Osmotically stable L forms of Haemophilus influenzae and their significance in testing sensitivity to penicillins

Cell wall deficiency - an alternate bacterial lifestyle?

Historically, many species of bacteria have been reported to produce viable, cell wall deficient (CWD) variants. A variety of terms have been used to refer to CWD bacteria and a plethora of methods described in which to induce, cultivate and propagate them. In this review, we will examine the long history of scientific research on CWD bacteria examining the methods by which CWD bacteria are generated; the requirements for survival in a CWD state; the replicative processes within a CWD state; and the reversion of CWD bacteria into a walled state, or lack thereof. In doing so, we will present evidence that not all CWD variants are alike and that, at least in some cases, CWD variants arise through an adaptive lifestyle switch that enables them to live and thrive without a cell wall, often to avoid antimicrobial activity. Finally, the implications of CWD bacteria in recurring infections, tolerance to antibiotic therapy and antimicrobial resistance will be examined to illustrate the importance of greater understanding of the CWD bacteria in human health and disease.

Effects of various test media on the activities of 21 antimicrobial agents against Haemophilus influenzae

As considerable variation in the antimicrobial susceptibility of Haemophilus influenzae has been reported, the effects of various test media on the susceptibility of H. influenzae were studied. MICs were determined by three laboratories for 21 antimicrobial agents against a panel of 100 selected isolates. Testing was performed using a reference NCCLS frozen broth microdilution method with Haemophilus test medium (HTM) broth and dried commercial MIC trays rehydrated with the following media: in-house and commercially prepared HTM broth, Mueller-Hinton broth with 2% lysed horse blood and NAD, IsoSensitest broth with 2% lysed horse blood and NAD, and IsoSensitest broth-based HTM. Overall, all results were very reproducible, with the MIC at which 50% of the isolates tested are inhibited (MIC(50)), MIC(90), and geometric mean MIC being within one doubling dilution by all six methods and at all three testing centers for 15 of the 21 agents tested. Interlaboratory differences were more marked than intralaboratory differences or differences among media. Cefprozil, cefaclor, and trimethoprim-sulfamethoxazole results differed the most, while results for ampicillin, amoxicillin-clavulanic acid, cefdinir, cefixime, ceftriaxone, and clarithromycin were the most reproducible. However, these variations in results caused considerable differences in susceptibility rates for agents for which NCCLS susceptible breakpoints were close to the geometric mean MIC, particularly for cefaclor and cefprozil. This was much less of a problem when pharmacokinetic-pharmacodynamic breakpoints were used. Reproducible susceptibility results were obtained for a wide range of agents against H. influenzae in three laboratories using a variety of media that support the growth of this fastidious species.

Susceptibilities of Streptococcus pneumoniae and Haemophilus influenzae to 10 oral antimicrobial agents based on pharmacodynamic parameters: 1997 U.S. Surveillance study

The susceptibilities of Streptococcus pneumoniae (1,476 strains) and untypeable Haemophilus influenzae (1,676 strains) to various oral beta-lactam, macrolide-azalide, and fluoroquinolone antimicrobial agents were determined by broth microdilution. Organisms were isolated from specimens obtained from outpatients in six geographic regions of the United States. MIC data were interpreted according to pharmacodynamically derived breakpoints applicable to the oral agents tested. Among H. influenzae strains, 41.6% were beta-lactamase positive. Virtually all H. influenzae strains were susceptible to amoxicillin-clavulanate (98%), cefixime (100%), and ciprofloxacin (100%), while 78% were susceptible to cefuroxime, 57% were susceptible to amoxicillin, 14% were susceptible to cefprozil, 9% were susceptible to loracarbef, 2% were susceptible to cefaclor, and 0% were susceptible to azithromycin and clarithromycin. Among S. pneumoniae isolates, 49.6% were penicillin susceptible, 17.9% were intermediate, and 32.5% were penicillin resistant, with penicillin MICs for 50 and 90% of the isolates tested of 0.12 and 4 microg/ml, respectively. Overall, 94% of S. pneumoniae isolates were susceptible to amoxicillin and amoxicillin-clavulanate, 69% were susceptible to azithromycin and clarithromycin, 63% were susceptible to cefprozil and cefuroxime, 52% were susceptible to cefixime, 22% were susceptible to cefaclor, and 11% were susceptible to loracarbef. Although ciprofloxacin has marginal activity against S. pneumoniae, no high-level fluoroquinolone-resistant strains were found. Significant cross-resistance was found between penicillin and macrolides-azalides among S. pneumoniae isolates, with 5% of the penicillin-susceptible strains being macrolide-azalide resistant, compared with 37% of the intermediate isolates and 66% of the resistant isolates. Resistance was highest in S. pneumoniae isolates from patients younger than 10 years of age, middle ear and paranasal sinus specimens, and the southern half of the United States. With the continuing rise in resistance, judicious use of oral antimicrobial agents is necessary in all age groups.

Characterization of the inoculum effect with Haemophilus influenzae and beta-lactams

An inoculum effect is defined as a four-fold or greater increase in MIC with an increase in bacterial inocula. Haemophilus influenzae was tested for an inoculum effect with ampicillin, cefuroxime, and amoxicillin/clavulanate using the standard initial inocula (5 x 10(5) CFU/mL) and a higher initial inocula (1 x 10(7) CFU/mL). An inoculum effect was observed with both beta-lactamase (TEM-1, ROB-1) positive and beta-lactamase negative strains of H. influenzae when MICs were determined based on turbidity. MICs based on viable cell counts however, demonstrated that only beta-lactamase positive strains of H. influenzae produced an inoculum effect. These observations suggest that MICs determined based on turbidity, using high initial inocula, are not reliable when examining the inoculum effect in H. influenzae. The magnitude of the inoculum effect with beta-lactamase positive strains was beta-lactam dependent (ampicillin > amoxicillin/clavulanate > cefuroxime). beta-lactam kill-curves confirmed the aforementioned results. Addition of the beta-lactamase inhibitor clavulanate completely reversed the inoculum effect in beta-lactamase (TEM-1 and ROB-1) positive strains of H. influenzae with all beta-lactams tested. Introduction of the beta-lactamase gene TEM-1 on plasmid vector pLS88 into a beta-lactamase negative strain of H. influenzae (Rd) produced an inoculum effect based on viable cell counts. In conclusion, our results suggest that the beta-lactam inoculum effect demonstrated by H. influenzae is the result of beta-lactamase production and is poorly assessed by turbidity.

Nontypeable Haemophilus influenzae: pathogenesis and prevention

In this paper, we describe the ability of nontypeable Haemophilus influenzae (NTHi) to coexist with the human host and the devastating results associated with disruption of the delicate state of balanced pathogenesis, resulting in both acute and chronic respiratory tract infections. It has been seen that the strains of NTHi causing disease show a marked genetic and phenotypic diversity but that changes in the lipooligosaccharide (LOS) and protein size and antigenicity in chronically infected individuals indicate that individual strains of NTHi can remain and adapt themselves to avoid expulsion from their infective niche. The lack of reliance of NTHi on a single mechanism of attachment and its ability to interact with the host with rapid responses to its environment confirmed the success of this organism as both a colonizer and a pathogen. In vitro experiments on cell and organ cultures, combined with otitis media and pulmonary models in chinchillas, rats, and mice, have allowed investigations into individual interactions between NTHi and the mammalian host. The host-organism interaction appears to be a two-way process, with NTHi using cell surface structures to directly interact with the mammalian host and using secreted proteins and LOS to change the mammalian host in order to pave the way for colonization and invasion. Many experiments have also noted that immune system evasion through antigenic variation, secretion of enzymes and epithelial cell invasion allowed NTHi to survive for longer periods despite a specific immune response being mounted to infection. Several outer membrane proteins and LOS derivatives are discussed in relation to their efficacy in preventing pulmonary infections and otitis media in animals. General host responses with respect to age, genetic makeup, and vaccine delivery routes are considered, and a mucosal vaccine strategy is suggested.

Evaluation of Haemophilus influenzae isolates with elevated MICs to amoxicillin/clavulanic acid

A 1994 to 1995 national Haemophilus influenzae surveillance study of 1910 strains showed that 13 strains (0.7%) were resistant to amoxicillin/clavulanic acid (MIC, > or = 8/4 micrograms/ml). These and other selected strains were investigated further in this study. Susceptibility of the surveillance study strains was determined with the commercial microdilution trays used in the original study and in triplicate with reference broth microdilution trays prepared by the investigators, as well as by Etest and disk diffusion. Amoxicillin/clavulanic acid resistance was confirmed for only one of the surveillance study strains. This strain produced double zones of growth with Etest and disk-diffusion methods, with the double zone containing spheroplasts. When the amoxicillin/clavulanic acid MICs of all beta-lactamase positive strains were compared, MIC results obtained with surveillance study trays and the Etest were one to two dilutions higher than MICs obtained with reference trays. The distribution and modal amoxicillin/clavulanic acid MICs of beta-lactamase-positive and -negative strains was essentially the same for a comparison group of strains using reference trays, in contrast to a fourfold higher modal MIC for beta-lactamase-positive strains using surveillance study reagents and strains. These differences in MICs could be attributed to variations in inoculum, the presence of spheroplasts, and/or a difference in potency of amoxicillin and/or clavulanic acid in the tray and Etest reagents used. Methods for assessing the adequacy of the clavulanic acid content are not adequate, amoxicillin control values and a beta-lactamase-positive H. influenzae control strain are required.

Postantibiotic effect of meropenem on members of the family Enterobacteriaceae determined by five methods

The postantibiotic effect (PAE) of meropenem was determined for 11 strains, both clinical isolates and reference strains of members of the family Enterobacteriaceae. The study compares PAE results obtained by five methods used to monitor bacterial regrowth, including viable counting, alone and in combination with impedance; bioluminescence, alone and in combination with impedance; and a morphological technique. After exposure of the test organisms to meropenem (0.1 x to 100 x MIC) for 2 h, concentration-dependent differences in counts by bioluminescence and viable counts were observed, the latter always being lower. The differences varied with the test organism. For example, after exposure of Providentia stuartii NCTC 10318 to 0.1 x MIC, the counts were 5.5 x 10(5) and 2.0 x 10(5) whereas after exposure of Citrobacter freundii MR76 to 0.1 x MIC of meropenem the counts were 2.3 x 10(6) and 6.8 x 10(3) by bioluminescence and viable counting, respectively. The discrepancies were probably due to the relative inability of the viable counting procedure to detect fragile aberrant morphologies and resulted in differences in the calculated PAE values. With methods which do not detect fragile morphologies, the PAE may be underestimated. A general trend was observed for the order of magnitude of the PAEs by the following methods (in order of decreasing magnitude of PAE): (i) morphological technique, (ii) bioluminescence technique alone, (iii) bioluminescence in combination with impedance, (iv) viable counting in combination with impedance, and (v) viable counting alone. It is our opinion that of the methods examined in this study, bioluminescence in combination with impedance best reflects the true values for PAEs, and these results were examined more closely.

N-acetyl-D-glucosamine medium improves recovery of Haemophilus influenzae from sputa of patients with cystic fibrosis

A modified selective medium supplemented with N-acetyl-D-glucosamine (NAG), hemin, and NAD plus two cefsulodin disks, for primary isolation of nonencapsulated Haemophilus influenzae from sputum of patients with cystic fibrosis, is described. Isolation of H. influenzae from this medium, designated NAG medium, was compared with recovery by standard media and immunochemical detection of H. influenzae with monoclonal antibody 8BD9. The H. influenzae recovery rate increased from 31% with standard media to 42% with NAG medium. H. influenzae was detected by immunoperoxidase staining in 54% of the sputum specimens. The results of this study demonstrate that NAG medium improves H. influenzae recovery, although immunoperoxidase staining is superior for detection of H. influenzae from sputum of cystic fibrosis patients.

Comparative kill and growth rates determined with cefdinir and cefaclor and with Streptococcus pneumoniae and beta-lactamase-producing Haemophilus influenzae

The relationship between the growth rate and the kill rate was used to evaluate and to compare the in vitro bactericidal activities of cefdinir, a new oral cephalosporin, and cefaclor against Streptococcus pneumoniae and beta-lactamase-producing strains of Haemophilus influenzae. These frequently encountered pathogens of community-acquired respiratory tract infections are usually susceptible to both drugs. The MIC ranges for cefdinir and cefaclor were, respectively, 0.03 to 0.06 and 0.25 to 0.5 micrograms/ml for S. pneumoniae and 0.25 and 4 to 8 micrograms/ml for H. influenzae. The colony counts (CFU per milliliter) measured after 6 h of exposure to a range of antibiotic concentrations in broth were plotted against the colony count of the control culture over the same period of time. Higher kill rates versus bacterial growth rates were noted for S. pneumoniae for both drugs (positive balance). Conversely, lower kill rates versus growth rates were noted for H. influenzae for both drugs (negative balance). In conclusion, the bactericidal activities of both drugs against S. pneumoniae and H. influenzae were similar when expressed by the relationship between the growth rate and the kill rate at 6 h, but cefdinir was more active at lower concentrations.

Ampicillin killing curve patterns for ampicillin-susceptible nontypeable Haemophilus influenzae strains by the agar dilution plate count method

Ampicillin killing curve patterns for 20 strains of ampicillin-susceptible nontypeable Haemophilus influenzae were determined by the agar dilution plate count method. The paradoxical effect was detected in the 24-h killing curve patterns for each strain. For the biphasic effect, minimum survivor percentages (maximum killing) occurred over a narrow range of ampicillin concentrations immediately above the MIC, with survivor percentages then rising rapidly to peak at approximately 1-log10-unit increment higher. The 24-h minimum survivor percentages for the 20 strains ranged from approximately 0.01% (rapid killing) to greater than 10% (slow killing). In comparison with the previous results for typeable strains, the present findings suggest that nontypeable stains are, on average, killed much more slowly. Based on the initial 24-h killing curve patterns for the 20 strains, 4 strains were selected as putative representatives of the range of bactericidal responses encountered. These strains were then studied to examine the reproducibility of the 24-h patterns and to determine sequential killing curves. These patterns were found to be reproducible and served to characterize the relative killing responses of the strains. In the sequential studies of three of the four strains, tiny colonies having the gross and microscopic characteristics of L-forms were found to be present on the agar dilution plate count plates prior to the application of penicillinase at 48 and 72 h. Such colonies reverted to vegetative forms within 24 to 48 h after application of penicillinase to the panels. Of particular interest was the observation that the paradoxical effect was manifested both by the L-form colonies and by the reverted vegetative colonies. The late development of L-forms was observed for both rapidly and slowly killed strains.

Haemophilus influenzae: antibiotic susceptibility

Ampicillin resistance was first reported among clinical isolates of Haemophilus influenzae in 1972. Reports of chloramphenicol resistance followed shortly thereafter. The principal mechanism of resistance to these two antibiotics is enzymatic. Although other mechanisms have been described, they are found in comparatively few strains. The genetic information for the inactivating enzymes is plasmid mediated and therefore readily transmissible to susceptible strains. Consequently, effective therapy for invasive disease caused by this pathogen has been seriously compromised. As antibiotic susceptibility became less predictable, in vitro testing became increasingly important. Unfortunately, the standardization of methods for laboratory testing has been slow and complicated by the fastidious nature of the organisms. This review traces the development of antibiotic resistance in H. influenzae, discusses the mechanisms which appear to be important in mediating resistance, explores newer antimicrobial agents which might be useful in the treatment of infection, and analyzes the various approaches to in vitro testing.

Ampicillin killing curve patterns of Haemophilus influenzae type b isolates by agar dilution plate count method

The responses of 20 ampicillin-susceptible Haemophilus influenzae type b clinical isolates to the bactericidal action of ampicillin were studied by using a modified agar dilution plate count method. A well-defined paradoxical effect was observed in each of the 24-h killing curve patterns for 19 of the 20 isolates, the remaining isolate showing a less-well-defined but suggestive paradoxical effect after 48 h of ampicillin exposure. For each isolate, the lowest 24-h persister percentage representing maximum killing (paradoxical trough percentage) occurred over a narrow range of concentrations immediately above the MIC, with such paradoxical trough percentages for the 20 isolates ranging from greater than 0.1 to less than 0.001%. Three isolates selected to represent slow, intermediate, and rapid responses were investigated by repetition of 24-h studies and by determination of expanded killing curve patterns. Resultant agar dilution plate count killing curve patterns were found to be reproducible and strain dependent and served to characterize each isolate. The paradoxical effect became more distinct with the prolongation of ampicillin action. Maximum killing was again evident for a narrow range of ampicillin concentrations immediately above the MIC, with persister percentages rising rapidly over the next few ampicillin concentrations to peak at 1 to 2 log10 increments higher than trough percentages. Based on the broad range of responses observed for the 20 isolates, the consistent presence of the paradoxical effect, and the time-dependent nature of bactericidal action, we suggest that the MBC and MBC/MIC ratios are inadequate indices of bactericidal action and that the all-or-none concept of "antimicrobial tolerance" should be abandoned.

Capsular variation in experimental strains of Haemophilus influenzae

This study sought to demonstrate that clinically untypable strains of Haemophilus influenzae are derivable from previously capsulated ones. Penicillin-induced forms were employed to explore in vivo and in vitro a possible mechanism of the reversible cycle vegetative to L-phase revertant. Normal H. influenzae type b (Rab), capsule-deficient strain ATCC 9333, and experimental L-phase and its revertants were used in this investigation. Capsular antigens, polyribose phosphate (PRP) content of each strain was assayed by orcinol and rocket immunoelectrophoretic methods. Intra- and inter-strain PRP differences were statistically analysed. Strain differences between in vivo and in vitro passaged extracts of strain 9333 and 9333 were significant (t-test P less than 0.01). There were also significant differences in vivo and in vitro between penicillin-treated, L-phase infected mouse isolates and penicillin-free, L-phase infected mouse isolates; and also between penicillin-treated, L-phase infected mouse isolates and revertant Rab infected mouse isolates (Mann-Whitney U-test P less than 0.02, P less than 0.01, respectively). These findings suggest that untypable isolates of H. influenzae are derivable from otherwise capsulated strains, depending on decapsulating factors in the microenvironment. Clinical implications of the findings are discussed.

Isolation of spheroplastic forms of Haemophilus influenzae from sputum in conventionally treated chronic bronchial sepsis using selective medium supplemented with N-acetyl-D-glucosamine: possible reservoir for re-emergence of infection

The isolation rate of Haemophilus influenzae from patients with persistent production of purulent sputum has been increased by the routine use of a selective medium. Nevertheless, some purulent sputum still fails to yield a pathogen. The selective medium was supplemented with N-acetyl-D-glucosamine to encourage primary isolation of colony forming, spheroplastic H influenzae, which reverted to normal forms on subculture. On the basis of in vitro experiments it is postulated that these spheroplastic forms of H influenzae may be induced by inadequate antimicrobial chemotherapy and may be responsible for re-emergence of symptoms in these patients during or shortly after stopping chemotherapy.

Effect of inoculum size on the susceptibility of Haemophilus influenzae b to beta-lactam antibiotics

The current prevalence of ampicillin-resistant Haemophilus influenzae b meningitis requires accurate knowledge of susceptibility to alternative antibiotics. One variable affecting susceptibility is inoculum size. We studied the susceptibility of 200 clinical isolates of H. influenzae b to ampicillin, carbenicillin, and cefamandole at inocula of 10(5) and 10(7) CFU by two techniques. Fifty ampicillin-susceptible and fifty ampicillin-resistant strains were tested for susceptibility to ampicillin by broth dilution while 100 of each were tested by agar dilution. An inoculum effect was found, being greatest with the ampicillin-resistant strains. The range of minimal inhibitory concentrations for the resistant strains was 25 to 800 microgram of ampicillin per ml at an inoculum of 10(5) and 2,000 to less than 6,000 microgram of ampicillin at 10(7); 1.0 to 150 microgram of carbenicillin per ml at 10(5) and 6.2 to 2,000 microgram of carbenicillin per ml at 10(7); 0.4 to 2.0 microgram of cefamandole at 10(5) and 1.0 to 125 microgram/ml at 10(7). Because of this inoculum effect, we would not recommend the use of carbenicillin or cefamandole for therapy of ampicillin-resistant H. influenzae meningitis.

Use and interpretation of Schlichter's test on Haemophilus influenzae: relation of in vitro to in vivo results for cefamandole

When Haemophilus influenzae infections are treated by an antibiotic acting on the bacterial wall, the adequacy of antimicrobial therapy can be assessed by Schlichter's test. This test may be carried out using Mueller Hinton broth (or Mueller Hinton broth with 50% pooled serum and a supplement of Ca++ and Mg++) supplemented with Fildes' enrichment and an inoculum adjusted to the 0.5 McFarland turbidity standard diluted 200x. However, correct reading of end points can be obtained only by phase contrast microscopic examination, which allows the establishment of good correlation between the in vitro and in vivo findings. In patients with lung infections successfully treated with cefamandole, the presence of spheroplasts in samples derived from Schlichter's tests correlates well with clinical improvement and eradication of the pathogenic organism checked by transtracheal aspiration.

Growth curves, microscopic morphology, and subcultures of beta-lactamase-positive and -negative Haemophilus influenzae under the influence of ampicillin and cefamandole

In contrast to the results obtained with ampicillin, the minimum inhibitory concentrations of cefamandole against Haemophilus influenzae were within the same range (0.5 to 1.5 mug/ml) whether or not the strains were beta-lactamase producers. The minimum bactericidal concentrations were somewhat higher for beta-lactamase-positive strains (6.4 mug/ml) than for negative strains (1.2 mug/ml). In a culture with high initial microbial density, monitored by recording optical densities, the addition of 10 mug of cefamandole per ml brought about rapid lysis of a beta-lactamase-negative strain. Observation of a beta-lactamase-positive strain revealed, in the early part of the growth curve, absence of lysis and an increase of biomass similar to that observed in a drug-free control curve. In contrast to the results obtained with ampicillin, the culture consisted uniformly of spherical forms, probably in the process of division, which were capable of generating colonies. When the microbial density exposed to cefamandole was increased still further, persistent bacillary forms were observed, and after 24 h hydrolysis had eliminated every trace of microbiologically active cefamandole.

Method for evaluating broth culture media: application to Haemophilus

A method was devised to test the growth-promoting ability of a broth medium. The "dilute to extinction" method determines the inoculum required to develop heavy turbidity in a broth with overnight incubation. A statistical method using Poisson distribution was used to show that a single Haemophilus cell can develop heavy turbidity in an optimal broth. The dilute to extinction method was used to evaluate the shelf life of stored media, to titrate the growth factor requirements of Haemophilus, and to evaluate the use of purified hemin and nicotinamide adenine dinucleotide in a broth medium for the growth of Haemophilus. Of the media tested, the most suitable formulation was Mueller-Hinton broth supplemented with 10 microgram of hemin and 10 microgram of nicotinamide adenine dinucleotide per ml. The dilute to extinction method appears to be especially useful in the development of broth media for fastidious organisms. The method could also be used to assure the quality of other broth media which are required to support the growth of small inocula in the clinical or research laboratory.

Haemophilus influenzae in otitis media and sinusitis: serotypes and susceptibilty to ampicillin and amoxycillin in vitro

In order to obtain Haemophilus influenzae, other than Type b, with highly probable human pathogeniticy strains were collected that had been isolated in abundant numbers from middle ear or maxillary sinus secretions of 157 patients with otitis media or sinusitis. The distribution of serotypes was as follows: nontypable 33.8%, Type b 26.1% Type a 19.1%, Type c 7.6%, Type e 5.7%, Type f 5.1%, and Type d 2.5%. The type distribution did not depend on the source of the strains. All strains were susceptible to ampicillin and amoxycillin in vitro; the broth dilution minimum inhibitory concentrations (MIC) of both antibiotics varied only fourfold; typical MIC values were 0.125 microgram/ml and 0.25 microngram/ml, respectively. Susceptibility did not vary with the source or type of the strains nor with the presence or absence of concomitant penicillin therapy.

Comparative acitivity of ampicillin and cefuroxime against three types of Haemophilus influenzae

On the basis of their susceptibility to ampicillin, strains of Haemophilus influenzae can be divided into three types: type 1 are normally susceptible strains, type 2 produce stable spheroplasts from low inocula, and type 3 are beta-lactamase producers. Because of the production of spheroplasts, standard broth and agar dilution techniques have failed to differentiate between the responses of type 2 and 3 strains to ampicillin, or to identify the superiority of cefuroxime over ampicillin against the beta-lactamase-producing strains. Disk susceptibility tests with heavily seeded plates were also difficult to interpret. To overcome these problems, we developed a medium that supports the growth of H. influenzae, but not survival of spheroplasts, thereby reducing the complicating influence of spheroplast formation. Utilization of the medium made it possible to identify beta-lactamase-producing strains via both minimal inhibitory concentration and disk susceptibility techniques, as well as the superiority of cefuroxime over ampicillin against such strains. In vivo experiments showed that cefuroxime and ampicillin are equally active against infections with type 1 and 2 strains, but that cefuroxime is superior to ampicillin against infections with type 3 beta-lactamase-producing strains.

Antigens of Haemophilus influenzae

Three antigenic preparations were obtained from a non-capsulated strain of Haemophilus influenzae by ultrasonic disintegration, hot phenol extraction and from a fluid culture. They were designated H. influenzae cytoplasmic antigen (H(1-5); H. influenzae cell wall antigen (HCW); and H. influenzae culture filtrate antigen (HCF). Studies showed that H(1-5) antigen contained heat stable and heat labile components. The heat stable fraction stained positively for polysaccharide, had a positive limulus lysate test and there was immunological cross-reactivity between this and heat stable fractions of HCW and HCF. Limulus lysate assay indicated the presence of endotoxin in HCW and HCF preparations. Heat stable as well as heat labile antigens of H. influenzae should be given consideration in future studies regarding the pathogenicity of this organism in the lower respiratory tree. The specificity of the heat stable antigen of H. influenzae needs to be determined.

Isolation of L-forms by blood culture

Culture media for the isolation of bacterial L-forms from the blood were studied. The most successful media had an osmolality of more than 1100 mosm/kg and this appeared to be a critical factor in determining success.

Relative morphological effects induced by cefoxitin and other beta-lactam antibiotics in vitro

Cefoxitin, a new semisynthetic cephamycin antibiotic, induced filament formation at subinhibitory concentrations with a beta-lactamaseless strain of Enterobacter cloacae (HSC 18410 M66). The extent of filament induction by cefoxitin was similar to that seen with cephalothin, cefazolin, and benzylpenicillin. Filament induction by cefoxitin was markedly less than that seen with cephalexin, carbenicillin, ticarcillin, cephradine, and cephapirin. Antibiotics which failed to induce filaments at any level tested included cephaloridine, cephacetrile, cephalosporin C, the cephamycins, 6-aminopenicillanic acid, 7-aminocephalosporanic acid, A16884, A16886, and FL-1060. Those antimicrobial agents tested which lacked an aromatic substituent in the 7-position (for cephems) or in the 6-position (for penams) did not induce filaments. These observations suggest a possible relationship between filament induction of the test organism and the molecular nature of constituents in the 7- or 6-position of beta-lactams.

Preliminary clinical trials with phosphonomycin

The interpretation of in vitro susceptibility tests of Haemophilus influenzae performed by the agar or broth dilution methods with Levinthal enrichment was found to be markedly influenced by the production of spheroplasts by this species. Using an inoculum of 10⁷ organisms/ml, this phenomenon was frequently evident macroscopically as a haziness on agar substrates and in broths containing cell wall-acting agents, such as ampicillin, cephalothin, and penicillin, but was not noted with chloramphenicol. Phase-contrast microscopic examination of the haze from these sources revealed numerous spherical bodies in contrast to the typical cocco-bacillary forms observed in growth controls. With this inoculum size, minimal bactericidal concentrations could not be determined since subculture of 0.1 ml of the hazy broths or the surface haze onto chocolate agar resulted in most instances in the development of a small number of colonies which, upon smear and gram stain, revealed typical Haemophilus morphology. An inoculum of 10⁴ organisms/ml abolished the haziness on agar surfaces and in broths and resulted in clear-cut end points. Also, although spherical bodies were still present, they were distinctly less in number as contrasted to tests performed with an inoculum of 10⁷ organisms/ml. It is recommended that minimal inhibitory concentration end points in antibiotic susceptibility tests be determined by microscopic, rather than macroscopic, observation of the growth milieu to determine the presence or absence of morphologically typical bacilli which, when observed, is indicative of true in vitro resistance.

Haemophilus influenzae type B resistant to tetracycline isolated from children with meningitis

During a three-year-period, 1971-73 inclusive, haemophili isolated from 96 children with severe infections, of whom 73 had meningitis and 19 acute epiglottitis, were serotyped and tested for sensitivity to antibacterial drugs. All strains were identified as Haemophilus influezae type b, and were sensitive to ampicillin, chloramphenicol, and trimethoprim. However, 3 isolates--from a boy aged 11 months and a girl aged 1 year with meningitis, and a girl aged 2 years with epiglottitis--were highly resistant to tetracycline, with a median minimal inhibitory concentration of 50 mug tetracycline hydrochloride per ml (resistance ratio greater than or equal to 50). Resistance was also demonstrated to doxycycline, oxytetracycline, and rolitetracycline and, in one strain, to minocycline. No evidence was obtained that the resistant organisms were capable of inactivating tetracyclines.