endobronchial inflammatory states.

GT160-246, a toxin binding polymer for treatment of Clostridium difficile colitis

GT160-246, a high-molecular-weight soluble anionic polymer, was tested in vitro and in vivo for neutralization of Clostridium difficile toxin A and B activities. Five milligrams of GT160-246 per ml neutralized toxin-mediated inhibition of protein synthesis in Vero cells induced by 5 ng of toxin A per ml or 1.25 ng of toxin B per ml. In ligated rat ileal loops, 1 mg of GT160-246 neutralized fluid accumulation caused by 5 microg of toxin A. At doses as high as 80 mg/loop, cholestyramine provided incomplete neutralization of fluid accumulation caused by 5 microg of toxin A. GT160-246 protected 80% of the hamsters from mortality caused by infection with C. difficile, whereas cholestyramine protected only 10% of animals. Treatment of C. difficile-infected hamsters with metronidazole initially protected 100% of the hamsters from mortality, but upon removal of treatment, 80% of the hamsters had relapses and died. In contrast, removal of GT160-246 treatment did not result in disease relapse in the hamsters. GT160-246 showed no antimicrobial activity in tests with a panel of 16 aerobic bacteria and yeast and 22 anaerobic bacteria and did not interfere with the in vitro activities of most antibiotics. GT160-246 offers a novel, nonantimicrobial treatment of C. difficile disease in humans.

Performance of an automated Q-beta replicase amplification assay for Mycobacterium tuberculosis in a clinical trial

We present data from a clinical trial study in which an automated version (Galileo) of a previously described Q-Beta replicase-amplified probe assay (J. S. Shah et al., J. Clin. Microbiol. 33:1435-1441, 1995) was used for the direct detection of Mycobacterium tuberculosis complex in sputum. The assay was designed to target specific regions of 23S rRNA found in M. tuberculosis, Mycobacterium bovis, Mycobacterium africanum, and Mycobacterium microti and had a sensitivity ranging from approximately <10 to 300 CFU. The assay was tested for cross-hybridization by using large numbers (e.g., 10(5)to 10(10) CFU/assay) of 133 other organisms commonly found in respiratory tract samples, including non-M. tuberculosis Mycobacterium spp., other bacteria, fungi, and viruses. All of these competitors tested negative by the assay. Automated assay results for 780 respiratory tract samples (sputum or bronchoalveolar lavage specimens) collected and tested at three trial sites in the United States) were compared with the results of culture and acid-fast microscopy. Aliquots of conventionally digested and decontaminated sputum pellets were heated at 100 degrees C and mechanically disrupted prior to hybridization and background reduction, amplification, and detection in a closed disposable test pack. Pertinent elements of individual patient histories relating to tuberculosis exposure, previous active disease, antituberculosis therapy status, etc., were considered in the resolution of discrepant results for 48 (assay false-positive) samples. Seventy-one of 90 (78.9%) culture-positive samples were positive when tested in the Galileo assay, while 7% of culture-negative samples were assay positive, corresponding to a sensitivity of 79% and a specificity of 93%. Following resolution of discrepant results by chart review, the sensitivity and specificity for the Q-Beta replicase amplification assay with the Galileo analyzer were 84 and 97%, respectively. A total of 69.2% of smear-negative (culture positive) samples were detected by the assay. Ten test packs at a time were automatically processed by the Galileo analyzer without operator intervention following loading of samples. The first result was reported in approximately 3 h, and the last result was available in 6.5 h. To our knowledge, this is the first report of a clinical study with a fully automated amplification probe hybridization assay for the detection of pathogens directly from a clinical specimen.

Detection of Mycobacterium tuberculosis directly from sputum by using a prototype automated Q-beta replicase assay

We have adapted an assay for the direct detection of Mycobacterium tuberculosis using a prototype automated instrument platform in which probes are amplified with Q-beta replicase. The assay was based on amplification of specific detector probe following four cycles of background reduction (reversible target capture) in a closed disposable pack. The assay signal was the time required for fluorescence to exceed background levels (response time [RT]). RT was inversely related to the number of M. tuberculosis rRNA target molecules in the sample. Equivalent signals and noises were observed in assays containing either sputum or buffer. All mock samples containing > or = 10 CFU of M. tuberculosis responded in the assay (average RT, 13.91 min), while most (83%) samples containing as many as 10(7) CFU of Mycobacterium avium gave no response during a 25-min amplification reaction. The samples containing M. avium which did respond had an average RT of 17.04 min. Seventy-five percent (167 of 223) of samples containing no target gave no responses; the remaining 25% had an average RT of 15.53 min. Eighty-three frozen sputum samples were tested to develop a candidate cutoff RT for the assay prior to more extensive clinical testing. After resolution of discrepant results and with a 14-min RT cutoff, 30 of 38 M. tuberculosis-positive samples were positive by the assay; 1 of 45 negative samples responded within 14 min. Assay sensitivity, specificity, and positive and negatives predictive values in this pilot study were 79, 98, 97, and 85%, respectively.

Identification of Salmonella enteritidis from experimentally infected hens using a colorimetric DNA hybridization method

Identification of Salmonella enteritidis from cloacally challenged commercial laying hens was studied by comparing bacterial isolations using conventional methods with detection by the use of the GENE-TRAK colorimetric DNA probe assay. More positive test results were obtained using the latter on days 14, 28, and 42 postchallenge, but the difference between the two methods was not statistically significant. Over the duration of the experiment, positive cloacal samples were statistically more frequent from a commercial strain of white leghorn hens when compared with a commercial brown egg-producing strain (28/60 vs. 9/57; chi-square 1 df = 12.9, P < 0.001). Eggs having various shell defects were produced by the infected hens only after Salmonella challenge. These defects included, in order of frequency, elongated shape, thin shells, off-white color (tints), small size, wrinkles, and pimples. No Salmonella could be recovered from 193 defective eggs, nor were positive isolates made from additional tests performed on 50 normal eggs. Proteus sp. was isolated from 10 eggs, however. Our observations demonstrate that the GENE-TRAK colorimetric method is comparable with conventional bacteriology for the identification of Salmonella in cloacal samples taken from laying hens. Moreover, the two methods demonstrate the existence of breed differences in susceptibility to S. enteritidis challenge.

Q-beta replicase-amplified assay for detection of Mycobacterium tuberculosis directly from clinical specimens

We report the results of a study conducted to evaluate the performance of manual Q-Beta replicase-amplified Mycobacterium tuberculosis complex assay compared with that of culture for detecting M. tuberculosis directly from digested sputum pellets. A total of 261 specimens submitted to three tuberculosis testing laboratories were analyzed. Culture and acid-fast bacillus smear results were provided by the tuberculosis testing laboratories. Of these 261 specimens, 34 (13% prevalence rate) were positive for M. tuberculosis by culture. The samples were digested and decontaminated by the testing laboratories by using their standard digestion and decontamination procedures. An aliquot of the digested and decontaminated pellet was sent to GENE-TRAK. The digested and decontaminated pellet was neutralized by washing it with 0.067 M phosphate buffer (pH 6.8), and the bacteria present in the washed pellet were heat inactivated at 100 degrees C for 15 min. The samples were combined with sample processing buffer containing GuSCN and were treated for 6 min in the GENE-TRAK Sample Processing Instrument to release the nucleic acids. The release rRNA was analyzed in a manual Q-Beta replicase assay format which incorporates elements of sandwich hybridization, reversible target capture, and Q-beta replicase signal amplification technologies. In comparison with culture, the overall assay sensitivity and specificity were 97.1 and 96.5%, respectively. The positive predictive value was 80.5%, and the negative predictive value was 99.5%. After analysis of discrepant results, the assay sensitivity and specificity were 97.3 and 97.8, respectively, and the prevalence rate was 14%. The positive predictive value and the negative predictive value were 87.8 and 99.5%, respectively. The Q-Beta replicase assay is rapid sensitive, semiquantitative, and specific for the direct detection of M. tuberculosis from clinical specimens.

Detection of Mycobacterium tuberculosis directly from spiked human sputum by Q-beta replicase-amplified assay

We report on a rapid, sensitive, Q-Beta replicase-amplified nucleic acid hybridization assay for the detection of Mycobacterium tuberculosis directly from spiked human sputum. Specimens were processed by either an N-acetyl-L-cysteine-NaOH or a 2% NaOH digestion-decontamination method and then washed to neutralize the pH of the cell pellet. The washed sputum pellets were heated at 100 degrees C to inactivate the M. tuberculosis organisms. The heat-inactivated samples were mechanically lysed at 5,000 rpm for 6 min in the GENE-TRAK Sample Processing Instrument in the presence of zirconium oxide beads and a buffer containing guanidine thiocyanate. The released nucleic acid was subjected to the GENE-TRAK Q-Beta replicase-amplified, dual-capture assay. The assay sensitivity was 10(3) purified rRNA targets or 1 CFU of M. tuberculosis spiked into M. tuberculosis-negative human sputum. There was a low level of noise because of the limitations of performing a signal amplification assay in an open system. High levels of other mycobacterial rRNA (approximately 10(7) organisms), including rRNAs of Mycobacterium avium and Mycobacterium gordonae, did not interfere with the sensitivity of the assay.

Infection with a plasmid-free variant Chlamydia related to Chlamydia trachomatis identified by using multiple assays for nucleic acid detection

Clinical samples in transport media from 40 patients exhibiting pathologies potentially caused by Chlamydia trachomatis infection were analyzed for chlamydial nucleic acid, and the results were compared with those of culture. Chlamydial culture was performed by a shell vial centrifugation method with HeLa 229 host cells. Polymerase chain reaction (PCR) assays were used to detect either regions on a 7.5-kb plasmid characteristic of C. trachomatis (plasmid-PCR) or a segment of the 16S rRNA genes (rRNA-PCR). All PCR results were confirmed by hybridization with probes for the specific amplified products in either a Southern or a dot blot format. An RNase protection (RNP) assay was used to detect genus-specific chlamydial 16S rRNA directly from the clinical samples. The PCR assays detected C. trachomatis but not other bacteria, including Chlamydia spp. C. trachomatis was isolated from six samples which were positive by the rDNA-PCR and plasmid-PCR assays. Five of the culture-positive specimens were positive by the RNP assay. Twenty-two samples were negative by all criteria. Surprisingly, nine samples were positive by rRNA-PCR and RNP assays only. Nucleic acid sequencing of the rRNA-PCR-amplified products indicated a close relationship between the variants and C. trachomatis. The data may indicate an unrecognized process in C. trachomatis infection or that these patients were infected by a variant strain of C. trachomatis which lacks the C. trachomatis-specific plasmid.

Cystic fibrosis. Infection and immunity to Pseudomonas

Chronic pulmonary infection with P. aeruginosa in CF may result from: 1. An initial failure of clearance mechanisms (increased adherence) leading to the development of a highly compartmentalized inflammatory reaction; 2. Inhibition of clearing mechanisms for bacteria present in the bronchial lumen; and 3. A largely ineffective, and possibly damaging, hyperactivity of inflammatory cells in the lumen and bronchial wall. The special relationship between the CF host and P. aeruginos, always long-term, and frequently subtle in its complexity, needs further understanding in order to develop new strategies for the treatment of chronic lung infections with this organism.

Granulocyte transfusions in septic adult and newborn rats: distribution of granulocytes and effect on peripheral blood and bone marrow

Granulocyte transfusions are increasingly being used as therapy for newborns with sepsis and neutropenia. We injected either group B Streptococcus or phosphate-buffered saline solution intraperitoneally into adult and newborn rats. Human granulocytes, labeled with chromium 51, were transfused seven hours later. When the newborn rats were killed 13 to 19 hours after injection, they had 10(2) to 10(6) cfu/gm Streptococcus organisms in both lung and brain. Only one third of the adult rats had 10(2) to 10(4) cfu/gm Streptococcus organisms in either lung or brain. A greater proportion of the transfused granulocytes was present in lung and brain tissue of newborn rats, compared with adult rats (p less than 0.05), irrespective of infection. Granulocyte transfusion did not change the peripheral blood leukocyte count in adult rats but increased the count in newborn rats (p less than 0.05). The immature myeloid pool in the bone marrow of adult rats increased significantly with either infection or transfusion (p less than 0.01). The immature pool in newborn rats increased significantly only with infection (p greater than 0.001), although the combination of infection and transfusion also had a significant effect on the pool (p less than 0.01). Infection and both infection and transfusion, but not transfusion alone, significantly affected the mature myeloid bone marrow pool in adult and newborn rats (p less than 0.001). The depletion of the mature myeloid elements of the bone marrow in response to infection was dramatic in neonatal rats, compared with that in adult rats. Both transfused granulocytes and hematogenously spread streptococci lodge in the brains and lungs of neonatal rats more effectively than in those of adult rats.

A new colorimetric nucleic acid hybridization assay for Listeria in foods

Non-isotopic colorimetric detection has been applied in a rapid nucleic acid dipstick hybridization assay for detection of Listeria spp. in food and environmental samples. The assay takes approximately 2.5-3 h following a two day broth and plate enrichment. Hybridization occurs between fluorescein labeled detector probes, poly(deoxyadenosine)-tailed capture probes, and Listeria-specific regions of 16 S ribosomal RNA. These target:probe complexes are captured on poly(deoxythymidine) coated plastic dipsticks. Detection is based on binding of horseradish peroxidase conjugated anti-fluorescein antibody to the hybridization complex, and enzyme-mediated color development. The colorimetric endpoint is read on a photometer at 450 nm. In these initial studies, 306 inoculated dairy, meat and seafood samples, and 200 environmental samples were tested. When compared with total culture results the hybridization assay had unconfirmed positive and false-negative rates of approximately 1.4-2.9% and 0.8-4.7%, respectively.

Purification and characterization of an extracellular protease from Pseudomonas cepacia

An extracellular proteinase (PSCP) produced by Pseudomonas cepacia was purified from culture supernatants by ammonium sulfate precipitation, anion exchange chromatography on DEAE-Sephacel, and G200 gel filtration chromatography. The protease has an apparent Mr of 34,000 by electrophoresis. Substrates cleaved by the protease include gelatin, hide powder, and collagen but not human immunoglobulin G (IgG), IgM, secretory IgA, or IgA. The enzyme had the characteristics of a metalloprotease, a pH optimum of 6, and a temperature optimum of 45 degrees C. Intratracheal instillation of purified PSCP into rat lungs produced a bronchopneumonia characterized by polymorphonuclear cell infiltration and proteinaceous exudation into large airways. Rats responded immunologically to active immunization with PSCP, but this response was not protective against subsequent lung infection with P. cepacia. PSCP was shown to have antigenic similarity with Pseudomonas aeruginosa elastase by an immunoblotting technique. Sera from 10 cystic fibrosis patients, with and without a previous history of P. cepacia colonization, were shown to possess antibody reactive against PSCP.

Comparative studies of nucleic acid hybridization assay for Listeria in foods

A nucleic acid hybridization assay has been developed for Listeria spp. in dairy foods and environmental samples. The assay is based on detection of unique Listeria 16S rRNA sequences by using a 32P-labeled synthetic DNA probe. Inclusivity and exclusivity of the probe were confirmed with 139 Listeria isolates representing all known species, and 73 non-Listeria bacterial strains. In this paper, we present results from our preliminary studies comparing the hybridization assay with conventional culture on a total of 575 specimens that represent a variety of inoculated and uninoculated foods and environmental samples. The assay, which is done in a filter manifold format after 2 days of cultural enrichment, requires a total assay time of less than 2.5 days. The false-negative rate for all sample groups tested using the GENE-TRAK hybridization assay was less than the rate for culture. Thus, the new assay allows rapid screening of the indicated product groups and provides reliable numerical results.

Isolation of Listeria: a review of procedures and future prospects

Recent documented foodborne outbreaks of listeriosis have underscored the need for improved isolation and identification procedures for Listeria. This review considers the development of selective enrichment media, various approaches to improving efficiency of isolation, and efforts to shorten enrichment periods. The application of simplified rapid nucleic acid hybridization techniques, in combination with improved cultural methods is the most promising of these approaches. Such methodological improvements should facilitate gathering data on important questions concerning the epidemiology of Listeria, and the natural history of listeriosis.

Colonization of the respiratory tract with Pseudomonas cepacia in cystic fibrosis. Risk factors and outcomes

Between 1981 and 1983, some 85 patients with cystic fibrosis at Rainbow Babies and Childrens Hospital, Cleveland, developed colonization or infection of the respiratory tract with Pseudomonas cepacia. Twenty-nine (34 percent) of the colonized patients died; four were female patients with fulminant bacteremia with P cepacia prior to death. Case-control studies showed that increasing severity of underlying cystic fibrosis, increasing age, having a sibling with cystic fibrosis who was colonized with P cepacia, and previous hospitalizations were associated with increased risk of colonization. In patients with mild cystic fibrosis, no differences in clinical outcome were seen during the period of study; however, patients colonized with P cepacia who had moderate or advanced cystic fibrosis were hospitalized longer and died sooner after colonization, compared with control subjects with similar severity of cystic fibrosis. The excess mortality associated with such colonization varied in magnitude and trend according to the patient's sex and severity of underlying cystic fibrosis, reflecting the combined influence of colonization with P cepacia, sex, and severity of cystic fibrosis on the mortality of the patients. The source and mode of transmission of P cepacia were not determined, but the data suggest a possible nosocomial source. The results of this investigation showed that colonization with P cepacia most often affected patients with moderate or advanced cystic fibrosis and was associated with an adverse clinical outcome in these patients.

Therapeutic evaluation of piperacillin for acute pulmonary exacerbations in cystic fibrosis

The efficacy and pharmacokinetics of piperacillin monotherapy were studied in 46 patients with cystic fibrosis. Two patients were dropped from the study within 24 hr of enrollment because of drug-associated nausea and vomiting. Initially fourteen older patients (greater than 12 years) receiving piperacillin 450 mg/kg/day underwent a preliminary evaluation. Based on the results, 30 younger patients (less than or equal to 12 years) randomized in a double-blind fashion received either 600 or 900 mg/kg/day of piperacillin in six divided doses. Pharmacokinetic parameter estimates for t1/2 Vdss, and Cl were similar for first dose and steady-state evaluations. In 27 patients, approximately 43% of the administered dose was recovered in the urine after 4 hr. Piperacillin CiR averaged 49% of the total Cl. No difference in overall clinical efficacy could be identified between 600 and 900 mg/kg/day of piperacillin using two different objective scoring systems. Although a reduction in sputum Pseudomonas colony counts was greater following the 900 mg/kg/day regimen, this appeared to be independent of clinical effect. In 14 patients (32%), a distinct adverse serum-sicknesslike reaction was observed. The incidence of this reaction appeared to increase as the dose of piperacillin increased. All signs and symptoms of this reaction resolved within 36 hr of discontinuing piperacillin administration but recurred immediately on rechallenge in four patients. All patients with the adverse reaction were subsequently treated with beta-lactam antibodies without ill effect. Overall, clinical improvement appeared to be independent of the piperacillin dose. Our data support the use of total daily piperacillin dosages not exceeding 600 mg/kg.

Pseudomonas cepacia: decrease in colonization in patients with cystic fibrosis

The incidence and prevalence of Pseudomonas cepacia pulmonary colonization were noted to be increasing in patients with cystic fibrosis (CF). Previous work had indicated a greater prevalence of P. cepacia among siblings (with CF) of patients colonized by P. cepacia as well as an association of initial positive P. cepacia cultures with a hospitalization. Because of uncertainty regarding the source and mode of transmission, limited precautionary measures were instituted in 1983, including physical separation of hospitalized patients colonized with P. cepacia from non-colonized patients, reeducation of staff concerning basic infection control procedures, explanation to families regarding these precautionary efforts, and institution of separate summer camp sessions. Repeated environmental cultures throughout the hospital were negative for P. cepacia. Coincident with the institution of control measures, a sharp decline in incidence occurred (8.2% in 1983 versus 1.7% in 1984). These results are suggestive of patient-to-patient transmission. Because P. cepacia infections have been associated with shorter survival in some patients with CF, we will continue our current segregation measures.

Pseudomonas cepacia: biology, mechanisms of virulence, epidemiology

Pseudomonas cepacia, originally described as a plant pathogen, has emerged as an important cause of infection in altered hosts, particularly in the hospital setting. This organism's ability to survive and proliferate in a variety of solutions, medications, and even disinfectants and antiseptics has resulted in numerous clusters of common-source nosocomial infections. Many patients exposed to P. cepacia are merely colonized, but serious infections, including surgical and burn wound infections, bacteremia, meningitis, pneumonia, peritonitis, and urinary tract infections, are not rare. The virulence properties of this pathogen remain poorly characterized. Recently, P. cepacia has been reported in some cystic fibrosis centers as an increasingly frequent pulmonary pathogen. This trend has caused considerable concern because of reports of occasional cases of fulminant necrotizing pneumonia and bacteremia. Conversely, many patients with CF who become colonized with this organism have no ill effects. The epidemiology of P. cepacia in the CF population is unclear, but some patients probably acquire the organism from colonized siblings with CF. Circumstantial evidence suggests that the organism may also be acquired in the hospital. Treatment of infections is exceedingly difficult, particularly in patients with CF, because P. cepacia is resistant to a broad range of antibiotics.

Association with phagocytic inhibition of anti-Pseudomonas aeruginosa immunoglobulin G antibody subclass levels in serum from patients with cystic fibrosis

Serum from cystic fibrosis patients colonized with Pseudomonas aeruginosa specifically inhibits phagocytosis of P. aeruginosa by alveolar macrophages. Serum was examined for P. aeruginosa lipopolysaccharide-specific immunoglobulin G (IgG) subclass levels (by enzyme-linked immunosorbent assay) and for the effect on macrophage phagocytosis (by radiolabeled P. aeruginosa uptake). Sera from cystic fibrosis patients with no known P. aeruginosa colonization history had negligible amounts of lipopolysaccharide-specific IgG and a mean phagocytic enhancement of 5%. The sera of normal volunteers also had negligible amounts of lipopolysaccharide-specific IgG. Serum from cystic fibrosis patients with P. aeruginosa respiratory tract infections had substantial titers (range, 1:20 to 1:1,280) of lipopolysaccharide-specific IgG2, IgG3, and IgG4 and a mean phagocytic inhibition of 56%. However, these patients had low or absent titers of lipopolysaccharide-specific IgG1. No consistent variation in the level of individual IgG subclasses in the sera of colonized patients was observed, as determined by radial immunodiffusion. The results suggest that during P. aeruginosa infection phagocytosis-inhibitory activity develops coincident with production of lipopolysaccharide-specific IgG subclasses.

Ceftazidime therapy in patients with cystic fibrosis and multiply-drug-resistant pseudomonas

The in vitro activity of ceftazidime against Pseudomonas aeruginosa and P. cepacia isolates from patients with cystic fibrosis was compared with that of other antipseudomonal drugs. Ceftazidime was as potent as imipenem against P. aeruginosa and the only drug effective against P. cepacia. An evaluation of the elimination kinetics of ceftazidime in 20 cystic fibrosis patients revealed an elimination half-life of 1.76 hours, an apparent distribution volume of 0.27 liters/kg, and a serum clearance rate of 133.9 ml/minute/1.73m2. Urinary recovery of ceftazidime was 87 percent within the first 24 hours after administration of the drug, with 65 percent recovered in the first two-hour fraction. Probenecid administration had no effect on the elimination kinetics of ceftazidime. Forty-three patients who had either shown no response to conventional therapy or had sputum Pseudomonas isolates that were susceptible only to ceftazidime received 75 courses of therapy. In 67 percent of these patients, the clinical response, when evaluated using an objective clinical efficacy scoring system, was considered favorable. Clinical failures were not associated with the development of drug resistance. Thus, ceftazidime can be recommended for the treatment of acute pulmonary exacerbations in patients with cystic fibrosis.

Use of an automatic refraction device in a Third World country

The vision welfare services in many Third World countries are compromised by the shortage of trained ophthalmic vision care workers. We investigated the feasibility of fulfilling part of the needs in this area by training local personnel in the use of automatic refraction devices. A nurse from the Vila Base Hospital in Vanuatu was given minimal training in the use of such an instrument (Nikon NR 2000), and given guidelines for the preparation of ophthalmic prescriptions. Sixty-nine subjects in the Village of Mélé in Vanuatu were seen by both the nurse and an optometrist, and the prescriptions issued by both workers were compared. The use of automatic refractors under those conditions holds promise for filling the needs in Third World countries, and suggestions are given for adapting these instruments for the particular conditions encountered during this study.

Prevalence of myopia in school children in Vanuatu

The onset of myopia typically occurs in childhood and increases during puberty. We studied the vision and refractive errors of 977 school children (ages 6 to 17 years) in 1983. Myopia in the group was extremely low; 97% had vision of 6/6, and 1.3% had myopia greater than 0.25D. Regression analysis revealed a change in mean refraction of -0.016D/year for males and -0.024D/year for females. There were no significant differences between males and females. These children engaged in about 8 hours of school work per day, and we conclude that genetic factors predominate over environmental factors in the determination of myopic refractive errors for this group.

In-vitro activity of ciprofloxacin and other antibacterial agents against Pseudomonas aeruginosa and Pseudomonas cepacia from cystic fibrosis patients

The in-vitro activities of ciprofloxacin, a new oxyquinoline derivative, norfloxacin and six anti-pseudomal beta-lactam antibiotics were tested against pulmonary isolates of smooth and mucoid colony forms of Pseudomonas aeruginosa, and Ps. cepacia from children with cystic fibrosis. Ciprofloxacin was the most effective of the agents tested against either species. Minimal inhibitory concentrations of ciprofloxacin were 0.5, and 16 mg/l, for 90% of the Ps. aeruginosa and Ps. cepacia strains tested, respectively. No effect of inoculum size or discordance between inhibitory or bactericidal concentrations was observed. Ciprofloxacin is a potentially useful agent for the treatment of acute pseudomonal pulmonary exacerbations in children with cystic fibrosis.

Comparison of cefpiramide (HR-810) and four anti-pseudomonal beta-lactam agents against pseudomonas isolates from children with cystic fibrosis

Cefpiramide (HR-810), ceftazidime, piperacillin, ticarcillin, and aztreonam were tested against tobramycin-sensitive and -resistant strains of Pseudomonas aeruginosa and tobramycin/amikacin-resistant isolates of Ps. cepacia recovered from the sputum of patients with cystic fibrosis. Against Ps. aeruginosa, none of the drugs inhibited 90% of the test strains at levels of less than 128 mg/l. Median minimal, inhibitory concentrations (MIC50) for all of the beta-lactam agents were lower for tobramycin-sensitive versus tobramycin-resistant isolates of Ps. aeruginosa. Ceftazidime was the most effective agent against Ps. cepacia. Aminoglycoside-resistance appears to be associated with significant beta-lactam resistance in Ps. aeruginosa isolated from the sputum of patients with cystic fibrosis.

Occurrence and antimicrobial susceptibility of gram-negative nonfermentative bacilli in cystic fibrosis patients

Isolation of nonfermentative gram-negative bacilli (other than Pseudomonas aeruginosa) from respiratory tract cultures of cystic fibrosis (CF) patients has increased in recent years. Species recovered include Pseudomonas cepacia, P. maltophilia, P. fluorescens/putida, P. alcaligenes, P. pseudoalcaligenes, P. stutzeri, Acinetobacter spp., Achromobacter xylosoxidans, Flavobacterium spp., and CDC groups IVe and Ve. Although colonization with most of these organisms is sporadic, P. cepacia (and to a lesser extent, P. maltophilia) is usually isolated consistently, and can be associated with significant clinical deterioration. Occurrence of P. cepacia in CF respiratory tract cultures obtained close to the time of death rose nearly ten-fold from 1979 to 1982. Strains representing all nonfermentative gram-negative species encountered were assayed for susceptibility to 17 newer antimicrobial agents. Ceftazidime, n-formimidoyl thienamycin, and aztreonam were most active; cefsulodin, ceforanide, and ceftriaxone were not active against these isolates.

Pharmacokinetics and cerebrospinal fluid penetration of ceftazidime in children with meningitis

The single dose pharmacokinetics and cerebrospinal fluid (CSF) penetration of ceftazidime were determined in 10 children with bacterial meningitis. Serum ceftazidime pharmacokinetics showed a distinct age dependence in which the clearance in children less than 1 month of age was markedly reduced. Ceftazidime concentrations in CSF, which ranged from 1.4-8.5 micrograms/ml, exceeded the minimum bactericidal concentrations for infecting pathogens throughout the 8-hour sampling period. These concentrations were found to be independent of CSF cell count, protein concentration or the day of therapy on which the study was performed. The ratio of CSF to serum ceftazidime concentration increased with time, suggesting that ceftazidime was cleared more slowly from CSF than from peripheral blood. Our data support the initiation of a study comparing the efficacy of ceftazidime to conventional therapy in children with bacterial meningitis.

Proteinases of Pseudomonas aeruginosa evoke mucin release by tracheal epithelium

We have determined the potential of exoproducts from pathogenic bacteria to stimulate the release of high molecular weight mucins from goblet cells of airway epithelium in a rabbit tracheal explant system. Culture supernatants from proteolytic strains of Pseudomonas aeruginosa and Serratia marcescens, but not supernatants from a number of non-proteolytic strains, released mucins from goblet cells. Highly purified elastase and alkaline proteinase from P. aeruginosa stimulated goblet cell mucin release in a dose-dependent fashion. Lipopolysaccharide, exotoxin A, and alginate of P. aeruginosa did not possess mucin release properties. Proteolytic activity was required for mucin release by P. aeruginosa elastase, but such release in goblet cells was not mediated by cyclic AMP. Morphologic studies suggested rapid release of mucins from goblet cells was response to elastase by a process resembling apocrine secretion. Several nonbacterial proteinases mimicked the effect of Pseudomonas proteases. These studies provide support for the hypothesis that bacterial and other play a role in the pathogenesis of mucus hypersecretion in acute and chronic lung infections.

Ceftazidime as initial therapy for suspected bacterial infections in hospitalized pediatric patients

Ceftazidime, a new beta-lactam antibiotic, was used to treat 60 children with suspected bacterial infections occurring outside the central nervous system. The patients ranged in age from 0.1 to 21 years and received 30 mg of ceftazidime per kg up to a total single dose of 1 g administered every 8 h. Fifty-three pathogens were isolated from 43 children before the initiation of therapy. All children responded clinically, although one child failed bacteriologically and five children were considered colonized at the end of ceftazidime therapy. Adverse reactions associated with ceftazidime administration were primarily alterations in laboratory parameters and were clinically insignificant. Ceftazidime administered on an 8-h dosing regimen is effective monotherapy for the treatment of childhood infections.

An in-hospital evaluation of the sonic mist ultrasonic room humidifier

It is generally recognized that nebulizers can be a source of nosocomial infection. 'Cold mist' room humidifiers are a particular problem because they are difficult to sterilize. We evaluated a new device, the Sonic Mist ultrasonic room humidifier, to determine how quickly it became contaminated during continuous use by a population of cystic fibrosis patients. In addition, the study was designed to test the effectiveness of placing a bacterial filter on the air inlet of the humidifier. We found that the entire humidifier could withstand repeated gas sterilization. Data obtained from 18 humidifiers involving cystic fibrosis patients indicate that the earliest humidifier contamination occurred after 5 days of continuous use. Although all patients had large numbers of gram-negative bacilli as predominant sputum flora, only 7 episodes of contamination were found during 34 humidifier-use periods. Three units equipped with filters became contaminated (5-7 days) and four unfiltered units became contaminated (6-11 days), indicating that the use of an inlet filter made no apparent difference. The organisms recovered from contaminated units were not found as sputum flora and would not generally be considered of clinical significance in cystic fibrosis sputum cultures. Probable sources of the organisms were room dust and hand contamination. A further test of the inlet filter was performed by exposing filtered and unfiltered units to mist from an intentionally contaminated humidifier. Again, the contamination rate was low and the filter apparently made no difference. These results indicate that the Sonic Mist humidifier may be appropriate for hospital use if adequate sterilization and contamination-monitoring practices are followed.

Pulmonary cellular response to chronic irritation and chronic Pseudomonas aeruginosa pneumonia in cats

A model of chronic pulmonary infection was used for studying cellular events in a sequential manner. In this model, agarose beads containing Pseudomonas aeruginosa were instilled endotracheally into cats. Nine cats were inoculated with agarose beads containing P. aeruginosa, and four others were inoculated with sterile beads. With a fiberoptic bronchoscope, bronchial washings were obtained biweekly for up to 30 weeks. The quantitative pulmonary inflammatory cell response and alveolar macrophage morphology of the animals exposed to P. aeruginosa were compared with those for the animals exposed to a chronic irritant (agarose beads). Bronchial washings of all animals before inoculation showed that 70 to 90% of the cells were macrophages. After inoculation with P. aeruginosa, a persistent inflammatory response was observed (60 to 70% granulocytes). In the sterile-bead-inoculated group, the response was less prominent (30 to 40% granulocytes). As early as 2 weeks after inoculation, alveolar macrophages from infected animals were larger and had cytoplasmic features that differed from those of controls. Electron microscope examination showed prominent surface alterations in alveolar macrophages from the infected cats. These alterations persisted from 2 to 12 weeks after infection. In animals inoculated with sterile beads, alveolar macrophages exhibited less extensive surface changes that had resolved by week 8. Histologically, chronic bronchiolitis and pneumonia were more severe in the infected animals than in controls. This model of chronic inflammation and macrophage stimulation, which is similar to the chronic pneumonia of cystic fibrosis, may be a useful approach to answer questions on the role of macrophage activation in chronic lung disease.

A double-blinded comparative study of sultamicillin and potassium penicillin V in the treatment of childhood streptococcal pharyngitis

Fifty-two children with positive pharyngeal cultures for group A streptococci were randomized to receive phenoxymethyl penicillin or sultamicillin, an ester of ampicillin and sulbactam. By serological and bacteriological criteria, sultamicillin was effective in 100% of the 20 evaluable cases of infection and carriage while penicillin was effective in six out of eight (75%) and three out of eight (93%) respectively. Of the eight children with infections treated with sultamicillin, three (37.5%) became recolonized with the organism compared to none of the children in the penicillin group. These differences were not statistically significant.

In vitro activities of aztreonam, piperacillin, and ticarcillin combined with amikacin against amikacin-resistant Pseudomonas aeruginosa and P. cepacia isolates from children with cystic fibrosis

Amikacin, combined with aztreonam, piperacillin, or ticarcillin, synergistically inhibited amikacin-resistant sputum isolates of Pseudomonas aeruginosa and P. cepacia from children with cystic fibrosis. Ticarcillin-amikacin was the least active combination. Aminoglycoside resistance should not preclude the use of beta-lactam-aminoglycoside combinations in the treatment of pulmonary infections in cystic fibrosis.

Cultures of thoracotomy specimens confirm usefulness of sputum cultures in cystic fibrosis

Bacteriologic cultures of sputum and specimens obtained at thoracotomy from 17 patients with cystic fibrosis were compared. All organisms found in the surgical specimens were found in the sputum. Only two surgical specimens failed to yield any organisms. The most frequently isolated organisms were Pseudomonas aeruginosa (41%) and Pseudomonas cepacia (35%). Serotypes of P. aeruginosa and antibiogram results on both P. aeruginosa and P. cepacia further supported the concordance of the isolates from the two sources. In addition, anaerobic cultures were obtained in specimens from 10 patients with CF and revealed two patients with anaerobic colonization of the lower respiratory tract. These findings also correlated well with the sputum cultures. The correlation of sputum and lung specimen culture results supports the value of sputum culture in the management of lung disease in CF.

Efficacy and safety of ceftriaxone in serious pediatric infections

Thirty-four patients aged 1 month to 19 years were treated with ceftriaxone for suspected bacterial infections. Bacterial pathogens were isolated from 25 children. The overall bacterial cure rate was 88%, with an overall clinical response rate of 96%. No side effects requiring cessation of therapy were observed. Ceftriaxone proved to be safe and effective in the treatment of serious infections in children.

In vitro inhibition of lymphocyte proliferation by Pseudomonas aeruginosa phenazine pigments

Human lymphocyte proliferation is inhibited in vitro in the presence of killed Pseudomonas aeruginosa or cell-free P. aeruginosa culture supernatants. A comparison of culture supernatants obtained under similar conditions from Staphylococcus aureus, Escherichia coli, P. aeruginosa, and Pseudomonas cepacia strains demonstrated that all P. aeruginosa supernatants were strongly inhibitory, whereas supernatants from other bacteria were mildly inhibitory or not inhibitory at all. These P. aeruginosa inhibitors prevent proliferative responses of resting cells upon mitogen activation and decrease [3H]thymidine uptake when added to human lymphocytes undergoing active proliferation in culture. The inhibitory effect is reversible and not due to cytotoxicity. Most of the inhibitory activity present in crude supernatants was detected in ultrafiltrates of molecular weights below 2,000. Purified P. aeruginosa pyocyanine, a low-molecular-weight phenazine pigment present in culture supernatant, was strongly inhibitory for lymphocyte proliferation. Extraction of pyocyanine and phenazine pigments from inhibitory P. aeruginosa supernatants eliminated their inhibitory activity. Inhibitors were recovered from reverse-phase chromatographic cartridges by both chloroform and methanol elution, indicating that pyocyanine and other phenazine pigments present in P. aeruginosa supernatants are responsible for the inhibition of lymphocyte proliferation. In addition to the identification of phenazine pigments as lymphocyte proliferation inhibitors, several criteria ruled out major contributions of P. aeruginosa polysaccharide, exotoxin A, and proteases to this phenomenon. P. aeruginosa strains selected for very low protease production or for very low exotoxin A production produced supernatants as inhibitory for lymphocyte proliferation as supernatants obtained from clinical P. aeruginosa isolates. Purified P. aeruginosa lipopolysaccharide and protease preparations failed to induce reversible lymphocyte proliferation inhibition. Finally, heat inactivation of P. aeruginosa supernatants at 100 degrees C for 60 min inactivates exotoxin A and proteases but produced only a moderate decrease of the inhibitory activity for lymphocyte proliferation.

Once-daily vs. continuous aminoglycoside dosing: efficacy and toxicity in animal and clinical studies of gentamicin, netilmicin, and tobramycin

The dosing frequency of aminoglycoside antibiotics may alter efficacy and toxicity independent of total daily dose. Once-daily tobramycin dosing was compared with continuous infusion in three models of efficacy. Acute pneumonia due to Pseudomonas aeruginosa in guinea pigs responded better to once-daily dosing, and chronic pneumonia in rats and endocarditis in rabbits responded equally to both regimens. Dogs given gentamicin, tobramycin, or netilmicin once daily, with maximum serum concentrations of greater than 100 mg/liter, had less nephrotoxicity than dogs given continuous infusions. Tobramycin was given once daily or continuously to 52 patients with cystic fibrosis who in 10 days had no change in creatinine clearance or hearing despite maximum serum tobramycin concentrations of 40 mg/liter. Intermittent dosing of aminoglycosides, causing infrequent large maximum serum concentrations, may be less toxic and equally efficacious as frequent dosing.

Protective immunization against chronic Pseudomonas aeruginosa pulmonary infection in rats

Rats were immunized systemically with various doses of the polyvalent Pseudomonas aeruginosa vaccine PEV-01. After a series of two or three doses (25 to 50 micrograms each) at 8- to 11-day intervals, animals were challenged intratracheally by the agarose bead technique with a serotype 5 P. aeruginosa strain at periods of 9 to 42 days. Immunized animals developed circulating antibodies (primarily immunoglobulin M) against vaccine components at levels significantly higher than challenged, nonimmunized controls (P less than 0.005). Eight to ten days postinfection, histological sections of lungs from immunized animals showed only minimal inflammation associated with infectious foci (agarose beads) as compared with the extensive pathological changes of airways and parenchyma seen in infected nonimmunized control animals. However, no significant reduction in bacterial numbers was observed. Such protection lasted at least 6 weeks after the final immunization. It is speculated that the vaccine may contain components of cell surface proteins and virulence exoproducts.

Suppression of in vitro lymphocyte DNA synthesis by killed Pseudomonas aeruginosa

Whole antibiotic-killed classic Pseudomonas aeruginosa organisms elicited human lymphocyte [3H]thymidine (TdR) uptake in vitro after 5 days in culture. However, high concentrations of the same preparation did not elicit [3H]TdR incorporation. The investigation of this lymphocyte unresponsiveness revealed that a high dose of P. aeruginosa, when added to lymphocyte cultures together with optimal concentrations of lymphocyte activators (e.g., plant lectins or whole killed Staphylococcus aureus Cowan 1), caused a potent, nonspecifically expressed inhibition of lymphocyte [3H]TdR uptake in response to these mitogens. High doses of P. aeruginosa were not cytotoxic to lymphocytes, and the inhibition caused was reversed when lymphocytes were washed free of bacteria. The inhibition of [3H]TdR uptake by high-dose P. aeruginosa did not require the generation of adherent suppressor cells or prostaglandin-mediated, steroid-sensitive or radiation-sensitive suppressor mechanisms. At optimal lymphocyte stimulatory concentrations of P. aeruginosa, the addition of indomethacin or the depletion of adherent cells caused an increase in lymphocyte [3H]TdR incorporation. This is consistent with an adherent-cell population regulating [3H]TdR uptake in response to P. aeruginosa via a prostaglandin-dependent pathway. This population was not involved in the inhibition of lymphocyte [3H]TdR uptake by high concentrations of P. aeruginosa.

Induction of phagocytic inhibitory activity in cats with chronic Pseudomonas aeruginosa pulmonary infection

Chronic pulmonary infection has been established in cats by repeated intrapulmonary inoculation of viable Pseudomonas aeruginosa enmeshed in agarose beads. In the serum of all chronically infected animals, a substance(s) developed which inhibited phagocytosis of P. aeruginosa by normal cat alveolar macrophages. Phagocytosis was measured by incubating macrophage monolayers (5 X 10(5) alveolar macrophages) for 20 min in the presence of 3H-labeled bacteria and 5% serum from control or infected animals. Inhibitory activity developed 4 to 16 weeks after initial infection, and inhibition of phagocytosis of P. aeruginosa in the presence of infected cat serum ranged from 30 to 79%. After inhibitory activity developed, it persisted throughout the remainder of the experiment in each animal. The activity was specific for P. aeruginosa of the infecting serotype and did not affect phagocytosis of gram-positive organisms. Inhibitory activity was unchanged by heating serum at 56 degrees C for 30 min. We have previously described a P. aeruginosa-specific, heat-stable, phagocytosis-inhibitory activity in the serum of patients with cystic fibrosis. Since inhibitory activity also develops in cats with chronic P. aeruginosa pulmonary infection, such activity may not be a primary intrinsic abnormality in patients with cystic fibrosis. The animal model described here offers a system for following the development of and for characterization of the P. aeruginosa-specific phagocytosis-inhibitory activity.

Antibodies to proteases and exotoxin A of Pseudomonas aeruginosa in patients with cystic fibrosis: Demonstration by radioimmunoassay

Sera from 33 patients with cystic fibrosis and two pediatric patients being treated for chronic pulmonary infections not related to cystic fibrosis and six sera or serum pools from uninfected individuals were tested with a microtiter radioimmunoassay for reactivity against exotoxin A and two proteases from Pseudomonas aeruginosa. Exotoxin A was purified from a low-protease strain of P. aeruginosa and shown to have adenosine diphosphate-ribose transferase activity and mouse lethality. Proteases were purified from an isolate of P. aeruginosa from a patient with cystic fibrosis and had proteolytic activity against elastin and collagen in an assay employing dimethylated protein substrates. The antibody responses of the patients detected using 125I-labeled antibody to human immunoglobulin were correlated with clinical evaluations expressed as a composite score based on pulmonary findings, case histories, growth and nutrition, and chest X rays. Values in the radioimmunoassay for patients' sera were compared with those of a control serum pool and expressed as the ratio of counts per minute (cpm) in patient serum to the cpm in the control pool. Inverse correlations were found between these ratios for each of the pseudomonas exoproducts and clinical scores; highest ratios occurred in patients showing the lowest clinical scores. These results confirm that proteases and exotoxin A of P. aeruginosa are produced in cystic fibrosis pulmonary infections due to P. aeruginosa and suggest that they may serve as significant virulence factors in these chronic infectious states.

Isolation and characterization of mutants of Escherichia coli K12 resistant to the new aminoglycoside antibiotic, amikacin

Spontaneous mutants of Escherichia coli K12 that are resistant to the new aminoglycoside antibiotic, amikacin, were isolated. These mutants have simultaneously acquired cross-resistance to kanamycin, gentamicin and neomycin but not to streptomycin or spectinomycin. Sensitivity of the mutant strains to the non-aminoglycoside antibiotics, ampicillin, tetracycline and polymyxin, was unaffected. The mutation responsible for amikacin resistance was mapped by PI transduction and found to be tightly linked to strA, distal with respect to spcA and aroE.