Suppressed distribution of protein A on the surface of Staphylococcus aureus as a morphological characteristic of erythromycin-resistant strain.

To identify a new morphological phenotype of erythromycin (EM)-resistant Staphylococcus aureus (S. aureus) were isolated in vitro from EM-sensitive parent strain, and the distribution of staphylococcus specific protein A (SpA) on the surface of these strains was examined morphologically by using applied immunoelectron microscopy. The isolated EM-resistant strains had thickened cell walls, and the distribution of SpA on the surfaces of these strains was demonstrated to be lower than that of the parent strain. The SpA suppression was confirmed by enzyme-linked immunosorbent assay (ELISA) using fixed EM-resistant cells. Moreover, the spa gene of EM-resistant cells was detected by polymerase chain reaction (PCR) and confirmed by quantitative real-time PCR assay, showing that the expression of SpA was repressed at the transcriptional level in these strains. Furthermore, ELISA assay showed that whole EM-resistant cell SpA content was significantly decreased. Therefore, it was considered that the suppression of surface SpA on the EM-resistant strain was due to regulated SpA production, and not dependent on the conformational change in SpA molecule expression through cell wall thickening. These results strongly suggest that suppressed SpA distribution on the EM-resistant S. aureus is a phenotypical characteristic in these strains.

Non-deacetylated poly-N-acetylglucosamine-hyperproducing Staphylococcus aureus undergoes immediate autoaggregation upon vortexing.

Biofilms are microbial communities of cells embedded in a matrix of extracellular polymeric substances generated and adhering to each other or to a surface. Cell aggregates formed in the absence of a surface and floating pellicles that form biofilms at the air-liquid interface are also considered to be a type of biofilm. Staphylococcus aureus is a well-known cause of biofilm infections and high-molecular-weight polysaccharides, poly-N-acetylglucosamine (PNAG) is a main constituent of the biofilm. An icaADBC operon comprises major machinery to synthesize and extracellularly secrete PNAG. Extracellular PNAG is partially deacetylated by IcaB deacetylase, and the positively charged PNAG hence interacts with negatively charged cell surface to form the major component of biofilm. We previously reported a new regulator of biofilm (Rob) and demonstrated that Rob binds to a unique 5-bp motif, TATTT, present in intergenic region between icaADBC operon and its repressor gene icaR in Yu et al. The deletion of the 5-bp motif induces excessive adherent biofilm formation. The real function of the 5-bp motif is still unknown. In an attempt to isolate the 5-bp motif deletion mutant, we isolated several non-adherent mutants. They grew normally in turbid broth shaking culture but immediately auto-aggregated upon weak vortexing and sedimented as a lump resulting in a clear supernatant. Whole genome sequencing of the mutants identified they all carried mutations in icaB in addition to deletion of the 5-bp motif. Purification and molecular characterization of auto-aggregating factor in the culture supernatant of the mutant identified that the factor was a massively produced non-deacetylated PNAG. Therefore, we created a double deficient strain of biofilm inhibitory factors (5-bp motif, icaR, rob) and icaB to confirm the aggregation phenomenon. This peculiar phenomenon was only observed in Δ5bpΔicaB double mutant but not in ΔicaR ΔicaB or ΔrobΔicaB mutant. This study explains large amount of extracellularly produced non-deacetylated PNAG by Δ5bpΔicaB double mutation induced rapid auto-aggregation of S. aureus cells by vortexing. This phenomenon indicated that Staphylococcus aureus may form biofilms that do not adhere to solid surfaces and we propose this as a new mechanism of non-adherent biofilm formation of S. aureus.

IgG immune complexes with Staphylococcus aureus protein A enhance osteoclast differentiation and bone resorption by stimulating Fc receptors and TLR2.

Staphylococcus aureus is a main pathogen of osteomyelitis and protein A is a virulence factor with high affinity for IgG. In this study, we investigated whether S. aureus affects the differentiation and bone resorption of osteoclasts through the IgG-binding capacity of protein A. Staphylococcus aureus pre-treated with serum or IgG showed marked enhancement in osteoclastogenesis and bone resorption compared to non-treated S. aureus or a protein A-deficient mutant. Blocking of the Fc receptor and deletion of the Fcγ receptor gene in osteoclast precursor cells showed that enhanced osteoclastogenesis stimulated by S. aureus IgG immune complexes (ICs) was mediated by the Fc receptor on osteoclast precursor cells. In addition, osteoclastogenesis stimulated by S. aureus ICs but not the protein A-deficient mutant was markedly reduced in osteoclast precursor cells of Myd88-knockout mice. Moreover, NFATc1, Syk and NF-κB signals were necessary for osteoclastogenesis stimulated by S. aureus ICs. The results suggest the contribution of a of Toll-like receptor 2 (TLR2)-Myd88 signal to the activity of S. aureus ICs. We further examined the expression of pro-inflammatory cytokines that is known to be enhanced by FcγR-TLR cross-talk. Osteoclasts induced by S. aureus ICs showed higher expression of TNF-α and IL-1ß, and marked stimulation of proton secretion of osteoclasts activated by pro-inflammatory cytokines. Finally, injection of S. aureus, but not the protein A-deficient mutant, exacerbated bone loss in implantation and intra-peritoneal administration mouse models. Our results provide a novel mechanistic aspect of bone loss induced by S. aureus in which ICs and both Fc receptors and TLR pathways are involved.

Intracellular morphological changes in Staphylococcus aureus induced by treatment with sodium hypochlorite.

Sodium hypochlorite (NaOCl) is commonly used as a disinfectant; however, its bactericidal mechanism has not yet been clarified. In the present study, the bactericidal mechanism of NaOCl was examined using microscopy and gel electrophoresis techniques with Staphylococcus aureus strain 209P. S. aureus cells treated with 500 and 1000 ppm NaOCl for 5 and 15 min were observed by SEM and TEM. SEM images of the bacterial cells treated with NaOCl showed an irregular surface, with cells being partially invaginated. TEM images of the bacterial cells showed cytoplasmic alterations, accompanied by a partially irregular cellular surface. Under a fluorescence microscope, we clearly observed fluorescence quenching in the 1000 ppm NaOCl-treated cells. Based on these observations, which indicated that NaOCl damaged chromosomal DNA, we next extracted chromosomal DNA from bacterial cells treated with NaOCl and performed agarose gel electrophoresis. Chromosomal DNA was absent in the DNA sample from the bacterial cells treated with 500 ppm NaOCl. From these biochemical results, it was strongly suggested that NaOCl degrades the chromosomal DNA of S. aureus. We consider that the morphological changes in the cytoplasm induced by NaOCl may be related to NaOCl-induced degradation of S. aureus chromosomal DNA.

Does ß-hexosaminidase function only as a degranulation indicator in mast cells? The primary role of ß-hexosaminidase in mast cell granules.

ß-Hexosaminidase, which is generally present in the lysosome, is essential for glycoprotein metabolism in the maintenance of cell homeostasis. In mast cells (MCs), large amounts of ß-hexosaminidase are present in the granules as opposed to the lysosome, and the biological role of MC ß-hexosaminidase has yet to be fully elucidated. Therefore, we investigated the biological role of ß-hexosaminidase in MC granules. Bone marrow-derived MCs from C57BL/6 (BL/6-BMMC) or ß-hexosaminidase gene-deficient (hexb(-/-)-BMMC) mice were transplanted into MC-deficient (WBB6F1/J-Kit(W)/Kit(W-v) [W/W(v)]) mice to generate MC-reconstituted models. In asthma model experiments, no differences were observed in the symptoms of BL/6, W/W(v), BL/6-BMMC-reconstituted W/W(v), or hexb(-/-)-BMMC-reconstituted W/W(v) mice. In Staphylococcus epidermidis experimental infection model experiments, the severity of symptoms and frequency of death were markedly higher in W/W(v) and hexb(-/-)-BMMC-reconstituted W/W(v) mice than in BL/6 and BL/6-BMMC-reconstituted W/W(v) mice. The growth of S. epidermidis in an in vitro study was clearly inhibited by addition of BL/6-BMMC lysate, but not by addition of hexb(-/-)-BMMC lysate. Moreover, suppression of bacterial proliferation was completely recovered when bacteria were incubated with hexb(-/-)-BMMC lysate plus ß-hexosaminidase. Transmission electron microscopy indicated that the cell wall of S. epidermidis was heavily degraded following coincubation of bacteria with BL/6-BMMC lysate, but not following coincubation with hexb(-/-)-BMMC lysate. These findings strongly suggest that MC granule ß-hexosaminidase is crucial for defense against bacterial invasion, but is not involved in the allergic response. Our results also suggest that the bactericidal mechanism of ß-hexosaminidase involves degradation of bacterial cell wall peptidoglycan.

Thickening of the cell wall in macrolide-resistant Staphylococcus aureus.

Macrolides are widely used at low dosage for long-term therapy of chronic sinusitis. Twenty clinical macrolide-resistant Staphylococcus aureus strains were morphologically compared with 10 clinical macrolide-sensitive strains. PCR amplification was performed to determine the presence of four known macrolide resistance genes. Transmission electron microscopy revealed significantly thicker cell walls in clinical macrolide-resistant strains. Even though the ultrastructural characteristics were shared by all macrolide-resistant strains, they were not associated with the presence or absence of the known macrolide-resistance genes. We also demonstrated that macrolide-resistant mutant strains derived in vitro from a macrolide-sensitive parent strain had thickened cell walls and did not harbor the known macrolide-resistance genes. These results, therefore, revealed that macrolide-resistant S. aureus strains have thickened cell walls as a common ultrastructural characteristic and that cell wall thickening is likely mediated by an unknown gene which is unrelated to any known macrolide resistance gene.

Ultrastructural cell wall characteristics of clinical gentamycin-resistant Staphylococcus aureus isolates.

The frequent use of gentamycin (GM) ointment for the treatment of skin infections has led to an increase in the number of GM-resistant clinical isolates of Staphylococcus aureus. We examined the ultrastructural characteristics of 14 clinical strains of S. aureus by transmission electron microscopy. Seven of these isolates were GM-resistant, and seven isolates were GM-sensitive. We found that the cell wall of GM-resistant strains (32.24 ± 5.99 nm) was significantly thicker than that of GM-sensitive strains (19.02 ± 2.72 nm). We genetically characterized these isolates by polymerase chain reaction, targeting the genes for three aminoglycoside-modifying enzymes, aac(6')-aph(2''), aph(3')-III, and ant(4')-I. All GM-resistant strains tested carried the gene encoding aac(6')-aph(2''). However, we were unable to establish a link between a specific gene and cell wall thickening, because one GM-resistant strain was also positive for aph(3')-III. We also demonstrated that a GM-resistant mutant strain, derived in vitro from a GM-sensitive S. aureus parent strain (209P), also exhibited a thickened cell wall. These results strongly suggest that a thickened cell wall is a common ultrastructural characteristic of GM-resistant S. aureus clinical strains.

The surface layer of Tannerella forsythia contributes to serum resistance and oral bacterial coaggregation.

Tannerella forsythia is an anaerobic, Gram-negative bacterium involved in the so-called "red complex," which is associated with severe and chronic periodontitis. The surface layer (S-layer) of T. forsythia is composed of cell surface glycoproteins, such as TfsA and TfsB, and is known to play a role in adhesion/invasion and suppression of proinflammatory cytokine expression. Here we investigated the association of this S-layer with serum resistance and coaggregation with other oral bacteria. The growth of the S-layer-deficient mutant in a bacterial medium containing more than 20% non-heat-inactivated calf serum (CS) or more than 40% non-heat-inactivated human serum was significantly suppressed relative to that of the wild type (WT). Next, we used confocal microscopy to perform quantitative analysis on the effect of serum. The survival ratio of the mutant exposed to 100% non-heat-inactivated CS (76% survival) was significantly lower than that of the WT (97% survival). Furthermore, significant C3b deposition was observed in the mutant but not in the WT. In a coaggregation assay, the mutant showed reduced coaggregation with Streptococcus sanguinis, Streptococcus salivarius, and Porphyromonas gingivalis but strong coaggregation with Fusobacterium nucleatum. These results indicated that the S-layer of T. forsythia plays multiple roles in virulence and may be associated with periodontitis.

Antimicrobial effects of Burow's solution on Staphylococcus aureus and Pseudomonas aeruginosa.

Burow's solution has been shown to be effective against chronic suppurative otitis media and otitis externa. We demonstrated that Burow's solution had antibacterial effects against Staphylococcus aureus and Pseudomonas aeruginosa, inducing ultrastructural changes in these bacteria in vitro. S. aureus strain 209P and P. aeruginosa strain IID1130 were treated with 13% Burow's solution. Viable cell counts were determined to measure bactericidal effects. Ultrastructural changes in cells of both strains were examined by scanning electron microscopy (SEM) and transmission electron microscopy (TEM). Viable cell counting revealed that S. aureus cells treated with Burow's solution were killed within 30 min. The viable cell count of P. aeruginosa was reduced by 1 × 10(7) colony-forming units/ml (CFU/ml) after a 60-min treatment. SEM examination of S. aureus revealed blebbing on the surface of bacterial cells, whereas TEM revealed undulating deformation of the bacterial cell wall, diluted cytoplasm, and cell membrane detachment. SEM observations of P. aeruginosa revealed a more apparent undulating deformation of the bacterial cell surface. TEM observations also revealed deformations in the bacterial cell wall and diluted cytoplasm in both bacteria. These findings show that Burow's solution is active against S. aureus and P. aeruginosa, resulting in damage to the cell wall.

GlmS and NagB regulate amino sugar metabolism in opposing directions and affect Streptococcus mutans virulence.

Streptococcus mutans is a cariogenic pathogen that produces an extracellular polysaccharide (glucan) from dietary sugars, which allows it to establish a reproductive niche and secrete acids that degrade tooth enamel. While two enzymes (GlmS and NagB) are known to be key factors affecting the entrance of amino sugars into glycolysis and cell wall synthesis in several other bacteria, their roles in S. mutans remain unclear. Therefore, we investigated the roles of GlmS and NagB in S. mutans sugar metabolism and determined whether they have an effect on virulence. NagB expression increased in the presence of GlcNAc while GlmS expression decreased, suggesting that the regulation of these enzymes, which functionally oppose one another, is dependent on the concentration of environmental GlcNAc. A glmS-inactivated mutant could not grow in the absence of GlcNAc, while nagB-inactivated mutant growth was decreased in the presence of GlcNAc. Also, nagB inactivation was found to decrease the expression of virulence factors, including cell-surface protein antigen and glucosyltransferase, and to decrease biofilm formation and saliva-induced S. mutans aggregation, while glmS inactivation had the opposite effects on virulence factor expression and bacterial aggregation. Our results suggest that GlmS and NagB function in sugar metabolism in opposing directions, increasing and decreasing S. mutans virulence, respectively.

Cell-wall thickness: possible mechanism of acriflavine resistance in meticillin-resistant Staphylococcus aureus.

Acriflavine resistance in the clinical meticillin-resistant Staphylococcus aureus isolate KT24 was found not to be mediated by multidrug efflux pumps encoded by qacA/B, smr, qacE, qacG, qacH, qacJ or norA. Early uptake and accumulation of ethidium bromide in MRSA KT24 was significantly lower than that in a susceptible strain, although the efflux rates were similar. Therefore, a permeability barrier in MRSA KT24 may be the conceivable mechanism of acriflavine resistance. Interestingly, it was found that MRSA KT24 had a significantly thickened cell wall, and that cell-wall thickness increased gradually during bacterial growth. In contrast, cell size and surface area in MRSA KT24 were not different from those in the susceptible strain. Moreover, MRSA KT24 exposure to sub-MIC concentrations of acriflavine resulted in a thicker cell wall. These results indicate that cell-wall thickness may be responsible for acriflavine resistance in S. aureus.

Pleiotropic roles of polyglycerolphosphate synthase of lipoteichoic acid in growth of Staphylococcus aureus cells.

Lipoteichoic acid (LTA) is one of two anionic polymers on the surface of the gram-positive bacterium Staphylococcus aureus. LTA is critical for the bacterium-host cell interaction and has recently been shown to be required for cell growth and division. To determine additional biological roles of LTA, we found it necessary to identify permissive conditions for the growth of an LTA-deficient mutant. We found that an LTA-deficient S. aureus Delta ltaS mutant could grow at 30 degrees C but not at 37 degrees C. Even at the permissive temperature, Delta ltaS mutant cells had aberrant cell division and separation, decreased autolysis, and reduced levels of peptidoglycan hydrolases. Upshift of Delta ltaS mutant cells to a nonpermissive temperature caused an inability to exclude Sytox green dye. A high-osmolarity growth medium remarkably rescued the colony-forming ability of the Delta ltaS mutant at 37 degrees C, indicating that LTA synthesis is required for growth under low-osmolarity conditions. In addition, the Delta ltaS mutation was found to be synthetically lethal with the Delta tagO mutation, which disrupts the synthesis of the other anionic polymer, wall teichoic acid (WTA), at 30 degrees C, suggesting that LTA and WTA compensate for one another in an essential function.

Characteristic cell wall ultrastructure of a macrolide-resistant Staphylococcus capitis strain isolated from a patient with chronic sinusitis.

Fourteen-membered-ring macrolides have an antiinflammatory effect, in addition to their antibacterial effect, and are widely used at low dosages for long-term therapy for chronic inflammatory disease such as diffuse pan-bronchiolitis and chronic sinusitis. A macrolide-resistant coagulase-negative staphylococcal strain was obtained from the maxillary sinus of a patient with chronic sinusitis, who failed long-term macrolide therapy. The isolated strain was characterized as Staphylococcus capitis and had an MIC for erythromycin greater than 128 microg/ml. Morphological observation demonstrated that this macrolide-resistant S. capitis strain had a thicker cell wall than macrolide-sensitive S. capitis strains. Moreover, the strain was not carrying any other than the four genes that are known mainly to encode for macrolide resistance in S. aureus. Therefore, the strain had an unknown macrolide-resistance mechanism that might be related to cell wall thickening.

Susceptibility of periodontopathogenic and cariogenic bacteria to defensins and potential therapeutic use of defensins in oral diseases.

Antimicrobial peptides play an important role in the human innate immune defense system. In the oral cavity, a number of antimicrobial peptides, including defensins and LL37, are produced from various tissues such as salivary glands, gingival epithelium, tongue and buccal mucosa. These peptides are believed to function as a host defense system by controlling the activities of commensal bacteria and thus preventing the colonization and growth of pathogenic bacteria in oral cavity. Two major oral diseases, dental caries and periodontitis are known as infectious diseases. Therefore, it is of great interest to elucidate the mechanisms underlying the onset and progression of these diseases by investigating the interaction between cariogenic, or periodontopathogenic bacteria and antimicrobial peptides. Since these peptides have a broad antimicrobial spectrum, they are implicated as possible therapeutic agents. Therefore, in this review, we first focus on the susceptibility of oral bacteria, especially cariogenic and periodontopathogenic bacteria, to antimicrobial peptides, and then we discuss their potential diagnostic and clinical therapeutic uses.

Role of ciprofloxacin in its synergistic effect with fosfomycin on drug-resistant strains of Pseudomonas aeruginosa.

BACKGROUND: The aim of this study was to investigate the synergistic effect of ciprofloxacin (CPFX) and fosfomycin (FOM) on CPFX-resistant Pseudomonas aeruginosa strains. METHODS: The synergistic effect was evaluated using the fractional inhibitory concentration index, acute bactericidal effect and morphological observation. RESULTS: In the fractional inhibitory concentration index experiments, the combination of CPFX with FOM showed a synergistic effect in 20 of 74 (27.0%) strains of P. aeruginosa. From the morphological observations, it was determined that CPFX affected the outer membrane structure. CPFX combined with FOM caused striking morphological changes, resulting in bacteriolysis. A time lag experiment suggested that the addition of CPFX prior to FOM produced more pronounced bactericidal activity than the addition of FOM prior to CPFX. CONCLUSIONS: These results indicate that the combination of CPFX with FOM induces a synergistic effect on CPFX-resistant P. aeruginosa strains. The role of CPFX is thought to be related to damage of the outer membrane, enhancing FOM penetration.

A 4-aminofurazan derivative-A189-inhibits assembly of bacterial cell division protein FtsZ in vitro and in vivo.

Out of 95,000 commercially available chemical compounds screened by the anucleate cell blue assay, 138 selected hit compounds were further screened. As a result, A189, a 4-aminofurazan derivative was found to inhibit FtsZ GTPase with an IC(50) of 80 mug/ml and to exhibit antibacterial activity against Staphylococcus aureus and Escherichia coli. Light scattering demonstrated that A189 inhibited FtsZ assembly in vitro, and microscopic observation of A189-treated E. coli indicated that A189 perturbed FtsZ ring formation and made bacterial cells filamentous. However, nucleoids staining with DAPI revealed that A189 did not affect DNA replication and chromosome segregation in bacterial filamentous cells. Furthermore, A189 made sulA-deleted E. coli cells filamentous. Taken together, these findings suggest that A189 inhibits FtsZ GTPase activity, resulting in perturbation of FtsZ ring formation, which leads to bacterial cell death.

Identification and molecular characterization of an N-Acetylmuraminidase, Aml, involved in Streptococcus mutans cell separation.

We previously demonstrated Streptococcus mutans produces two bacteriolytic enzymes of 100 kDa and 80 kDa (G. Yoshimura et al. Microbiol. Immunol. 48, 465-469, 2004). Here, we identified the protein sequence of these enzymes and found they come from a single gene product designated as automutanolysin (Aml). Aml has a modular design where the N-terminus contains five 13-amino-acid repeats and a C-terminal enzyme active domain. Aml selectively lyses S. mutans and S. sobrinus but no other oral streptococci. This suggests Aml possesses strong substrate specificity towards cariogenic bacteria present in the human oral cavity. Analysis of S. mutans peptidoglycan fragments released by Aml shows the enzyme is an N-acetylmuraminidase. We found Ca(2+) enhances the activity; and EGTA, EDTA and iodoacetic acid inhibit the activity. The optimum pH range for lytic activity was 6 to 7. Disruption of the aml gene in S. mutans results in the formation of a longer bacterial cell chain length that was dispersed by the addition of a low concentration of Aml. This suggests Aml is involved in S. mutans cell separation.

Innate defences against methicillin-resistant Staphylococcus aureus (MRSA) infection.

The innate immune system is the primary defence against bacterial infection. Among the factors involved in innate defence, anti-microbial peptides produced by humans have recently attracted attention due to their relevance to some diseases and also to the development of new chemotherapeutic agents. Staphylococcus aureus is one of the major human pathogens, causing a variety of infections from suppurative disease to food poisoning. Methicillin-resistant S. aureus (MRSA) is a clinical problem and with the recent emergence of a vancomycin-resistant strain, this will pose serious problems in the near future. In investigating the molecular biology of S. aureus infections to develop new chemotherapeutic agents against MRSA infections, knowledge of the interaction of innate anti-microbial peptides with S. aureus is important. In vitro and in vivo experiments demonstrate that exposure of S. aureus to host cells can induce the anti-microbial peptides beta-defensin-2 (hBD2), hBD3, and LL37/CAP18. The induction level of these peptides differs among strains, as does the susceptibility of the strains, with MRSA strains exhibiting lower susceptibility. In summary, the susceptibility of S. aureus strains, including MRSA strains, to components of the innate immune system varies, with the MRSA strains showing more resistance to both innate immune factors and chemotherapeutic agents.

Identification and molecular characterization of an N-acetylmuramyl-L-alanine amidase Sle1 involved in cell separation of Staphylococcus aureus.

We purified a peptidoglycan hydrolase involved in cell separation from a Staphylococcus aureus atl null mutant and identified its gene. Characterization of the gene product shows a 32 kDa N-acetylmuramyl-L-alanine amidase that we designated Sle1. Analysis of peptidoglycan digests showed Sle1 preferentially cleaved N-acetylmuramyl-L-Ala bonds in dimeric cross-bridges that interlink the two murein strands in the peptidoglycan. An insertion mutation of sle1 impaired cell separation and induced S. aureus to form clusters suggesting Sle1 is involved in cell separation of S. aureus. The Sle1 mutant revealed a significant decrease in pathogenesis using an acute infection mouse model. Atl is the major autolysin of S. aureus, which has been implicated in cell separation of S. aureus. Generation of an atl/sle1 double mutant revealed that the mutant cell separation was heavily impaired suggesting that S. aureus uses two peptidoglycan hydrolases, Atl and Sle1, for cell separation. Unlike Atl, Sle1 is not directly involved in autolysis of S. aureus.

[Antimicrobial activity of fosfomycin under various conditions against standard strains, beta-lactam resistant strains, and multidrug efflux system mutants].

The purpose of this study was to evaluate the possible benefit of fosfomycin (FOM) as prophylactic antibiotic in terms of antimicrobial activity and the potential of inducibility of beta-lactamase, compared with cefazolin, cefotiam, cefmetazole, and piperacillin that are commonly used as perioperative agents. The in vitro activity of FOM against aerobic Gram-negative bacteria using Mueller-Hinton agar or nutrient agar supplemented with glucose-6-phosphate (G6P) as tested medium increased within a range from 2 to 256 times the activity in the medium without G6P. However, the susceptibility of Gram-positive bacteria to FOM remained largely unchanged with or without G6P. There was no aerobic- or anaerobic-bacteria which changed susceptibility against beta-lactam antibiotics under various tested medium conditions. FOM demonstrated strong bactericidal activity against Escherichia coli and Pseudomonas aeruginosa in a dose dependent manner, and decreased viable cell counts of Staphylococcus aureus. In the case of P. aeruginosa, transmission electron micrographs study revealed that numerous lysed cells were present 2 hours after treatment with FOM at four times the MIC. First and second generation cephalosporins induced AmpC-type beta-lactamase in a dose dependent manner among beta-lactamase inducible strains of P. aeruginosa and Enterobacter cloacae. On the other hand, inducible activity of FOM on beta-lactamase production was less than 1/25 to 1/65 compared with those of cephalosporins. In addition, FOM maintained strong antimicrobial activity for over then 20 years after marketing, because of the excellent stability against various types of beta-lactamase produced by plasmid-carrying bacteria and clinical isolates. FOM was not extruded by four types of efflux systems, such as MexAB-OprM, MexCD-OprJ, MexXY/ OprM and MexEF-OprN, however beta-lactam antibiotics were substrates of MexAB-OprM and MexCD-OprJ. In conclusion, FOM provides adequate coverage for both aerobic Gram-positive and Gram-negative bacteria causing postoperative infections. Further, FOM would not select/concentrate beta-lactamase producing bacteria in the clinical fields and would not be a substrate for multidrug efflux system of P. aeruginosa.