The ONTAI study - a survey on antimicrobial dosing and the practice of therapeutic drug monitoring in German intensive care units.

PURPOSE: Optimization of antibiotic therapy is still urgently needed in critically ill patients. The aim of the ONTAI survey (online survey on the use of Therapeutic Drug Monitoring of antibiotics in intensive care units) was to evaluate which strategies intensive care physicians in Germany use to improve the quality of antibiotic therapy and what role a Therapeutic Drug Monitoring (TDM) plays. METHODS: Among the members of the German Society for Anaesthesiology and the German Society for Medical Intensive Care Medicine and Emergency Medicine, a national cross-sectional survey was conducted using an online questionnaire. RESULTS: The questionnaire was completely answered by 398 respondents. Without TDM, prolonged infusion was judged to be the most appropriate dosing regimen for beta lactams. A TDM for piperacillin, meropenem and vancomycin was performed in 17, 22 and 75% of respondents, respectively. For all beta lactams, a TDM was requested more often than it was available. There was great uncertainty as to the optimal pharmacokinetic/pharmacodynamic index for beta-lactams. 86% of the respondents who received minimal inhibitory concentrations adapted the therapy accordingly. CONCLUSION: German intensive care physicians are convinced of TDM for dose optimization. However, practical implementation, the determination of MICs and defined target values are still lacking.

Therapeutic drug monitoring-guided high dose meropenem therapy of a multidrug resistant Acinetobacter baumannii - A case report.

BACKGROUND: Infections with multidrug resistant Acinetobacter baumannii in immunocompromised patients are life-threatening. Therapeutic options are rare in this context, but patients are dependent on an effective antibiotic therapy. Thus, new antibiotic strategies are deemed necessary. CASE PRESENTATION: This case report recounts the therapeutic drug monitoring-guided meropenem therapy of a 32 years old patient admitted with acute exacerbation of cystic fibrosis. Veno-venous extracorporeal membrane oxygenation was initiated on the first day of admission to the intensive care unit. The patient showed insufficient serum trough levels of meropenem despite the maximum approved dose (2g every 8h) was administered which was due to augmented renal clearance. Through continuous infusion of the same cumulative dose, target levels were reached. On day 17 of admission, the patient underwent successful double-lung-transplant surgery and extracorporeal membrane oxygenation was ended. Unfortunately, the donor's lung was colonized with a multidrug resistant Acinetobacter baumannii that was positive for OXA-23 carbapenemase. Hence a combination therapy of intravenous sulbactam, tigecycline, meropenem and inhalative colistin was established, with a known minimal inhibitory concentration for meropenem of 32 mg/l. Under continuous infusion of 8 g meropenem/day, serum levels exceeded 32 mg/l over 12 days. The patient was transferred from the intensive care unit to a general ward without any signs of infection. CONCLUSIONS: Therapeutic drug monitoring-guided meropenem may be a sound new therapeutic option in eradicating multidrug resistant Acinetobacter and offer a novel therapeutic option in the field of personalized medicine.

Superior vena cava syndrome related to mediastinal lymphoma in late pregnancy: A case report.

We report the initial diagnosis in a 28-year-old nulliparous woman of a primary mediastinal B-cell lymphoma in late pregnancy. For several weeks the patient had had symptoms of mediastinal obstruction, such as dyspnea, cough, swelling of the face and upper limbs. However, these symptoms had been misattributed to the pregnancy and a common cold. Due to a rapid decline in the patient's cardiovascular performance, she was transferred to the closest perinatal center in the 34th week of pregnancy, whereupon a cesarean section was performed. The diagnosis of a primary mediastinal B-cell lymphoma was made postpartum from a biopsy. This case emphasizes the importance of timely antenatal investigation in pregnant women with symptoms consistent with mediastinal obstruction. Thoracic ultrasonography can be a valuable tool for the detection of tumor-associated pleural and pericardial effusions.

Simultaneous quantification of cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid and piperacillin in human serum using an isotope-dilution HPLC-MS/MS method.

The aim of the current study was to develop and validate a robust multi-analyte high performance liquid chromatography tandem mass spectrometry (HPLC-MS/MS) method for simultaneous quantification of cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid and piperacillin, which are the most commonly used antibiotics in intensive care units. Sample clean-up included a protein precipitation protocol, followed by chromatographic separation on a C8 reverse phase HPLC column within 4 min, using a formic acid-ammonium formiate methanol step-elution gradient. All compounds were detected with electrospray ionization (ESI+) mass spectrometry in multiple reaction time monitoring. The method was validated according to the protocol from the European Medicines Agency and was thoroughly evaluated for interferences and quantification linearity. Linear relationships between peak area responses and drug concentrations were obtained in the range of 0.25-200 mg/l for cefepime, 0.25-120 mg/l for meropenem, 0.05-10 mg/l for ciprofloxacin, 0.125-10 mg/l for moxifloxacin, 0.125-50 mg/l for linezolid and 0.5-400 mg/l for piperacillin with an R2 > 0.997. Imprecision and inaccuracy values (both intra- and inter-assay) were ≤ 6.8% and ≤10.9% for all analytes in quality control samples, respectively. The assay proved to be selective for the study antibiotics, and the internal standards consistently compensated for matrix effects. The described simple and reliable HPLC-MS/MS assay is a powerful tool for routine TDM of cefepime, meropenem, ciprofloxacin, moxifloxacin, linezolid and piperacillin in human serum in clinical laboratories. With a total process time of approximately 30 min, it allows for accurate and selective quantification up to the expected pharmacokinetic peak concentrations.

Glucose-induced insulin secretion is potentiated by a new imidazoline compound.

Sulfonylureas stimulate insulin secretion independent of the blood glucose concentration. This can lead to hypoglycaemia in type 2 diabetic patients. Over the last years a number of imidazoline derivatives have been identified that stimulate insulin secretion in a more glucose-dependent way. In agreement with this, our aim was to generate imidazoline derivatives with a potential for the treatment of type 2 diabetic patients. We developed the compound 2-[4-(4-chlorophenyl)-3-(2-methoxyethoxy)-2-naphthalenyl]-4,5-dihydro-1-H-imidazole monohydrochloride (LY389382) with an imidazoline moiety and investigated its effects on glucose-dependent insulin secretion in a beta-cell line, isolated rat islets and in vivo. We could demonstrate that LY389382 induces insulin secretion in MIN6 cells and rat islets in a glucose-dependent manner (EC50=1.1 microM and 0.3 microM, respectively). Furthermore during hyperglycaemia LY389382 increased insulin secretion in a dose-dependent manner in healthy rats, whereas the compound had no effect at euglycemia in a tenfold higher dosage. After 7 days of treatment of Zucker Diabetic Fatty [ZDF/ (Gmi/fa)] rats with LY389382 with a dose of 15 mg/kg twice daily the blood glucose concentration was reduced from 22.7 +/- 1.7 mM to 16.6 +/- 2.3 mM. During the same time period the glucose concentration increased from 21.7+/-1.7 mM to 28.9 +/- 1.3 mM in the vehicle-treated group (P<0.05). The drop of the insulin level was also inhibited by LY389382 in ZDF rats. In contrast to other well-characterised imidazolines that have been shown to induce a glucose-dependent insulin secretion only within a limited range of concentrations, LY389382 stimulates insulin secretion over a concentration range of at least two log units in a glucose-dependent manner. These data suggest that this imidazoline compound has a potential for the treatment of type 2 diabetes.

Fused bicyclic Gly-Asp beta-turn mimics with potent affinity for GPIIb-IIIa. Exploration of the arginine isostere.

6-[4-Amidinobenzoyl]amino]-tetralone-2-acetic acid is a potent antagonist of GPIIb-IIIa. Substitution in the meta position of the benzamidine, or replacement with a heteroaryl amidine was tolerated in this series. Use of an acyl-linked 4-alkyl piperidine as an arginine isostere also provided active compounds. Compounds from this series provided substantial systemic exposure in the rat following oral administration.

Fused bicyclic Gly-Asp beta-turn mimics with specific affinity for GPIIb-IIIa.

Disubstituted isoquinolones 2 and 3 have affinity for GPIIb-IIIa and represent leads for further structural evaluation. Structure-activity studies centered on the bicyclic beta-turn mimic contained in these molecules indicated that this moiety could accommodate a variety of modifications. Specifically, monocyclic, 6, 5-bicyclic, and 6,7-bicyclic structures provide compounds with affinity for GPIIb-IIIa. Within the 6,6-series, isoquinoline, tetralin, tetralone, and benzopyran nuclei yield potent antagonists that are specific for GPIIb-IIIa. Attachment of the arginine isostere (benzamidine) to the supporting nucleus can be accomplished with an ether or amide linkage, although the latter enhances activity. Several compounds in this series provided measurable blood levels after oral dosing. Conversion of the acid moiety in these molecules to an ester generally provided compounds which gave greater systemic exposure after oral administration. Absolute bioavailabilities in the rat for the ethyl ester prodrug derivatives of the tetralin, tetralone, and benzopyran analogues of 3 were 28%, 23%, and 24%, respectively.

ATP and integrity of human red blood cells.

In spite of the well known significance of ATP in the energy dependent life processes, the role of ATP in maintaining cellular integrity is poorly understood. A possible model for studying ATP dependent life processes is to monitor the kinetics of changes seen intra/extracellularly during ATP depletion. In our model system anticoagulated human whole blood was incubated at different temperatures to reduce intracellular ATP without addition of any chemicals. The red blood cells in their own plasma were incubated for several days at 4 degrees C or at 37 degrees C, and ATP, glucose, K+, Na+, hemoglobin, water content, mean corpuscular volume (MCV), pH and Ca2+ were analyzed in time-sequences. All the examined parameters remained practically unchanged at 4 degrees C, while at 37 degrees C total ATP and glucose decreased parallel and after a transient increase of MCV, the water content of red blood cells decreased. As the actual ATP fell below 10% of the initial ATP content (at 48 h), the release of potassium sharply increased. Release of hemoglobin started only after 96 hours of incubation. Maximums of changes of the examined parameters were found at different time intervals. The maximal speed of concentration changes for glucose was found at 12-24 hours of incubation and at 24-36 hours for ATP, at 48-60 hours for K+(-)Na+ and after 96 hours for hemoglobin.

A progesterone-induced protein increases the synthesis of asymmetric antibodies.

The immunological effects of progesterone are mediated by a 34-kDa protein named the progesterone-induced blocking factor (PIBF). PIBF induces increased production of Th2-type cytokines; thus, it might stimulate antibody synthesis by B cells. There is a population of antibodies which, owing to the presence of a mannose-rich oligosaccharide residue on one of the Fab arms of the molecule, possess an asymmetric structure. Due to the asymmetric structure these molecules have no effector functions; however, they might act as blocking antibodies. This study was aimed at investigating the effect of progesterone-dependent immunomodulation on antibody production by B cells, with special emphasis on the synthesis of asymmetric nonprecipitating antibodies. The ratio of asymmetric IgG was significantly higher in supernatants of hybridoma cells cultured in the presence of PIBF than in those cultured in the absence of PIBF. Lymphocytes from healthy pregnant women produce significantly more PIBF than those of women with pathological pregnancies. The present studies revealed a positive relationship between asymmetric antibody content of the sera and PIBF expression on lymphocytes. Blocking of progesterone receptors by RU 486 or neutralizing endogenous PIBF activity by specific antibody significantly reduced the production of asymmetric antibodies in pregnant mice. Effector function of conventional and asymmetric antibodies was compared in a TNF alpha neutralization assay. Purified asymmetric anti-TNF alpha antibodies did not neutralize the cytotoxic effect of TNF alpha on L929 murine fibroblast target cells, whereas conventional anti-TNF alpha antibodies in the same concentration significantly (P < 0.001) reduced cytotoxicity. Our data suggest that PIBF induces increased production of asymmetric antibodies. These antibodies fail to exhibit effector functions and by blocking fetally derived antigens might contribute to protection of the fetus.

[Clinical immunological features and interferon therapy in chronic hepatitis C]. / Klinikai immunológiai megfigyelések és interferon terápia krónikus C hepatitisben.

Clinical and immunological findings of 74 patients with chronic hepatitis C have been reported and experiences with interferon-alpha treatment of 31 patients are summarized. In addition, the first results of anti-HCV screening of blood donors are also briefly described. Transfusion in the history was noted in 69% of patients and the time, elapsed from the transfusion to the diagnosis was a mean of 7.15 +/- 8.1 years. Concerning the severity of the liver disease, chronic persistent hepatitis was established in 40%, active hepatitis in 45% and cirrhosis in 15% of the patients, respectively. Cholestasis was recorded in 32% of the cases. A significant elevation of serum immunoglobulin levels was noted in 83%, an antibody to liver specific protein (anti-LSP) has occurred in 80%, cryoglobulinaemia in 44% and circulating immune complexes in 33% of the patients. Natural killer cell activity of peripheral blood mononuclear cells significantly decreased. HLA B8 and DR3 antigens were found with elevated frequency (36.6% and 42.1%). Recombinant interferon-alpha at a weekly dose of 3MU thrice, for six months, has normalized serum alanine aminotransferase in 45% of patients and a sustained remission was found in 26%. The treatment resulted in the clearance of HCV-RNS from the serum in 40% of patients and that well correlated with the complete remission. In the good responders, a decrease in CD4+ cell count and a moderate decrease in CD8+ cell count as well as a transient rise in B cell count were seen during the treatment. Mitogen-induced lymphoproliferative response and natural killer cell activity increased. Predictors of response were as follows: female sex, shorter time elapsed from transfusion, absence of HLA, A1, B8, DR3 and serum anti-HBc negativity. Anti-HCV has been found in 0.33--0.38% of blood donors screened, and it is suggested, that a liver disease accompanied with elevated serum alanine aminotransferase, may be present in about 25-30% of anti-HCV positive symptom-free persons.

[Isoprinosine therapy in chronic hepatitis C (multicenter placebo-controlled double-blind prospective study)]. / Krónikus C hepatitis isoprinosin kezelése (Multicentrikus, prospektív, placebo-kontrollos kettös-vak vizsgálat).

A placebo controlled clinical trial. Thirty two patients with chronic C hepatitis have been enrolled in a double blinded study to assess the therapeutic effect on an orally given antiviral-immunomodulatory drug, Isoprinosine. Seventeen patients were given Isoprinosine (3 g/day) and fifteen were on placebo. The treatment has been lasted for four months, when patients examined monthly. Clinical signs, liver function tests and side effects were evaluated. At the end of the trial, side effects and elevated serum alanine aminotransferase (ALT/GPT) levels occurred with higher frequency in Isoprinosine-treated patients. The results show that this antiviral drug has no beneficial effect in chronic C hepatitis.

[Hepatitis virus (HBV, HCV, HDV) markers in chronic liver diseases. Comparative studies in two East-Central European countries]. / Hepatitis vírus (HBV, HCV, HDV) markerek idült májbetegségekben. Osszehasonlító vizsgálatok két közép-kelet-európai országban.

The prevalence of hepatitis virus markers in patients with chronic liver diseases from two countries has been studied: 68 patients (38 alcoholic hepatitis or cirrhosis, 30 chronic HBsAg-positive hepatitis) from Hungary as well as 109 patients (55 alcoholic liver disease, 45 chronic hepatitis or cryptogenic cirrhosis and 9 hepatoma) from Romania were examined for HBsAg, anti-HBs, anti-HBc, anti-HCV and anti-HDV, using the corresponding Abbott Elisa test systems. In alcoholic liver disease HBsAg occurred in 6/38 patients from Hungary and in 22/55 patients respectively, that is HBV markers occurred with significantly higher frequency in alcoholic patients from Romania (p less than 0.05). In the Hungarian group a total of 36 patients were HBsAg positive and out of them 5 had anti-HDV (13.9%), while out of 21 Romania HBsAg carriers 10 patients had anti-HDV (47.6%). Among 9 hepatoma patients 4 had HBsAg, 6 anti-HBs and 7 anti-HBc and 4 had anti-HCV and 3 had anti-HDV. One patient with hepatoma had both HBsAg and anti-HCV plus anti-HDV as well. Results suggest that the infection with hepatitis viruses in alcoholic liver diseases is more common in Romania than in Hungary, and the prevalence of delta virus infection in HBV carriers is also significantly higher in Romania than in Hungary.

Changes of T-lymphocyte-subsets and their consequences in B-CLL.

The distribution of T-lymphocyte subsets of 18 patients with lymphocytic leukaemia tested with monoclonal antibodies as well as E-rosettes formations and EAC-rosettes formations were studied. The patients classified according to RAI (stages 0-II. and III-IV.) a proportional decrease of T-lymphocytes was observed only, whereas their absolute number increased. T-lymphocyte subsets also changed: the ratio of CD4 positive lymphocytes reduce, while the proportion of CD-8 positive lymphocytes increased. The ratio of the two cell groups was below the normal value (1.8 and 1.0, respectively). This value is lower in stages III-IV., and refers to a serious immune imbalance, the latter being responsible for acute infections. The four weeks medication with Leukeran and COP resulted in unchanged rates of pathological cells with a decrease in the number of lymphocytes. These phenomena primarily refer to clonal damage of the cell line, resulting in pathological T-helper and T-suppressor functions. Owing to the relatively long lifespan of the lymphocytes, only a prolonged cytostatic treatment can yield favorable results in therapy.

Membrane fluidity of trophoblast cells and susceptibility to natural cytotoxicity.

This study examines the relationship between membrane lipid microviscosity and susceptibility of villous trophoblast to lysis by natural cytotoxic cells. Trophoblast-enriched cell suspensions prepared from term human placentae were treated with cholesteryl hemisuccinate (CHS)--a modulator of membrane lipid microviscosity. CHS-treated cells were more susceptible targets for natural lymphocyte cytotoxicity than were untreated controls. In binding experiments, increased binding of lymphocytes to CHS-treated target cells was found. Preincubation with progesterone prevented membrane rigidification by CHS. Progesterone, cortisol, and estriol restored the impaired resistance of CHS-treated trophoblast cells to lysis. We determined microviscosity and progesterone concentration in villous surface membranes, prepared from placentae from idiopathic spontaneous abortions and normal first-trimester pregnancies. An inverse relationship was found between progesterone content and microviscosity of the membranes. Microviscosity of the membranes from abortion placentae was significantly higher (P less than .01) and progesterone concentration was significantly lower (P less than .001) than those in the membranes of normal first trimester placentae.

Urinary Escherichia coli infection presenting with jaundice.

A 53-year-old man with lupus erythematosus (LE) developed an acute hemolytic crisis. Alpha-hemolytic Escherichia coli were isolated from the patient's urine and feces, and high titer anti-alpha-hemolytic antibodies appeared in his serum. The hemolytic crisis could be controlled by specific antibiotic treatment of the urinary tract infection. It is assumed that the patient's basic disease -- and the steroid therapy applied -- facilitated the progression of the urinary tract infection, and before starting with adequate antibiotic treatment his erythrocytes must have been subjected to the effect of massive amounts of alpha-hemolysin. The idea that alpha-hemolysin might contribute to the development of severe hemolysis in man is discussed. It is also assumed that harbouring alpha-hemolytic E. coli in the gut may represent a special risk for the immunocompromised host.

Cryoglobulinaemia and cryofibrinogenaemia in IgA nephropathy: a follow-up study.

Sera and plasmas from 50 patients with IgA nephropathy (IgA-NP) have been investigated for the presence of cryoglobulin (CG) and cryofibrinogen (CF), respectively, 2-5 cryoprotein determinations being made for each patient. CG was transiently found in 20 of 50 patients (40%), but in none of 20 healthy blood donors, whereas CF was found in 37 of 50 patients (74%) and in 4 of 20 healthy blood donors. The cryoprecipitates were of single and mixed component types. All but 2 of the patients with CF had haematuria. Nearly all of them had histories of long exposure to the cold as manual workers at the onset or recognition of their disease. There was no clinical remission during a 2-to-5-year follow-up if cryoproteinaemia persisted. A certain correlation was detected between the composition of the CP and the renal immunohistological findings. It is suggested that renal deposition of circulating CF or local formation of CF might be responsible for the tubulo-interstitial fibrocellular changes, which are of prognostic importance.

[Synthesis of the T-antigen trisaccharide O-beta-D-galactopyranosyl-(1 to 3)-O-(2-acetamido-2-deoxy-alpha-D-galactopyranosyl)-(1 to 6)-D-galactopyranose and O-beta-D-galactopyranosyl-(1 to 3)-O-(2-acetamido-2-deoxy-alpha-D-galacopyranosyl)-(1 to 6)-D-glucopyranose and their binding to proteins]. / Synthese der t-antigenen trisaccharide O-beta-D-galactopyranosyl-(1 to 3)-O-(2-acetamido-2-desoxy-alpha-D-galactopyranosyl)-(1 to 6)-D-galactopyranose und O-beta-D-galactopyranosyl-(1 to 3)-O-(2-acetamido-2-desoxy-alpha-D-galactopyranosyl)-(1 to 6)-D-glucopyranose und deren anknüpfung an proteine.

The synthesis of the trisaccharides O-beta-D-galactopyranosyl-(1 to 3)-O-(2-acetamido-2-deoxy-alpha-D-galactopyranosyl)-(1 to 6)-D-galactopyranose (15) and O-beta-D-galactopyranosyl-(1 to 3)-O-(2-acetamido-2-deoxy-alpha-D-galactopyranosyl)-(1 to 6)-D-glucopyranose (27) is described and the synthesis of alpha-D-glycosides by reaction of 3,4,6-tri-O-acetyl-2-azido-2-deoxy-beta-D-galactopyranosyl chloride with highly reactive hydroxyl groups is discussed. The trisaccharide 27 was coupled with serum albumin by formation of an imine intermediate and reduced to an amine, to yield a synthetic T-antigen. A similar coupling of 15 was unsuccessful.