Effect of surgical adhesion reduction devices on the propagation of experimental intra-abdominal infection.

HYPOTHESIS: The use of certain surgical adhesion reduction devices where there is a risk of concomitant bacterial contamination potentiates intra-abdominal infection. DESIGN: Evaluation of adhesion reduction devices in an experimental model of intra-abdominal infection. SETTING: Experimental animal model. INTERVENTIONS: Adhesion reduction devices were administered at the time of bacterial challenge. MAIN OUTCOME MEASURES: Animal mortality rate, abscess formation, and bacterial counts in peritoneal fluid and blood cultures. RESULTS: The use of bioresorbable membrane adhesion reduction devices in the presence or absence of antibiotic therapy did not alter the disease process as compared with appropriate control groups. However, adhesion reduction gels prepared from sodium hyaluronate and carboxymethylcellulose chemically modified with carbodiimide or ferric ion complexed sodium hyaluronate increased the incidence of peritonitis in treated animals. Gel formulations containing diimide-modified carboxymethylcellulose did not have this effect. CONCLUSIONS: The use of certain adhesion reduction devices resulted in the propagation of intra-abdominal infection in an experimental rat model. This outcome was dependent on the composition of the device employed. The use of adhesion reduction devices should be tested in appropriate models of infection where there is the risk of concomitant bacterial contamination.

Protection against experimental intraabdominal sepsis by two polysaccharide immunomodulators.

Two immunomodulating polysaccharides, poly-(1-6)-beta-glucotriosyl-(1-3)-beta-glucopyranose (PGG)-glucan and Bacteroides fragilis polysaccharide A (PS A), were evaluated for the prevention of mortality and abscess formation associated with experimental intraabdominal sepsis. Prophylactic treatment with a combination of these compounds significantly reduced mortality (8% vs. 44% in the saline-treated control group) and the incidence of abscesses (30% vs. 100% in the saline-treated control group) after challenge with rat cecal contents. These compounds were also effective when administered therapeutically after bacterial contamination of the peritoneal cavity. PS A treatment conferred long-term protection against abscess formation and resulted in significantly fewer total aerobes and anaerobes in the peritoneal fluid of animals challenged with cecal contents. These data demonstrate the usefulness of two immunomodulatory polysaccharides in preventing experimental intraabdominal sepsis in the absence of antimicrobial therapy and may represent a new adjunct to antibiotic regimens currently used to prevent clinical cases of this disease.

Prophylaxis with the immunomodulator PGG glucan enhances antibiotic efficacy in rats infected with antibiotic-resistant bacteria.

The emergence of multiple antibiotic-resistant microorganisms has led to a search for alternatives to traditional therapeutic regimens. PGG glucan is a soluble beta-glucan immunomodulator that selectively enhances the microbicidal activities of neutrophils and macrophages without stimulating proinflammatory cytokine production. In the present studies, we examined the ability of PGG glucan to act in concert with antibiotics to decrease mortality in a rat model of intraabdominal sepsis using antibiotic-resistant bacteria as infectious inocula. Results of these studies demonstrated that prophylaxis with PGG glucan in combination with antibiotics provided enhanced protection against lethal challenge with Esherichia coli or Staphylococcus aureus as compared with the use of antibiotics alone.

Passive transfer of poly-(1-6)-beta-glucotriosyl-(1-3)-beta-glucopyranose glucan protection against lethal infection in an animal model of intra-abdominal sepsis.

Previous studies have established the efficacy of soluble polymers of poly-(1-6)-beta-glucotriosyl-(1-3)-beta-glucopyranose (PGG) glucan, a biological-response modifier, in protecting against mortality associated with experimentally induced peritonitis in a rat model. PGG glucan-treated animals showed increases in total leukocyte counts and enhanced bacterial clearance from blood. To further explore the mechanisms) by which this agent confers protection, studies were performed to examine whether protection could be transferred from PGG glucan-treated animals to naive recipients via spleen cells (SC), SC lysates, or serum. Passive-transfer experiments indicated that the responsible factor(s) was transferable by whole SC and SC lysates, as well as by peripheral leukocytes or serum from animals treated with PGG glucan. The transferable factor(s) was resistant to pronase and trypsin digestion, was heat stable at 56 or 80 degrees C, and was not removed by NH4SO4 precipitation. The protective effect of PGG glucan was abrogated by treatment with indomethacin, a potent inhibitor of prostaglandin synthesis. Administration of a purified prostaglandin extract from the sera of PGG glucan-treated animals protected against mortality in the peritonitis model. Furthermore, treatment of rats with exogenous synthetic prostaglandin E2 also conferred protection against mortality. These results suggest that the protective effect exhibited by PGG glucan in the rat peritonitis model is mediated, at least in part, by prostaglandins.

Polysaccharide-mediated protection against abscess formation in experimental intra-abdominal sepsis.

Abscess formation is a major complication of intra-abdominal sepsis that causes significant morbidity and mortality. In such cases, Bacteroides fragilis is the predominant anaerobic isolate. In a rat model of intra-abdominal sepsis, the capsular polysaccharide complex (CPC) from B. fragilis promotes abscess formation and when administered sub-cutaneously, protects against this host response by a T cell-dependent immune mechanism. In the present study, the polysaccharide A (PS A) component of CPC protected animals against challenge with live heterologous bacterial species (mixtures of anaerobes and facultative organisms) that are most commonly isolated from intra-abdominal abscesses in humans. Protection against heterologous bacterial challenge was transferred by T cells. Administration of PS A shortly before or even after challenge with B. fragilis protected against this host response. In experiments designed to simulate fecal contamination of the human peritoneal cavity, PS A protected animals against abscess formation induced by a rat cecal contents inoculum. The surprisingly broad protective activity of PS A indicates that this molecule is likely suppressing a nonspecific host tissue reaction that forms in response to a variety of abscess-inducing organisms and that it might be useful in preventing abscess formation associated with intra-abdominal sepsis in the clinical setting.

Structural features of polysaccharides that induce intra-abdominal abscesses.

The capsular polysaccharide complex from Bacteroides fragilis promotes the formation of intra-abdominal abscesses--a pathologic host response to infecting microorganisms. This complex consists of two distinct polysaccharides, each with repeating units that have positively charged amino groups and negatively charged carboxyl or phosphate groups. Analysis of these polysaccharides as well as other charged carbohydrates before and after chemical modification revealed that these oppositely charged groups are required for the induction of intra-abdominal abscesses in a rat model.

Axonal necrosis of enteric autonomic nerves in continent ileal pouches. Possible implications for pathogenesis of Crohn's disease.

OBJECTIVE: Axonal necrosis was first described in samples of small intestine from patients with Crohn's disease (A.M. Dvorak et al. Hum Pathol 1980; 11:620-634). Clinically evident inflammation of continent ileal reservoirs (pouches) has clinical features that resemble Crohn's disease. Possible similarities in the pathogenesis of Crohn's disease and pouchitis were sought using ultrastructural and microbiologic tools to identify damaged enteric nerves and tissue bacteria. METHODS: An encoded ultrastructural and microbiologic study of replicate biopsies from 114 samples of human intestine was done. Biopsies from ileum, colon, conventional ileostomy or continent pouch were obtained from patients with ulcerative colitis, Crohn's disease, or familial polyposis and grouped into three clinical study groups (control, normal pouch, pouchitis), based on clinical and endoscopic criteria. Biopsies were prepared for electron microscopy with standard methods; replicate biopsy samples were washed extensively before preparing cultures designed to identify aerobic as well as facultative and obligate anaerobic bacteria (Onderdonk et al. J Clin Microbiol 1992; 30:312-317). The ultrastructural diagnosis of damaged enteric nerves was based on previously published criteria for axonal necrosis (A.M. Dvorak and W. Silen. Ann Surg 1985; 201:53-63). Intergroup comparisons were tested for significance using Chi-square analysis. RESULTS: The highest incidence of axonal necrosis was present in Crohn's disease control biopsies (53%), regardless of whether bacteria were present (or not) in cultures of replicate biopsies. Axonal necrosis also occurred in more ulcerative colitis and familial polyposis biopsies (regardless of biopsy site) that had positive bacterial cultures than in those that did not (p < 0.001). In addition, axonal necrosis was documented in 42% of the pouch biopsies from ulcerative colitis and familial polyposis patients, particularly in those pouches that were found to be inflamed by clinical criteria and that also had positive bacterial cultures of the biopsied tissues. Control biopsies from patients with ulcerative colitis and familial polyposis had significantly less nerve damage than pouch biopsies in the presence of positive cultures (p < 0.01). Among the clinically inflamed pouches biopsied in ulcerative colitis or familial polyposis patients, we found that none had damaged enteric nerves when bacterial cultures were negative (p < 0.005). If the presence of axonal necrosis alone was compared with the presence of undamaged enteric nerves in all biopsies from patients with ulcerative colitis, a highly significant number of ulcerative colitis biopsies with axonal necrosis occurred in pouches (72%) compared with controls (p < 0.001). CONCLUSIONS: The ultrastructural finding of axonal necrosis in Crohn's disease confirms previous studies. The presence of damaged enteric nerves in patients with pouchitis provides ultrastructural support to the clinical impression of similarities between pouchitis and Crohn's disease. The association of damaged nerves and invasive bacteria in pouchitis suggests mechanistic similarities for the pathogenesis of Crohn's disease that requires further investigation.

Anti-infective effect of poly-beta 1-6-glucotriosyl-beta 1-3-glucopyranose glucan in vivo.

Mice challenged with Escherichia coli or Staphylococcus aureus were protected against lethal peritonitis by the intravenous administration of 10 micrograms of poly-beta 1-6-glucotriosyl-beta 1-3-glucopyranose (PGG) glucan per animal 4 to 6 h prior to bacterial challenge. Subsequent studies with the rat model for intra-abdominal sepsis indicated that intramuscular doses of 10 to 100 micrograms per animal 24 and 4 h prior to surgical implantation of the bacterial inoculum reduced the early mortality associated with the peritonitis phase of this experimental disease process. Quantitative cultures of blood obtained from challenged rats showed that significantly fewer organisms were present in the blood of PGG glucan-treated animals than in that of untreated animals. Quantitative studies of leukocytes of rats and mice following a single injection of PGG glucan showed a modest transient increase in the total leukocyte count. The possible mechanisms by which protection occurs in the animal model system are discussed.

Microbiologic assessment of tissue biopsy samples from ileal pouch patients.

Tissue biopsy samples from patients with and without ileal pouches were examined by electron microscopic and microbiologic culture techniques to determine the numbers and types of microorganisms closely associated with or within the tissue biopsy samples. The disease status of each patient was determined by endoscopic and histopathologic methods. Of the 78 biopsy samples included in this study, 64 (82%) yielded obligately anaerobic and/or facultative bacteria when they were cultured. Fourteen of the 78 samples (17.9%) were negative by culture. Of the positive samples, 54 contained facultatively anaerobic bacterial species and 50 yielded obligately anaerobic species. The total counts for facultatively anaerobic bacteria for samples from patients with pouchitis were significantly greater than for samples from patients in control groups. In addition, the number of samples from patients with normal pouches that did not contain obligate anaerobes was significantly less than that from patients with pouchitis; 4 of 23 and 6 of 12 samples, respectively (P less than 0.043). For samples in which organisms were detected, there was agreement with electron microscopic detection of bacteria in 23 of 27 samples, for an overall sensitivity of electron microscopy compared with that of culture of 85%. The qualitative studies resulted in the characterization of 273 isolates comprising 77 different phenotypes. The specificity of these findings in patients with ileal pouchitis is discussed.

Human gut mucosal mast cells: ultrastructural observations and anatomic variation in mast cell-nerve associations in vivo.

One hundred and seventeen coded intestinal biopsy specimens were examined by electron microscopy. All surgical biopsies were obtained from uninvolved sites of patients with two inflammatory bowel diseases (ulcerative colitis or Crohn's disease) and from patients with preneoplastic and neoplastic diseases (adenocarcinoma, rectal polyp, familial polyposis). Biopsy sites included normal ileum, colon, and rectum as well as conventional ileostomies and continent pouches constructed from the ileum. The data reported here describe the ultrastructural anatomy of human gastrointestinal tract mucosal mast cells in vivo and their anatomic associations with enteric nerves.

Ultrastructural evidence for piecemeal and anaphylactic degranulation of human gut mucosal mast cells in vivo.

One hundred and seventeen coded intestinal biopsies were examined by electron microscopy and evaluated for morphological evidence of mast cell and basophil secretion in situ. Sixty percent of the biopsies had evidence of secretion. Mast cell secretion was evident in control biopsies, many of which were obtained from uninvolved tissues of patients with inflammatory bowel disease. Biopsies of inflamed continent pouches from ulcerative colitis (UC) patients showed more mast cell secretion than noninflamed UC pouch biopsies. This evidence of mast cell secretion supports recent work that documents high constitutive levels of histamine in jejunal fluids of Crohn's disease patients and suggests a proinflammatory role for mast cells in inflammation associated with pouchitis.

Comparison of in vivo and in vitro efficacy of ceftizoxime.

Two hundred obligately anaerobic bacterial isolates from human clinical sources were tested for susceptibility to ceftizoxime using a standard National Committee for Clinical Laboratory Standards microwell system. In general, the minimal inhibitory concentrations (MIC50) ranged from less than 0.125 to 32 microgram/ml; however, the MIC50 for Bacteroides fragilis averaged greater than 128 microgram/ml. This finding is inconsistent with the results of in vivo testing of ceftizoxime in an animal model of intra-abdominal sepsis (B fragilis is a major contributor to the development of intra-abdominal abscesses). Various modifications of in vitro assay parameters, including basal media (brain-heart infusion [BHI] or Wilkins-Chalgren [WC]) and methods (microwell, broth, and agar dilutions), were compared. Ten B fragilis isolates from the original clinical study were used. Results indicate that the activity of ceftizoxime decreased between two- and fourfold after storage for 48 hours at -80 degrees C, regardless of methodology or basal media. When microwell was compared with broth dilution, there was a four- to 64-fold decrease in MIC values by the latter method using BHI but little variation using WC. No differences were observed when the incubation time was varied. Preliminary data indicate that MIC values from broth dilution using BHI correspond with those of agar dilution assays. These results suggest methodologic as well as environmental discrepancies with regard to susceptibility testing of ceftizoxime. These differences may lead to misinterpretation of the true susceptibility of organisms to this agent, particularly when the results are compared with in vivo observations.

Animal model system for studying virulence of and host response to Bacteroides fragilis.

Experimental animal model systems have been used by many investigators to explore the pathogenicity of obligate anaerobes. During the last 15 years, research in our laboratory has utilized an experimental model for intraabdominal sepsis to define the contribution of obligate anaerobes to the infectious process. These studies have shown that obligate anaerobes are important components of the polymicrobic flora present during such infection. Moreover, certain anaerobes, such as Bacteroides fragilis, possess specific virulence factors, such as the capsular polysaccharide, that appear to be important to the infectious process. More recent research has used modifications of the original model system to evaluate the host immune response to B. fragilis. These studies indicate that immunization with the capsular polysaccharide provides a T cell-dependent immunity to abscess development when animals are challenged with B. fragilis. It has also been shown that the killing of B. fragilis is T cell dependent. The observations made with regard to B. fragilis in this animal model system are discussed.

Intraperitoneal host cellular responses and in vivo killing of Bacteroides fragilis in a bacterial containment chamber.

A bacterial containment chamber was used to evaluate the peritoneal cellular response to Bacteroides fragilis during intraperitoneal challenge. This containment system was also used to determine the fate of bacteria within the peritoneal cavities of animals immunized, either actively or through adoptive transfer of cells or cell lysates, with the capsular polysaccharide of B. fragilis. This system demonstrated that the dominant cell types in the peritoneal cavities within 48 h of implantation of the containment chambers containing B. fragilis were neutrophils and macrophages. However, the early cellular response in immunized animals included an increase in the lymphocyte population within 4 h of challenge which was not detected in naive animals. In immunized animals, a later dramatic increase in the lymphocyte population at approximately 4 to 6 days following implantation of the containment chambers occurred. This increase in the lymphocyte population in immunized animals coincided with a decline in the viable bacterial counts within the chambers from 10(8) to 10(9) CFU/ml to less than 10(2) CFU/ml. A similar decline was not seen in naive animals challenged in the same manner. Killing of B. fragilis within containment chambers occurred when spleen cells, T cells, or lysates of T cells from actively immunized animals were passively transferred to naive recipient animals. It was shown that the factor responsible for bacterial killing was not antibody mediated, since bacteria contained within dialysis sacs with an exclusion of 50 kilodaltons were still killed in this model. Moreover, removal of T cells from adoptively transferred cell populations before transfer abrogated the decline in viable bacterial populations. The postulated mechanisms by which this bacterial killing occurred are discussed.

Bacteroides vulgatus outer membrane antigens associated with carrageenan-induced colitis in guinea pigs.

Previous experiments with the carrageenan model for ulcerative colitis demonstrated that the inflammatory response in guinea pigs can be enhanced by immunization with Bacteroides vulgatus and subsequent feeding of this organism to experimental animals. The studies reported here show that antigens extractable from the bacterial outer membrane by EDTA are responsible for this effect. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis was used to analyze the outer membrane proteins from various strains as well as the lipopolysaccharides (LPS) extractable by the phenol-water method. Although the observed pattern of outer membrane proteins was complex, the strains could be divided into two electrophoretic types (phenons) on the basis of immunoblotting against a panel of antisera. Cross-absorbed antisera used in immunoblotting experiments identified four outer membrane proteins uniquely associated with the phenon capable of enhancing the colitis inflammatory response. These proteins had molecular weights of 100,000, 57,000, 34,000, and 21,000 when measured in 8% to 12% acrylamide gradient sodium dodecyl sulfate gels. Other antigens identified included at least one type of smooth LPS, three types of rough LPS, and a common antigen of 30,000 molecular weight among the strains of B. vulgatus tested. The outer membrane preparations were used in animal immunization and challenge experiments, and the severity of colitis was correlated with one electrophoresis type. The potential role of membrane proteins in the enhancement of colitis is discussed.

Adoptive transfer of immune enhancement of experimental ulcerative colitis.

Previous experiments with the carrageenan model for ulcerative colitis have shown that the inflammatory response in guinea pigs can be enhanced by immunization with and subsequent feeding of Bacteroides vulgatus to experimental animals. The present studies showed that only certain strains of B. vulgatus are capable of provoking immune enhancement of ulcerative colitis. Animals were fed carrageenan and various strains of viable B. vulgatus after immunization with a strain of B. vulgatus isolated from a guinea pig with experimentally induced colitis. Histological comparison of immune and nonimmune groups revealed that immune animals which received B. vulgatus from a patient with inflammatory bowel disease had a significantly (P less than 0.025) greater number of histopathological lesions at 21 days than did nonimmune animals. Immune animals receiving B. vulgatus isolated from a clinically normal source did not show any significant difference in disease status when compared to nonimmune animals. Additional experiments showed that adoptive transfer of spleen cells from animals immunized with B. vulgatus to nonimmune recipient animals is effective in transferring the immune enhancement demonstrated in actively immunized animals. Animals which received immune spleen cells with concurrent feeding of B. vulgatus showed a significant (P less than 0.005) increase in inflammation over control groups, in the absence of high titers of circulating antibody. These experiments indicate that B. vulgatus strain-specific factors are important to immune enhancement of experimental disease and also suggest an involvement of the cell-mediated immune system in this model.

Enhancement of experimental ulcerative colitis by immunization with Bacteroides vulgatus.

Previous studies with the guinea pig model for ulcerative colitis have shown that the inducing agent, carrageenan, does not provoke ulcerations in germfree guinea pigs, but animals monoassociated with Bacteroides vulgatus develop cecal ulcerations when fed carrageenan. In an effort to define the role of B. vulgatus in this model system, conventional guinea pigs were immunized with B. vulgatus before carrageenan treatment. Immunized animals developed both circulating antibody and positive skin tests for the homologous antigen. A comparison of B. vulgatus-immune and nonimmune carrageenan recipients after 30 days of carrageenan treatment revealed ulcerations of the ceca and large intestine in both groups, but the immune group developed more severe lesions than the nonimmune group. The most severe intestinal lesions were detected in B. vulgatus-immune animals fed both carrageenan and daily doses of viable B. vulgatus. Immune recipients of B. vulgatus alone did not develop ulcerations, but showed histological evidence of intestinal inflammation. Lesions observed in B. vulgatus-immune animals were most severe in the colon and rectum, in contrast to more severe cecal lesions detected in nonimmune carrageenan recipients. Similar experiments with Bacteroides fragilis as an antigen for immunization showed no difference between immune and nonimmune groups. These results suggest that immunization with B. vulgatus enhances the severity of carrageenan-induced colitis.

Evidence for T cell-dependent immunity to Bacteroides fragilis in an intraabdominal abscess model.

It has been shown that active immunization of rats with the capsular polysaccharide of Bacteroides fragilis protects these animals against abscess development following intraperitoneal challenge with this species. Passive transfer of hyperimmune globulin from immunized animals to nonimmune recipients provided protection against B. fragilis bacteremia in challenged animals, but did not confer protection against abscess development. On the other hand, adoptive transfer of spleen cells from immunized animals to nonimmunized recipients resulted in protection against abscesses following challenge with B. fragilis. These data suggested that a T cell-dependent immune response was involved in protection against abscess development after immunization with B. fragilis capsular antigen. To determine the possible role of cell-mediated immunity prompted by the capsular antigen, inbred congenitally athymic OLA/Rnu rats and their phenotypically normal littermates were actively immunized. Despite the development of high titers of anti-B. fragilis capsular antibody, 100% of actively immunized athymic rats developed abscesses, as did 100% of unimmunized athymic control rats. However, no phenotypically normal littermate control rats that were actively immunized developed abscesses, while 100% of phenotypically normal unimmunized rats developed abscesses. Additional studies showed that adoptive transfer of T cell-enriched spleen cell preparations from Wistar/Lewis rats immunized with the capsular polysaccharide to nonimmune recipients also resulted in protection against B. fragilis-induced abscesses. We conclude that the protection afforded by immunization with B. fragilis capsule against intraabdominal abscesses caused by that organism is T cell-mediated and does not require the presence of serum antibody.

Production of experimental ulcerative colitis in gnotobiotic guinea pigs with simplified microflora.

Conventional guinea pigs provided with a solution of 5% (wt/vol) degraded carrageenan as the sole source of oral fluids developed ulcerations of their ceca and large intestines within 30 days. Similar lesions were not detected in germfree guinea pigs treated in an identical manner, suggesting that an intestinal microflora was necessary for development of intestinal lesions. To simplify the bacterial flora required for production of cecal ulcerations, 10 pools consisting of 10 bacterial strains each were isolated from the cecal microflora of carrageenan-treated animals. Groups of germfree guinea pigs were associated with 2 of the 10 pools by orogastric intubation and observed for development of disease. One-half of each group was treated with carrageenan. The two bacterial pools were characterized by the presence of cytopathic effects for WI-38 and Vero cells, increased chemotactic activity, and increased concentrations of long-chain fatty acids. The results indicated that animals associated with those two pools developed cecal ulcerations during carrageenan treatment. Preliminary results also indicated that cecal ulcerations developed in germfree animals mono-associated with a strain of Bacteroides vulgatus isolated from one of the pools, regardless of whether carrageenan was administered, suggesting a bacterial involvement in disease development in the absence of carrageenan treatment.

Clostridium difficile in gnotobiotic mice.

Germfree mice associated with Clostridium difficile developed intestinal disease characterized by polymorphonuclear cell infiltration of the lamina propria, diarrhea, and cecal cytotoxin concentrations positive at a 10(-6) dilution. The numbers of viable bacteria never exceeded 10(10) colony-forming units per g (dry weight). Despite the high toxin levels and chronic inflammation over a 30-day period, the mortality rate was low (less than 2%). Daily treatment of these animals with two oral doses of 2 mg of vancomycin resulted in stool levels of greater than 200 micrograms/ml, well in excess of the minimum inhibitory concentration for C. difficile. This therapy decreased viable cell density by 2 to 3 logs and increased the spore counts from 10(5.8) to 10(7.8) colony-forming units per g (dry weight) by day 7, and animals were free of detectable toxin. However, once therapy was stopped, viable bacteria and spore counts and cytotoxin concentrations returned to previous levels. Treatment of mice with concentrations of clindamycin shown to be inhibitory in vitro had no effect on C. difficile toxin titers or bacterial counts, although the appearance of a clindamycin-resistant population was noted. These data indicate that vancomycin, given orally, decreases the concentration of toxin, but C. difficile survive as spores. By contrast, large populations of vegetative cells and high cytotoxin levels persist when clindamycin is used, even at an inhibitory concentration.