Role of the thymus in streptococcal cell wall-induced arthritis and hepatic granuloma formation. Comparative studies of pathology and cell wall distribution in athymic and euthymic rats.

Systemic administration of an aqueous suspension of group A streptococcal cell wall fragments to susceptible rats induces acute and chronic polyarthritis, as well as noncaseating hepatic granulomas. To gain insight into the role of the thymus in the pathogenesis of this experimental model, pathologic responses and cell wall tissue distribution were compared in congenitally athymic rats (rnu/rnu) and their euthymic littermates (NIH/rnu). Within 24 h, both rat strains developed acute arthritis, characterized by polymorphonuclear leukocytic exudate in the synovium and joint spaces. This acute process was maximal at day 3 and gradually subsided. Beginning 2-3 wk after injection, the euthymic, but not the athymic, rats developed the typical exacerbation of arthritis, characterized by synovial cell hyperplasia with villus formation and T helper/inducer lymphocyte-rich mononuclear cell infiltration. This process eventually resulted in marginal erosions and destruction of periarticular bone and cartilage. Parallel development of acute and chronic hepatic lesions was observed. Bacterial cell wall antigen distribution and persistence were similar in the athymic and euthymic rats. Cell wall antigens were demonstrated in the cytoplasm of cells within subchondral bone marrow, synovium, liver, and spleen, coincident with the development of the acute lesions, and persisted in these sites, although in decreasing amounts, for the duration of the experiment. Our findings provide evidence that the acute and chronic phases of the experimental model are mechanistically distinct. The thymus and functional thymus derived-lymphocytes appear not to be required for the development of the acute exudative disease but are essential for the development of chronic proliferative and erosive disease. Induction of disease is dependent upon cell wall dissemination to and persistence in the affected tissues.

A pharmacokinetic-pharmacodynamic model for the mobilization of CD34+ hematopoietic progenitor cells by AMD3100.

BACKGROUND: AMD3100 is a small-molecule CXCR4 antagonist that has been shown to induce the mobilization of CD34 + hematopoietic progenitor cells from bone marrow to peripheral blood. AMD3100 has also been shown to augment the mobilization of CD34 + cells in cancer patients when administered in combination with granulocyte colony-stimulating factor (G-CSF) (filgrastim). The purpose of this study was to characterize the exposure-response relationship of AMD3100 in mobilizing CD34 + cells when administered as a single agent in healthy volunteers. METHODS: AMD3100 concentrations and CD34 + cell counts obtained from 29 healthy subjects in a single-dose, intensively sampled pharmacokinetic/pharmacodynamic (PK-PD) study were analyzed by use of nonlinear mixed effects regression with the software NONMEM. FOCE (first order conditional estimation) with interaction was the estimation method, and simultaneous PK-PD fitting was adopted. RESULTS: The pharmacokinetics of AMD3100 was described by a 2-compartment model with first-order absorption. The population estimates (+/-SE) for clearance and central volume of distribution were 5.17 +/- 0.49 L/h and 16.9 +/- 3.79 L, respectively. CD34 + cell mobilization was best described by an indirect effect model that stimulates the entry process of CD34 + from bone marrow to peripheral blood in the form of a sigmoid maximum effect model. The population estimates (+/-SE) of maximum effect, concentration causing 50% of maximum response, and equilibration time were 12.6 +/- 4.89, 53.6 +/- 11.9 mug/L, and 5.37 +/- 1.31 hours, respectively. CONCLUSIONS: This study characterizes the exposure-response relationship of AMD3100 in mobilizing CD34 + cells after subcutaneous administration. This PK-PD model will be useful in assessing relevant covariates and for optimizing the use of AMD3100 in various patient populations.

Review of adverse experiences and tolerability in the first 2,516 patients treated with imipenem/cilastatin.

The clinical and laboratory data relating to the adverse experiences and tolerability of imipenem/cilastatin in the first 2,516 patients treated with the antibiotic are reviewed, with special reference to the last 793. Clinical adverse experiences were predominantly related to the gastrointestinal system (nausea and vomiting), local injection site, and allergy (rash). A low frequency of drug-related seizures was also reported. The most frequent adverse laboratory experiences were transient elevations of liver function test values. In general, the safety profile was similar to that of other beta-lactam antibiotics.

Varicella vaccine (VARIVAX) in healthy children and adolescents: results from clinical trials, 1987 to 1989.

A total of 3303 healthy children and adolescents, aged 12 months to 17 years, were vaccinated with one of five production lots of a live attenuated varicella vaccine (VARIVAX) containing 1000 to 1625 plaque-forming units per dose. The vaccine was generally well tolerated. Ninety-six percent (2381/2475) of vaccinees responded to vaccination by producing antibody as measured by a glycoprotein-based enzyme-linked immunosorbent assay; 99% (569/576) of those tested maintained antibody at 1 year following vaccination. The incidence of varicella following household exposure in vaccinees was approximately 12%; household contact historically results in 87% infection. Nearly all of the vaccinees who had varicella after vaccination had a clinically modified disease.

Haemophilus influenzae type b conjugate vaccine (meningococcal protein conjugate) (PedvaxHIB): clinical evaluation.

Although systemic infections caused by Haemophilus influenzae type b occur worldwide, detailed epidemiologic data are available in but a few countries. The public health impact of morbidity, mortality, and serious sequelae from disease caused by H influenzae type b has stimulated the search for control strategies. In the United States now, active immunoprophylaxis is largely favored over treatment of prophylaxis with antibiotics. This preference stems from three major observations: that high mortality and morbidity persist despite the availability of potent antimicrobial agents, that antibiotic-resistant strains of H influenzae type b have emerged, and that implementation of antimicrobial prophylaxis on a large scale has been unsatisfactory. Moreover, universal vaccination has been projected as offering a higher economic benefit than other control strategies. A matter of more proximate importance, however, is the search for H influenzae type b vaccines that will confer protection to all age groups, including infants younger than 18 months of age and subpopulations specifically at risk for invasive disease caused by H influenzae type b. Haemophilus b conjugate vaccine (meningococcal protein conjugate), PedvaxHIB (PRP-OMPC), is a conjugate H influenzae type b vaccine developed at Merck Sharp & Dohme Research Laboratories that now is undergoing extensive clinical evaluation to assess its prospects for disease control when first administered in early infancy. This is an interim report of results obtained in studies conducted in diverse locations throughout the United States.

The efficacy results and safety profile of imipenem/cilastatin from the clinical research trials.

Imipenem/cilastatin is highly effective for infections in many body sites against a broad range of gram-positive and gram-negative aerobic and anaerobic bacteria. During therapy, development of resistance is uncommon except in the case of Pseudomonas aeruginosa in which the incidence appears similar to that for other beta-lactam antibiotics. There appears to be a very low probability of cross-resistance. The clinical and laboratory adverse reactions are similar in type to those for other beta-lactam antibiotics. The frequency of colonization and superinfection during treatment with imipenem/cilastatin has been comparable to other antibiotics in comparative trials and to literature reports for other antibiotics for noncomparative trials.

Imipenem/cilastatin therapy of serious infections: a U.S. multicenter noncomparative trial.

Imipenem/cilastatin, which combines a broad-spectrum antibiotic derived from thienamycin with a specific enzyme inhibitor, was administered in dosages of 1 to 4 gm/day to 717 patients in a multicenter noncomparative trial. Ninety-nine percent of the bacterial pathogens tested were susceptible to imipenem, and 86% were eradicated. Clinical outcome was favorable in 85% or more of the cases when assessed according to the site of infection, and 92% of the cases responded to treatment overall. Development of resistance was rare except for Pseudomonas aeruginosa, which became resistant in 19% of the patients infected with that organism. More than half the patients with resistant P aeruginosa had a favorable clinical outcome, however. Superinfection occurred in approximately 4% of all patients. The adverse clinical experiences occurring most frequently were related to gastrointestinal function (nausea, vomiting, and diarrhea). In general, the safety profile of imipenem/cilastatin was similar to that of other beta-lactam antibiotics.

Atypical erysipelas caused by group G streptococci in a patient with cured Hodgkin's disease.

Erysipelas developed in a young woman whose condition had been in remission for ten years after treatment of stage IIIA Hodgkin's disease. The erysipelas was atypical both in its clinical manifestation and its causative organism. The patient had an erythematous, macular eruption on both buttocks and thighs. Group G streptococci, a rare cause of erysipelas, were isolated from both blood cultures and a skin biopsy specimen. The unusual clinical manifestation of the disease when the patient was initially seen may have been the result of a group G streptococcal bacteremia, coupled with impairment of the lymphatic drainage of the involved area from a partial thoracic duct obstruction and a restrictive cardiomyopathy, both secondary to previous irradiation treatment.

Vaccination of infants and children against hepatitis B.

Hepatitis B infection and its sequelae constitute a significant public health problem in the United States. It is estimated that 300,000 acute hepatitis B infections occur each year, with about 25% accompanied by both clinical illness and jaundice. Some infections become chronic and ultimately may cause development of liver cirrhosis or primary hepatocellular carcinoma. The risk of chronicity is especially great with infections that occur in infancy. Highly effective vaccines comprised of purified hepatitis B surface antigen (HBsAg) particles are now available for the prevention of hepatitis B infection. A first-generation vaccine utilized HBsAg derived from the plasma of infected persons; this has now been replaced by two similar vaccines that incorporate HBsAg produced by genetically engineered strains of the common bakers' yeast, Saccharomyces cerevisiae. Improved use of vaccine is needed to reduce and ultimately eliminate hepatitis B infection. Vaccination already is recommended for persons recognized to be at increased risk of exposure to virus-containing blood or other body fluids (e.g., infants born to carrier mothers, household or sexual contacts of carriers); however, mass vaccination of adolescents and infants is needed to interdict effectively a majority of all exposures to the hepatitis B virus.

Effect of detergents on streptolysin S precursor.

Group A streptococci which produce streptolysin S contain a cellular precursor to streptolysin S in the membranes and cytoplasm which is activatable by blending in a Vortex mixer with glass beads and ribonucleic acid (RNA)-core (RNA preparation from yeast). Although no activation of precursor occurred when it was mixed with detergents, it was activated when blended with glass beads and detergents such as Tergitol NP-40 and Brij 35. Maximum activation of precursor was achieved in 1 to 2% detergent, in pH 6.5 buffer, and after 8 min of blending. Detergents Tween 20, 40, 60, and 80, Brij 56, and Lubrol WX also activated precursor, but, of all the hemolysin preparations, those with Tween 40 or 60 or Lubrol WX were the most stable. The addition of RNA-core during or after blending of precursor with detergents enhanced the titer and stability of the hemolysin. This was due in part to the association of the hemolytic moiety with RNA-core. Activation of precursor in the membrane was better with a detergent, whereas that in the cytoplasm was better with RNA-core. Therefore, precursor from two different cellular locations can be differentiated by the effects of RNA-core and detergents on precursor titer.

Intramuscular imipenem/cilastatin in multiple-dose treatment regimens: review of the worldwide clinical experience.

Multicenter noncomparative trials of intramuscular administration of imipenem/cilastatin for the treatment of a variety of infections requiring multiple-dose therapy are reviewed. Fourteen centers in the United States and 18 centers elsewhere participated in these studies. A total of 686 patients (461 evaluable) were treated worldwide. The severity of the infection was rated as moderate in 58.9%, mild in 37.2% and severe in 0.6%. The most common sites of infection were the skin and soft tissue (36.2%) and intra-abdominal (17.6%). Polymicrobial infections were relatively common (27%). Dosing regimens in evaluable patients were 500 mg every 12 h (45.1%), 750 mg every 12 h (36.2%) and 500 mg every 8 h (18.6%). The overall clinical outcome was favorable (clinical cure or improvement) for 95% or more of the evaluable patients with the various body system infections, except in gynecologic infections where 89% of the evaluable patients had a favorable outcome and for sepsis where the favorable outcome was 76%. Where data were available for analysis (skin and soft tissue infections) there was no difference in favorable clinical outcome among patients with moderate infection treated with 1.0 g/day (95% favorable) compared with 1.5 g/day (94% favorable). The overall bacteriologic eradication rate was 91%. Clinical adverse effects were similar in type but less common in frequency than those noted in other studies with the intravenous formulation, with nausea, vomiting and diarrhea being most common; no instances of seizures or confusion were observed. The laboratory adverse effects were similar to those seen in other studies with the intravenous formulation, with increased liver enzyme values the most common. The intramuscular injection was well tolerated in 87% of the patients and moderately well tolerated in 6.6%. The efficacy and low incidence of side effects of the intramuscular formulation of imipenem/cilastatin are significant advantages in the cost-effective treatment of infections.

Activation of streptolysin S-related cellular potential hemolysin by grinding with glass beads.

Cellular potential hemolysin, the precursor to extracellular streptolysin S, was activated by grinding with glass beads on a Vortex mixer. Hemolysin activity was markedly enhanced by the addition of ribonucleic acid-core during the grinding. Determinants for optimum results with the beads included small bead size, prewashing of beads with acetic acid, and appropriate bead volume during grinding. The increased sensitivity of this technique over those previously used revealed cellular potential hemolysin in cells grown in the presence of glucose, which inhibits streptolysin S production. The basis for the increased sensitivity of this procedure may be due to the binding of cellular potential hemolysin or ribonucleic acid to the beads.

Lysis and protoplast formation of group B streptococci by mutanolysin.

Group B streptococci, refractory to previously tested muralysins under physiological conditions, were successfully converted to protoplasts by use of a recently describede N-acetyl muramidase, mutanolysin, derived from a streptomycete. Purified enzyme was effective, but crude preparations, although degrading cell walls, simultaneously produced peculiar effects of cytoplasmic coagulation, retention of cell shape, loss of some intracellular enzymes, and a rise in optical density. Addition of purified mutanolysin to the array of muralysins (group C streptococcal phage-associated lysin, lysozyme), previously successful in preparing protoplasts of different streptococci, now makes possible enzymatic preparation of protoplasts of streptococci of groups A, B, C. D. G, and H.

Vaccine induced immunologic memory for hepatitis B surface antigen: implications for policy on booster vaccination.

This paper reviews published literature on the long-term persistence of immunologic memory for HBsAg after a course of hepatitis B vaccine and the functional significance this has for policy on booster vaccination. Several studies have shown that vaccine induced antibody (anti-HBs) specific for the surface antigen (HBsAg) of hepatitis B virus (HBV) is protective at a serum concentration of 10 milli-International Units per milliliter (mIU ml-1). When acquired passively (e.g. from hepatitis B immune globulin), susceptibility to infection returns as antibody declines. However, vaccine induces active synthesis of anti-HBs accompanied by immunologic memory for HBsAg that affords ongoing protection independent of antibody. Persistent memory over periods of 5 years or more is evident from large, rapid increases in antibody following booster vaccination, even in subjects who have lost antibody. Complementary studies, using an in vitro enzyme linked immunosorbent assay (spot-ELISA), show that the number of memory B lymphocytes able to produce anti-HBs does not diminish as the level of antibody declines. That immunologic memory provides effective immunity is suggested by serologic studies over periods of 5 years or more of vaccinees frequently exposed to HBV. Although many failed to maintain at least 10 mIU ml-1 of antibody, there have been very few clinically significant breakthrough infections. Thus, it appears unnecessary to give healthy vaccinees a booster vaccination when the level of anti-HBs falls below 10 mIU ml-1. Current studies suggest good retention of immunologic memory in healthy vaccinees over periods of 5-12 years. While additional studies will better define the limits of this phenomenon, routine booster vaccination should not be needed to sustain immunologic memory and protection within 5 years and perhaps longer after the primary vaccination series.

Cellular location of streptolysin O.

Streptolysin O was measured in subcellular fractions of group A streptococci obtained after preparation of protoplasts in a hypertonic buffer containing raffinose. Most of the activity was located in the periplasm (the region between cell wall and membrane) and did not differ in several characteristics from that of extracellular streptolysin O. Of the enzymes used as subcellular markers, aldolase and maltase (cytoplasmic) and acid phosphatase (membrane associated) were in the same fractions as found in other bacteria. However, the location of alkaline phosphatase differed from that of other bacteria in the most of the activity was in cytoplasm rather than in the periplasm.

Cellular streptolysin S-related hemolysins of group A Streptococcus C203S.

Group A streptococci strain C203S, grown in heart infusion broth with 0.3% maltose, produce two cellular hemolysins related to extracellular streptolysin S (SLS). Enzymatic lysis of the streptococci by group C streptococcal phage-associated lysin results in release of low titer, labile hemolysin, which can be stabilized by ribonucleic acid (RNA)-core (RNA preparation from yeast). This labile hemolysin can be detected only after the higher titer cellular streptolysin O is removed by erythrocyte membranes or inactivated by N-ethylmaleimide. The other cellular SLS-related hemolysin is released in a latent state (potential hemolysin) which can be activated to high-titer hemolysin by sonication with RNA-core. The titer of such activated hemolysin depends upon the intensity of sonic energy, duration of sonication, and amount of RNA-core. RNA obtained from the streptococci is far less effective than RNA-core. When the cocci are disrupted by sonication or grinding, potential hemolysin and/or activated form may be released, depending upon the conditions employed. The potential hemolysin material is large and heterogeneous; activation appears to involve, in part, disaggregation or fragmentation. Labile hemolysin, potential hemolysin, and the activated form of potential hemolysin can all be converted to hemolysin having the same hemolytic and physical properties as RNA-core SLS, suggesting that all have the same hemolytic moiety. The presence of glucose in heart infusion broth prevents formation of both potential hemolysin and RNA-core SLS by log-phase cells, whereas addition of glucose to a culture in heart infusion broth with 0.3% maltose stops accumulation of potential hemolysin but does not affect continuation of RNA-core SLS release. These results suggest that potential hemolysin is a cellular precursor to RNA-core SLS.

Streptolysin S activation by lipoteichoic acid.

Lipoteichoic acid from streptococci and Staphylococcus aureus both activated membrane-bound precursor streptolysin S and induced the formation of extracellular streptolysin S. Lipoteichoic acid could replace other substances, such as yeast ribonucleic acid core, that act as carriers for hemolysin but which are not components of the streptococcus or the host. Lipoteichoic acid may play a role as the physiological carrier of streptolysin S to host tissues.

Membrane and cytoplasmic location of streptolysin S precursor.

Group A streptococci which produce streptolysin S (SLS) contain a cellular potential hemolysin (CPH) which is precursor to extracellular SLS. Since the cellular location of CPH is unknown, protoplasts prepared with group C phage-associated lysin or mutanolysin from 18 strains of group A streptococci were fractionated into subcellular components and assayed for CPH. In all strains, most of the CPH was membrane associated, and most could not be removed from membranes by washing with buffer or 2 M LiCl. CPH remaining in the cytoplasmic fraction was sedimentable, but not associated with membrane fragments. Ribonuclease digestion neither solubilized nor inactivated CPH from membranes. Streptococcal proteinase also did not affect CPH, although it did inactivate SLS. We conclude that group A streptococci contain a major pool of CPH in the membrane and a smaller pool in the cytoplasm.