Opsonization of T1M1 group A Streptococcus: dynamics of antibody production and strain specificity

A chemiluminescence method was used to study opsonization of group A Streptococcus (GAS) of serotype T1M1 in serum samples ("sera") obtained from Swedish patients with invasive and noninvasive GAS infection and from healthy blood donors. Acute-phase serum samples ("acute sera") generally demonstrated low ability to opsonize the patient's own GAS isolate, regardless of clinical manifestation. Only approximately 15% of serum samples obtained from healthy blood donors demonstrated high opsonic activity against a standard T1M1 strain. Opsonization of 62 T1M1 isolates (obtained during 1980-1998) by a single immune serum sample showed considerable variation; this indicates that high opsonic immunity may develop only against the infecting isolate or identical clones. T1M1 GAS isolated from 1987 through 1990 were better opsonized by the immune serum sample than were isolates obtained before 1987 or after 1990, a finding that suggests a temporal change of the surface properties that affect opsonization.

Randomized comparison of linezolid (PNU-100766) versus oxacillin-dicloxacillin for treatment of complicated skin and soft tissue infections

This randomized, double-blind, multicenter trial compared the efficacy and safety of linezolid, an oxazolidinone, with those of oxacillin-dicloxacillin in patients with complicated skin and soft tissue infections. A total of 826 hospitalized adult patients were randomized to receive linezolid (600 mg intravenously [i.v.]) every 12 h or oxacillin (2 g i.v.) every 6 h; following sufficient clinical improvement, patients were switched to the respective oral agents (linezolid [600 mg orally] every 12 h or dicloxacillin [500 mg orally] every 6 hours). Primary efficacy variables were clinical cure rates in both the intent-to-treat (ITT) population and clinically evaluable (CE) patients and microbiological success rate in microbiologically evaluable (ME) patients. Safety and tolerability were evaluated in the ITT population. Demographics and baseline characteristics were similar across treatment groups in the 819 ITT patients. In the ITT population, the clinical cure rates were 69.8 and 64.9% in the linezolid and oxacillin-dicloxacillin groups, respectively (P = 0.141; 95% confidence interval -1.58 to 11. 25). In 298 CE linezolid-treated patients, the clinical cure rate was 88.6%, compared with a cure rate of 85.8% in 302 CE patients who received oxacillin-dicloxacillin. In 143 ME linezolid-treated patients, the microbiological success rate was 88.1%, compared with a success rate of 86.1% in 151 ME patients who received oxacillin-dicloxacillin. Both agents were well tolerated; most adverse events were of mild-to-moderate intensity. No serious drug-related adverse events were reported in the linezolid group. These data support the use of linezolid for the treatment of adults with complicated skin and soft tissue infections.

Molecular epidemiology of nga and NAD glycohydrolase/ADP-ribosyltransferase activity among Streptococcus pyogenes causing streptococcal toxic shock syndrome

Severe invasive group A streptococcal (GAS) infections emerged in the late 1980s, yet no single virulence factor has been common to all isolates from infected patients. A strong association was recently found between isolates of such cases (regardless of M type) and the production of NAD glycohydrolase (NADase). Of interest, all M-1 strains isolated after 1988 were positive for NADase, whereas virtually all M-1 GAS were previously negative for NADase. Genetic analysis demonstrated that GAS isolates were >96% identical in nga and >99% identical in their upstream regulatory sequences. Furthermore, because NADase-negative strains did not produce immunoreactive NADase, we concluded that additional regulatory element(s) control NADase production. NADase purified from GAS altered neutrophil-directed migration and chemiluminescence responses and had potent ADP-ribosyltransferase activity. In summary, the temporal relationship of NADase expression, alone or with other streptococcal virulence factors, may contribute to the pathogenesis of invasive GAS infections.

The pathogenesis of clostridial myonecrosis

These pieces of evidence can be assimilated into a molecular and cellular model of pathogenesis which is initiated by direct toxin effects upon venous capillary endothelial cell function, leading to expression of pro-inflammatory mediators and adhesion molecules, and initiation of platelet aggregation. Toxin-induced hyperadhesion of leukocytes (see above section) with enhanced respiratory burst activity (due to toxins directly or to toxin-induced IL-8 or PAF synthesis by host cells) and toxin-induced chemotaxis deficits could result in neutrophil-mediated vascular injury. Direct toxin-induced cytopathic effects on EC may also contribute to vascular abnormalities associated with gas gangrene. Over prolonged incubation periods, PLC at sublytic concentrations causes EC to undergo profound shape changes similar to those described following prolonged TNF or interferon gamma exposure. In vivo, conversion of EC to this fibroblastoid morphology could contribute to the localized vascular leakage and massive swelling observed clinically with this infection. Similarly, the direct cytotoxicity of PFO could disrupt endothelial integrity and contribute to progressive edema both locally and systemically. Thus, via the mechanisms outlined above, both PLC and PFO may cause local, regional and systemic vascular dysfunction. For instance, local absorption of exotoxins within the capillary beds could affect the physiological function of the endothelium lining the postcapillary venules, resulting in impairment of phagocyte delivery at the site of infection. Toxin-induced endothelial dysfunction and microvascular injury could also cause loss of albumin, electrolytes, and water into the interstitial space resulting in marked localized edema. These events, combined with intravascular platelet aggregation and leukostasis, would increase venous pressures and favor further loss of fluid and protein in the distal capillary bed. Ultimately, a reduced arteriolar flow would impair oxygen delivery thereby attenuating phagocyte oxidative killing and facilitating anaerobic glycolysis of muscle tissue. The resultant drop in tissue pH, together with reduced oxygen tension, might further decrease the redox potential of viable tissues to a point suitable for growth of this anaerobic bacillus. As infection progresses and additional toxin is absorbed, larger venous channels would become affected, causing regional vascular compromise, increased compartment pressures and rapid anoxic necrosis of large muscle groups. When toxins reach arterial circulation, systemic shock and multiorgan failure rapidly ensue, and death is common.

Clostridial gas gangrene. I. Cellular and molecular mechanisms of microvascular dysfunction induced by exotoxins of Clostridium perfringens

Mechanisms responsible for the rapid tissue destruction in gas gangrene are not well understood. To examine the early effects of Clostridium perfringens exotoxins on tissue perfusion, a rat model of muscle blood flow was developed. Intramuscular injection of a clostridial toxin preparation containing both phospholipase C (PLC) and theta-toxin caused a rapid (1-2 min) and irreversible decrease in blood flow that paralleled formation of activated platelet aggregates in venules and arterioles. Later (20-40 min), aggregates contained fibrin and leukocytes, and neutrophils accumulated along vascular walls. Flow cytometry confirmed that these clostridial toxins or recombinant PLC induced formation of P-selectin-positive platelet aggregates. Neutralization of PLC activity in the clostridial toxin preparation completely abrogated human platelet responses and reduced perfusion deficits. It is concluded that tissue destruction in gas gangrene is related to profound attenuation of blood flow initiated by activation of platelet responses by PLC.

Clostridial gas gangrene. II. Phospholipase C-induced activation of platelet gpIIbIIIa mediates vascular occlusion and myonecrosis in Clostridium perfringens gas gangrene

Clostridium perfringens gas gangrene is a fulminant infection, and radical amputation remains the single best treatment. It has been hypothesized that rapid tissue destruction is related to tissue hypoxia secondary to toxin-induced vascular obstruction, and previous studies demonstrated that phospholipase C (PLC) caused a rapid and irreversible decrease in skeletal muscle blood flow that paralleled the formation of intravascular aggregates of activated platelets, fibrin, and leukocytes. In this study, flow cytometry demonstrated that PLC stimulated platelet/neutrophil aggregation in a gpIIbIIIa-dependent fashion. Pretreatment of animals with heparin or depletion of leukocytes reduced blood-flow deficits, and aggregate formation caused by PLC. It is concluded that fulminant tissue destruction in gas gangrene results from profound attenuation of blood flow caused by PLC-induced, gpIIbIIIa-mediated formation of heterotypic platelet/polymorphonuclear leukocyte aggregates. Therapeutic strategies that target gpIIbIIIa may prevent vascular occlusion, maintain tissue viability, and provide an alternative to radical amputation for patients with this infection.

Streptococcal toxic shock syndrome associated with necrotizing fasciitis

Streptococcal toxic shock syndrome (strep TSS) with associated necrotizing fasciitis is a rapidly progressive process that kills 30-60% of patients in 72-96 h. Violaceous bullae, hypotension, fever, and evidence of organ failure are late clinical manifestations. Thus, the challenge to clinicians is to make an early diagnosis and to intervene with aggressive fluid replacement, emergent surgical debridement, and general supportive measures. Superantigens such as pyrogenic exotoxin A interact with monocytes and T lymphocytes in unique ways, resulting in T-cell proliferation and watershed production of monokines (e.g. tumor necrosis factor alpha, interleukin 1, interleukin 6), and lymphokines (e.g. tumor necrosis factor beta, interleukin 2, and gamma-interferon). Penicillin, though efficacious in mild Streptococcus pyogenes infection, is less effective in severe infections because of its short postantibiotic effect, inoculum effect, and reduced activity against stationary-phase organisms. Emerging treatments for strep TSS include clindamycin and intravenous gamma-globulin.

Construction and virulence testing of a collagenase mutant of Clostridium perfringens

Clostridium perfringens produces several extracellular toxins and enzymes, including an extracellular collagenase or kappa toxin that is encoded by the colA gene. To determine if the ability to produce collagenase was a significant virulence factor in cases of gas gangrene or clostridial myonecrosis that are caused by C. perfringens, a chromosomal colA mutant was constructed by homologous recombination and subsequently virulence tested in the mouse myonecrosis model. The results clearly indicate that loss of the ability to produce collagenase does not alter the ability of the mutant to establish a virulent infection. By contrast, infection with a mutant unable to produce alpha-toxin led to a marked decrease in virulence. These results indicate that collagenase is not a major determinant of virulence in C. perfringens -mediated clostridial myonecrosis.

Variable susceptibility to opsonophagocytosis of group A streptococcus M-1 strains by human immune sera

Immunity to group A streptococci (GAS) is thought to be related to the acquisition of type-specific antibody directed against the M protein. However, recent work suggests that immunity may only be strain and not M-type specific. Therefore, susceptibility of 70 different GAS M-1 strains to opsonization and killing by convalescent sera was compared by using a highly sensitive chemiluminescence assay and by standard bactericidal assay. Sequencing of the emm1 gene in 10 strains with variable susceptibility to opsonization revealed 100% homology in 9 strains. Several substitutions in the N-terminal and 2 in the A3 repeat regions of strain CS-190 were associated with profound resistance to opsonization. Thus amino acid substitutions within different regions of the M-1 protein molecule may adversely affect opsonization by immune sera. In addition, non-M protein factors from identical M types influence susceptibility to phagocytosis. These findings may in part explain the persistently high prevalence of M-1 strains worldwide over the last 15 years.

Staging of the baboon response to group A streptococci administered intramuscularly: a descriptive study of the clinical symptoms and clinical chemical response patterns

Group A streptococcal infections, ranging from necrotizing fasciitis and myositis to toxic shock syndrome, have increased over the last 10 years. We developed the first primate model of necrotizing fasciitis and myositis. Thirteen baboons were inoculated intramuscularly with group A streptococci (GAS). Eleven animals survived for > or = 11 days before sacrifice, and two animals died within 2 days. The site of inoculation of the survivors exhibited an intense neutrophilic influx (stage I), followed by a lymphoplasmacytic influx (stages II and III). This was accompanied by the appearance of markers of an acute and then a chronic systemic inflammatory response. In contrast, the site of inoculation of the two nonsurvivors exhibited intravascular aggregates of neutrophils at its margin with no influx of neutrophils and with extensive bacterial colonization. We conclude that GAS inoculation induces a local and systemic acute neutrophilia followed by a chronic lymphoplasmacytic response; failure, initially, of neutrophilic influx into the site of inoculation predisposes to systemic GAS sepsis and death; and this three-stage primate model approximates the human disease.

Lethal effect of carbon K-shell photoionizations in Chinese hamster V79 cell nuclei: experimental method and theoretical analysis

To test a possible specific effect of carbon K-shell ionizations in DNA, survival curves for Chinese hamster V79 cells were measured for X irradiations at energies below and above the carbon K-shell ionization threshold. Specific values of the X-ray energies (250 and 340 eV) were chosen to ensure isoattenuation of the two kinds of radiation within the cell. An enhancement of lethality by a factor of about 2 was found for X rays at 340 eV compared to below the threshold at 250 eV. This may be attributed to the production of highly efficient carbon K-shell ionizations located on DNA. A model of X-ray lethality (Goodhead et al., Radiat. Prot. Dosim. 52, 217-223, 1994) was extended to allow for a possible lethal effect from clusters of reactive species induced by K-shell photoionizations (K-shell clusters). Within this model, the increase in lethality above the carbon K-shell threshold may be explained by a value of 2% for the lethal efficiency of K-shell clusters overlapping the DNA. An extrapolation to the lethal effect of more complex ion-induced K-shell ionizations indicates that K-shell ionization may be a major process in the biological effectiveness of heavy ions.

Mycobacterium fortuitum meningitis associated with an epidural catheter: case report and a review of the literature

Mycobacterium fortuitum is a rapidly growing organism that has rarely been associated with meningitis. A patient developed M. fortuitum meningitis as the result of a permanent indwelling, contaminated, epidural catheter. Diagnosis and treatment of the disease are difficult in that clinical features may be indolent, and many antimicrobials with activity against M. fortuitum have minimal cerebrospinal fluid penetration. This patient was cured with an antibiotic regimen that consisted of doxycycline, ciprofloxacin, imipenem, and clarithromycin, and removal of the epidural catheter.

Type-specific opsonophagocytosis of group A Streptococcus by use of a rapid chemiluminescence assay

A whole-blood chemiluminescence (CL) assay was developed to determine the presence of type-specific opsonic antibodies against group A streptococcus (GAS). Convalescent sera with high bactericidal activities against an M-1 serotype were used to opsonize different M-types of GAS. CL responses were monitored for 20 min, and results were expressed as integral counts/minute per phagocyte. CL responses of phagocytes incubated with M-1 GAS opsonized with homologous (M-1) serum were significantly higher than responses of phagocytes incubated with heterologous (M-3) GAS. Adsorption of convalescent serum against the homologous, but not the heterologous, strain markedly reduced the CL response, demonstrating type specificity. The CL assay showed a high correlation with the indirect bactericidal test (r=0.90). In conclusion, this CL assay is a rapid, highly sensitive, specific, and reproducible method for quantifying type-specific opsonic antibodies against GAS and will be a useful tool for future clinical, basic science, and epidemiological studies.

Reduction of the gamma-ray component from 252Cf fission neutron source--optimization for biological irradiations and comparison with MCNP code

Gamma-rays contribute 33% of the absorbed dose from an unfiltered 252Cf fission neutron source. To reduce this gamma-ray component and to enable radiobiological experiments at as high a dose rate as possible, Monte Carlo calculations for several filter materials (Al, Fe, Pb and concrete) have been made using MCNP neutron and photon transport code version 4a. A lead filter of thickness 4 cm was found to reduce the gamma-ray component to 6.7% of the total dose whilst reducing the neutron dose by only about 10%. Such a filter was installed at the MRC 252Cf neutron irradiation facility and dosimetric measurements were made using a TE-TE chamber and a 7LiF(Mg, Cu, P) TLD. Monte Carlo simulations agree with experimental measurements of neutron and gamma-ray doses within 6%. V79-4 Chinese hamster cells were irradiated with lead-filtered and unfiltered neutrons and also with 60Co gamma-rays at two dose rates. The survival fraction obtained for each radiation was consistent with the reduced gamma-ray dose. The relative biological effectiveness for neutrons alone, corrected for gamma-ray effects, was found to be 9.2 +/- 3.4 from the initial slopes and 3.1 +/- 0.5 at 10% survival, both relative to the acute gamma-rays.

Comparison of adherence to and penetration of a human laryngeal epithelial cell line by group A streptococci of various M protein types

Clinically isolated group A streptococci (GAS) of different M protein types were studied using aminoglycoside exclusion and [2,8-3H]adenine radiolabeled GAS assays to compare the abilities of different strains to adhere to and internalize within human laryngeal epithelial (HEp-2) cells. GAS isolated from patients with pharyngitis and GAS isolated from patients with more severe disease, such as necrotizing fasciitis, adhered to and penetrated HEp-2 cells equally well. M3, M4, M6, and M12 strains adhered to and were internalized within HEp-2 cells more than M1 strains. M18 GAS producing hyaluronic acid capsules were less adherent and less invasive than the M3, M4, M6, and M12 strains. An M3-producing GAS strain and its M protein-deficient isogenic strain adhered similarly to HEp-2 cells, but the M protein-deficient strain exhibited greater penetration. Preincubation of HEp-2 cells with an N-terminal synthetic M3 peptide did not alter the adherence or penetration by an M3 strain. In summary, this study demonstrates that GAS from invasive and non-invasive disease adhere to and penetrate HEp-2 cells equally well and that multiple strains of GAS with various M protein types have the ability to adhere to and penetrate HEp-2 cells.

The flesh-eating bacterium: what's next?

Since the 1980s, there has been a marked increase in the recognition and reporting of highly invasive group A streptococcal (GAS) infections associated with shock and organ failure, with or without necrotizing fasciitis. Such dramatic cases have been defined as streptococcal toxic shock syndrome (StrepTSS). Strains of GAS isolated from patients with invasive disease have been predominantly M types 1 and 3, which produce either pyrogenic exotoxin A or B or both. The clinical and demographic features of streptococcal bacteremia, myositis, and necrotizing fasciitis are presented and compared with those of StrepTSS. Current concepts in the pathogenesis of invasive streptococcal infection will be presented, with emphasis on the interaction between GAS virulence factors and host defense mechanisms. Finally, new concepts in the treatment of StrepTSS will be discussed.

Teicoplanin for skin and soft tissue infections: An open study and a randomized, comparative trial versus cefazolin

An open trial and a multicenter, three-group, randomized trial versus cefazolin were performed to study the use of teicoplanin in the treatment of serious skin and soft tissue infections caused by Gram-positive bacteria. A total of 418 patients were entered into the randomized trial, 293 of whom were available for efficacy analysis, and 262 patients were entered in the open trial. The randomized trial had three arms: intramuscular (125 patients) vs intravenous (148 patients) teicoplanin vs cefazolin (145 patients). In both trials teicoplanin was administered once daily, originally as 3 mg/kg per day, with the option of higher doses in the open trial. Cefazolin was given at a dose of 1.5-4 g/day, in three divided doses. In the randomized trial, teicoplanin and cefazolin showed similar overall efficacy. The higher dose of teicoplanin (6 mg/kg) was significantly more effective than the lower dose (3 mg/kg), particularly in patients with diabetes. In the open trial, teicoplanin had a clinical success rate of 93%. There was no significant difference in the incidence of adverse events between the cefazolin and teicoplanin groups. Outpatient ambulatory therapy was shown to be a practical method of administering teicoplanin. Once-daily dosing with teicoplanin may allow physicians to treat skin and soft tissue infections on a totally outpatient basis.

Induction of DNA-protein crosslinks in Chinese hamster V79-4 cells exposed to high- and low-linear energy transfer radiation

The induction of DNA-protein crosslinks (DPCs) in Chinese hamster V79-4 cells after irradiation under hypoxic and aerobic conditions at 277 K with 60Co gamma rays, 238Pu alpha particles and aluminum K (Al(K)) ultrasoft X rays has been determined using a nitrocellulose filter binding assay. The dose dependences for the induction of DPCs, which involves covalent linkage, are linear over the absorbed dose range used (0-400 Gy with alpha-particle and gamma radiation, 0-600 Gy with Al(K) X rays). The yield of DPCs induced under hypoxic conditions is 55, 51 and 25 DPCs per gray per cell for 60Co gamma rays, alpha particles and Al(K) X rays, respectively. The yield of DPCs is significantly reduced in the presence of oxygen by 20, 50 and 79% for 60Co gamma rays, alpha particles and Al(K) X rays, respectively. Since the mean size of the DNA attached to the protein is uniform for 60Co gamma rays and alpha particles, variations in the DNA size do not influence the yields of DPCs. Although a DPC may be considered as a complex lesion combining two macromolecules, the dependence of the yield of DPCs on LET does not reflect the ionizing density of the radiations used. Further, this dependence on LET and the effect of oxygen do not reflect the corresponding dependences determined for a variety of biological responses. From these findings and knowledge of the radiation tracks, it is proposed that DPCs induced particularly under aerobic conditions with 60Co gamma rays are formed mainly in the sparsely ionizing segments of the radiation track.

Novel therapies in streptococcal toxic shock syndrome

The systemic manifestations of severe invasive group A streptococcal infections, such as streptococcal toxic shock syndrome, are mediated by an overwhelming inflammatory response induced by streptococcal superantigens and other virulence factors. The high mortality rates associated with streptococcal toxic shock syndrome demonstrate a need for better therapy in these diseases. Novel strategies to attenuate or prevent streptococcal toxic shock syndrome at different stages of illness have been proposed. The most promising therapies include agents that by various mechanisms attenuate the inflammatory response or the action of streptococcal toxins/superantigens, or both.

Chromosomal instability in the descendants of unirradiated surviving cells after alpha-particle irradiation

We have demonstrated chromosomal instability in the clonal descendants of hemopoietic stem cells after irradiating murine bone marrow with alpha-particles. However, because cells that are irradiated by alpha-particles are defined by a Poisson distribution of individual particle traversals, there is an inevitable proportion of unirradiated cells in the surviving population. The calculated expected proportions of irradiated and nonirradiated cells indicate that the number of clonogenic cells transmitting chromosomal instability is greater than the number expected to be hit and survive. To investigate further this discrepancy, we studied the effects of interposing a grid between the cells and the alpha-particle source so that the surviving population consists predominantly of untraversed stem cells. Comparison with the same irradiation conditions without the grid reveals that the same level of instability is induced. The data confirm that alpha-particles induce chromosomal instability but instability is demonstrated in the progeny of nonirradiated stem cells and must be due to unexpected interactions between irradiated and nonirradiated cells. This untargeted effect has important implications for mechanistic studies of radiation action and for assessment of radiation risk.