Phase variation of type 1 fimbriae in Escherichia coli is under transcriptional control.

An operon fusion of the lac genes to those required for synthesis of type 1 fimbriae (pili) has been achieved in a K12 strain of Escherichia coli lysogenized by the bacteriophage mu d (Ap4, lac). Synthesis of beta-galactosidase, therefore, reflected pil gene transcription and was used as a probe of fimbrial regulation. Expression of the operon fusion was found to oscillate, demonstrating that phase variation between fimbriate and nonfimbriate states is under transcriptional control. The transition rates from fimbriate to nonfimbriate were 1.05 X 10(-3) per bacterium per generation and from nonfimbriate to fimbriate, 3.12 X 10(-3) per bacterium per generation.

Conjugal transfer of the gonococcal penicillinase plasmid.

Certain gonococci, which heretofore have lacked a conjugal mating system, can sexually transfer a small plasmid (4.5 x 10)6) daltons) which carries the gene for beta-lactamase production. Frequencies of conjugal transfer were similar into diverse recipients (other gonococci, Neisseria flava, and Escherichia coli), which suggests that gonococci may transfer the plasmid promiscuously in nature.

The efficacy and safety of daptomycin vs. vancomycin for the treatment of cellulitis and erysipelas.

BACKGROUND: Results from previous trials suggest that daptomycin may result in faster clinical improvement than penicillinase-resistant penicillins or vancomycin for patients with complicated skin and skin structure infections. OBJECTIVE: The objective was to evaluate whether daptomycin treatment of cellulitis or erysipelas would result in faster resolution compared with vancomycin. DESIGN: The study was a prospective, evaluator-blinded, multi-centre trial. Patients were randomised to receive daptomycin 4 mg/kg once daily or vancomycin according to standard of care for 7-14 days. PATIENTS: Adults diagnosed with cellulitis or erysipelas requiring hospitalisation and intravenous antibiotic therapy were eligible for enrolment. RESULTS: The clinical success rates were 94.0% for daptomycin and 90.2% for vancomycin (95% confidence interval for the difference, -6.7%, 14.3%). There were no statistically significant differences between treatment arms in the time to resolution or improvement in any of the predefined clinical end-points. Both daptomycin and vancomycin were well tolerated. CONCLUSIONS: There was no difference in the rate of resolution of cellulitis or erysipelas among patients treated with daptomycin or vancomycin. Daptomycin 4 mg/kg once daily appeared to be effective and safe for treating cellulitis or erysipelas.

Treatment of staphylococcal infections with cyclic lipopeptides.

Daptomycin is the first of a new class of antibiotics, the cyclic lipopeptides, for which a novel mechanism of action is hypothesised. Owing to its mode of action, daptomycin is rapidly bactericidal without being bacteriolytic, is active against static- and growing-phase bacteria, and has a low resistance rate in vitro. Phase III clinical trials have demonstrated that daptomycin is as effective as standard therapy for the treatment of complicated skin and soft-tissue infections associated with Gram-positive infections, and daptomycin-treated patients benefited from a reduced time to clinical resolution. Daptomycin has also been shown to be as effective as standard therapy in the treatment of bacteraemia associated with Staphylococcus aureus, with or without endocarditis. These results indicate that daptomycin is a useful therapeutic option for treating Gram-positive infections, particularly those caused by S. aureus.

Treatment challenges in the management of complicated skin and soft-tissue infections.

Complicated skin and soft-tissue infections (cSSTIs) are a significant clinical problem, partially owing to increasing resistance of infecting bacteria to current antibiotic therapies. Two case studies that illustrate complications that can arise when treating cSSTIs are outlined, and methods that can be used to address the problem and the final treatment outcome are detailed. Although these are specific examples, intolerance of and bacterial resistance to current antibacterial therapies are problems that are often seen in the clinical setting and must be addressed appropriately. The use of new antibiotic agents is one potential solution to these problems, and some of these agents are highlighted. Selecting the most appropriate therapy for an infection is often crucial for patient welfare. This article presents some potential approaches to the treatment of cSSTIs.

Growth advantage and enhanced toxicity of Escherichia coli adherent to tissue culture cells due to restricted diffusion of products secreted by the cells.

This study was undertaken to examine whether Escherichia coli adherent to tissue cells gain advantages over nonadherent bacteria due to their proximity to the cells. We used tissue culture cells and isogenic derivatives of a proline auxotrophic strain of E. coli that were fimbriated (Fim+) or nonfimbriated (Fim-), and were heat-labile enterotoxin producing (Tox+) or toxin nonproducing (Tox-). We found that the Fim+ bacteria; which were capable of adhering to tissue culture cells, initiated growth much sooner than did nonadherent Fim- bacteria; the adherent bacteria used tissue cell-derived proline, which was available at high concentrations only in the zone of bacterial adherence. Likewise, cyclic AMP secreted by adherent (Fim+) bacteria was maintained at high concentration on the tissue cell surfaces. As few as 2 X 10(5) adherent Fim+ Tox+ bacteria exert toxic activity upon Y1 adrenal cells, whereas toxin secreted in the medium by 6 X 10(6) Fim- Tox+ bacteria was undetectable. The results suggest that the growth advantage and enhanced toxicity of adherent E. coli is due to restricted diffusion of products secreted by the tissue culture and bacterial cells, respectively.

Interference with the mannose binding and epithelial cell adherence of Escherichia coli by sublethal concentrations of streptomycin.

When Escherichia coli was grown in sublethal concentrations of streptomycin, mannose binding activity and epithelial cell adherence of the E. coli cultures at stationary phase were significantly reduced in the drug-grown organisms. In a strain whose minimal inhibitory concentrations was 30 mug/ml, the percentage of reduction in mannose binding activity was dose related over a range of concentrations between 0.5 and 10 mug/ml streptomycin. Concomitant with the drug-induced suppression of mannose binding activity, antigenic and ultrastructural alterations on the surface of the drug-grown organisms were observed by agglutination tests and electron microscopy, respectively. The streptomycin effect was reversible, required actively growing organisms, and was most apparent in the early log-phase of growth. High doses of antibiotic were ineffective when added to cultures which had acquired mannose binding activity. An isogenic derivative with high-level resistance to streptomycin was obtained as a single-step mutation from the test E. coli strain. Whereas the isogenic mutant possessed mannose binding activity and adhering ability similar to the parent strain, it was resistant to the streptomycin-induced suppression of the two activities at enormous concentrations (up to 10,000 mug/ml) of streptomycin. Taken together the results suggest that the suppression of epithelial cell adherence and mannose binding activity of E. coli grown in sublethal concentrations of streptomycin is a result of classic mechanisms of drug action upon the bacterial ribosome. The results support the possibility that antibiotics may act through mechanisms other than inhibition of growth and bacterial killing to eradicate bacteria from mucosal surfaces.

Study of exclusive charmless semileptonic B decays and |Vub|.

We study semileptonic B decay to the exclusive charmless states pi, rho/omega, eta, and eta;{'} using the 16 fb(-1) CLEO Upsilon(4S) data sample. We find B(B0-->pi-l+nu)=(1.37+/-0.15stat+/-0.11sys)x10(-4) and B(B0-->rho-l+nu)=(2.93+/-0.37stat+/-0.37sys)x10(-4) and find evidence for B+-->eta'l+nu, with B(B+-->eta'l+nu)=(2.66+/-0.80stat+/-0.56sys)x10(-4). From our B-->pilnu rate for q2>16 GeV2 and lattice QCD, we find |Vub|=(3.6+/0.4stat+/0.2syst-0.4thy+0.6)x10(-3) [corrected]

Human tissue research in the genomic era of medicine: balancing individual and societal interests.

Advances in DNA sequencing technology and in our understanding of the human genome are ushering in a new era of genomic medicine, one with dramatic potential to not only benefit society through research involving human tissue, but also to cause economic or psychosocial harms to tissue donors and their families. This delicate situation requires that the needs of tissue donors be carefully considered and balanced with those of the medical research community, especially on issues concerning confidentiality, consent, and compensation. We analyzed the tensions between tissue donors and researchers over the research use of human tissue. We also reviewed several approaches, including the establishment of tissue-trustee infrastructures at academic medical centers, aimed at achieving a more equitable balance between individual donor protection and societal benefits derived from tissue-based research. Arch Intern Med. 2000;160:3377-3384.

Primary hyperoxaluria type 1: improved outcome with timely liver transplantation: a single-center report of 36 children.

BACKGROUND: The appropriate use of liver transplantation in children with type-1 primary hyperoxaluria (PH-1) is not well established. We reviewed our experience with 36 children with PH-1, including 12 who underwent liver transplantation. PATIENTS AND METHODS: From 1989-1998, 36 children from 10 families in northern Israel were diagnosed with PH-1. Eight children presented with renal failure; seven of these eight had the severe infantile form of the disease. One child was treated with kidney transplantation alone. Combined liver-kidney transplantation has been performed in nine children and preemptive liver transplantation in three children. A review of the patients' charts for the following parameters was performed: age, clinical signs, and renal sonographic findings at diagnosis, age at onset of dialysis, and current status. Type of transplant, pre- and posttransplant urine oxalate excretion, current renal function, survival, and complications were recorded in liver recipients. RESULTS: Of the 23 nontransplanted children, 9 died of complications related to severe systemic oxalosis and 14 are alive (mean follow-up, 7.4 years), including 2 who are candidates for transplantation. The child who underwent only kidney transplantation died of unrelated causes. Of the 12 liver recipients, 2 died within the first 3 months posttransplant and another child underwent retransplantation due to hepatic arterial thrombosis. At intervals after transplant ranging from 6-54 months, 10 recipients are alive (7 of the 9 recipients of combined liver-kidney transplants and all 3 recipients of preemptive liver transplants). Mean GFR in the 10 survivors is 77 ml/min/m2. In 9 of these 10, daily urinary oxalate excretion normalized. Renal function has improved (mean GFR 86 vs. 58 ml/min/m2) but renal oxalate deposits remain in the three recipients of isolated liver grafts. CONCLUSIONS: Our decade-long experience with children with PH-1 supports strategies for early diagnosis and timely liver transplantation. Preemptive isolated liver transplantation should be considered in children who develop the disease during infancy or in those with slowly progressive disease when significant symptoms develop. Combined liver-kidney transplantation is suggested for children with end-stage renal disease.

Effective treatment of gonorrhoea.

Effective therapy of gonorrhoea has changed drastically over the years, reflecting the progessive acquisition of relative antibiotic resistance by the causative organism. Although in the US. th 1974 USPHS recommendations are the best guidelines for management at present, recent epidemiological trends may obviate some of these provisions. The most important of these trends is the emergence of R-factor carrying strains capable of producing penicillinase, thereby making these strains absolutely resistant to clinically achievable levels of penicillin. This review analyses this problem in the context of reasonable therapeutic goals and also discusses optimum management of patients with such complications as pharyngeal infection, pelvic inflammatory disease and disseminated gonococcal infection.

Disseminated gonococcal infection (DGI) and gonococcal arthritis (GCA): II. Clinical manifestations, diagnosis, complications, treatment, and prevention.

This is the second part of an integrated review of disseminated gonococcal infection (DGI) and gonococcal arthritis (GCA). It covers clinical manifestations, spectrum of GCA, diagnosis and treatment. These disorders are important since DGI may be the most frequent form of acute arthritis in sexually active younger females, and other selected groups. Although the spectrum of disease is varied, it may be classified into stages and clinical subgroups. N. gonorrhoeae strains causing DGI in the U.S. have been highly sensitive to penicillin. Such findings require revision in beliefs that high-dose intravenous penicillin is needed for effective initial therapy of GCA. Recommended treatment protocols for localized gonorrhea and DGI are reviewed as well as the occurrence and implications for treatment of penicillinase-producing N. gonorrhoeae (PPNG) infection in the U.S.

Pulmonary blood flow and ventilation-perfusion heterogeneity.

We studied the independent influence of changes in perfusion on pulmonary gas exchange in the left lower lobe (LLL) of anesthetized dogs. Blood flow to the LLL (QLLL) was raised 50% (increased QLLL) or reduced 50% (decreased QLLL) from baseline by partial occlusion of the right or left pulmonary artery, respectively. Minute ventilation and alveolar PCO2 of the LLL remained constant throughout the study. We determined ventilation-perfusion distributions of the LLL using the multiple inert gas elimination technique. Increased QLLL impaired LLL pulmonary gas exchange. All dispersion indexes and all arterial-alveolar difference areas increased (P less than 0.01). Decreased QLLL increased the log standard deviation of the perfusion distribution (P less than 0.05) and reduced the log standard deviation of the ventilation distribution (P less than 0.01) but did not affect the dispersion indexes or alveolar-arterial difference areas. We conclude that ventilation-perfusion heterogeneity is increased by independent changes in perfusion from normal baseline blood flow, even when ventilation and alveolar gas composition remain constant.

Regional alveolar hypoxia does not affect air embolism-induced pulmonary edema.

We studied the effects of regional alveolar hypoxia on permeability pulmonary edema resulting from venous air embolization. Anesthetized dogs had the left upper lobe removed and a double-lumen tube placed so that right lung and left lower lobe (LLL) could be ventilated independently. Air was infused into the femoral vein for 1 h during bilateral ventilation at an inspiratory O2 fraction (FIO2) of 1.0. After cessation of air infusion the LLL was then ventilated with a hypoxic gas mixture (FIO2 = 0.05) in six animals and an FIO2 of 1.0 in six other animals. Lung hydroxyproline content was measured as an index of lung dry weight. LLL bloodless lobar wet weight-to-hydroxyproline ratio was 0.33 +/- 0.06 mg/micrograms in the animals exposed to LLL hypoxia and 0.37 +/- 0.03 mg/micrograms (NS) in the animals that had a LLL FIO2 of 1. Both values were significantly higher than our laboratory normal values of 0.19 +/- 0.01 mg/micrograms. We subsequently found in four more dogs exposed to global alveolar hypoxia before and after air embolism that the air injury itself significantly depressed the hypoxic vasoconstrictor response. We conclude that regional alveolar hypoxia has no effect on pulmonary edema formation due to air embolism. The most likely reason for these findings is that the air embolism injury itself interfered with hypoxic pulmonary vasoconstriction.

Hypoxic pulmonary vasoconstriction does not affect hydrostatic pulmonary edema formation.

We studied the effects of regional hypoxic pulmonary vasoconstriction (HPV) on lobar flow diversion in the presence of hydrostatic pulmonary edema. Ten anesthetized dogs with the left lower lobe (LLL) suspended in a net for continuous weighing were ventilated with a bronchial divider so the LLL could be ventilated with either 100% O2 or a hypoxic gas mixture (90% N2-5% CO2-5% O2). A balloon was inflated in the left atrium until hydrostatic pulmonary edema occurred, as evidenced by a continuous increase in LLL weight. Left lower lobe flow (QLLL) was measured by electromagnetic flow meter and cardiac output (QT) by thermal dilution. At a left atrial pressure of 30 +/- 5 mmHg, ventilation of the LLL with the hypoxic gas mixture caused QLLL/QT to decrease from 17 +/- 4 to 11 +/- 3% (P less than 0.05), pulmonary arterial pressure to increase from 35 +/- 5 to 37 +/- 6 mmHg (P less than 0.05), and no significant change in rate of LLL weight gain. Gravimetric confirmation of our results was provided by experiments in four animals where the LLL was ventilated with an hypoxic gas mixture for 2 h while the right lung was ventilated with 100% O2. In these animals there was no difference in bloodless lung water between the LLL and right lower lobe. We conclude that in the presence of left atrial pressures high enough to cause hydrostatic pulmonary edema, HPV causes significant flow diversion from an hypoxic lobe but the decrease in flow does not affect edema formation.

Effect of regional alveolar hypoxia on permeability pulmonary edema formation in dogs.

We studied the effects of regional alveolar hypoxia on permeability pulmonary edema formation. Anesthetized dogs had a bronchial divider placed so that the left lower lobe (LLL) could be ventilated with a hypoxic gas mixture (HGM) while the right lung was continuously ventilated with 100% O2. Bilateral permeability edema was induced with 0.05 ml/kg oleic acid and after 4 h of LLL ventilation with an HGM (n = 9) LLL gross weight was 161 +/- 13 (SE) g compared with 204 +/- 13 (SE) g (P less than 0.05) in the right lower lobe (RLL). Bloodless lobar water and dry weight were also significantly lower in the LLL as compared with the RLL of the study animals. In seven control animals in which the LLL fractional inspired concentration of O2 (FIO2) was 1.0 during permeability edema, there were no differences in gravimetric variables between LLL and RLL. In eight additional animals, pulmonary capillary pressure (Pc), measured by simultaneous occlusion of left pulmonary artery and vein, was not significantly different between LLL FIO2 of 1.0 and 0.05 either before or after pulmonary edema. We conclude that, in the presence of permeability pulmonary edema, regional alveolar hypoxia causes reduction in edema formation. The decreased edema formation during alveolar hypoxia is not due to a reduction in Pc.

Effect of regional alveolar hypoxia on gas exchange in dogs.

We studied the effects of left lower lobe (LLL) alveolar hypoxia on pulmonary gas exchange in anesthetized dogs using the multiple inert gas elimination technique (MIGET). The left upper lobe was removed, and a bronchial divider was placed. The right lung (RL) was continuously ventilated with 100% O2, and the LLL was ventilated with either 100% O2 (hyperoxia) or a hypoxic gas mixture (hypoxia). Whole lung and individual LLL and RL ventilation-perfusion (VA/Q) distributions were determined. LLL hypoxia reduced LLL blood flow and increased the perfusion-related indexes of VA/Q heterogeneity, such as the log standard deviation of the perfusion distribution (log SDQ), the retention component of the arterial-alveolar difference area [R(a-A)D], and the retention dispersion index (DISPR*) of the LLL. LLL hypoxia increased blood flow to the RL and reduced the VA/Q heterogeneity of the RL, indicated by significant reductions in log SDQ, R(a-A)D, and DISPR*. In contrast, LLL hypoxia had little effect on gas exchange of the lung when evaluated as a whole. We conclude that flow diversion induced by regional alveolar hypoxia preserves matching of ventilation to perfusion in the whole lung by increasing gas exchange heterogeneity of the hypoxic region and reducing heterogeneity in the normoxic lung.

Effect of inspired CO2 on ventilation and perfusion heterogeneity in hyperventilated dogs.

We studied the effect of inspired CO2 on ventilation-perfusion (VA/Q) heterogeneity in dogs hyperventilated under two different tidal volume (VT) and respiratory rate conditions with the use of the multiple inert gas elimination technique. Dogs anesthetized with pentobarbital sodium were hyperventilated with an inspired fraction of O2 of 0.21 by using an increased VT (VT = 30 ml/kg at 18 breaths/min) or an increased respiratory rate (VT = 18 ml/kg at 35 breaths/min). The arterial CO2 tension (PaCO2) was varied to three levels (20, 35, and 52 Torr) by altering the inspired PCO2. The orders of type of ventilation and PaCO2 level were randomized. Compared with normocapnia, VA/Q heterogeneity was increased during hypocapnia induced by increased respiratory rate ventilation, which was indicated by an increase in dispersion indexes and arterial-alveolar inert gas partial pressure difference areas (P < 0.01). In contrast, VA/Q heterogeneity was not affected by hypocapnia when a large VT ventilation was used. Under the conditions of our study, hypercapnia did not result in statistically significant changes in VA/Q heterogeneity with either type of ventilation. Increased VT ventilation reduced dead space at all PaCO2 levels (P < 0.01) and reduced the log standard deviation of the ventilation distribution during normocapnia (P < 0.05) and hypocapnia (P < 0.01). We conclude that hypocapnia increased VA/Q heterogeneity when hyperventilation was achieved with a rapid respiratory rate. Therefore, a lack of improvement in VA/Q matching with inhaled CO2 may be associated with the use of a large VT. These data suggest that hypocapnic bronchoconstriction may be important in mediating hypocapnia-induced VA/Q inequality in dogs.

Lack of alveolar O2 during lung reperfusion does not decrease edema formation.

We previously reported that pulmonary arterial occlusion for 48 h followed by 4 h of reperfusion in awake dogs results in marked edema and inflammatory infiltrates in both reperfused and contralateral lungs (Am. Rev. Respir. Dis. 134: 752-756, 1986; J. Appl. Physiol. 63: 942-950, 1987). In this experiment we study the effects of alveolar hypoxia on this injury. Anesthetized dogs underwent thoracotomy and occlusion of the left pulmonary artery. Twenty-four hours later the dogs were reanesthetized, and a double-lumen endotracheal tube was placed. The right lung was continuously ventilated with an inspiratory O2 fraction (FIO2) of 0.35. In seven study animals the left lung was ventilated with an FIO2 of 0 for 3 h after the left pulmonary artery occluder was removed. In six control animals the left lung was ventilated with an FIO2 of 0.35 during the same reperfusion period. Postmortem bloodless wet-to-dry weight ratios were 5.87 +/- 0.20 for the left lower lobe and 5.32 +/- 0.12 for the right lower lobe in the dogs with hypoxic ventilation (P less than 0.05 for right vs. left lobes). These values were not significantly different from the control dog lung values of 5.94 +/- 0.22 for the left lower lobe and 5.11 +/- 0.07 for the right lower lobe (P less than 0.05 for right vs. left lobes). All values were significantly higher than our laboratory normal of 4.71 +/- 0.06. We conclude that reperfusion injury is unaffected by alveolar hypoxia during the reperfusion phase.

Renal function in full-term neonates with hyperbilirubinemia.

The purpose of this study was to investigate the effect of unconjugated hyperbilirubinemia on endogenous creatinine clearance and urinary excretion of sodium, phosphorus, lysozyme, and amino acids in full-term infants. Thirty-seven healthy, breast-fed newborns who were not exposed to phototherapy were studied on their third to fifth day of life. Twenty had neonatal hyperbilirubinemia with a mean indirect bilirubin value of 16.4 mg/dl, whereas 17 who were used as controls had a mean indirect bilirubin value of 7.8 mg/dl. Urine was collected, and samples were taken for examination of creatinine, lysozyme, sodium, and phosphorus concentration. Urinary sediment, glucose, and amino acid levels were also measured. Serum total and direct bilirubin, creatinine, sodium, and phosphorus measurements were taken at the beginning of urine collection. Calculations were made for creatinine clearance, fractional excretion of sodium (FENa), and tubular reabsorption of renal phosphate per deciliter glomerular filtrate (TP/GFR). The means (+/-1 SD) of creatinine clearance, FENa, and TP/GFR were 27.0 +/- 14.2 ml/min/1.73 m2, 0.53% +/- 0.49%, and 5.72 +/- 1.16 mg/dl GF, respectively, in the hyperbilirubinemic group compared with 21.1 +/- 9.4 ml/min/1.73 m2, 0.4% +/- 0.47%, and 6.01 +/- 0.51 mg/dl GF, respectively, in the controls. No statistically significant differences were found between the groups for any of the examined parameters of either glomerular or tubular function. Neonatal hyperbilirubinemia < 20.8 mg/dl has no detrimental effect on renal function of healthy, breast-fed, full-term newborns, and no modification in the approach regarding renal function is necessary in these babies.