Trimethoprim versus gentamicin for the prevention of bacteriuria following transrectal biopsy of the prostate--do patients need additional anaerobic cover?

OBJECTIVES: To study the incidence of aerobic and anaerobic bacteriuria in patients undergoing transrectal ultrasound-guided biopsies of the prostate. A comparative assessment of efficacy of trimethoprim with gentamicin for the prevention of bacteriuria following the transrectal biopsy of the prostate. To assess the need for additional prophylaxis against anaerobes for patients undergoing transrectal biopsies of the prostate gland. PATIENTS AND METHODS: In a pilot study during 1995-1997, all the patients undergoing transrectal ultrasound-guided biopsy of the prostate were randomised to receive either trimethoprim or gentamicin prophylaxis prior to the procedure. Midstream urine (MSU) samples were taken just prior to biopsy and 72 h later. A patient questionnaire to determine the symptoms of urinary tract infection (UTI) accompanied the 72-hour MSU request form. Urine samples were cultured aerobically, using a semiquantitative technique if dipstick analysis revealed the presence of blood, pus cell or nitrite. In addition to the routine aerobic culture, post-biopsy samples were also cultured for anaerobes by direct and enrichment methods. Bacteriuria was defined as a pure or mixed growth of 10(5) colony-forming units/ml. Fisher's test of exact probability was used for statistical analysis. RESULTS: 115 patients were available for final analysis. 53 had received gentamicin and 62 trimethoprim. Four patients had pre-existing bacteriuria (3.5%), 3 in the trimethoprim group and 1 in the gentamicin group. Post-operative bacteriuria developed in 5 patients given gentamicin (9.4%) and 1 given trimethoprim (1.6%). This difference was not statistically significant (p = 0.085). Post-procedure bacteriuria was asymptomatic in all but 1 case. Anaerobes were detected in only 5 MSUs (4.3%) post-biopsy. CONCLUSION: Though there was no statistical significant difference in the rates of bacteriuria following administration of trimethoprim and gentamicin, data appear to favour trimethoprim prophylaxis. Further studies are warranted. Transrectal biopsy of the prostate is associated with a low incidence of anaerobic UTI. In view of the very low incidence of anaerobic bacteriuria, routine antibacterial prophylaxis against anaerobes does not appear to be justified.

Herpes simplex virus-specific immune responses in subjects with frequent and infrequent orofacial recrudescences.

BACKGROUND: Following the primary infection of the orofacial region with herpes simplex virus (HSV) type 1, the virus remains latent in the ganglia for the lifetime of the host but can reactivate at intervals and cause recrudescent lesions. The frequency of these episodes varies considerably from one individual to another. OBJECTIVES: To compare immune responses in two groups of subjects: those with frequent orofacial lesions, defined as 10 or more per year (n = 12), and those with infrequent lesions, defined as three or fewer per year (n = 20). METHODS: Plasma and peripheral blood mononuclear cells were collected from each individual for the series of immunological tests listed in the following results section. RESULTS: Although IgG titres specific for HSV, measured by enzyme-linked immunosorbent assay (ELISA), were not different between the two groups, there was a significantly higher HSV-specific IgE titre in the frequent group. The percentages of CD3-, CD4- and CD8-positive cells in peripheral blood, assessed by flow cytometry, and the in vitro lymphoproliferative response to the non-specific mitogen concanavalin A, did not differ between the two groups. T-cell responses to HSV were assessed by in vitro lymphoproliferation with tritiated thymidine incorporation and subsequent calculation of the stimulation index; cytokine production [interferon (IFN)-gamma and interleukin (IL)-10] into the culture supernatant as a result of the stimulation was measured by ELISAs. The mean +/- SEM stimulation index was 4.1 +/- 0.2 in the subjects with frequent lesions and 11.8 +/- 3.1 in the subjects with infrequent lesions, a difference that was significant. The mean IL-10 concentrations found in the subjects with frequent and infrequent lesions were 154 and 110 pg mL-1, respectively, a difference that did not reach significance. However, the IFN-gamma production was significantly lower in the subjects with frequent lesions compared with those with infrequent lesions: mean 835 and 1679 pg mL-1, respectively. CONCLUSIONS: Thus, from the HSV-specific T-cell proliferation, IFN-gamma production and IgE results, patients who experience frequent recrudescences may tend towards the production of T-helper 2 cytokines in response to the virus, which may lead, in turn, to less effective control of viral replication in the periphery following reactivation from latency.

Differential effect of phototherapy on the activities of human natural killer cells and cytotoxic T cells.

Exposure to ultraviolet B (UV-B) light is recognized to induce suppression of certain immune responses, particularly delayed hypersensitivity. However, its effect on cytotoxic T lymphocyte (CTL) activity, of major importance in the resistance to viruses and tumours, has not been assessed to the same extent. In this study five normal subjects, seropositive for herpes simplex virus (HSV), underwent a standard course of broadband UV-B therapy, as used in the treatment of psoriasis. They received whole-body irradiation thrice weekly for four weeks with incremental doses dependent on skin type. Blood samples were taken immediately before, at two time points during, and at the end of the therapy. An HSV-specific CTL assay was performed using autologous B cells transformed with Epstein-Barr virus as targets. No consistent modulation in CTL activity was obtained as a result of the therapy. The CTLs were separated into CD4 and CD8 subsets by positive selection and, again, no effect of irradiation on CTL activity within each of these two populations was observed. In contrast, the natural killer (NK) cell activity, assessed by the lysis of K562 cells, was significantly reduced at the first time point after the initiation of the phototherapy in all five subjects, and it continued to decline as the treatment progressed. Thus a differential effect of UV-B exposure on cytotoxic activity has been demonstrated: the HSV-specific CTL response is unchanged, while the NK response is suppressed.

Mupirocin-resistant Staphylococcus aureus in a specialist school population.

Staphylococcus aureus strains resistant to mupirocin (MIC > 4000 mg l-1) were recovered from children and staff at a school for children with eczema and/or asthma or cystic fibrosis after mupirocin had been used to treat eczematous lesions. At least three distinct strains of S. aureus were involved and resistance was shown to be due in most isolates to a transmissible plasmid. The need for monitoring the extended use of this valuable antibiotic is emphasized.

Rapid differentiation of Streptococcus milleri from other beta-haemolytic group A, C, and G streptococci by simple screening tests.

Eighty five beta-haemolytic Lancefield group A(23), C(22), and G(40) streptococci were tested for sulphonamide sensitivity, ability to degrade beta-D glucuronide (groups C and G) and bacitracin sensitivity (group A). Identification of isolates was initially confirmed by the API 20 STREP system. Zones of beta-haemolysis were too variable for correct Streptococcus milleri identification in 10% of cases. However, only group C and G S. milleri were both sulphonamide-resistant and beta-D glucuronide-negative. Two group A S. milleri strains could have been mis-identified as Streptococcus pyogenes if combined sulphonamide and bacitracin resistance had not been noted. In a busy diagnostic laboratory, screening of beta-haemolytic group A, C, and G streptococci for sulphonamide sensitivity is recommended. Sulphonamide-resistant group A S. pyogenes can be distinguished from S. milleri by bacitracin sensitivity. S. milleri can be rapidly and cheaply differentiated from other sulphonamide-resistant group C and G streptococci by a simple 4 h commercial beta-D glucuronide assay.

Seminal polyamines as agents of cervical carcinoma: production of aneuploidy in squamous epithelium.

The effects of several polyamines found in seminal fluid on the cell cycle and ploidy of three cervical cell lines and of primary epithelial cells cultured from cervical biopsy specimens were monitored by fluorescent flow cytometry. The rate of cell growth did not change but there were indications of either hypodiploidy or hyperdiploidy in some cultures at certain concentrations of spermine and spermidine. An interaction of exogenous polyamines with the DNA of cervical cells was shown to occur, leading to changes in ploidy with, perhaps, the potential to induce or promote dysplasia.

Orthostatic hypotension following right ventricular myocardial infarction corrected with mineralocorticoid therapy.

Severe hypotension while standing became a problem in a patient after discharge from the hospital following right ventricular myocardial infarction. Hemodynamic studies showed that right ventricular systolic function did not maintain adequate left ventricular preload and that the patient did not compensate for cardiac dysfunction by increasing blood volume. Volume expansion by mineralocorticoid therapy corrected the orthostatic hypotension and ameliorated symptoms. Hypotension eventually resolved and therapy was stopped four months after the myocardial infarction.

The use of tissue culture for the detection of mycotoxins.

After incubation with 20 different mycotoxin standards and extracts from fungi and feed stuffs, fluorescent flow cytometry was used to measure viability of NS-1 cells and compared to microscopic assessment of cytotoxicity on stained HEp-11 monolayers. Both methods gave essentially the same results but the cytometric analysis offered a more quantitative approach and was particularly appropriate in the screening of extracts containing fats. The potential uses of a cytotoxic test in the analysis of feed stuffs and fungal extracts for the presence of mycotoxins are discussed.

Variation in lymphoproliferative responses during recrudescent orofacial herpes simplex virus infections.

Sixty-five patients with recrudescent orofacial herpes simplex virus (HSV) infections all had circulating HSV-specific antibody measured by ELISA and cell-mediated immunity (CMI) to HSV by in vitro lymphoproliferation. Thirteen control subjects with no history of HSV were negative for both tests. Thirty-three patients, repeatedly investigated during 6 to 38 months, had between 1 and 8 recrudescences each. Lymphoproliferative responses to HSV were low during recrudescence, rose to a peak a few weeks later and then declined to a positive background level. However, ELISA titres and lymphoproliferative responses to concanavalin A were high throughout, and peripheral blood mononuclear cell (PBMC) subset numbers measured by fluorescent flow cytometry remained within normal limits. During HSV lesions, depressed lymphoproliferation to HSV was abrogated by removal of CD8+ T cells from PBMC either by using a panning technique (nine patients) or by cell sorting (three patients). Reconstitution of the CD8-depleted population suppressed the lymphoproliferative response to HSV. Depletion of CD8+ T cells did not affect lymphoproliferation to HSV outwith recrudescence (four patients), nor lymphoproliferative responses to another antigen (PPD; five patients) during recrudescence. Thus, reduced lymphoproliferation to HSV during recrudescence may be due to HSV-specific CD8+ suppressor T lymphocyte function, rather than lack of HSV-responsive lymphocytes. This may result in depression of normal CMI responses to the virus during an asymptomatic recurrence allowing recrudescent lesions to develop.

Nuclear DNA analysis of prostate tissues: correlation with stage and grade of tumour.

Flow cytometry was used to analyse the DNA content of 20 unfixed prostatic specimens obtained from patients with cancer of the prostate. The tumours were of different stages and grades of differentiation and the numbers of cells in each phase of the cell cycle were compared to those obtained from 26 patients with benign prostatic hyperplasia. It was noted that, as the cancer progressed from a well to a poorly differentiated state, there was a distinct shift in the distribution of cells in the G0/G1 phase towards the S and G2+M phases. This was particularly marked in cases with a summed Gleason score of 7-10, and was independent of the stage and bulk of the tumour. Furthermore, all tumours with a Gleason score of 7 or more exhibited a tetraploid histogram, whereas only 2 of 14 patients with a well or moderately well differentiated cancer had tetraploid histograms. Two patients were found to have tumours with aneuploid DNA content, and both died within 2 years from the time of diagnosis. Although it is too early to speculate on the place flow cytometry in the clinical management of patients with cancer of the prostate, the results generated from this present study suggest that flow cytometry may be capable of providing prognostic information not supplied from histopathological analysis.

Papillomavirus and c-myc antigen expression in normal and neoplastic cervical epithelium.

Cervical punch biopsy specimens or brushings were collected from 33 patients with cervical human papilloma virus (HPV) infection, cervical intraepithelial neoplasia (CIN), or invasive cervical carcinoma, and from eight control patients with recent normal cervical cytology. Prostatic chippings obtained from six men with benign prostatic hypertrophy were used as further controls. Biopsy specimens and brushings were assayed by flow cytometry for c-myc oncogene antigen and papillomavirus antigen expression and rate of cell division (by measuring DNA content). Results obtained from analysis of specimens and brushings were similar in terms of c-myc antigen and total DNA content, but when the percentages of nuclei from biopsy and brush specimens staining positively with antibody to papilloma viral antigens were compared, brush specimens gave consistently higher percentages than biopsy specimens. More specimens from normal epithelium were c-myc antigen positive (five of eight, (63%) than specimens from CIN II or III (two of 10, 20%), or invasive carcinoma (0%). No association was found between c-myc antigen expression and cell division. HPV antigen positive specimens were found to contain more dividing cells than negative specimens.

Severe eczema herpeticum is associated with prolonged depression of cell-mediated immunity to herpes simplex virus.

Nine patients with eczema herpeticum (EH) and 2 with atopic eczema and recurrent cold sores were investigated for cell-mediated immunity (CMI) and antibodies (Ab) to herpes simplex virus (HSV). All patients had Ab to HSV and a high lymphoproliferation response to concanavalin A and all but 3 showed lymphoproliferation to HSV antigens. These 3 patients had very severe EH and absent CMI to HSV for many months after clinical recovery despite normal Ab and concanavalin A responses. In 2 of them, depletion of CD8+ T cells by panning restored the lymphoproliferative response to HSV. Thus their absent CMI may be due to suppressor cell function rather than lack of responsive cells.

Flow cytometric analysis of cellular DNA in human prostate cancer: relationship to 5 alpha-reductase activity of the tissue.

Flow cytometry of 20 prostate cancer specimens was carried out and the percentage DNA content in each phase of the cell cycle was correlated to the 5 alpha-reductase activity of the tumour. A group of 20 hyperplastic specimens was also entered into this study as control. Tumours were divided into 3 groups on the basis of their 5 alpha-reductase activity. This classification made it possible to identify a group of tumours of which none formed metastases (diploid tumours with 5 alpha-reductase activity greater than 20 pmol/mg protein/30 min and with less than 10% of the cells undergoing mitosis) and a second group of which 78% had metastasised at the time of presentation (diploid tumours with 5 alpha-reductase activity less than 10 pmol/mg protein/30 min and with more than 15% of the cells undergoing mitosis). DNA content within each of the 5 alpha-reductase groups appeared also to correlate with the histological grade of the cancer but no relationship was established with the stage of the disease. Our results suggest that a multi factorial discriminant combining DNA ploidy and 5 alpha-reductase measurements offers a good prognostic index for the assessment of disease progression in prostate cancer and that this might form the basis of a new approach to the treatment of this disease.

Lymphoproliferative and serological responses to herpes simplex virus during primary infection, recrudescence, and re-infection in a murine model.

Mice were infected epidermally with herpes simplex virus type 1 (HSV-1) after mild tape stripping. Some were re-infected by the same route several weeks later; recrudescences were induced in others by UV-irradiation before the primary infection followed by re-irradiation and tape stripping at a later date. Clinical symptoms were noted; serological responses to HSV and lymphoproliferative and phenotypic analysis of local lymph node cells were measured throughout. Experience of a primary lesion did not prevent lesions developing again on re-infection although morbidity and mortality were decreased. Recrudescent lesions were less severe than primary or secondary lesions, never zosteriform and healed rapidly. Antibodies to HSV were not found to play a major role in preventing development of lesions. The lymphoproliferative response on primary infection was maximal just after the lesions were most severe and then waned. There was a second, although not accelerated, lymphoproliferative response on re-infection with a persisting high level for at least one month. On recrudescence, limiting dilution culture analysis of lymphoproliferation demonstrated a recruitment within two days of HSV-1 specific lymphocytes to lymph nodes draining sites of lesions, which may limit their severity and duration.

Immune responses to herpes simplex virus in patients with facial herpes simplex and those with eczema herpeticum.

The immune response to herpes simplex virus (HSV) was studied in 59 patients with primary and recrudescent facial HSV infections. The patients included nine with atopic eczema, seven of whom had eczema herpeticum (EH). All patients had antibodies to HSV (measured by ELISA) and all but three had HSV-specific cell mediated immunity (CMI) (measured by in vitro lymphoproliferation). Thirteen control subjects were negative for both tests. All three patients with absent CMI to HSV had suffered from severe EH and had depressed CMI to HSV for several months following an attack. In two of these EH patients, a positive CMI response was produced by in vitro removal of CD8 + ve T lymphocytes from peripheral blood mononuclear cells using a panning technique. Thus the absence of CMI to HSV in these patients was due to suppressor cell function rather than a lack of specifically responsive cells. The other four EH patients with normal CMI to HSV had suffered less severe EH, but no association between the absence of CMI to HSV and serum IgE level or activity of the eczema was apparent in the atopic patients. No specific anti-HSV IgE antibody was detectable.