Bacterial isolation and antibiotic susceptibility from diabetic foot ulcers in Kenya using microbiological tests and comparison with RT-PCR in detection of S. aureus and MRSA.

OBJECTIVES: Diabetic foot ulcers (DFUs) often lead to hospital admissions, amputations and deaths; however, there is no up-to-date information on microbial isolates from DFUs and no mention of utilization of molecular techniques in Sub-Saharan Africa. We conducted a cross-sectional study among 83 adult patients at a tertiary hospital in Kenya over 12 months. The study aimed to isolate, identify bacteria, their antibiotic susceptibility patterns in active DFUs, and to compare standard microbiological methods versus a real-time PCR commercial kit in the detection of Staphylococcus aureus DNA and methicillin-resistant S. aureus (MRSA) DNA. RESULTS: Eighty swabs (94%) were culture-positive; 29% were Gram-positive and 65% were Gram-negative. The main organisms isolated were S. aureus (16%), Escherichia coli (15%), Proteus mirabilis (11%), Klebsiella pneumoniae (7%) and Pseudomonas aeruginosa (7%). The bacterial isolates showed resistance to commonly used antibiotics such as ampicillin, amoxicillin, cefepime, ceftazidime, cefuroxime, clindamycin, erythromycin, piperacillin-tazobactam, tetracycline and trimethoprim-sulphamethoxazole (TMPSMX). Thirty-one percent of the S. aureus isolated and 40% of the Gram-negatives were multi-drug resistant organisms (MDROs). There was a high prevalence of nosocomial bacteria. MRSA were not identified using culture methods but were identified using PCR. PCR was more sensitive but less specific than culture-based methods to identify S. aureus.

Design and Comparative Evaluation of the Anticonvulsant Profile, Carbonic-Anhydrate Inhibition and Teratogenicity of Novel Carbamate Derivatives of Branched Aliphatic Carboxylic Acids with 4-Aminobenzensulfonamide.

Epilepsy is one of the most common neurological diseases, with between 34 and 76 per 100,000 people developing epilepsy annually. Epilepsy therapy for the past 100+ years is based on the use of antiepileptic drugs (AEDs). Despite the availability of more than twenty old and new AEDs, approximately 30% of patients with epilepsy are not seizure-free with the existing medications. In addition, the clinical use of the existing AEDs is restricted by their side-effects, including the teratogenicity associated with valproic acid that restricts its use in women of child-bearing age. Thus, there is an unmet clinical need to develop new, effective AEDs. In the present study, a novel class of carbamates incorporating phenethyl or branched aliphatic chains with 6-9 carbons in their side-chain, and 4-benzenesulfonamide-carbamate moieties were synthesized and evaluated for their anticonvulsant activity, teratogenicity and carbonic anhydrase (CA) inhibition. Three of the ten newly synthesized carbamates showed anticonvulsant activity in the maximal-electroshock (MES) and 6 Hz tests in rodents. In mice, 3-methyl-2-propylpentyl(4-sulfamoylphenyl)carbamate(1), 3-methyl-pentan-2-yl-(4-sulfamoylphenyl)carbamate (9) and 3-methylpentyl, (4-sulfamoylphenyl)carbamate (10) had ED50 values of 136, 31 and 14 mg/kg (MES) and 74, 53, and 80 mg/kg (6 Hz), respectively. Compound (10) had rat-MES-ED50 = 13 mg/kg and ED50 of 59 mg/kg at the mouse-corneal-kindling test. These potent carbamates (1,9,10) induced neural tube defects only at doses markedly exceeding their anticonvuslnat-ED50 values. None of these compounds were potent inhibitors of CA IV, but inhibited CA isoforms I, II and VII. The anticonvulsant properties of these compounds and particularly compound 10 make them potential candidates for further evaluation and development as new AEDs.

Two Simple Rules for Improving the Accuracy of Empiric Treatment of Multidrug-Resistant Urinary Tract Infections.

The emergence of multidrug-resistant (MDR) uropathogens is making the treatment of urinary tract infections (UTIs) more challenging. We sought to evaluate the accuracy of empiric therapy for MDR UTIs and the utility of prior culture data in improving the accuracy of the therapy chosen. The electronic health records from three U.S. Department of Veterans Affairs facilities were retrospectively reviewed for the treatments used for MDR UTIs over 4 years. An MDR UTI was defined as an infection caused by a uropathogen resistant to three or more classes of drugs and identified by a clinician to require therapy. Previous data on culture results, antimicrobial use, and outcomes were captured from records from inpatient and outpatient settings. Among 126 patient episodes of MDR UTIs, the choices of empiric therapy against the index pathogen were accurate in 66 (52%) episodes. For the 95 patient episodes for which prior microbiologic data were available, when empiric therapy was concordant with the prior microbiologic data, the rate of accuracy of the treatment against the uropathogen improved from 32% to 76% (odds ratio, 6.9; 95% confidence interval, 2.7 to 17.1; P < 0.001). Genitourinary tract (GU)-directed agents (nitrofurantoin or sulfa agents) were equally as likely as broad-spectrum agents to be accurate (P = 0.3). Choosing an agent concordant with previous microbiologic data significantly increased the chance of accuracy of therapy for MDR UTIs, even if the previous uropathogen was a different species. Also, GU-directed or broad-spectrum therapy choices were equally likely to be accurate. The accuracy of empiric therapy could be improved by the use of these simple rules.

Efficacy of an injectable combination anthelmintic (nitroxynil+clorsulon+ivermectin) against early immature Fasciola hepatica compared to triclabendazole combination flukicides given orally or topically to cattle.

The objective was to compare the efficacy against artificially induced 2- and 4-week old early immature triclabendazole-susceptible liver flukes (Fasciola hepatica) of an injectable combination of nitroxynil, clorsulon and ivermectin with oral and pour-on combination formulations containing triclabendazole. Groups of yearling Angus or Angus cross cattle were confirmed fluke free before being artificially infected with 500 Sunny Corner strain triclabendazole-susceptible liver fluke metacercariae. Two or four weeks after infection, cattle were treated with the test combination Nitromec (10.2mg/kg nitroxynil, 2.0mg/kg clorsulon, 0.2mg/kg ivermectin), or oral Flukazole C+Se (triclabendazole/oxfendazole/Selenium), oral Fasimec C (triclabendazole/ivermectin) or Genesis Ultra Pour-On (triclabendazole/abamectin). At intervals cattle were weighed, faecal sampled for liver fluke egg counts and blood sampled for liver serum enzyme analysis. Cattle were slaughtered 14 weeks after infection for recovery of adult flukes; fluke egg counts and liver pathology assessment. All cattle increased in body weight by 0.4-0.8kg/day but there were no significant differences between control and treated groups or between the treatment groups. Geometric mean 14-week fluke egg counts and total fluke counts for all treatments, were significantly less (p<0.05) than the control group, except for the group treated with Genesis Ultra Pour-On, 2 weeks after infection. Nitromec treatment of 2-week old flukes was 83% and 95% effective as assessed by 14-week egg and fluke counts, respectively, compared to Flukazole C; 96% and 99%, Fasimec C; 70% and 46%, and Genesis Pour-On, which was ineffective, with egg and fluke count reductions of 0% and 8%, respectively. Against 4-week old flukes, Nitromec treatment was 88% and 99% effective when assessed by 14-week egg and fluke counts, respectively, with Flukazole C; 98% and 99%, Genesis Pour-On; 98% and 82% and Fasimec C; 91% and 61% effective, respectively. Group mean levels of the bile duct-associated enzyme gamma glutamyl transpeptidase (GGT) and the parenchymal associated enzymes, aspartate amino-transferase (AST) and glutamate dehydrogenase (GLDH) increased above the normal range 8 and 11 weeks after infection in the untreated control animals and the group treated 2 weeks after infection with Genesis Pour-On. The groups treated with Fasimec at 2 or 4 weeks after infection, also had elevated enzyme levels. The use of liver-associated enzyme assay is supported as supplementary indicators of fluke-induced pathology.

Defective DNA repair as a potential mechanism for the rapid development of drug resistance in Plasmodium falciparum.

The development and spread of highly drug-resistant parasites pose a central problem in the control of malaria. Understanding mechanisms that regulate genomic stability, such as DNA repair, in drug-resistant parasites and during drug treatment may help determine whether this rapid onset of resistance is due to an increase in the rate at which resistance-causing mutations are generated. This is the first report to demonstrate DNA repair activities from the malaria-causing parasite Plasmodium falciparum that are specific for ultraviolet light-induced DNA damage. The efficiency of DNA repair differs dramatically among P. falciparum strains with varying drug sensitivities. Most notable is the markedly reduced level of repair in the highly drug-resistant W2 isolate, which has been shown to develop resistance to novel drugs at an increased rate when compared to drug-sensitive strains. Additionally, the antimalarial drug chloroquine and other quinoline-like compounds interfered with the DNA synthesis step of the repair process, most likely a result of direct binding to repair substrates. We propose that altered DNA repair, either through defective repair mechanisms or drug-mediated inhibition, may contribute to the accelerated development of drug resistance in the parasite.

[Current approaches to treatment of secondary sulfonylamide drug resistance in Type II diabetes mellitus]. / Sovremennye podkhody k lecheniiu vtorichnoi sul'fanilamidnoi rezistentnosti pri sakharnom diabete II tipa.

A differentiated approach toward treating secondary sulfanilamide resistance in patients with type II diabetes and proposed therapeutic regimens simple enough to be adopted in the management of the patients in question permit achieving satisfactory hypoglycemic effect maintaining an acceptable level of glucose in the blood.

An overview of selected diseases and drug needs in the llama and alpaca industries.

The North American llama and alpaca industries will probably continue to expand at a rate of 20-25% per year for at least the next one to two decades. As a result, while the total population will always be small relative to the cattle and swine industries, the total numbers of alpacas and llamas will be substantial. Accordingly, it is appropriate and timely to begin the process of getting drugs approved for usage in these species. Four drugs that warrant consideration for NRSP-7 evaluation and approval are: Ivermectin for the prevention of P. tenuis infections. Chlorsulon for the treatment of Fasciola hepatica infections. Ceftiofur sodium for the treatment of various bacterial infections. Omeprazole for the management and prevention of third compartment ulcers.

The use of glucan as immunostimulant in the treatment of paracoccidioidomycosis.

A group of 10 patients, nine of them seriously infected with Paracoccidioides brasiliensis (G1), received glucan (beta-1,3 polyglucose) as an immunostimulant intravenously once a week for one month, followed by monthly doses (10 mg) over an 11-month period, together with a specific anti-fungal agent as an immunostimulant. A second group of eight moderately infected patients (G2) was treated with only the anti-fungal agent. Among the patients in G1, there was only one case of relapse compared with five in G2. Values for the erythrocyte sedimentation rate (ESR) showed a significant difference (P < 0.001) post-treatment in G1 patients, when compared with the pretreatment levels. There was also a significant reduction (P < 0.001) in the level of serum antibodies to P. brasiliensis in the G1 patients in post-treatment examinations. The phytohemagglutinin (PHA) skin test showed a positive reaction among the patients in G1 (P < 0.01) post-treatment and there was a tendency towards an increase in the number of CD4+ T lymphocytes in both groups after treatment. The serum level of tumor necrosis factor (TNF) proved to be significantly higher (P < 0.02) in the G1 patients during treatment. In the G1 patients, the correlation between ESR and TNF tended to be negative whereas that between ESR and serum antibodies was positive. The present results indicate that the patients who received glucan, in spite of being more seriously ill, had a stronger and more favorable response to therapy.

[A new drug sulfaton in the combined treatment of infections with sulfanilamide derivatives and diaminopyrimidine]. / Novyi preparat su'lfaton v kombinirovannoi terapii infektsii proizvodnymi su'lfanilamida i diaminopirimidina.

Derivatives of diaminopyrimidine as potentiators of the effect of the derivatives of sulfanilamide and other antibacterial drugs are discussed. Experimental data on sulfation, a new combined preparation, based on sulfamonomethoxine (a sulfanilamide derivative) and trimethoprim (a diaminopyrimidine derivative) are presented. Brief clinical characteristics of sulfation, its administration routes, doses, dosage advantages and better tolerance as compared to co-trimethoxazole+ (biseptol) are described.

Chemotherapy of caecal coccidiosis: efficacy of toltrazuril, sulphaquinoxaline/pyrimethamine and amprolium/ethopabate, given in drinking water, against field isolates of Eimeria tenella.

Treatment with toltrazuril, sulphaquinoxaline/pyrimethamine and amprolium/ethopabate prevented mortality in chickens infected with field isolates of Eimeria tenella. Amprolium/ethopabate was the most effective drug in reducing lesions caused by the parasites. Few oocysts of E tenella were produced in birds medicated with sulphaquinoxaline/pyrimethamine or amprolium/ethopabate and none in those medicated with toltrazuril.

The combined use of artemether, sulfadoxine and pyrimethamine in the treatment of uncomplicated falciparum malaria.

29 male patients (14 from Taunggyi, 6 from Rangoon and 9 from Tharrawaddy in Burma) were treated simultaneously with 200 mg artemether (Single intramuscular dose), 1500 mg sulfadoxine and 75 mg [corrected] pyrimethamine (orally). The mean parasite clearance time was 106.7 +/- 48.7 h. Side effects were few and self-limiting. 13 of 29 patients had recrudescences before day 28; as all the patients were living in towns, reinfection was unlikely. This parasite clearance time was longer than that in patients treated with artemether alone (600 mg total dose), and the recrudescence rate was higher. This drug combination is not recommended for patients in areas where sulfadoxine/pyrimethamine resistance is already established.

Comparative efficacy of alternative primary therapies for Plasmodium falciparum infections in Malawi.

In Malawi, where high levels of chloroquine resistance were shown using a modified 7-day in vivo test, amodiaquine and pyrimethamine-sulfadoxine were evaluated as alternative initial therapies for Plasmodium falciparum infections in children under 5 years old. Therapy success rates, judged by parasite clearance by day 7 after initiation of therapy, were significantly greater among 39 children treated with amodiaquine at 10 mg/kg (90%), 37 receiving amodiaquine at 25 mg/kg (97%), and 34 receiving pyrimethamine-sulfadoxine (100%) at a dose of 25 mg sulfadoxine/kg, than among those treated with chloroquine at a dose of 25 mg/kg (59%) (P = 0.01). Extension of the follow-up period of those receiving amodiaquine (25 mg/kg) and pyrimethamine-sulfadoxine to 21 d revealed a progressively increasing rate of parasite recrudescence in the amodiaquine group (34%), but no recrudescence in the pyrimethamine-sulfadoxine group. These results suggest that, in Malawi, amodiaquine and pyrimethamine-sulfadoxine are superior to chloroquine in producing prompt clearance of P. falciparum parasites among young children, and that pyrimethamine-sulfadoxine alone is superior to the 4-aminoquinolines in sustaining P. falciparum clearance.

[Pharmacological activity of the furfuryl amine salt of 4-chloro-N-(2-furylmethyl)-5-sulfamoyl anthranilic acid]. / Farmakologicheskaia aktivnost' furfurilaminovoi soli 4-khlor-N-(2-furilmetil)-5-sul'famoilantranilovoi kisloty.

Furfuryl amine salt of 4-chloro-N-(2-furylmethyl)-5-sulfamoyl anthranilic acid was shown to exert more pronounced diuretic and saluretic action in rats, mice and dogs than that of furosemide. The previous administration of furfuryl amine salt of furosemide promoted normalization of the excretory processes of the kidney and increased survival rate of rats in ischemia of the single kidney. The antiedema activity of the drug was found to be much more pronounced than that of furosemide.

The susceptibility of Plasmodium falciparum to sulfadoxine and pyrimethamine: correlation of in vivo and in vitro results.

In 1982, 2 of 14 Plasmodium falciparum infections acquired in East Africa and diagnosed in Copenhagen were resistant to treatment with sulfadoxine plus pyrimethamine (Fansidar), while in 1983, 6 of 18 were so. The in vivo tests were supplemented by determinations of drug concentrations in serum, and 4 isolates from in vivo-sensitive cases and 6 from in vivo-resistant cases were selected for in vivo tests. These were performed in ordinary RPMI 1640 medium and in a medium with physiological p-aminobenzoic acid and folic acid concentrations. Pharmacokinetic aberrations were found to be of possible importance in only 2 of the in vivo-resistant cases. In vitro susceptibility to sulfadoxine was found to be uniformly low in all isolates. Testing with a combination of sulfadoxine and pyrimethamine in the medium with physiological concentrations of cofactors probably reflects the in vivo situation most accurately, but in all but 1 of the isolates studied in vitro the in vivo susceptibility to Fansidar would be predicted by in vitro susceptibility to pyrimethamine in either medium. The concentration of p-aminobenzoic acid in serum, quantitated by high performance liquid chromatography, was found to be subject to wide variation, and this may have implications for in vitro testing.

[Antibiotic treatment of perforated appendicitis in childhood--a prospective study]. / Die antibiotische Behandlung der Appendicitis perforata im Kindesalter--Eine prospektive studie.

A prospective randomised study (I) was carried out on 130 children undergoing laparotomy for perforated appendicitis. The present study evaluates the therapeutic effectiveness of different antibiotic regimens in modifying the rate of post-operative complications (intraabdominal abscess, ileus, wound infiltration or abscess). During the first year of this study two treatment groups were used. Group A consisted of 29 children treated with Sulfometrol/Trimethoprim; the rate of postoperative complications was 44.8%. Group B consisted of 36 children treated with mezlocillin, the rate of complications being 13.8%. However, the same treatment with mezlocillin during the second year of the prospective study showed an increase of this rte to 39% (28 children--group C). The final group of 37 children was treated during the second year with mezlocillin and metronidazole (group D). The postoperative rate of complications was 10.8%. A retrospective analysis of further 80 children (study II) with perforated appendicitis treated with mezlocillin and metronidazole showed a consistent low rate of postoperative complications at 10.2%. In 6.8% of children studied, an operative intervention was necessary (four cases of ileus, four wound abscesses). The mean postoperative hospitalisation period decreased from 22.7 days in group A to 15.2 days in group D and finally to 14 days in study II. The present study shows that an effective and persistent attenuation of the rate of postoperative complications after perforated appendicitis in children depends on an early onset of therapy and on the appropriate choice of antibiotic drugs that are effective against aerobic and anaerobic microorganisms.

In vivo and in vitro susceptibility of Plasmodium falciparum to sulphadoxine/pyrimethamine in Liberia, West Africa.

The in vivo response of Plasmodium falciparum to standard treatment with sulphadoxine/pyrimethamine was studied in 19 hospital patients from Yekepa town with hypoendemic malaria and in 28 children, two to nine years old, living in a village with holoendemic malaria. In vitro tests were performed on eight isolates. In the hospital patients all parasites cleared with mean clearance time of 2.2 (range one to three) days and no recrudescence occurred during a 28-day follow-up period. In the village children, despite a high sporozoite inoculation rate, recurrent parasitaemias were only recorded after 28 days, suggesting a rather long-lasting prophylactic effect against reinfection by the drug combination. In vitro, inhibition of parasite multiplication was achieved by 3 X 10(-7) M sulphadoxine and 3.8 X 10(-9) M pyrimethamine.

Malignant pyoderma.

Malignant pyoderma is a destructive, ulcerating skin disease that occurs chiefly in young adults. Only eight cases of this rare disease have been reported. The head and neck have been involved in all cases, and a predilection for the periauricular region has been noted in several of the cases. Although the disease is progressive and chronic, responses to high-dose systemic corticosteroids have been noted, but usually a flare is associated with a reduction in dose. An additional case is described in which therapy with isotretinoin and sulfapyridine led to complete remission.

Evaluation of a mixture of trimethoprim and sulphaquinoxaline for the treatment of poultry: safety and palatability studies.

The safety of a 1:3 mixture of trimethoprim (TMP) and sulphaquinoxaline (SQX) for administration in food or water was assessed in broiler chickens, chicks of an egg laying strain and breeding fowl. The only effects recorded in six-week-old broilers medicated for seven days at levels ranging from 16 to 133 mg TMP plus SQX per kg bodyweight were decreases in water or food consumption, probably caused by unpalatability at overdosage levels, and associated decreases in weight gain and packed cell volume at an achieved overdose level of 4.4 times the recommended use concentration (RUC). Breeding fowl medicated at levels of 1 X or 3 X RUC for 14 days showed slightly reduced reproductive performance reflected by lowered egg production, egg weight and hatchability. These effects were temporary and performance equal to that of unmedicated birds was re-established by 14 days after medication ceased. Week-old chicks medicated for five days at levels from 0.7 to 4.7 X RUC showed normal growth rate over 12 days. Eleven-day-old chicks could not distinguish medicated from unmedicated water.

Evaluation of a mixture of trimethoprim and sulphaquinoxaline for the treatment of bacterial and coccidial diseases of poultry.

Representative experiments from work undertaken to develop a synergistic mixture of trimethoprim and sulphaquinoxaline for the preventive treatment of certain poultry diseases are described. Sulphaquinoxaline in the diet for four days was shown to achieve at least an 85 per cent higher blood level than nine other sulphonamides in chicks, and the efficacies of various trimethoprim/sulphaquinoxaline regimes in the diet or in the drinking water were demonstrated against pasteurellosis, colisepticaemia and five kinds of coccidiosis. Regimes for bacterial diseases were begun one day before infection but those for coccidial diseases were begun on the same day as infection or later. Overall, a total dose of 30 mg/kg bodyweight/day (trimethoprim/sulphaquinoxaline = 1:3) controlled these seven diseases. The same treatment was also shown to control sulphaquinoxaline-resistant strains of Escherichia coli and Eimeria acervulina. Although both drinking water and food were used for drug administration, twice the inclusion rate was required in food to that in water for equivalent efficacy. The significance of different modes of expression of dosages for bacterial and coccidial diseases is explained.