Randomized, controlled, dose-range study of Ro 25-8315 given before and after a high-dose combination chemotherapy regimen in patients with metastatic or recurrent breast cancer patients.

PURPOSE: To evaluate the safety, pharmacokinetics, and efficacy of three different dose levels of pegylated granulocyte colony-stimulating factor (Ro 25-8315) on progenitor cell mobilization and hematologic recovery in cancer patients. PATIENTS AND METHODS: Breast cancer patients (n = 36) were randomly assigned to receive before (part I) and after (part II) chemotherapy either a single-dose injection of Ro 25-8315 (20 microg/kg, n = 9; 60 microg/kg, n = 9; 100 microg/kg, n = 10) or a standard daily dose of filgrastim (part I, 10 microg/kg/d; part II, 5 microg/kg/d) (control group, n = 8). RESULTS: Overall, Ro 25-8315 was well tolerated. In part I, more progenitor cell mobilization was observed with Ro 25-8315 100 microg/kg. The peak of circulating CD34(+) cells was obtained at day +5 in the four groups, and the absolute neutrophil count (ANC) returned to less than 20 x 10(9)/L by day +15. In part II, high levels of circulating CD34(+) cells (> 20 cells/microL) were obtained in all four groups. The chemotherapy-induced neutropenia (< 1 x 10(9)/L) was similar in the four groups. Ro 25-8315 100 microg/kg was more effective than filgrastim in reducing the number of patients with an ANC less than 0.5 x 10(9)/L on day +12 after chemotherapy. CONCLUSION: A single injection of Ro 25-8315 100 microg/kg might be the optimal dose for steady-state peripheral-blood progenitor cell mobilization. A single injection of 20, 60, or 100 microg/kg could be as efficient as daily administration of filgrastim to correct chemotherapy-induced cytopenia. The optimal dose of Ro 25-8315 should be determined according to the planned chemotherapy regimen.

Production of human monoclonal IgG antibodies reacting with cytomegalovirus (CMV).

A human monoclonal antibody (MoAb) reacting with cytomegalovirus (CMV) has been produced using somatic cell hybridization between Epstein-Barr virus (EBV) infected B lymphocytes and a human-mouse heteromyeloma cell line (SHM-D33). The hybrids were selected in HAT medium containing 5 x 10(-7) ouabain. The median level of Ig production was 5 (0.1-20) micrograms/10(6) cells/day. One selected hybridoma (IB-8E9H5) has been maintained in continuous culture for more than 30 months with a stable IgG2, lambda production. Molecular hybridization using EBV-specific probes demonstrate that our hybrids have lost the IR-1 EBV sequence during fusion. Unexpectedly, these blotting experiments revealed the presence of multiple EBNA-1 sequences dispersed among the genomic DNA of the SHM-D33 cell line. Screening for anti-CMV specificity was performed by ELISA and confirmed by immunofluorescence staining. Thus far, three CMV reference strains and 14 local strains are stained by the MoAb as early as 3 h after CMV infection of human fibroblasts, apparently through the recognition of a nuclear viral antigen of 67 kDa. In conclusion, this technique permits (a) the removal of the EBV genome contained in the lymphoblastoid parental cell line and (b) the production of human anti-CMV MoAb with potential applications in the prevention of life threatening CMV infections.

Empiric antimicrobial therapy with aztreonam or ceftazidime in gram-negative septicemia.

In an open, comparative study, 225 patients with severe underlying diseases and suspected gram-negative bacillary septicemia were randomly assigned to receive aztreonam or ceftazidime empirically, 2 g intravenously three times daily. Twenty-five patients in the aztreonam group and 22 in the ceftazidime group had blood cultures that grew aerobic gram-negative bacilli and were evaluable for response to therapy. All pathogenic strains were sensitive to treatment. In the aztreonam group, 22 (88 percent) patients had cures, three (12 percent) had failures, and seven (28 percent) had development of superinfections (five were caused by gram-positive cocci and two by fungi). In the ceftazidime group, 18 (82 percent) patients had cures, one had improvement, three (14 percent) had failures, and three had superinfections. The median peak serum bactericidal activity was 1:2,048 after aztreonam administration and 1:512 after ceftazidime administration. Failures were not related to resistant strains or to low serum bactericidal activity.

Use of the quinolones in the prophylaxis and treatment of granulocytopenic immunocompromised cancer patients.

The potential use of the quinolones in the prophylaxis and treatment of febrile episodes in granulocytopenic patients is reviewed. Of 7 controlled prophylactic studies performed with quinolones, 2 were double-blind and placebo-controlled. The occurrence of fever and mortality due to infection was not reduced with quinolone prophylaxis, although the occurrence of Gram-negative bacteraemia was significantly reduced. The delay to first fever was occasionally increased, and this was associated with a reduction in the number of days with antimicrobial agents. No effect was observed on disseminated fungal infections with quinolone prophylaxis. Breakthrough bacteraemia and subsequent infections were due to resistant organisms, mainly Gram-positive organisms (streptococci, staphylococci). Tolerability and compliance were excellent and were occasionally better than with the classic regimen [nonabsorbable antibiotics and cotrimoxazole (trimethoprim/sulfamethoxazole)]. Six controlled studies dealing with empiric treatment with the quinolones were reviewed. Overall, the results suggested that monotherapy with ciprofloxacin may be used in patients with a good prognosis (short and less severe neutropenia, solid tumours, compliant patients). Combinations with broad spectrum penicillins, netilmicin or teicoplanin seem to be as effective as the classic regimens (a broad spectrum penicillin or cephalosporin plus aminoglycosides), although the number of patients was limited (n = 334). The response rate of Gram-positive bacteraemia was lower with quinolone-containing regimens except for a combination that included teicoplanin.

In vitro activity of sulbactam in combination with various beta-lactam antibiotics.

Forty-three strains (beta-lactamase positive and negative) from the species of Haemophilus influenzae, Neisseria gonorrhoeae, Staphylococcus aureus, Escherichia coli, Serratia marcescens, Enterobacter cloacae, Acinetobacter baumanii, and Pseudomonas aeruginosa were studied for synergy between sulbactam and several beta-lactam antibiotics. Using a checkerboard method, synergy was observed with 10 to 55% of the beta-lactamase negative strains. Synergy was more frequent with the strains producing beta-lactamase. Using the killing curve method, synergy was also observed between sulbactam and beta-lactam antibiotics against some beta-lactamase negative strains. In addition, the regrowth of a resistant subpopulation was prevented by sulbactam.

Study of the influence of protein binding on serum bactericidal titres and killing rates in volunteers receiving ceftazidime, cefotaxime and ceftriaxone.

The influence of protein binding on anti-staphylococcal activity of cefotaxime, ceftazidime and ceftriaxone was evaluated using an ex vivo cross-over study in human volunteers. Serum inhibitory and bactericidal titres were measured using samples collected 1 h and 6 h after infusion of 2 g of cefotaxime and ceftazidime and 1 g of ceftriaxone. Time-kill curves were done using the same samples. Twelve strains of Staphylococcus aureus were studied including six capsulated strains of known capsule types. Two media were compared: Mueller-Hinton and 'capsule' medium. The MICs and MBCs of oxacillin-susceptible strains measured in capsule medium were higher than in Mueller-Hinton, hence the higher serum inhibitory and bactericidal titres in the latter medium. The effect of protein binding was evaluated, using the difference between expected serum titres, from serum concentration and MICs or MBCs measured in serum-free medium, and the area under the time-kill curve corrected for the serum concentration and the sensitivity of the strains. The anti-staphylococcal activity of ceftriaxone was markedly affected by its strong protein binding.

Bacteraemia caused by non-aeruginosa Pseudomonas species in a cancer centre.

Fifty-one episodes of bacteraemia due to Pseudomonas species other than Pseudomonas aeruginosa occurring between 1980 and 1990 in a Belgian cancer centre were reviewed. This corresponded to an incidence of 0.62/1000 admissions, or 1.5% of all bacteraemic episodes. Twenty-nine episodes, each with several positive blood culture sets were considered clinically significant, including six patients belonging to a well-documented outbreak of pseudobacteraemia with Xanthomonas maltophilia and associated with contaminated blood sampling tubes. The respiratory tract was the source in six (20.7%), an infected intravenous catheter in 10 (34.5%) and the source was unknown in seven (24.1%). Seven patients died from infection (24.1%). Twenty-three episodes with a single positive blood culture set were considered clinically not significant, although four of them were considered significant by the Centers for Disease Control (CDC) criteria because of the presence of symptoms and specific antibiotic treatment being administered. None of the patients with a single isolate died from infection despite the fact that 17 of 22 did not receive an effective antimicrobial agent. All isolates were susceptible to co-trimoxazole.

Wound dressing in major head and neck cancer surgery: a prospective randomized study of gauze dressing vs sterile vaseline ointment.

A total of 207 patients were randomized in a prospective comparative study of standard gauze dressing vs sterile vaseline ointment. 179 patients were evaluable. All patients received antimicrobial prophylaxis. The two groups (86 standard and 93 vaseline) were comparable as far as age (mean, 57 yr; range, 21-84), genders (155 males/24 females), weight (mean, 66 kg; range, 40-69), type of surgery, previous or concomitant anticancer treatment. Severity of surgery was identical, as was the severity of cancer, in the two groups. Wound infection within 20 days of surgery occurred in 31.2% (29/93) of the vaseline group and 24.4% (21/86) in the standard group (NSS). Bacteremia occurred in three patients from the vaseline group and in four patients from the standard group. Bronchopneumonia occurred in 10 patients from the vaseline group and 14 patients in the standard group. The spectrum of microorganisms recovered was similar in the two groups. The need for antimicrobial treatment (empiric or for documented infections) within 20 days after surgery was 34.4% (32/93) in the vaseline group and 36.0% (31/86) in the standard group. The median delay to infection (range in days) in the vaseline group was 9 (5-15) for wound and 6 (1-12) for bronchopneumonia. For the standard group the corresponding delays were 8 (4-15) and 7 (2-19). Vaseline dressing was not associated with an increased risk of infection as compared to the standard gauze dressing.

Dibekacin assay in serum by automated fluorescence polarization immunoassay (Abbott Tdx): comparison with high-performance liquid chromatography, substrate-labelled fluorescent immunoassay and radioimmunoassay.

An immunoassay based on fluorescence polarization detection (FPIA) has been recently adapted for dibekacin. This has been compared with a reference method (high-performance liquid chromatography), and two other methods used in clinical laboratories for monitoring this aminoglycoside, namely substrate-labelled fluorescent immunoassay (SLFIA) and radioimmunoassay (RIA). FPIA was fast and more reliable than SLFIA or RIA, and offered therefore superior performance. However, its nominal cost per assay is high.

In vitro activity of coumermycin alone or in combination against Staphylococcus aureus and Staphylococcus epidermidis.

The in vitro activity of coumermycin was tested against oxacillin-susceptible and resistant strains of Staphylococcus aureus and Staphylococcus epidermidis, and compared with that of penicillin G, oxacillin, minocyclin, erythromycin, vancomycin, teicoplanin, rifampicin and LM 427. The MICs were measured using the agar dilution method with an inoculum of 10(5) cfu/spot. Coumermycin was the most active antibiotic with MIC90 of 0.025-0.2 mg/l. The MICs of coumermycin remained unchanged by further incubation for 48 h. The combination of coumermycin with ciprofloxacin, an inhibitor of subunit A of the DNA gyrase, was studied by the time-kill curve method and resulted in a synergistic effect when subinhibitory concentrations of either antibiotic were used. The combination of coumermycin with rifampicin or LM 427 was antagonistic.

Influence of antibiotics on motility and adherence of human neutrophils studied in vitro.

The influence of 14 antibiotics on chemotaxis, motility and adherence of human neutrophils has been studied. Neutrophils were preincubated for 30 min at 37 degrees C with the antibiotics. Chemotaxis was studied in antibiotic-free and antibiotic-containing agar using zymosan-activated serum and fMLP as stimuli. Adherence was studied in plastic microtitre plates. Most of the antibiotics studied did not affect the three functions studied. Daptomycin occasionally decreased random migration without affecting chemotaxis and adherence. Chemotaxis was occasionally modified by some of the quinolones, although this depended on the volunteer tested. The level of inhibition could be significant in diseased patients.

Ticarcillin-clavulanic acid therapy in severe infections.

Twenty patients with severe infections were treated with a fixed combination of ticarcillin + clavulanic acid. Nineteen of them had severe underlying diseases. Fifteen were bacteraemic; four of these were in shock. Eleven were infected with microorganisms resistant in vitro to ticarcillin. Eleven were clinically cured, 6 improved and 3 failed to respond, the latter being infected with ticarcillin-resistant microorganisms (2 E. coli, 1 P. mirabilis). Six patients experienced side-effects, which were usually mild and reversible, consisting mainly of moderate elevation of serum transaminases. In one patient ticarcillin-clavulanic acid was stopped due to worsening of a pre-existing drug hepatitis.

Study of in vitro selected resistance of Pseudomonas aeruginosa to cefoperazone, ceftazidime, azthreonam and imipenem.

Ten strains of Pseudomonas aeruginosa were plated on agar containing cefoperazone, ceftazidime, azthreonam or imipenem alone and in combination with ampicillin or cefoxitin as inducers, and/or amikacin (MIC/4), according to Szybalsky. Regrowing colonies were randomly selected for MIC and MBC determinations. The numbers of regrowing colonies were occasionally increased by a beta-lactamase inducer, although amikacin significantly reduced it. Some 243 colonies were further studied. The most frequent phenotypes of resistance (195 mutants) were: resistance to cefoperazone, ceftazidime, azthreonam (99 regrowing colonies); resistance to cefoperazone, azthreonam (36); resistance to cefoperazone (17); resistance to cefoperazone, ceftazidime, azthreonam, imipenem (17). A total of 28/31 R mutants retained their phenotype after 15 subcultures in antibiotic-free medium. The mutants R cefoperazone, ceftazidime, azthreonam were studied by quantitative beta-lactamase evaluation in agar with substrate and non-substrate antibiotics, substrate profile study spectrophotometrically, crypticity study by comparing beta-lactamase activity of intact and sonicated cells spectrophotometrically, isoelectric focusing of sonicate extracts and dialysis experiments for trapping evaluation. These mutants were characterized by a 240-fold increase in beta-lactamase production (Pi = 8.7) and unchanged permeability. beta-lactamase trapping was demonstrated but could not explain alone the phenotype of resistance. These studies suggest that mutants constitutive for beta-lactamase production were easily selected in vitro. Amikacin was able significantly to prevent their emergence.

Comparative in vitro activity of CI934, a new fluoroquinolone, alone and in combination with coumermycin, against gram-positive bacteria.

The in vitro activity of Cl934, a new quinolone antimicrobial agent, was studied against 314 strains of Gram-positive bacteria representing 6 genera: Staphylococcus aureus, Streptococcus faecalis, S. agalactiae, S. pyogenes, S. pneumoniae, S. milleri, viridans streptococci, Listeria monocytogenes, Corynebacterium JK, Mycobacterium fortuitum and Bacillus spp.; and compared with that of enoxacin, ciprofloxacin, penicillin G, ampicillin, coumermycin, oxacillin, vancomycin, teicoplanin, rifampin, rifapentine, LM 427, erythromycin, minocycline, tetracycline and clindamycin. The agar dilution method was used. Cl934 was very active in vitro, with MIC90 less than or equal to 0.5 mg/l against most species tested, except for S. faecalis and M. fortuitum. It was usually 2 to 8-fold more active than ciprofloxacin. Cl934 was also tested by the killing curve method, alone and in combination with coumermycin. It was rapidly bactericidal against most species tested, including S. faecalis. A synergistic interaction was observed with coumermycin against S. aureus, S. agalactiae, S. milleri and S. faecalis. The only antagonistic interaction occurred against L. monocytogenes exposed to 8 X MIC of Cl934 with 2 X MIC of coumermycin.

Randomized study of minocycline + gentamicin compared with metronidazole + gentamicin for prophylaxis or treatment of mixed infections in abdominal surgery.

Seventy patients admitted for abdominal surgery requiring short-term perioperative prophylaxis were randomized to receive minocycline + gentamicin or metronidazole + gentamicin. Thirty patients were considered to be infected at the time of surgery and were treated with the same regimen. In the prophylactic cohort, one patient from each group developed postoperative fever. One patient receiving minocycline developed a wound infection. The overall infection rate was 2.6%. In the treatment cohort, it appeared that the patients receiving metronidazole had more severe underlying diseases than those receiving minocycline. Consequently, more postoperative non-infectious complications were observed in the former. Minocycline + gentamicin appeared at least as effective than metronidazole + gentamicin in preventing postoperative infectious complications associated with abdominal surgery or in treating intra-abdominal infections.

[Prevention using pefloxacin of infections in cancer patients with granulocytopenia]. / Prévention par la péfloxacine des infections chez les malades cancéreux granulocytopéniques.

The practical procedures of digestive tract decontamination and prophylaxis of bacterial infection in granulocytopenic patients are debated. Fluoroquinolones are active against Gram-negative bacilli and have few side-effects. Pefloxacin was administered prophylactically to patients with cancer and granulocytopenia. None of them developed Gram-negative septicaemia, but 2 cases of streptococcal septicaemia were observed. The drug was well tolerated by all patients except one. Studies are currently in progress to try to reduce the incidence of septicaemia caused by Gram-positive cocci, using pefloxacin combined with penicillin.

[Rapid diagnosis in infectious diseases]. / Diagnostic rapide en maladies infectieuses.

Rapid detection of infectious agents has recently received a lot of interest. The aim of this article is to review its various aspects in terms of real impact on the medical handling of the infected patient as well as economical impact. Few examples are developed in detail, including technical strategies: sexually transmitted diseases due to Chlamydia trachomatis; gastroenteritis due to rotavirus and adenovirus, bacterial pneumonia and meningitis, and acute tonsillitis due to beta-hemolytic group A streptococci.

Pharmacokinetic evaluation of single daily dose amikacin.

The pharmacokinetic parameters of amikacin given once daily were compared to those of amikacin given bd at different daily dosages. In adult patients, 'peak' serum concentrations (30 min after 30 min infusion) were linearly proportional to the dose given with the following equation:-'peak' = 4.23 (dose in mg/kg)-3.93 (r, 0.827; P less than 0.0001). Areas under curves were also proportional to the dose and were not affected by the schedule of administration (od or bd). Serum half-life was neither affected by the dose nor the schedule of administration. However, the half-life was approximately 3 h in adult patients with infections and was greater than 4 h in elderly patients. In multiple dose studies, no accumulation was observed either in children or adults. However, 'peak' serum concentrations increased slightly. New recommendations for therapeutic drug monitoring need to be formulated.

In vitro susceptibility of aerobic gram-negative blood culture isolates to oxolinic acid, norfloxacin, ciprofloxacin, enoxacin, pefloxacin, ofloxacin and oxo-enoxacin.

100 gram-negative strains isolated from blood cultures were selected for the evaluation of the in vitro activity of oxolinic acid, norfloxacin, ciprofloxacin, enoxacin, pefloxacin, ofloxacin and oxo-enoxacin. Ciprofloxacin showed the highest intrinsic activity. Oxo-enoxacin, the major metabolite of enoxacin, was 10-15-fold less active than enoxacin. Against Enterobacteriaceae and Vibrionaceae, all fluorinated quinolones except norfloxacin were equally effective, while against non-fermenters, ciprofloxacin and ofloxacin demonstrated greater activity than the others. Resistance to oxolinic acid had a detrimental effect on susceptibility to the new fluorinated quinolones.