Uwe Ullmann

New aspects on the pathophysiology of wound infection and wound healing — The problem of lowered oxygen pressure in the tissue

SummaryThere is a correlation between tissue oxygen tension, incidence of infection and disturbance of wound healing. Scientific investigations in recent years have documented that infection and tissue repair are processes consuming oxygen. Animal experiments have shown that oxygenation of the tissue is essential for the elimination of pathogens, the stimulation of phagocytosis as well as for the degradation of dead tissue structures and the synthesis of new tissue structures. Hypoxia and hypovolemia are of crucial significance for the impairment of organ functions. An effective therapy for disorders of oxygenation has not been feasible so far, except for clinical anesthesiological efforts to increase the oxygen saturation of hemoglobin and hyperbaric oxygen therapy. However, it has recently been possible to synthesize an oxygen carrier which supports respiratory oxygen physiologically. With tetrachlorodecaoxide (TCDO), a causal therapeutic concept for the topical treatment of infected hypoxic wounds with chronic disturbance of wound healing has been introduced for the first time.ZusammenfassungEs besteht ein Zusammenhang zwischen Gewebesauerstoffspannung, Infektionsrate und Wundheilungsstörung. Wissenschaftliche Untersuchungen der letzten Jahre haben belegt, daß Infektion und Gewebereparation sauerstoffkonsumierende Prozesse sind. Tierexperimentelle Untersuchungen ergaben, daß die Oxygenierung des Gewebes essentiell ist für Erreger-Eliminierung, Stimulation der Phagozytose sowie Abbau von toten und Wiederaufbau von neuen Gewebestrukturen. Für die Schädigung der Organfunktion sind Hypoxie und Hypovolämie von wesentlicher Bedeutung. Eine effektive Therapie von Oxygenierungsstörungen war bisher nicht möglich, sieht man von klinisch-anästhesiologischen Bemühungen um die Sauerstoffbeladung des Hämoglobins und von der hyperbaren Sauerstofftherapie ab. Vor kurzem ist es jedoch gelungen, einen Sauerstoffträger zu synthetisieren, der den Atmungssauerstoff in physiologischer Weise unterstützt. Mit Tetrachlordecaoxid (TCDO) wurde erstmals ein kausales Therapiekonzept zur topischen Behandlung infizierter und chronisch heilungsgestörter hypoxischer Wunden eingeführt.

Clinical Relevance of CagA-specific Antibodies Related to CagA Status of Heliobacter pylori Isolates Using Immunofluorescence Test and PCR

AbstractBackground: The cagA (cytotoxin-associated gene A) protein is found in about 50% of Helicobacter pylori strains; its clinical relevance in gastroduodenal disease is uncertain. Patients and Methods: The frequency of IgG antibodies to cagA was studied by using a commercial Western blot assay in sera of 189 patients with endoscopically and histologically confirmed gastroduodenal disease. In addition, 38 H. pylori strains isolated from biopsies were analyzed by immunofluorescence test (IFT) and PCR for detection of cagA protein and cagA gene sequences, respectively. Results: 54.3–60.0% of all patients with gastrointestinal diseases (chronic gastritis, gastric or duodenal ulcer and chronic duodenitis) and 28.6% with a normal mucosa were found to be positive for anti-cagA IgG antibodies. There was no significant difference in anti-cagA IgG seroprevalence between the different clinical entities. CagA-positive (cagA+) H. pylori strains were detected in 44.7% and 50% of the 38 isolates by PCR and IFT, respectively. 22 of 23 patients infected with cagA+ strains had anti-cagA antibodies. Using PCR as a gold standard, the sensitivity and specificity of the cagA IgG Western blot were 100.0% and 35.0%, respectively; the sensitivity and specificity of the cagA IFT were 76.5% and 71.4%, respectively. The incidence of the cagA+H. pylori strains detected either by PCR or IFT was significantly higher (p < 0.05 and p < 0.01, respectively) in patients with chronic duodenitis, gastric or duodenal ulcer compared to patients with chronic gastritis (66.7%, 80% and 30.4%, respectively). Conclusion: In this study the cagA-specific serological status in H. pylori infections as diagnosed by IgG Western blot was of no predictive value for severity of disease. In contrast, the cagA status of H. pylori isolates, diagnosed by IFT or PCR, was a predictive marker for severe disease and, therefore, also of clinical relevance in the assessment of the virulence of the infecting strain.

Pharmacokinetics of imipenem in patients undergoing major colon surgery

SummaryTen patients about to undergo a colorectal operation lasting an average of three hours received 500 mg each of imipenem and cilastatin i.v. preoperatively. During the operation blood and tissue samples were taken in order to determine the serum kinetics of the substances as well as the levels of imipenem in the cutis, subcutis, fascia, muscle, parietal peritoneum and colon. The imipenem concentrations were measured by HPLC. The mean peak serum concentration was 26 mg/l, the mean half-life 55 min and the AUC 40 mg/l/h−1. The serum pharmacokinetics of imipenem was subject to substantially larger fluctuations in this patient group than in subjects or patients without surgery. Imipenem rapidly penetrates into tissue, with peak concentrations being reached after 10–25 min. The highest imipenem concentrations were found in the colon, the lowest in the cutis and subcutis. After 1 h a level of 8 mg/kg imipenem was still found in the colon. The concentrations were > 1 mg/kg in all tissues for more than 3 h p. a. and thus within this period exceeded the MICs ofEscherichia coli andBacteriodes fragilis, the indicator organisms of intraabdominal infections.ZusammenfassungZehn Patienten, die sich einer kolorektalen Operation von durchschnittlich drei Stunden Länge unterziehen mußten, erhielten präoperativ je 500 mg Imipenem und Cilastatin i.v. Während der Operation wurden Blut und Gewebeproben für eine Serumpharmakokinetik sowie zur Bestimmung der Konzentrationen von Imipenem in der Kutis, Subkutis, Faszie, im Muskel, im Peritoneum parietale und Dickdarm entnommen. Die Imipenem-Konzentrationen wurden mit der HPLC-Methodik bestimmt. Die durchschnittliche Serumspitzenkonzentration lag bei 26 mg/l, die mittlere Halbwertszeit bei 55 min und die AUC bei 40 mg/l/h−1. Die Serumpharmakokinetik von Imipenem unterlag bei dieser Patientengruppe wesentlich größeren Schwankungen als bei Probanden oder Patienten ohne Operation. Imipenem penetriert schnell in das Gewebe. Nach 10–25 min wurden die höchsten Konzentrationen gemessen. Der Dickdarm weist die höchsten, Kutis und Subkutis die niedrigsten Imipenem-Konzentrationen auf. Im Dickdarm sind nach einer Stunde noch 8 mg/kg Imipenem nachzuweisen. In allen Geweben lagen die Konzentrationen mehr als drei Stunden p. a.=1 mg/kg und damit über diesen Zeitraum höher als die MHK-Werte vonEscherichia coli undBacteroides fragilis, den Leitkeimen bei intraabdominellen Infektionen.

Synergism between ciprofloxacin and fosfomycin in vitro.

Because of the mode of action of 4-quinolones, for theoretical reasons a synergism or antagonism is not to be expected in combinations with ~-lactams or aminoglycosides. On the contrary, the interaction of the substances is likely to be indifferent, as was also observed in the investigations of Haller (1), in which the combination effect of ciprofloxacin with nine different [Mactam antibiotics was as a rule additive or indifferent against Enterobacteriaceae and Pseudomonadaceae. In an earlier study, the interaction of nalidixic acid and fosfomycin was investigated in multiresistant Enterobacteriaceae and Pseudomonas aeruginosa strains (2, 3). Synergism was observed in a major proportion. For this reason the interaction of the new quinolone ciprofloxacin with fosfomycin was analysed against P. aeruginosa and Staphylococcus aureus. All microorganisms were freshly isolated from clinical material of patients from two surgical intensive-care units. Reference strains were P. aeruginosa ATCC 15442 and S. aureus ATCC 25923. Fosfomycin (Boehringer Mannheim, FRG) was used in concentrations of 128 to 0.25 mg/1, and ciprofloxacin (Bayer AG, Leverkusen, FRG) from 2 to 0.03 mg/1. The investigation of the combination effect was carried out with checkerboard titration using microtiter plates; test medium was Mueller-Hinton substrate (CM 405, Oxoid, Wesel) which was not supplemented with glucose-6-phosphate. The bacterial inoculum was 106/ml. After incubation for 18 h at 36°C ___ 1 ° C, the minimum inhibitory concentrations (MICs) were estimated visually. The following interpretation was applied for the calculation of the fractional inhibitory concentration index (FIC index) (4): FIC < 0.5: synergism, FIC = 0.51-1.0: addition, FIC > 1-2: indifference, FIC >2: antagonism. The results are summarized in Table 1. There was synergism against P. aeruginosa in 78% and additive behavior in 22% of the strains; the combination showed synergism against S. aureus in 95% and additive effects in only one strain of this species. For example, the MIC of fosfomycin for P. aeruginosa (8 mg/1) was reduced to 0.5 mg/1 in the presence of 0.25 mg/1 ciprofloxacin.

Chlamydia pneumoniae Infection and Restenosis in Patients with Coronary Heart Disease

Abstract.Background: The aim of this study was to establish whether Chlamydia pneumoniae is implicated in the development of restenosis in patients with coronary heart disease (CHD) after percutaneous transluminal coronary angioplasty (PTCA). Patients and Methods: 67 patients were selected for study after they underwent control angiography after PTCA. Sera were tested for anti-chlamydial antibodies with a genusspecific ELISA and a species-specific microimmunofluorescence test (MIFT). Oropharyngeal specimens were examined for the presence of antigen with a Chlamydia immunofluorescence test (IFT), C. pneumoniae IFT and semi-nested PCR. In addition, anamnestic findings were also included. To determine the general level of antibodies, an age- and sexmatched control group of 180 persons was also examined for Chlamydia and C. pneumoniae serology. Results: Coronary angiography revealed that 31 of the 67 patients had developed a restenosis. There was no significant correlation between serological and angiographic findings. However, the MIFT showed a higher positive rate, especially in IgA, in the restenosis group. C. pneumoniae was detected in the oropharynx by PCR and/or IFT in 20.8% and 16.0% of the cases in patients with and without a restenosis. PCR found more C. pneumoniae-positive cases in the restenosis patients than IFT. No association was found between the detection of Chlamydia antigen and serology. The women with restenosis were more frequently smokers (p = 0.012). Men with restenosis were significantly older (p = 0.015). C. pneumoniae serology based on the rELISA or the MIFT did not show any correlation with restenosis. Conclusion: No evidence was found to suggest that positive C. pneumoniae serology is a risk factor for the development of restenosis. However, whether the species-specific serological test, especially for IgA-antibodies, and the detection of C. pneumoniae in oropharyngeal specimens by PCR might be reliable diagnostic markers in these cases remains to be determined.

Campylobacteriosis des Menschen durch die Subspezies intestinalis und fetus unter Berücksichtigung sechs neuer Erkrankungen

ZusammenfassungCampylobacter fetus Subspeziesintestinalis und Subspeziesfetus sind beim Menschen opportunistische Krankheitserreger. Weltweit wurden bisher etwa 200 Erkrankungen beschrieben. Sechs neue Erkrankungen werden kurz vorgestellt. Am häufigsten ist die Sepsis, gefolgt von Meningitis. Wirksame Antibiotika sind Ticarcillin, Erythromycin, Clindamycin und Tetracyclin; weitgehende Resistenz besteht gegenüber Cefalotin, Cefazolin, Cefuroxim, Cefoxitin und Cefotaxim, mäßige Empfindlichkeit gegenüber Gentamicin. Die Epidemiologie der Erkrankung ist unklar. Männer sind etwa zweimal häufiger betroffen als Frauen. Bei 95% der Erkrankungen wurde die Subspeziesintestinalis isoliert. Bei 3,9% der Bevölkerung wurden Antikörper gegenCampylobacter fetus nachgewiesen.SummaryThe subspeciesintestinalis andfetus ofCampylobacter fetus are opportunistic pathogens in humans. So far, some 200 types of disease due to these pathogens have been reported from all over the world, and six new diseases are briefly described in this paper. The most frequent disease is sepsis, followed by meningitis. While ticarcillin, erythromycin, clindamycin and tetracycline are the antibiotics which show activity against these species, a large degree of resistance is seen against cephalothin, cefazolin, cefuroxime, cefoxitin and cefotaxime. There is a moderate degree of sensitivity to gentamicin. The epidemiology of the disease is not clear, and about twice as many men are affected as women. Subspeciesintestinalis was isolated in 95% of all diseases. Antibodies toCampylobacter fetus were detected in 3.9% of the population.The subspecies intestinalis and fetus of Campylobacter fetus are opportunistic pathogens in humans. So far, some 200 types of disease due to these pathogens have been reported from all over the world, and six new diseases are briefly described in this paper. The most frequent disease is sepsis, followed by meningitis. While ticarcillin, erythromycin, clindamycin and tetracycline are the antibiotics which show activity against these species, a large degree of resistance is seen against cephalothin, cefazolin, cefuroxime, cefoxitin and cefotaxime. There is a moderate degree of sensitivity to gentamicin. The epidemiology of the disease is not clear, and about twice as many men are affected as women. Subspecies intestinalis was isolated in 95% of all diseases. Antibodies to Campylobacter fetus were detected in 3.9% of the population.

Determination of imipenem and cilastatin in serum and tissue by high-pressure liquid chromatography

Imipenem (N-formimidoyl thienamycin) (MK-0787) is a crystalline derivative of thienamycin (1). Because of metabolic inactivation resulting from hydrolysis of the betalactam ring in imipenem by a renal dipeptidase (dehydropeptidase I) (2), cilastatin (MK-791), a renal dipeptidase inhibitor with no intrinsic antimicrobial activity (3, 4), is used concomitantly. Recently, sensitive methods of high-pressure liquid chromatography (HPLC) have been reported for the determination of imipenem and cilastatin (5-9). These methods require either two different column types (6) or the same column type but different procedures for sample preparation (5, 7) or post-column derivatization (9). This report describes a simple, rapid and sensitive HPLC method for the determination of both imipenem and cilastatin in serum and tissue. In clinical studies, however, it is necessary to determine both drugs, because information is lacking on the cilastatin content in various human tissues (10). The advantage of the method described is the sample preparation in one step for the determination of both drugs, especially if only small quantities of tissue samples are available.

Activity of 18 antimicrobial agents against multi-resistant strains of Staphylococcus aureus isolated from intensive care patients

SummaryDuring an outbreak of infections with multiple-resistantStaphylococcus aureus, 22 strains were isolated from 12 patients between November 1983 and March 1984 on two surgical intensive care units at Kiel University Hospital. Susceptibility of all strains was tested with the disc diffusion method and a microdilution test using different inocula of 102 and 105 cuf/ml. All strains were resistant to beta-lactam antibiotics, including thienamycin as well as to gentamicin, clindamycin, doxycycline, erythromycin and fosfomycin. Rifampicin was the most active substance in terms of w/v, followed by fusidic acid, ciprofloxacin, vancomycin, and trimethoprim/sulfamethoxazole. Netilmicin and chloramphenicol showed only moderate activity in relation to the antibiotic breakpoint, but were considered sensitive according to the disc diffusion test. Caution should be reserved for the use of imipenem against multiply-resistant staphylococci.ZusammenfassungZwischen November und März 1984 wurden auf zwei chirurgischen Intensivstationen des Universitätsklinikums Kiel bei Infektionen von 12 Patienten 22 multiresistenteStaphylococcus-aureus-Stämme isoliert. Die Empfindlichkeit der Isolate wurde mit der Agardiffusionsmethode und dem Mikrodilutionstest untersucht unter Verwendung von 102 und 105 KBE/ml. Alle Stämme erwiesen sich als resistent gegenüber Betalaktamantibiotika einschließlich Thienamycin sowie Gentamicin, Clindamycin, Doxycyclin, Erythromycin und Fosfomycin. Rifampicin war die aktivste Substanz, gefolgt von Fusidinsäure, Ciprofloxacin, Vancomycin und Trimethoprim/Sulfamethoxazol. Netilmicin und Chloramphenicol zeigten in den quantitativen Tests bezogen auf den Breakpoint lediglich mäßige Empfindlichkeit. Dagegen erwiesen sie sich als sensibel im Agardiffusionstest. Die therapeutische Anwendung von Imipenem bei Infektionen durch multiresistente Staphylokokken sollte sehr sorgfältig beobachtet werden; mit Therapieversagen ist zu rechnen.

Influence of Ly146032 on chemotaxis, chemiluminescence of PMN and lymphocyte transformation in vitro

SummaryThe influence of Ly146032, a new acidic lipopeptide, on chemotaxis, luminol-dependent chemiluminescence of human polymorphonuclear leukocytes (PMN) and phythemagglutinin induced lymphocyte transformation of murine cells was investigated. At therapeutic range there was no remarkable effect on the parameters tested. Incubation with more than 20 mg/l Ly146032 was followed by depression of chemiluminescence, whilst transformation of maximally PHA stimulated lymphocytes was suppressed by more than 32 mg/l Ly146032.ZusammenfassungUntersucht wurde der Einfluß von Ly146032, einem neuen Antibiotikum aus der Gruppe der sauren Lipopeptide, auf die Chemotaxis, die Luminol-abhängige Chemilumineszenz von menschlichen polymorphkernigen Leukozyten und die Phythaemagglutinin-induzierte Transformation muriner Lymphozyten. Im therapeutischen Bereich zeigte Ly146032 keine ausgeprägte Modulation der untersuchten Parameter. Die Chemilumineszenz von Granulozyten wurde erst durch Konzentrationen von mehr als 20 mg/l negativ beeinflußt. Die Transformation maximal PHA-stimulierter Lymphozyten wurde durch Konzentrationen von mehr als 32 mg/l negativ beeinflußt.