Human deficiency of the eighth component of complement. The requirement of C8 for serum Neisseria gonorrhoeae bactericidal activity.

The serum of a 23-yr-old woman with prolonged disseminated gonococcal infection syndrome failed to normally promote hemolysis of sensitized sheep red blood cells (RBC). The patient's serum was deficient in the eight component of complement (C8) as determined by functional assays, immunoelectrophoresis, and quantitative immunoprecipitation. Functional titers of each of her other complement components were normal. No serum inhibitors of C8 were detected. The patient's serum supported activation of both the classical and alternate complement pathways. Her fresh serum lacked any bactericidal activity against Neisseria gonorrhoeae, but addition of purified C8 or complement donor serum restored bactericidal activity as well as RBC hemolytic activity. Her serum gave normal opsonization of yeast particles and staphylococci and had normal capacity to coat sensitized RBC with C8 and C4 and to generate chemotactic activity. No defects were observed in the patient's blood coagulation mechanisms. Complement-mediated bacterial lysis may be important in human defense against bacteremic Neisseria infections.

Human seminal plasma inhibition of antibody complement-mediated killing and opsonization of Neisseria gonorrhoeae and other gram-negative organisms.

Seminal plasma diluted 1:5-1:1,000 gave marked inhibition of serum antibody complement-mediated bactericidal and opsonic effects against Neisseria gonorrhoeae and other gram-negative organisms. Serum that was bactericidal at a dilution of 1:5,120 was not bactericidal at a dilution of 1:10 when seminal plasma was added. Bactericidal action of immune human or rabbit sera, or purified immunoglobulin (Ig)G or IgM plus complement for six strains of N. gonorrhoeae, serogroups A, B, C, and Y of Neisseria meningitidis, Escherichia coli and other gram-negative rods was inhibited by seminal plasma. Using C8- or C7-deficient sera as antibody and complement sources, opsonization, phagocytosis, and killing of N. gonorrhoeae and E. coli 014-K7 were inhibited by seminal plasma. Opsonization, phagocytosis, and killing of Staphylococcus aureus 502A was not inhibited. For the gram-negative organisms, the early phase of the opsonization process, probably complement activation, appeared to be inhibited rather than the ingestion or polymorphonuclear leukocyte killing steps; addition of seminal plasma yielded a significant reduction in the percentage of polymorphonuclear cells with associated bacteria. Seminal plasma did not prevent attachment of IgG, IgM, or IgA antibodies to gonococci. It reduced serum hemolytic whole complement activity by 25%. The seminal plasma inhibitor was of low molecular weight and was stable at 56 degrees C for 30 min, but inhibitory activity was lost after heating to 100 degrees C for 10 min. It is likely that the inhibitory factor(s) is a low-molecular weight protease or protease inhibitor. Seminal plasma probably has an important role in inhibition of complement and antibody functions in the genital tract. It may enhance pathogenesis of agents of sexually transmitted diseases.

Vancomycin-induced neutropenia complicating bone marrow recovery in a patient with leukemia. Case report and review of the literature.

Neutropenia associated with intravenous vancomycin therapy is reported in a patient with chronic myelogenous leukemia. The patient received 12 days of vancomycin therapy without incidence; however, a second course of vancomycin initiated on hospital day 14 produced severe neutropenia. This delayed onset is typical of vancomycin-induced neutropenia. The neutropenia reversed, without complications, as soon as the vancomycin was discontinued.

Histoplasmosis in immunosuppressed patients.

Infection with Histoplasma capsulatum in 58 patients whose immune responses were suppressed (Immunosuppressed patients) (16 from the present series and 42 described previously) was analyzed. The most common underlying diseases were Hodgkin's disease (29 per cent), chronic lymphocytic leukemia (19 per cent) and acute lymphocytic leukemia (17 per cent). Sixty-three per cent of the patients had received cytotoxic drugs, and 57 per cent had taken corticosteroids. Widely disseminated infection occurred in 88 per cent of the patients, with predominant involvement of lungs and organs of the reticuloendothelial system. Localized pulmonary infection was present in the remaining patients. The most useful diagnostic method was bone marrow biopsy with microscopic examination for the intracellular yeast form of H. capsulatum. Biopsy of oral lesions, lung, liver and lymph node also proved diagnostically helpful. Growth of H. capsulatum in culture was frequently too slow to be beneficial in diagnosing histoplasmosis in ill patients. Serologic methods were of little diagnostic help in this population of immunosuppressed patients. The response to amphotericin B therapy was excellent (6.7 per cent mortality rate) in those patients in whom the diagnosis was established early and in whom a full course of antifungal therapy could be given. In contrast, the mortality rate in patients who received no antifungal therapy or less than 1 g of amphotericin B was 100 per cent.

Evaluation of broth media for routine culture of cerebrospinal and joint fluid specimens.

Broth cultures of cerebrospinal and joint fluids are important components in the culture detection of meningitis and septic arthritis. The authors examined 121 strains of bacteria isolated from clinical specimens representing 13 species or groups that cause meningitis and arthritis for growth in supplemented Thioglycolate broth (THIO), Supplemented Peptone Broth (SPB), and minced beef heart (MBH) media each alone or with added IsoVitaleX. Both SPB and MBH with IsoVitaleX performed better as broth culture media than the media without IsoVitaleX or THIO with or without IsoVitaleX.

Comparison of two BACTEC anaerobic culture media for recovery of anaerobic bacteria.

A selection of 22 anaerobic isolates, originally recovered from sterile body sites or wounds, was cultured in parallel in BACTEC anaerobic NR7A and lytic 37A bottles supplemented with volunteer human blood. The overall detection rate was 95% for the 37A medium and 75% for the NR7A medium (P = 0.003). The growth indices were consistently higher in the 37A bottles, and a positive result occurred sooner in the 37A medium in 11 of the 32 bottles positive in both media. In an analysis of patient specimens, the NR7A bottle had a 14% false-positive rate compared with 3% for the 37A bottle. The increase in recovery, coupled with the decrease in false-positive readings, make the lytic 37A bottle more efficacious than the NR7A bottle as an anaerobic culture medium.

Bactericidal action of nafcillin, vancomycin, and three cephalosporins against nafcillin-susceptible and nafcillin-resistant coagulase-negative staphylococci.

Coagulase-negative staphylococci (S. epidermidis, 43 strains; S. warneri, 16 strains; S. haemolyticus, five strains; and others, four strains) were tested by the agar dilution method for nafcillin susceptibility: 53 were susceptible with a minimal inhibitory concentration (MIC) of less than or equal to 2 micrograms/ml; four were of indeterminate susceptibility, MIC = 4-16 micrograms/ml; and 11 were resistant, MIC greater than or equal to 32 micrograms/ml. The bactericidal activities from 0 to 24 hr for nafcillin, vancomycin, cephalothin, cefazolin, and cefamandole, each at 16 micrograms/ml in broth, were determined for all the isolates. The data indicate that a nafcillin agar dilution susceptibility test result of resistance does not consistently predict lack of killing activity by the cephalosporins. It is likely that each cephalosporin would have to be tested against individual coagulase-negative staphylococci in order to determine a suitable therapeutic or prophylactic cephalosporin, if a cephalosporin were to be used. Vancomycin was bactericidal for all the nafcillin-resistant coagulase-negative organisms tested.

Infections or neoplasm as causes of prolonged fever in cancer patients.

Thirty-six consecutive patients with cancer who met the classical criteria for fever of unexplained origin (FUO) were identified. A total of 18 patients had infections including all 12 with leukemia, four of 12 with Hodgkin's disease, and two with solid tumors. Fungal infections were found in nine: histoplasmosis, three; candidiasis, three; and aspergillosis, systemic sporotrichosis, or cryptococcal meningitis, one each. Six patients had unresolved pyogenic infections and one had tuberculous pericarditis. Two others had viral etiologies. Granulocytopenia was significantly more common in the FUO patients with documented infections. Clinical or laboratory abnormalities suggesting involvement of a specific organ or organ system provided important clues indicating infections. Morphological examination of biopsy specimens, with cultures, was the best method for diagnosis. In 18 patients, 12 with lymphomas and 6 with solid tumors, only the neoplasm appeared responsible for the fever. In these patients there was a paucity of abnormalities indicating organ system involvement with infection. Regardless, physicians' diagnostic efforts should not be deterred in such patients. Repeated thorough evaluations for infection are warranted.

Synergistic action of trimethoprim and sulfamethoxazole for Nocardia asteroides: efficacious therapy in five patients.

Eighteen isolates of Nocardia asteroides were tested for in vitro susceptibility to trimethoprim (TMP) and sulfamethoxazole (SMZ) alone and in various combinations using disc and paper strip diffusion tests. TMP-SMZ showed synergistic action for two-thirds of teh nocardia isolates tested. Five patients with Nocardia pneumonia were treated with TMP-SMZ and all were cured. Four of the patients' isolates were tested and all showed synergistic patterns of inhibition with the spaced disc and paper strip methods. The agar diffusion disc and synergy tests of TMP-SMZ appear to correlate with clinical usefulness when the Nocardia are susceptible with large zones of inhibition around the combination TMP-SMZ disc.

Use of a siderophore detection medium, ethylene glycol degradation, and beta-galactosidase activity in the early presumptive differentiation of Nocardia, Rhodococcus, Streptomyces, and rapidly growing Mycobacterium species.

A simplified scheme for the presumptive early identification of Nocardia, Rhodococcus, rapidly growing Mycobacterium, and Streptomyces species is presented. The Nocardia and Streptomyces spp. and the Mycobacterium spp. were positive. The spp. were positive for siderophore activity, but only 25% of the Rhodococcus spp. were positive. The Rhodococcus and Mycobacterium spp. were negative for beta-galactosidase, while the Nocardia and Streptomyces spp. were positive. The Nocardia and Streptomyces spp. and the Mycobacterium spp. were negative for ethylene glycol degradation, while 75% of the Rhodococcus spp. were positive. In combination, these tests were useful for differentiating Mycobacterium, Rhodococcus, and Nocardia species but did not differentiate Nocardia from Streptomyces species.

Clinical use of the new beta-lactam antimicrobial drugs. Practical considerations for physicians, microbiology laboratories, pharmacists, and formulary committees.

New beta-lactam antimicrobial agents with extended antibacterial activity for gram-negative bacilli are being developed and marketed. These drugs provide major advances, especially for treatment of serious infections caused by multiresistant organisms. Several of the drugs have been marketed and many more will be available. Some of these drugs are considerably more costly than the older beta-lactams. The large number of new antimicrobial drugs coupled with their high costs pose complex problems for physicians, microbiology laboratories, and pharmacists. Community hospitals, large general hospitals, and tertiary care hospitals have different needs for patient care and will need different formats for unbiased education, susceptibility testing, pharmacy stocking, and controlling or monitoring for inappropriate use.

Studies on the relationships between serum bactericidal activity and uncomplicated genital infections due to Neisseria gonorrhoeae.

This report concerns the relationships between patients' uncomplicated genital infections due to Neisseria gonorrhoeae and the bactericidal activity of their sera against their infecting organisms. Forty isolates of N. gonorrhoeae and 91 serum samples were obtained from 23 patients with their first or repeated gonococcal infections. Of 32 sera obtained at the time of infection, 14 (44%) were bactericidal for the infecting strains. Of convalescent-phase sera from 27 infections, 12 (44%) were bactericidal; 22%-33% of convalescent-phase sera had increased bactericidal activity when compared with acute-phase sera or sera obtained before infection. Eleven patients developed 17 new infections after sera and negative cultures were obtained; in six (35%) the previously obtained sera were bactericidal but did not prevent infection.

Parameters of normal polymorphonuclear cell function in patients with repeated gonococcal infections.

The response to phagocytic stimuli was tested for polymorphonuclear (PMN) cells from gonorrhea repeaters, first-time infected patients, and never-infected controls. PMN function was assessed by measuring quantitative leukocyte iodination, glucose-1-C oxidation, and phagocytosis and killing of Staphylococcus aureus 502A. No significant differences in PMN function were noted for the three groups studied. However, white patients had significantly greater leukocyte iodination than black patients (p less than 0.05) and males tended to have greater leukocyte iodination than females (p less than 0.02). It is concluded that PMN cells from gonorrhea repeaters, first-time infected patients, and never-infected controls respond equally well to in vitro phagocytic stimuli. This implies that a significant defect in PMN cell function should not be implicated as a reason for the apparent susceptibility of gonorrhea repeaters to multiple genital gonococcal infections.

Expression of gonococcal protein II in Escherichia coli by translational fusion.

A protein II (P.II) gene from Neisseria gonorrhoeae was cloned in Escherichia coli and characterized by DNA sequence analysis. As with other reported P.II sequences, this gene contains an ATG initiation codon which is out of frame with respect to the remainder of the P.II amino acid sequence. A translational fusion was constructed in E. coli which linked the P.II sequence to the signal peptide of beta-lactamase. This P.II fusion differs from the gonococcal protein only in the first seven residues at the N terminus. In E. coli, the P.II fusion product exhibits properties analogous to those of P.II in N. gonorrhoeae. The P.II fusion product is a major component of the E. coli outer membrane and it is exposed on the cell surface. The P.II fusion protein also exhibits the heat-modifiable phenotype of gonococcal P.II.

DNA amplification and reverse dot blot hybridization for detection and identification of mycobacteria to the species level in the clinical laboratory.

A method incorporating DNA amplification and reverse dot blot hybridization for the detection and identification of mycobacteria to the species level is described. The amplification procedure allowed for the incorporation of digoxigenin-labeled UTP, which was detected by chemiluminescence, removing the need for radioactivity. Using a set of primers and probes from the gene for the 65-kDa heat shock protein of mycobacteria, previously reported in the literature, the reverse dot blot method correctly identified 12 of the 12 M. tuberculosis isolates and 45 of the 50 M. avium complex isolates. Two of the nonhybridizing M. avium complex isolates were reidentified as M. xenopi. The other three nonhybridizing M. avium complex isolates, which were identified as M. intracellulare, hybridized with the probe for M. tuberculosis, as did two ATCC strains of M. intracellulare. The amplified DNA of M. intracellulare was sequenced, and the sequence was compared with the sequence from M. tuberculosis. The sequence for M. avium differed from M. tuberculosis by 5 of 20 bases. The sequence for M. intracellulare differed from M. tuberculosis by 2 of 20 bases, but this difference did not result in sufficient thermal instability to affect hybridization. The use of chemiluminescence allowed as few as 10(2) CFU to be detected. The format of the assay is readily applicable for implementation in the clinical laboratory.

Evaluation of the autoSCAN-W/A rapid system for identification and susceptibility testing of gram-negative fermentative bacilli.

The autoSCAN-Walk-Away (W/A) system for identification and susceptibility testing was evaluated for 400 gram-negative fermentative bacteria by using the API 20E (366 isolates) and/or tube biochemical tests as the reference identification system and a frozen microdilution MIC tray system for susceptibility testing. The W/A system performed well for identification of this group of organisms representing 14 genera and 30 species, showing a sensitivity of 96% and results available in 2 h. Of the 16 misidentifications, 6 were with Serratia liquefaciens. A total of 63 isolates (17%) required further tests to complete the identification, compared with 106 (29%) of the isolates which required additional tests for the API 20E identification. Approximately half (32) of the additional tests with the W/A system were required in order to separate Citrobacter diversus from C. amalonaticus. For susceptibility determinations, the W/A system demonstrated an overall agreement of 93% (4,102 determinations) with 40 major errors (0.98%). However, of the 906 resistant organism-drug combinations in the study, there were 115 very major errors, for a false-susceptibility rate of 12.7% of the resistance determinations. Among these very major errors, 80% occurred with piperacillin and the cephalosporins. The W/A system completed the MIC determinations in 7 h; however, the difficulty in detecting resistance with some antimicrobial agents limited the advantages of the rapid susceptibility testing.