Antibacterial mechanisms of the lower respiratory tract. I. Immunoglobulin synthesis and secretion.

Immunoglobulin synthesis and secretion have been studied in the rabbit lower respiratory tract, both in the normal state and after infection with Diplococcus pneumoniae or Listeria monocytogenes. In vitro synthesis of immunoglobulin and specific antibody was assessed by incorporation of 14C-labeled amino acids into protein. Lower respiratory tract secretions and serum were analyzed for immunoglobulin and antibody against the infecting organism. Normal respiratory tract produced small quantities of immunoglobulin, most of which was IgG. After bacterial infection of the lower respiratory tract, there was a marked increase in local synthesis of immunoglobulin, especially IgG. Specific antibody of IgG class was produced in all lungs infected with listeria by the 11th day, and in lungs infected with pneumococcus by the 8th day. Secretions from all normal and infected lower respiratory tracts contained IgA and IgG. The IgA to IgG ratios in secretions of normal animals, and animals infected with listeria or pneumococcus, were 2.3, 2.5, and 2.6, respectively. Sera of animals infected with L. monocytogenes contained specific antibody of IgG class but lacked IgA antibody, whereas secretions had both IgA and IgG class antibody against listeria. Similarly, sera of animals infected with D. pneumoniae had IgG class antibody but no IgA antibody, whereas only IgA antibody was found in secretions. The evidence that locally synthesized immunoglobulin (especially IgA), including specific antibody, is secreted into the lower respiratory tract lumen is discussed. Further definition of the role of "local" antibacterial antibody in the respiratory tract is of considerable importance.

Cell-mediated immunity after bacterial infection of the lower respiratory tract.

Lower respiratory tract and systemic cell-mediated immunity have been studied in rabbits after infection with Listeria monocytogenes or Diplococcus pneumoniae. Respiratory tract cell-mediated immunity was evaluated by direct and indirect assays of migration inhibitory factor (MIF) production. Systemic delayed hypersensitivity was determined by means of intradermal testing with appropriate antigens. Aerosol exposure to listeria was followed by markedly increased numbers of free lower respiratory tract cells. These cells manifested antigen-stimulated inhibition of migration (mean inhibition of migration = 30.4%). Pneumococcal pneumonia was associated with similar but less dramatic changes. Intravenous administration of organisms was uncommonly followed by inhibition of lower respiratory tract cells in direct migration assays. Fractionated MIF, as well as crude supernates of antigen-stimulated lower respiratory tract and lymph node lymphocytes from animals exposed to listeria aerosols, caused inhibition of normal alveolar macrophage migration. MIF, produced by lymph node lymphocytes, has a molecular weight of approximately 65,000 and is inactivated by chymotrypsin or neuraminidase. Delayed dermal hypersensitivity to listeria antigen was observed in 54 of 55 animals exposed to listeria aerosols and in all 9 animals infected by the intravenous route. Delayed dermal reactions to pneumococcal sonicate antigen (but not capsular polysaccharide) followed D. pneumoniae respiratory tract infection in 19 of 28 animals, and was elicited in 5 of 6 animals after intravenous infection. Both local (macrophage migration inhibition) and systemic delayed hypersensitivity followed bacterial infection of the lower respiratory tract. MIF activity was shown to be one mechanism for inhibition of alveolar macrophage migration.

Increased polymorphonuclear leukocyte respiratory burst function in type 2 diabetes.

The predisposition to infection and chronic inflammation in diabetes may in part be related to the effects of hyperglycemia or other metabolic abnormality on polymorphonuclear leukocytes (PMN). We evaluated oxidative respiratory burst activity (superoxide production) in non-stimulated and stimulated PMN from 70 stable type 2 Hispanic diabetic patients, as compared to 70 healthy Hispanic individuals without diabetes. The influences of protein kinase C (PKC) inhibitors and certain antibiotics on superoxide production were examined. Both resting and stimulated (PMA, zymosan) PMN from diabetic individuals produced more superoxide than PMN from controls. Inhibitors of PKC, a possible mediator of the augmented respiratory burst activity, decreased superoxide production in all (resting and stimulated) diabetic and control PMN. Azithromycin, which is markedly concentrated by PMN, profoundly inhibited superoxide generation in all groups of diabetic and control cells. PMN from Hispanic diabetic patients produced greater quantities of superoxide than non-diabetic controls. This increased oxidative respiratory burst activity may predispose to infection and chronic inflammation in diabetes. PKC inhibitors and azithromycin inhibited this respiratory burst response. The possible role of PKC (especially PKC beta) as the mediator of this augmented respiratory burst response requires further evaluation, and may lead to therapeutic studies with appropriate inhibitors.

Effect of Intraoperative Phenylephrine Infusion on Redistribution Hypothermia During Cesarean Delivery Under Spinal Anesthesia.

An observational clinical study to evaluate the effect of phenylephrine infusion on maternal temperatures during scheduled cesarean delivery under spinal anaesthesia was conducted in 40 ASA physical status II parturients. Following placement of spinal anesthesia, phenylephrine infusion was initiated at 40 µg/min and titrated to maintain mean arterial pressure within 20 percent of baseline. Maternal oral temperature, heart rate, and blood pressure were measured at baseline, spinal placement, every 10 minutes thereafter for 60 minutes. Phenylephrine dose received was documented every ten minutes. The range in maternal temperature change was 0.06-0.29°C. The lowest recorded temperature was 36.3°C. Decreased maternal temperature was associated with duration of anesthesia and cumulative phenylephrine dose in a univariate model (P<0.001 for all). The multivariable model showed an association between a greater decrease in maternal temperature with larger doses of phenylephrine being administered.

Characteristics and mechanisms of azithromycin accumulation and efflux in human polymorphonuclear leukocytes.

Azithromycin achieves prolonged, high tissue concentrations in spite of low serum levels and obviously must be active at tissue sites of infection to be effective. These unique features prompted us to evaluate the interactions of azithromycin and human polymorphonuclear leukocytes (PMN). Uptake of radiolabeled antibiotic by PMN was determined by a velocity-gradient centrifugation technique and expressed as the ratio of cellular to extracellular drug concentration (C/E). Azithromycin was massively accumulated by human PMN (C/E=387.2 at 2 h). Uptake was not influenced by inhibitors of cellular metabolism, but phagocytosis slightly inhibited the entry of azithromycin into PMN. After removal of extracellular drug, the release (efflux) of azithromycin from PMN was extremely slow. Agents which neutralize lysosomal pH, preventing protonation and trapping of azithromycin, markedly increased antibiotic efflux. Active concentration and prolonged retention of azithromycin by phagocytic cells should allow delivery and subsequent release of accumulated drug at sites of infection.

Spontaneous peritonitis: a reappraisal.

Spontaneous bacterial peritonitis occurs frequently in cirrhotic patients. In order to define more accurately the spectrum of this disease, 55 cases of spontaneous peritonitis were compared with 56 controls (patients with negative ascitic fluid cultures). Of several presenting symptoms, only vomiting (p less than 0.01), fever (p less than 0.05), and severe gastrointestinal bleeding (p less than 0.05) were more prevalent in cases than controls. There were no physical signs and no laboratory studies that separated the two groups except for elevated serum amylases in controls. Studies of peritoneal fluid were rarely helpful and cell counts overlapped in the cases and controls. Spontaneous peritonitis is usually seen in patients with severe liver disease, but there are few distinctive symptoms, signs, or laboratory findings. The mortality rate is high, and it is uncertain from our data that antibiotic therapy alters this prognosis.

A cost analysis: general endotracheal versus regional versus monitored anesthesia care.

A prospective study was conducted to compare the total cost of all consumable products used to perform a general endotracheal anesthetic (GETA), a regional anesthetic, and a monitored anesthetic (MAC). For 1 month, providers completed a survey for each anesthetic rendered identifying type and quantity of consumables used. The mean cost of each type of anesthetic was identified. Analysis of variance was conducted using SPSS (version 7.5.1) to compare the mean costs of the three groups. Of 936 anesthetics performed, 536 surveys were returned (57%). The breakdown by type was GETA, 60% (N = 319); regional, 35% (N = 189); and MAC, 5% (N = 28). The mean cost per case type was GETA, $61.74; regional, $34.99; and MAC, $26.27. The cost of rendering a GETA was significantly greater (p < 0.0005) than that of either regional or MAC. Clinical practice guidelines were established to address areas in which cost savings could be realized and were provided to all anesthesia practitioners to assist in providing the safest and most cost-effective method of rendering an anesthetic.

[Mechanisms of azithromycin accumulation and efflux in human polymorphonuclear leukocytes]. / Mekhanizmy nakopleniia i vybrosa azitromitsina v polimorfnoiadernykh leikotsitakh cheloveka.

Azithromycin achieves prolonged, high tissue concentrations in spite of low serum levels and obviously must be effective at tissue sites of infection. These unique features prompted us to evaluate the interactions of azithromycin and human polymorphonuclear leukocytes (PMN). Uptake of radiolabeled antibiotic by PMN was determined by a velocity-gradient centrifugation technique and expressed as the ratio of cellular to extracellular drug concentration (C/E). Azithromycin was massively accumulated by human PMN (C/E = 387.2 at 2 h). Uptake was not influenced by inhibitors of cellular metabolism, but phagocytosis slightly inhibited the entry of azithromycin into PMN. After removal of extracellular drug, the release (efflux) of azithromycin from PMN was extremely slow. Agents which neutralize lysosomal pH, preventing protonation and trapping of azithromycin, markedly increased antibiotic efflux. Active concentration and prolonged retention of azithromycin by phagocytic cells should allow delivery and subsequent release of accumulated drug at sites of infection.

Risk factors for hepatitis C on the Texas-Mexico border.

OBJECTIVES: Our clinical experience suggested that hepatitis C virus (HCV) infection in this Texas-Mexico border area might have features, especially risk factors, that differ from some other areas of the United States. Therefore, we conducted a prospective analysis to investigate the epidemiology, risk factors, and certain other characteristics of HCV infection in the El Paso region. METHODS: During a 2-yr period, individuals with a positive HCV serology were considered as "patients" and those with a negative hepatitis serology panel were "controls." A questionnaire survey was conducted in person or by telephone with individuals (patients and controls) who agreed to participate in the interview process. RESULTS: We identified and interviewed 320 patients and 307 controls. All of the contacted patients and controls agreed to be interviewed. Many established and potential risk factors for HCV transmission were documented in the patients. Furthermore, multiple potential risk factors were often present in individual patients. However, on multivariate analysis only injection drug use, blood transfusion, and tattooing were found to be significant independent risk factors for HCV infection. In the great majority of patients, tattoos were applied by friends (including gang members), inmates in jail/prison, or self, rather than commercial parlors. CONCLUSIONS: Tattooing is an independent risk factor for HCV infection in this United States-Mexico border area. The role of nonsterile tattooing practices in HCV transmission merits additional examination in regard to precise risk settings, frequency, and mechanisms of infection.

Current challenges in antibiotic resistance.

The striking, widespread increase in bacterial resistance to antibiotics is an issue of great concern. Worldwide emergence of antibiotic resistances in our common gram-positive coccal pathogens is probably the most serious problem we have in the realm of bacterial infections. The most important of these organisms are penicillin-resistant Streptococcus pneumoniae, vancomycin-resistant Enterococcus, and methicillin- (and now vancomycin-) resistant Staphylococcus aureus. Although known by the above names, all of these organisms are multidrug-resistant. Beta-lactam and vancomycin resistances in gram-positive cocci are caused by altered cell wallñbinding sites with decreased affinity for the drug. Another serious problem is that of resistance in certain gram-negative bacilli due to extended-spectrum beta-lactamase production. These antibiotic resistances in common pathogens have made antimicrobial therapy of many infections extremely difficult or virtually impossible in some instances. The extensive, and often inappropriate, use of antibiotics in the U.S. and worldwide is the major factor in the emergence and spread of antimicrobial resistance. Microbial mechanisms, epidemiology, clinical importance, treatment, and prevention of these antibiotic resistance problems are discussed.

Inhibition of cell-free oxidative bactericidal activity by erythrocytes and hemoglobin.

Sickle cell anemia and other chronic hemolytic anemias are associated with an increased frequency of bacterial infections. There is evidence to suggest that in hemolytic states massive erythrocyte (RBC) ingestion by macrophages interferes with their antibacterial function, thereby predisposing infection. Stimulated by this possibility, we recently demonstrated that erythrophagocytosis by macrophages markedly inhibited intracellular killing of bacteria, and that zymosan-stimulated superoxide generation and chemiluminescence were also suppressed by RBC ingestion. We examined the effects of RBC components on generation of chemiluminescence, superoxide, and bactericidal activity by cell-free oxidative systems. Generation of chemiluminescence by hypoxanthine-xanthine oxidase was depressed in the presence of human RBC lysate or column-fractionated hemoglobin but not crystallized human hemoglobin (methemoglobin) (peak cpms of 15,522 [P = 0.00024], 28,360 [P = 0.0088], and 50,041 [P = 0.37], respectively, compared with 59,898 for positive controls). Similarly, hypoxanthine-xanthine oxidase production of superoxide was inhibited in the presence of column-fractionated human hemoglobin (43.8 versus 17.4 nmol per tube, P = 0.000001). A cell-free bactericidal system, acetaldehyde and xanthine oxidase with or without myeloperoxidase and Cl-, was markedly inhibited by column-purified hemoglobin. For example, after 2 h of incubation, surviving numbers of Staphylococcus aureus were: control (buffer only), 2.5 X 10(6)/ml; bactericidal system, none; bactericidal system plus hemoglobin, 2.2 X 10(6)/ml (P less than or equal to 0.03, bactericidal system versus other systems). Our studies have documented that interactions between RBC (hemoglobin) and reactive products of oxygen metabolism inhibit oxidative bactericidal mechanisms in cell-free systems as well as in macrophages.(ABSTRACT TRUNCATED AT 250 WORDS)

Interactions of dirithromycin with human polymorphonuclear leukocytes.

Dirithromycin, a new macrolide antibiotic, achieves prolonged, high levels in tissue. We previously demonstrated that certain macrolides are highly concentrated within phagocytic cells. This background information prompted us to evaluate the interactions of dirithromycin and human polymorphonuclear leukocytes (PMNs). After incubation with radiolabeled dirithromycin, antibiotic uptake by PMNs was determined by a velocity-gradient centrifugation technique and was expressed as the ratio of the cellular to the extracellular drug concentration (C/E). Dirithromycin was avidly accumulated by PMNs (C/E, 5 at 15 min, 10 at 30 min, 19 at 1 h, and 35 at 2 h). Uptake was dependent on cell viability, physiologic environmental temperature, and pH (optimum 8.6), but was not influenced by potential competitive inhibitors of membrane transport. Incubation with sodium cyanide caused an increase in dirithromycin accumulation by PMNs. Ingestion of microbial particles (mimicking in vivo infection) modestly inhibited the entry of dirithromycin into PMNs. After removal of extracellular drug, the efflux (release) of dirithromycin from PMNs was slow; only 10% was released within the first 30 min. This prolonged retention of dirithromycin within phagocytic cells might allow delivery and release of accumulated drug at sites of infection. The impact of intraphagocytic dirithromycin on cellular function was also evaluated. In a manner similar to that of other highly concentrated, weakly basic antibiotics, dirithromycin inhibited the respiratory burst response (superoxide production) in stimulated PMNs. The presence of dirithromycin slightly increased the intraphagocytic killing of Staphylococcus aureus in human PMNs. These interactions of dirithromycin with phagocytic cells may promote the extraphagocytic, and possibly the intraphagocytic, killing of infecting organisms.

Influence of pentoxifylline and its derivatives on antibiotic uptake and superoxide generation by human phagocytic cells.

Pentoxifylline modulates multiple activities of stimulated polymorphonuclear neutrophils (PMNs), including the respiratory burst response and membrane transport of certain substances (e.g., nucleosides). We found that several weakly basic antibiotics are highly concentrated by human PMNs and that these drugs also inhibit the respiratory burst response (by a mechanism different from that of pentoxifylline). Since both pentoxifylline and antibiotics will be administered to some patients with serious infections, we have evaluated several types of interactions between these drugs and human PMNs and have attempted to identify the mechanisms that produce alterations in cellular function. Roxithromycin, dirithromycin, and clindamycin were avidly concentrated by PMNs. Pentoxifylline and two derivatives (HWA-448 [torbafylline] and HWA-138 [albifylline]) increased the uptake of these antibiotics by PMNs, both in the resting state and during phagocytosis. Pentoxifylline, HWA-448, HWA-138, and the highly concentrated antibiotics each exerted an inhibitory effect on the stimulated respiratory burst response in PMNs. The combination of both pentoxifylline and a modulatory antibiotic (roxithromycin or clindamycin) inhibited superoxide production to a greater extent than either agent alone. This additive effect might be expected, since pentoxifylline and the modulatory antibiotics influence the respiratory burst activation pathway at different sites. The ability of pentoxifylline to augment the entry of antibiotics into neutrophils has important therapeutic implications. The consequences of this phenomenon might include improved intracellular bactericidal activity as well as efficient antibiotic delivery and release at sites of infection.

The effect of ethanol on adherence and phagocytosis by rabbit alveolar macrophages.

Several defects in host defense mechanisms of chronic alcoholics have been described, but the effect of ethanol on the alveolar macrophage has not been defined. Monolayers of rabbit alveolar macrophages established on plastic culture dishes were exposed to various agents to evaluate the maintenance of adherence. Ethanol produces a rapid onset loss of adherence in this system. The loss of adherence is (1) dose-dependent, (2) transient despite the continued presence of ethanol, and (3) due to a change in the macrophage. Similar rapid-onset, transient loss of adherence is produced by osmolar agents, inducers of cAMP, and colchicine. Phagocytosis of latex particles by rabbit alveolar macrophages in suspension is also transiently decreased by ethanol. These results suggest that inhibition of alveolar macrophage adherence and phagocytosis may be mediated by one or a combination of three mechanisms: osmolar forces altering the cell membrane, changes in cyctic nucleotide concentrations, or disruption of microtubules. Ethanol may act through some combination of these mechanisms to produce functional abnormalities of alveolar macrophages.