NIH consensus development statement on management of hepatitis B

OBJECTIVE

To provide health care providers, patients, and the general public with a responsible assessment of currently available data on the management of hepatitis B.

PARTICIPANTS

A non-DHHS, nonadvocate 12-member panel representing the fields of hepatology and liver transplantation, gastroenterology, public health and epidemiology, infectious diseases, pathology, oncology, family practice, internal medicine, and a public representative. In addition, 22 experts from pertinent fields presented data to the panel and conference audience.

EVIDENCE

Presentations by experts and a systematic review of the literature prepared by the Minnesota Evidence-based Practice Center, through the Agency for Healthcare Research and Quality. Scientific evidence was given precedence over anecdotal experience.

CONFERENCE PROCESS

The panel drafted its statement based on scientific evidence presented in open forum and on published scientific literature. The draft statement was presented on the final day of the conference and circulated to the audience for comment. The panel released a revised statement later that day at http://consensus.nih.gov. This statement is an independent report of the panel and is not a policy statement of the NIH or the Federal Government.

CONCLUSIONS

The most important predictors of cirrhosis or hepatocellular carcinoma in persons who have chronic HBV are persistently elevated HBV DNA and ALT levels in blood. Other risk factors include HBV genotype C infection, male sex, older age, family history of hepatocellular carcinoma, and co-infection with HCV or HIV. The major goals of anti-HBV therapy are to prevent the development of progressive disease, specifically cirrhosis and liver failure, as well as hepatocellular carcinoma development and subsequent death. To date, no RCTs of anti-HBV therapies have demonstrated a beneficial impact on overall mortality, liver-specific mortality, or development of hepatocellular carcinoma. Most published reports of hepatitis therapy use changes in short-term virologic, biochemical, and histologic parameters to infer likelihood of long-term benefit. Approved therapies are associated with improvements in intermediate biomarkers, including HBV DNA, HBeAg loss or seroconversion, decreases in ALT levels, and improvement in liver histology (Table). Although various monitoring practices have been recommended, no clear evidence exists for an optimal approach. The most important research needs include representative prospective cohort studies to define the natural history of the disease and large RCTs of monotherapy and combined therapies, including placebo-controlled trials, that measure the effects on clinical health outcomes. Table. Criteria Useful in Determining for Whom Therapy is Indicated: Patients for whom therapy is indicated: Patients who have acute liver failure, cirrhosis and clinical complications, cirrhosis or advanced fibrosis and HBV DNA in serum, or reactivation of chronic HBV after chemotherapy or immunosuppression; Infants born to women who are HBsAg-positive (immunoglobulin and vaccination). Patients for whom therapy may be indicated: Patients in the immune-active phase who do not have advanced fibrosis or cirrhosis. Patients for whom immediate therapy is not routinely indicated: Patients with chronic hepatitis B in the immune-tolerant phase (with high levels of serum HBV DNA but normal serum ALT levels or little activity on liver biopsy); Patients in the inactive carrier or low replicative phase (with low levels of or no detectable HBV DNA in serum and normal serum ALT levels); Patients who have latent HBV infection (HBV DNA without HBsAg). We recommend routine screening for hepatitis B of newly arrived immigrants to the United States from countries where the HBV prevalence rate is greater than 2%. Screening will facilitate the provision of medical and public health services for infected patients and their families and provide public health data on the burden of disease in immigrant populations. The screening test should not be used to prohibit immigration.

Comparison of clindamycin phosphate vaginal cream with triple sulfonamide vaginal cream in the treatment of bacterial vaginosis

BACKGROUND

Triple sulfonamide vaginal cream has been used to treat bacterial vaginosis for many years. There are few studies in which triple sulfonamide cream has been compared with newer regimens.

GOAL

To compare the efficacy and safety of clindamycin phosphate vaginal cream with that of triple sulfonamide vaginal cream in the treatment of bacterial vaginosis.

STUDY DESIGN

In this double-blind, randomized multicenter study, nonpregnant women 16 years of age or older with symptomatic bacterial vaginosis were assigned to receive either 2% clindamycin phosphate vaginal cream or triple sulfonamide vaginal cream for 7 days. Follow-up visits were conducted 5 to 10 days and 25 to 39 days after completion of treatment.

RESULTS

Clinical cure or improvement at 25 to 39 days was noted in 55 (69.6%) of 79 assessable participants who received clindamycin vaginal cream and in 33 (41.8%) of 79 women who received triple sulfonamide vaginal cream (P < 0.0001). Most of the difference between the treatment groups was noted in women with a history of bacterial vaginosis. Among women without a history of bacterial vaginosis, clindamycin and triple sulfonamide creams had similar efficacy. Evaluation of Gram-stained vaginal smears correlated with clinical outcome. Most patients in both treatment groups reported an improvement in symptoms. No significant difference was observed between the treatment groups in the incidence of adverse events.

CONCLUSION

Clindamycin 2% vaginal cream is more effective than triple sulfonamide vaginal cream in the treatment of bacterial vaginosis.

Defining the cost of educating undergraduate medical students at the University of Virginia

PURPOSE

To develop a model for calculating the cost of a four-year undergraduate medical education at the University of Virginia School of Medicine (UVA) in 1994-95.

METHOD

All data were based on faculty contact hours (FCHs), the primary driver of cost. (An FCH was an hour during which a faculty member was actively teaching.) First- and second-year data were derived from a published curriculum schedule. Third-year data were derived from hours spent in each clerkship and a series of calculations to assess direct teaching time in each clerkship accurately. Fourth-year data were modeled on an artificial but typical program consisting of the required clerkship in neurology, a two-day course in advanced cardiac life support, and seven elective blocks; electives were chosen based on relative overall popularity. The number of full-time-equivalent (FTE) faculty required was calculated. The salary costs of UVA full-time faculty were calculated. Other total direct costs, including the costs of support and administrative services as well as the costs of the educational contributions of housestaff and contract faculty, were calculated. The overall cost, including direct and indirect costs, was calculated. An average of 139 students per year was assumed.

RESULTS

The total number of FCHs was just under 100,000. The number of FTE faculty required was 223. UVA faculty salary and fringe benefits totaled $29,400,000. The costs of support and administrative services totaled $4,100,000; the costs of housestaff and contract faculty totaled $2,300,000. The overall educational costs totaled $49,600,000.

CONCLUSION

The overall cost of a four-year medical education at UVA was $357,000 per student. Although the process of calculating this cost was complex and, at times, based on assumptions open to debate, the model developed can be applied to any medical education setting.

Multicenter comparison of clotrimazole vaginal tablets, oral metronidazole, and vaginal suppositories containing sulfanilamide, aminacrine hydrochloride, and allantoin in the treatment of symptomatic trichomoniasis

BACKGROUND AND OBJECTIVES

Trichomonas vaginalis is a common vaginal pathogen. Oral metronidazole is the drug of choice for the treatment of trichomoniasis. Oral metronidazole, however, may cause unpleasant side effects and is contraindicated during the first trimester of pregnancy. In vitro studies and preliminary clinical data have suggested that intravaginal clotrimazole may be effective against this pathogen.

GOALS

To compare the efficacy of clotrimazole vaginal tablets, oral metronidazole, and vaginal suppositories containing sulfanilamide, aminacrine, and allantoin (AVC suppositories) in the treatment of women with symptomatic trichomoniasis.

STUDY DESIGN

In a multicenter, open-label trial conducted in 1982 and 1983, 168 symptomatic women with microscopically evident vaginal trichomoniasis were randomized to receive any of 2 g of metronidazole as a single oral dose, two 100-mg clotrimazole vaginal tablets once a day for 7 days, or vaginal suppositories containing 1.05 g of sulfanilamide, 14 mg of aminacrine hydrochloride, and 140 mg of allantoin (AVC suppositories) twice a day for 7 days. Wet mounts and cultures were repated at 1 to 2 and 4 to 6 weeks after completion of treatment.

RESULTS

The number of patients who had positive cultures after treatment were 40/45 (88.9%) in the clotrimazole group, 35/43 (81.4%) in the AVC suppository group, and 9/45 (20%) in the metronidazole group (P < 0.001). All treatments were associated with a reduction in reported symptoms. Oral metrohidazole was more effective in reducing symptoms than either of the topical preparations. Adverse events, mostly mild or moderate in severity, were reported by 7 (14.6%) of 48 patients who had received oral metronidazole and 4 (7.8%) of 51 women who used AVC suppositories. There were no adverse events reported by the 50 women who used clotrimazole vaginal tablets.

CONCLUSIONS

Oral metronidazole was more effective in eradicating T. vaginalis than clotrimazole vaginal tablets or AVC vaginal suppositories. All three regimens reduced symptoms; oral metronidazole was more effective in reducing symptoms than either topical preparation.

Use of a lactoferrin assay in the differential diagnosis of female genital tract infections and implications for the pathophysiology of bacterial vaginosis

BACKGROUND AND OBJECTIVES

Lactoferrin has served as a marker for leukocytes (polymorphonuclear neutrophils [PMN]) in clinical specimens.

GOAL

To investigate the potential of a lactoferrin latex agglutination test in the differential diagnosis of female genital infection.

STUDY DESIGN

Lactoferrin was quantified in the vaginal discharge of women with genital infections. Polymorphonuclear neutrophils were added to vaginal discharge and observed over 8 hours.

RESULTS

Vaginal lactoferrin titers were significantly elevated in women with trichomoniasis, candidiasis, and bacterial vaginosis (BV). Using a lactoferrin titer of > or = 1:40, the assay has a sensitivity of 79.3% and a specificity of 83.3% for the presence of trichomoniasis or bacterial vaginosis. Vaginal discharge from women with BV significantly destroyed added PMN.

CONCLUSIONS

Vaginal lactoferrin determinations may provide a useful screen for inflammatory genital infections and identify individuals who require additional diagnostic evaluation. The observed absence of PMN in bacterial vaginosis may result from the destruction of PMN in vaginal discharge rather than the absence of a primary inflammatory response.

Case report: increase in CD4 lymphocyte counts after splenectomy in HIV-infected patients

The records were reviewed of five human immunodeficiency virus (HIV) type 1-infected patients who underwent splenectomy, four for HIV-associated thrombocytopenia and one for gastric compression secondary to splenomegaly. After splenectomy, the four adult patients all had marked, sustained increases in their absolute CD4 lymphocyte counts; greater increases were observed in CD8 lymphocyte counts, accounting for decreases in the CD4:CD8 ratios. In patients 5 (one of triplets, all of whom were infected with HIV after a blood transfusion), absolute CD4 lymphocyte counts were stabilized after splenectomy; the other siblings manifested a decline in CD4 counts, which was associated with a delay in physical development and recurrent episodes of varicella. Immunohistochemical staining of spleen sections demonstrated significantly higher numbers of CD4 cells in splenic tissue from HIV-infected patients than from patients splenectomized secondary to trauma (2,070 +/- 284 vs. 962 +/- 296; p = 0.025). In addition, the HIV-infected patients had significantly higher percentages of CD4 lymphocytes in splenic tissue than in peripheral blood (49.3 +/- 11.0 vs. 20.3 +/- 7.9; p = 0.005), suggesting that CD4 cells were sequestered in the spleens of these patients. These findings have implications for the management of splenectomized HIV-infected patients with regard to optimal timing of initiation of zidovudine therapy and for prophylaxis of Pneumocystis carinii pneumonia.

Diagnostic methods for chlamydial infections in a high-risk population

An enzymeimmunoassay test performed well in comparison with cell culture in detecting chlamydial infections among 209 women at a public health clinic, detecting 73% of the infected patients. Clinical and epidemiological criteria alone identified only 52%. The authors consider the test an essential supplement to other criteria when looking for chlamydial infection in a high risk population.

Monoclonal-antibody-based enzyme-linked immunosorbent assay for Trichomonas vaginalis

Trichomonas vaginalis is estimated to infect 4 million women per year in the United States. The diagnosis of trichomoniasis is predominantly achieved by direct microscopic examination of vaginal exudates. This subjective diagnostic procedure is reported to be 75% sensitive under ideal circumstances. We have developed an enzyme-linked immunosorbent assay (ELISA) for the detection of T. vaginalis directly from vaginal exudates. The ELISA employs a monoclonal antibody specific for a 65-kilodalton surface polypeptide of T. vaginalis as the capture antibody in a sandwich format. A polyclonal rabbit anti-T. vaginalis antibody labeled with horseradish peroxidase serves as the probe. An evaluation of vaginal specimens from women attending clinics revealed a sensitivity and specificity of the ELISA of 89 and 97%, respectively, versus the culture technique. These results indicate the usefulness of this ELISA as an alternative to microscopic and culture methods for the detection of T. vaginalis in vaginal exudates.

Clinical approach to urethritis, mucocutaneous lesions, and inguinal lymphadenopathy in homosexual men

The spectrum of sexually transmitted diseases observed among homosexual men is diverse, but in general includes the same infections observed among heterosexuals. A systematic approach to the diagnosis of these diseases, incorporating sexual history, predominant symptoms, findings from physical examination, and office laboratory evaluation will frequently yield a specific diagnosis. Prompt diagnosis and treatment of patients, and when appropriate, of contacts are of critical importance to the prevention of unnecessary morbidity and further transmission of disease.

Contact-dependent cytopathogenic mechanisms of Trichomonas vaginalis

The cytopathogenic mechanisms of Trichomonas vaginalis have been debated since the 1940s. We examined the following three proposed pathogenic mechanisms: contact-dependent extracellular killing, cytophagocytosis, and extracellular cytotoxins. Serial observations of Chinese hamster ovary (CHO) cell monolayers exposed to trichomonads revealed that (i) trichomonads form clumps, (ii) the clumps adhere to cells in culture, and (iii) monolayer destruction occurs only in areas of contact with T. vaginalis. Kinetic analysis of target cell killing by trichomonads revealed that the probability of CHO cell death was related to the probability of contact with T. vaginalis, supporting the observation by microscopy that trichomonads kill cells only by direct contact. Simultaneous studies of 111indium oxine label release from CHO cells and trypan blue dye exclusion demonstrated that T. vaginalis kills target cells without phagocytosis. Filtrates of trichomonad cultures or from media in which trichomonads were killing CHO cells had no effect on CHO cell monolayers, indicating that trichomonads do not kill cells by a cell-free or secreted cytotoxin. The microfilament inhibitor cytochalasin D (10 micrograms/ml) inhibited trichomonad killing of CHO cell monolayers by 80% (P less than 0.0001). In contrast, the microtubule inhibitor vinblastine (10(-6) M) caused only 17% inhibition of trichomonad destruction of CHO cell monolayers (P less than 0.020), whereas colchicine (10(-6) M) had no effect. T. vaginalis kills target cells by direct contact without phagocytosis. This event requires intact trichomonad microfilament function; microtubule function appears not to be essential.

Geographic variation among isolates of Trichomonas vaginalis: demonstration of antigenic heterogeneity by using monoclonal antibodies and the indirect immunofluorescence technique

Although Trichomonas vaginalis causes one of the most common sexually transmitted diseases, little is known about the antigenic variation of the parasite or about differences between strains in epidemiology or virulence. Variation among isolates of T. vaginalis was investigated by using a panel of monoclonal antibodies, each reactive with different antigens, to test 88 isolates from diverse geographic areas of North America. All isolates of T. vaginalis reacted with at least one of the nine monoclonal antibodies; the individual antibodies reacted with 22%-76% of the isolates. A pool of two broadly reactive antibodies identified all isolates in the study. Four of the most narrowly reactive, or "specific," antibodies demonstrated differences in the antigenic composition of trichomonads isolated from patients in Seattle, Baltimore, and Brooklyn, New York (P less than .005 by chi 2 test). Application of these and other monoclonal antibody probes may facilitate epidemiological studies and provide rapid, reliable methods for direct diagnosis of trichomonads in clinical specimens.

Use of a time-kill technique for susceptibility testing of Trichomonas vaginalis

The emergence of metronidazole-resistant Trichomonas vaginalis and questions about the safety of metronidazole are significant concerns in treatment of trichomoniasis. At 24 h, a microtiter assay was used to test antimicrobial susceptibility of 16 recent isolates; the MICs of metronidazole ranged from less than 0.06 to 25 micrograms/ml. Observable motility as an endpoint correlated imperfectly with survival as measured in pour plates. Quantitative pour plate cultures of six T. vaginalis isolates after timed exposures to antimicrobial drugs demonstrated exquisite sensitivity to metronidazole with minimal trichomonacidal concentrations of 0.025 to 0.100 micrograms/ml. Killing of some T. vaginalis isolates by clotrimazole and rosoxacin occurred only at concentrations of 100 micrograms/ml. Resistance to both rosoxacin and clotrimazole correlated with increasing resistance to metronidazole (P less than 0.01).

Campylobacter osteomyelitis

We have reported a case of Campylobacter osteomyelitis, which we believe has not been previously reported. Symptoms and signs were nonspecific, but darkfield microscopy of a suspension of isolated bacteria was useful in making a presumptive diagnosis. Initial parenteral therapy based on sensitivity testing and prolonged oral doxycycline therapy was successful.

Decision analytic approach to the management of gonorrhea contacts

We used a combination of decision analytic and modeling techniques in constructing a model for study of the management of an asymptomatic woman presenting to a sexually transmitted disease clinic as a contact of a man with gonorrhea. Total cost (physical, emotional, and economic) is expressed in units of dysutility. Initially the probabilities and "costs" of anogenital gonorrhea, incubating syphilis, carriage of the agents of nongonococcal urethritis, and coincident pharyngeal gonorrhea are considered; complications and sequelae are then accounted for. The best strategy is to culture for Neisseria gonorrhoeae, treat immediately with tetracycline, and follow up sexual partners if the culture is positive. Dysutility values calculated for the strategies of just treating with standard regimens of tetracycline, procaine penicillin, or amoxicillin are 288, 310, and 560, respectively. Sensitivity analyses show that the most important factors in determining optimal strategy are the probabilities and costs associated with the patient's carriage of the agents of nongonococcal urethritis. In order for this decision to change, the dysutility value for nongonococcal urethritis would have to decrease to 17% of our best estimate, or the overall prevalence of nongonococcal urethritis would have to be reduced to 16% of our best estimate.

A comparison of rosoxacin with ampicillin and probenecid in the treatment of uncomplicated gonorrhea

Rosoxacin, a beta-lactamase-resistant, pyridyl quinolone derivative with in vitro activity against Neisseria gonorrhoeae, was compared to an oral regimen of ampicillin plus probenecid for the treatment of uncomplicated gonococcal infection. Fifty-seven patients were evaluated for the effectiveness of the two antibiotics. Thirty (97%) of 31 patients receiving rosoxacin were cured of their infection as were 25 (96%) of 26 patients who received the oral regimen of ampicillin plus probenecid. Both drug regimens were associated with a significant number of side effects. Of the ampicillin-treated group, 29% had diarrhea and/or abdominal cramping. Of the rosoxacin-treated patients, 52% had reactions classified as central nervous system effects; these included headaches, dizziness, euphoria, and drowsiness.

Beta-hemolytic activity of Trichomonas vaginalis correlates with virulence

The reasons that some women develop symptomatic trichomonal vaginitis, whereas many other infected women remain asymptomatic, are unclear, but it has been suggested that Trichomonas vaginalis strains vary in their intrinsic virulence. We describe beta-hemolytic activity in T. vaginalis which correlates with virulence in patients as well as in an animal model and in tissue culture. Fresh T. vaginalis isolates from four women with severe, symptomatic trichomoniasis had high-level (86.3 +/- 6.6%) hemolytic activity, whereas isolates from three completely asymptomatic women had low-level (45.3 +/- 8.4%) hemolytic activity (P less than 0.001). Hemolytic activity also correlated with the production of subcutaneous abscesses in mice (r = 0.74) and with destruction of CHO cell monolayers (r = 0.94). All of the 20 clinical isolates of T. vaginalis tested possessed hemolytic activity. The beta-hemolysin may be a virulence factor for T. vaginalis.

Gonococcal infection of the median penile raphe

Atypical involvement of the male genitourinary tract by Neisseria gonorrhoeae, such as isolated accessory glandular infection without urethritis, is a rare presentation of a common disease. We report a case of gonococcal abscess of the median raphe of the penis.

Zinc sensitivity of Trichomonas vaginalis: in vitro studies and clinical implications

The high zinc concentration (2.3-15.3 mM) in human prostatic secretions may be an important defense of the male lower urinary tract against infection by Trichomonas vaginalis. Trichomonads were rapidly killed by zinc salts at concentrations similar to those in prostatic fluid of normal men. There was some variation in the zinc sensitivity of 15 clinical isolates of T. vaginalis (minimal inhibitory concentration, 0.8-6.4 mM). A time-kill technique showed subtle differences in the kinetics of zinc killing of trichomonad strains. It was possible to select relatively zinc-resistant substrains of T. vaginalis from a zinc-sensitive population. Zinc resistance was a stable characteristic after multiple passages of substrains in growth medium without supplemental zinc. Variations in the zinc sensitivity of infecting T. vaginalis strains or in the zinc content of host prostatic secretions may be significant determinants of the natural history of T. vaginalis infection in men.

Canine prostatic secretions kill Trichomonas vaginalis

The zinc content of prostatic secretions is thought to be an important nonspecific defense against urinary tract infection in men. This investigation measured killing by prostatic fluid of Trichomonas vaginalis, a common sexually transmitted pathogen, and related this activity to zinc concentration. We used a canine model which closely resembles the human male genital tract. Prostatic secretions from all dogs killed all T. vaginalis isolates. There appear to be several mechanisms for killing of trichomonads by prostatic fluid. At prostatic fluid zinc concentrations comparable to those in normal men (greater than or equal to 3.2 mM), the rate of killing of trichomonads was proportional to the zinc concentration. At intermediate zinc levels, killing occurred by both zinc-dependent and zinc-independent mechanisms. A zinc-independent mechanism was responsible for antitrichomonal activity at relatively low zinc levels (less than 1.6 mM), comparable to those in the prostatic fluid of men with chronic prostatitis. This study suggests that the variable clinical spectrum of trichomoniasis in men may result from a balance between the zinc sensitivity of the T. vaginalis strains on one side and the content of both zinc and zinc-independent factors in prostatic fluid on the other.

Current therapy of vulvovaginitis

Trichomoniasis is reliably treated with a single 2-g dose of metronidazole; however, with this regimen simultaneous treatment of sexual partners is particularly important. Trichomoniasis in pregnant women, who should not receive metronidazole, might be treated initially with clotrimazole vaginal suppositories, which appear to cure about 50% of cases. Topical antifungal agents of the imidazole class are superior to polyenes in treating vulvovaginal candidiasis. Boric acid powder applied intravaginally in gelatin capsules for 14 days appears as effective as imidazoles. Nonspecific vaginitis is now recognized as involving infection with anaerobic bacteria of the vaginal flora as well as Gardnerella vaginalis. The condition is most successfully treated with a seven-day course of metronidazole, which probably acts by eradicating the anaerobes. In addition, metabolites of metronidazole may act directly on G. vaginalis. Sulfanilamide-aminacrine-allantoin preparations are much less effective than specific therapies and have no role in the treatment of vulvovaginitis.

Treatment of vulvovaginal candidiasis with boric acid powder

A double-blind comparison was made of the use of 14 daily intravaginal gelatin capsules containing 600 mg of boric acid powder versus the use of identical capsules containing 100,000 U nystatin diluted to volume with cornstarch for the treatment of vulvovaginal candidiasis albicans. Cure rates for boric acid were 92% at 7 to 10 days after treatment and 72% at 30 days, whereas the nystatin cure rates were 64% at 7 to 10 days and 50% at 30 days. The speed of alleviation of signs and symptoms was similar for the two drugs. There were no untoward side effects, and cervical cytologic features were not affected. In vitro studies found boric acid to be fungistatic and its effectiveness to be unrelated to pH. Blood boron analyses indicated little absorption from the vagina and a half-life of less than 12 hours. Acceptance by the patients was better than for "messy" vaginal creams, and self-made capsules containing boric acid powder are inexpensive (31 cents for fourteen) compared with the costly medication commonly prescribed.

Trichomonacidal activity of human polymorphonuclear neutrophils: killing by disruption and fragmentation

Polymorphonuclear neutrophils (PMNs) were shown to kill Trichomonas vaginalis in vitro; 10(2)-10(3) trichomonads were incubated with 3 x 10(6) PMNs on tissue culture plates, and surviving organisms were enumerated in pour plates. After 60 min of aerobic incubation at 37 C, 100% (+/- 0) of the trichomonads had been killed, and nitroblue tetrazolium was reduced at the interface between the PMNs and trichomonads. The importance of oxidative microbicidal systems was confirmed by the observations that only 12% +/- 12% of trichomonads were killed under anaerobic conditions and that aerobic killing was eliminated by the addition of catalase or superoxide dismutase. PMNs killed trichomonads in fresh or absorbed serum but not in bovine serum albumin, in heat-inactivated serum, or in the presence of 1 mM trypan blue; this finding suggested a role for alternative pathway activation of complement. Phase-contrast cinemicrography and electron microscopy revealed the pursuit and surrounding of individual trichomonads by groups of PMNs that were able to fragment the large protozoa and to phagocytize the pieces.

Gonococcal tenosynovitis-dermatitis and septic arthritis. Intravenous penicillin vs oral erythromycin

Twenty-three patients with disseminated gonococcal infections--15 with acute tenosynovitis, six with septic monoarticular arthritis, and two with both--were randomly given five days of erythromycin stearate or estolate, 500 mg orally every six hours (13 patients), or crystalline aqueous penicillin G potassium, 1 million units intravenously every three hours for three days (ten patients). There were no treatment failures. Cultures taken one and seven days and two and four weeks after completion of therapy were uniformly negative. Clinical resolution was rapid in both groups, as judged by response of fever, joint tenderness, and disappearance of joint effusion. Orally administered erythromycin is a useful alternative to penicillin in the treatment of disseminated gonococcal infections, particularly in penicillin-allergic pregnant women.

Failure of the Treponema pallidum immobilization test to provide additional diagnostic information about contemporary problem sera

Two hundred forty-five sera submitted to the Center for Disease Control, Atlanta, Ga., (CDC) were analyzed serologically in an attempt to demonstrate the diagnostic value of the Treponema pallidum immobilization (TPI) test when performed in addition to the fluorescent treponemal antibody-absorption (FTA-Abs) test. Diagnoses for the patients whose sera were tested were based on information supplied by the referring physicians. Fifty-four per cent of the diagnostic problems were resolved merely by the finding of a negative result with the FTA-Abs test. There was agreement between the serologic results of the referring laboratory and those of the CDC for 76% of sera tested by the Venereal Disease Research Laboratory test and for 71% of sera tested by the FTA-Abs test. For patients with treponemal disease, the sensitivity of the TPI test was 56% and that of the FTA-Abs test was 78%. When the FTA-Abs test was reactive, a negative TPI test was not significantly associated with systemic lupus erythematosus (P > 0.6) or other collagen vascular disease (P > 0.6), nor was a positive TPI test associated with treponemal disease (P > 0.09). It is concluded that once the result of the FTA-Abs test is known, the TPI test does not provide additional diagnostic information.

Sulfamethoxazole-trimethoprim synergism for Neisseria gonorrhoeae

Sulfamethoxazole and trimethoprim are synergistic against many bacteria in sulfamethoxazole/trimethoprim concentrations of 20:1, but single-dose therapy of gonorrhea with the combination is disappointing. We used agar dilution techniques to determine minimal inhibitory concentrations of sulfamethoxazole and trimethoprim for 168 gonococci isolated from men with acute urethritis in Atlanta, Ga. The geometric mean minimal inhibitory concentrations were 5.6 microgram of sulfamethoxazole per ml and 24.3 microgram of trimethoprim per ml, a ratio of 1:4. The concentration of sulfamethoxazole inhibiting 50% of gonococcal strains dropped only from 4.7 microgram/ml to 2.9 microgram/ml with the addition of a 1/20 dilution of trimethoprim. We studied synergism with various ratios of sulfamethoxazole to trimethoprim against 20 random strains. A ratio of 1:1 was always synergistic and was the most synergistic ratio for 15 strains, whereas the 19:1 ratio was never the most syngergistic. The 19:1 ratio failed to show synergism against seven strains, but showed antagonism at this ratio with five of these seven. The sulfamethoxazole/trimethoprim ratio of 19:1 usually achieved in serum after oral administration is minimally syngergistic and is sometimes antagonistic for gonococci.

Auxotypes and antibiotic susceptibility patterns of Neisseria gonorrhoeae from disseminated and local infections

The arginine-hypoxanthine-uracil auxotype has been linked with the propensity of gonococci to cause disseminated infections. Gonococci recovered from 25 patients with disseminated gonococcal infections were compared with gonococci recovered from matched controls, patients with uncomplicated gonorrhea selected during the same month. Minimal inhibitory concentrations of penicillin, tetracycline, erythromycin, and ampicillin, and the nutritional requirements (auxotypes) for proline alone, arginine alone, arginine, hypoxanthine and uracil together, serine alone and cysteine-cystine (wild type) were analyzed by discriminant analysis. Significant susceptibility to penicillin characterized strains causing disseminated infection, and a proline requirement was the most common auxotype (48%) among strains isolated in Atlanta. Together the minimal inhibitory concentration of penicillin and the proline auxotype best separated the strains causing gonorrhea. The arginine-hypoxanthine-uracil auxotype was was found in only 24% of strains causing disseminated infections. A trait other than auxotype must determine the capacity of the organisms to disseminate.

Accuracy of Gram's stain in identifying pneumococci in sputum

We prospectively examined the accuracy of Gram-stained sputum for identifying pneumococci in 42 patients with community-acquired pneumonia. We considered the Gram's stain positive if a preponderant flora or more than ten Gram-positive lancet-shaped diplococci were seen per oil immersion (x1,000) field. These criteria were met in 18 (62%) of 29 specimens that actually contained pneumococci as determined by a positive quellung reaction, or culture on plates or in mice. The Gram's stain was negative in 11 of 13 specimens that did not contain pneumococci. Of the 20 specimens yielding positive Gram's stains, 18 contained pneumococci. A positive Gram-stained smear of sputum strongly suggests the presence of pneumococci, but will miss 38% of specimens containing pneumococci. Deviation from these criteria substantially reduces the overall accuracy of the test.

Treatment of gonorrhea with trimethoprim-sulfamethoxazole

The following regimens were randomly administered to 271 men with gonococcal urethritis: 4.8 X 10(6) units of aqueous procaine penicillin G intramuscularly plus 1 g of probenecid orally (APPG); nine tablets of trimethoprim-sulfamethoxazole (TMP-SMZ; 720 mg of TMP and 3,600 mg of SMZ), orally as a single dose (TMP-SMZ-9); and 12 tablets of TMP-SMZ (960 mg of TMP and 4,800 mg of SMZ) orally as two doses of six tablets taken at a 6-hr interval (TMP-SMZ-12). The failure rates of the APPG, TMP-SMZ-9, and TMP-SMZ-12 regimens were 4%, 23%, and 19%, respectively. APPG was significantly more effective (P less than 0.05) than TMP-SMZ-9 or TMP-SMZ-12. Isolates of Neisseria gonorrhoeae from treatment failures as compared to those from treatment successes were significantly more resistant to SMZ (P less than 0.01) and to the TMP-SMZ combination in a ratio of 19 parts SMZ to one part TMP (P less than 0.05). Minimal inhibitory concentrations of SMZ, TMP, TMP-SMZ, and penicillin G showed positive correlation coefficients.

Biopharmacology of syphilotherapy

Data collected from experimental rabbit syphilis and from in vitro studies with nonpathogenic treponemes can be extended only with great caution to human syphilis. The following tentative conclusions may be drawn: penicillin acts on Treponema pallidum by interfering with cell wall synthesis. Concentrations of penicillin greater than 0.1 mug/ml do not have increased treponemicidal effect. Regimens producing penicillinemia for at least 8 days are considerably more efficient than treatment yielding high peak serum levels of brief duration. Treponemal residence in antibiotic-protected sites increases the need for long duration therapy. Other antibiotics are less effective than penicillin, and patterns of antibiotic interaction against treponemes do not match those seen with other bacteria.

Ophthalmia neonatorum: a chart review

Cases of ophthalmia neonatorum diagnosed at Grady Memorial Hospital 1967-1973 were reviewed. Of 302 cases 43 could be diagnosed as gonococcal, 86 chlamydial, 3 gonococcal and chlamydial, 31 staphylococcal, and 5 chemical. Silver nitrate prophylaxis was routinely employed. Gonococcal cases peaked during the third quarter of the year and chlamydial during the fourth quarter. Gonococcal cases were associated with a longer duration of ruptured fetal membranes. Definitive etiologic diagnosis could not be estalished on clinical grounds alone. Chlamydial ophthalmia was more common among black babies but other forms of ophthalmia were equally distributed with respect to race. The risk of gonococcal ophthalmia developing in an infant born to an infected mother was less than 2% if Credé prophylaxis is used. Therapy with topically applied sulfonamides was effective against chlamydial ophthalmia. Therapy with parenterally administered penicillin and topically applied antibiotics was effective against gonococcal ophthalmia.

Pharmacodynamics of cefazolin in the presence of normal and impaired renal function

The excretion of cefazolin, a new cephalosporin antibiotic, was studied in subjects with normal and impaired renal function. Twelve subjects with creatinine clearances ranging from 0 to 144 ml per min per 1.73 m(2) were given a single 500-mg intramuscular dose of cefazolin. Serum and urine levels were determined at intervals by agar diffusion. Peak serum levels in normals ranged from 44 to 70 mug/ml and occurred 30 to 60 min after injection. The mean serum half-life in normals was 1.6 h, and this was prolonged from 20 to 40% by simultaneous administration of probenecid. The total elimination constant varied linearly with the creatinine clearance in patients with renal impairment. The serum half-life in anephric patients was about 42 h. The fractional clearance of the drug varied directly with the serum level. Peak urine levels ranged from 60 to over 2,000 mug/ml, and more than 90% of the dose was recovered in the urine of normals during the first 24 h. The data suggest that cefazolin is cleared primarily by the glomerulus, with tubular and biliary secretion playing a secondary role.