Treatment of methicillin-sensitive Staphylococcus aureus bacteremia secondary to septic phlebitis using dalbavancin.

WHAT IS KNOWN AND OBJECTIVE: Treatment of bacteremia due to Staphylococcus aureus often requires prolonged therapy leading to increased hospital lengths of stay and associated costs. For certain patients, referral to an outpatient parenteral antimicrobial therapy (OPAT) programme serves as an alternative to increased inpatient length of stay. We report an alternative to OPAT using dalbavancin for the treatment of methicillin-sensitive Staphylococcus aureus (MSSA). CASE SUMMARY: A 54-year-old Caucasian man was brought to the emergency department from a rehabilitation centre with altered mental status and possible seizure. A peripheral intravenous catheter was placed in the left forearm, and the patient was transferred to the intensive care unit (ICU) for management of his acute psychosis, possible seizure and hyponatremia. Seven days into admission, the patient became febrile thought to be secondary to septic phlebitis of the forearm. Blood cultures were taken and organism identification using Nanosphere Verigene® BC-GP rapid diagnostic testing resulted in MSSA. The patient received treatment with cefazolin with a planned treatment duration of 14 days but because of the patient's history of alcohol abuse, psychosis requiring hospitalization via the Baker Act, and history of non-compliance to follow-up appointments, the patient was deemed ineligible for OPAT. Due to the limited treatment options, therapy for MSSA bacteremia was changed on day 6 of cefazolin therapy to dalbavancin to complete the 14-day treatment duration. Blood cultures were negative at the end of treatment and no relapse of infection occurred. WHAT IS NEW AND CONCLUSION: To our knowledge, this is the first case report using dalbavancin in clinical practice for the treatment of MSSA bacteremia secondary to septic phlebitis. This report highlights the potential role of the newer lipoglycopeptides, such as dalbavancin, in treating patients who require long-term parenteral antimicrobial therapy and are ineligible for treatment via OPAT.

Mechanisms involved in kaempferol-induced relaxation in rat uterine smooth muscle.

The effect of kaempferol on KCI (60 mM)-induced tonic contraction in isolated rat uterus and its modification by inhibitors of cAMP-dependent protein kinase (PKA) (Rp-cAMPS and TPCK), phosphodiesterase (papaverine), adenylyl cyclase (2',3'-dideoxyadenosine, DDA), transcription (actinomycin D), protein synthesis (cycloheximide) and ornithine decarboxylase (alpha-difluoromethyl-ornithine, DFMO), as well as a polyamine, spermine, have been assayed. Kaempferol (3 to 60 microM) induced concentration-dependent relaxation on KCl-induced tonic contraction (IC50: 10.1 +/- 1.89 microM). This relaxing effect was antagonized (p<0.05) by Rp-cAMPS (10 microM), TPCK (3 microM), DDA (100 microM), actinomycin D (4 and 12 microM), cycloheximide (100 microM), DFMO (10 mM), actinomycin D (12 microM) plus TPCK and actinomycin D (12 microM) plus spermine (1 mM). Furthermore, the displacement obtained with actinomycin D plus DFMO was not statistically significant. Our results suggest that kaempferol through cAMP produces transcriptional events and polyamines are, at least partially, involved in the relaxant effect of kaempferol.

Involvement of cAMP and beta-adrenoceptors in the relaxing effect elicited by flavonoids on rat uterine smooth muscle.

1. The effect of the flavonoids genistein (3-100 microM), kaempferol (3-60 microM) and quercetin (1-100 microM) on KCl (60 mM)-induced tonic contraction in rat smooth muscle was assayed. In the same way, the modification of these effects in the presence of an inhibitor of protein kinase (PKA) (Rp-cAMPS), an inhibitor of phosphodiesterase (papaverine) and beta-adrenoreceptor blocking agents (propranolol and atenolol) was studied. 2. The flavonoids totally relaxed the KCl-induced tonic contraction (IC50: genistein 20.2 +/- 2.0 microM, n = 11; kaempferol 10.1 +/- 1.6 microM, n = 8; quercetin 13.2 +/- 1.2 microM, n = 8). 3. The incubation with Rp-cAMPS (10 and 100 microM) 30 min prior to KCl shifted the dose-response curve of the flavonoids to the right, increasing their IC50 up to 27.8 +/- 3.8 and 31.9 +/- 7.3 microM, respectively, for genistein; 24.7 +/- 0.2 and 19.6 +/- 4.9 microM, respectively, for kaempferol; 18.8 +/- 2.2 and 18.4 +/- 1.5 microM, respectively, for quercetin. 4. Papaverine (3-100 microM) also relaxed the contraction induced by KCl and this effect was significantly displaced to the right with Rp-cAMPS (10 microM) (IC50 12.1 +/- 2.2 vs. 16.5 +/- 3.1 microM). Papaverine (3 microM) added to the organ bath 15 min before the contractile agent increased the relaxing effect of the flavonoids and significantly decreased their IC50 (genistein 20.2 +/- 2.0 vs. 9.8 +/- 1.4 microM; kaempferol 10.1 +/- 1.6 vs. 6.6 +/- 0.7 microM; quercetin 13.2 +/- 1.2 vs. 7.8 +/- 1.4 microM). 5. The incubation with atenolol (10 microM) did not alter the relaxing effect of the flavonoids. In the same experimental conditions, propranolol (10 microM) did not modify the effect of genistein and kaempferol, but shifted the response curve of quercetin significantly to the right (13.2 +/- 1.2 vs. 17.7 +/- 3.4 microM). 6. The results suggest that genistein, kaempferol and quercetin produced the relaxation of uterine smooth muscle by increasing intracellular cAMP. Beta-adrenoceptors could also be involved in the effect of quercetin.

Effect of spermine and alpha-difluoromethylornithine on KCl- and CaCl2-induced contraction in rat uterine smooth muscle.

1. The effect of a polyamine, spermine (0.3-30 mM), and an ornithine decarboxylase inhibitor, alpha-difluoromethylornithine (DFMO; 1-10 mM), given alone and in combination were studied on KCl (33, 60 or 90 mM)-induced tonic contraction and on the cumulative concentration-response curves elicited by CaCl2 (30 microM to 10 mM) in a depolarizing (with 33, 60 or 90 mM of KCl) calcium-free medium in isolated rat uterus. 2. Spermine elicited a concentration-dependent relaxation on KCl 33 mM (IC50 = 2.18 +/- 0.37 mM, n = 6), 60 mM (IC50 = 7.80 +/- 0.79 mM, n = 11) and 90 mM KCl (IC50 = 29.55 +/- 4.08 mM, n = 7) induced tonic contraction. The IC50 values were significantly different (P < 0.01). 3. DFMO relaxed the tonic contraction induced by 33 mM of KCl (Emax = 80.70 +/- 13.01%) but only relaxed the contractions induced by 60 and 90 mM of KCl to 23.60 +/- 4.60% and 16.90 +/- 4.10%, respectively. DFMO (10 mM) did not modify the concentration-dependent relaxation elicited by spermine on KCl (60 mM)-induced tonic contraction. 4. KCl (33, 60 or 90 mM) did not produce contraction in a calcium-free medium, but enabled CaCl2 (30 microM to 10 mM) to induce cumulative concentration-dependent contraction of the rat uterus. The EC50 values for CaCl2 were: 0.74 +/- 0.08 (n = 12), 0.34 +/- 0.03 (n = 14) and 0.48 +/- 0.02 (n = 12) mM in medium with 33, 60 or 90 mM of KCl, respectively. 5. Spermine (1 mM) and DFMO (1 mM) did not modify the concentration-response curves induced by CaCl2 in medium with 33 mM of KCl. Higher concentrations of spermine (3 mM) and DFMO (10 mM) strongly reduced the contractile effect of CaCl2 to 35.69 +/- 3.96% (n = 6) and 40.14 +/- 10.74% (n = 6). This inhibitory effect of spermine and DFMO was prevented by increasing KCl concentration in the medium to 60 or 90 mM. Thus, the Emax of CaCl2 in the presence of spermine (3 mM) was 66.26 +/- 6.96% and 89.02 +/- 2.89% in a 60 and 90 mM KCl medium, respectively. In the presence of DFMO (10 mM) the Emax of CaCl2 reached 100% when KCl was increased. 6. Spermine (1 mM) plus DFMO (1 mM) and spermine (1 mM) plus DFMO (10 mM) produced a synergic inhibitory effect of CaCl2-induced contraction in medium with 33 mM of KCl. Spermine (3 mM) plus DFMO (10 mM) produced a total inhibition of CaCl2-induced contraction. 7. The inhibitory effect of spermine (1 mM) plus DFMO (10 mM) was also prevented by increasing KCl concentration in the medium to 60 or 90 mM. The Emax for CaCl2 (10.9 +/- 5.5%) in the presence of KCl 33 mM increased up to 93.2 +/- 2.1% and 96.3 +/- 1.2% when the KCl concentration in the medium was enhanced to 60 or 90 mM. 8. Our results suggest that a calcium inhibitory effect of spermine and DFMO in isolated rat uterus could be produced, since this was prevented by depolarization, as a result of the increase of KCl concentration in the medium.

Partial contribution of polyamines to the relaxant effect of 17 alpha-estradiol in rat uterine smooth muscle.

1. The effects of 17 alpha-estradiol on KCl (60 mM), CaCl2 (30 microM to 10 mM) and vanadate (0.3 mM)-induced contractions in rat uterus have been assayed. Furthermore, the effect of 17 alpha-estradiol on calmodulin-stimulated cAMP-phosphodiesterase activity was also studied. 2. 17 alpha-estradiol relaxed the tonic contraction induced by KCl (60 mM) in a concentration-dependent way (IC50, 8.3 +/- 0.7 microM), and CaCl2 (0.1 to 10 mM) counteracted it. 3. CaCl2 (30 microM to 10 mM) produced concentration-dependent contraction of rat uterus in a calcium-free medium supplemented with 60 mM of KCl (EC50: 0.2 +/- 0.01 mM). 17 alpha-estradiol (8 microM) antagonized the contraction induced by CaCl2, increasing the EC50 value up to 0.7 +/- 0.1 mM (P < 0.01). 4. 17 alpha-estradiol (0.1 to 1 mM) relaxed in a concentration-dependent way the tonic contraction induced by vanadate in rat uterus incubated in a calcium-free medium and EDTA supplemented. The maximal relaxation achieved with 1 mM of 17 alpha-estradiol was 52.2 +/- 2.8%. 5. 17 alpha-estradiol (1 to 100 microM) did not modify the basal activity of cAMP-phosphodiesterase but inhibited the calcium plus calmodulin stimulated activity. The maximal inhibition achieved was 43 +/- 5.4%. 6. The relaxing effect of 17 alpha-estradiol on KCl (60 mM)-induced tonic contraction was unmodified with the antioestrogen tamoxifen (0.1 and 1 microM), the inhibitor of tirosine kinase (genistein, 10 microM) and the cAMP-dependent protein kinase inhibitor (Rp-adenosine 3',5'-monophosphothioate, triethylamine salt, 100 microM). However, the effect was antagonized with the inhibitor of transcription (actinomycin D, 5 micrograms/ml,), the inhibitor of protein synthesis (cycloheximide, 10 and 100 micrograms/ml), and the inhibitor of ornithine decarboxilase (alpha-difluoromethyl-ornithine, 10 mM). 7. Our results suggest that polyamines contribute to the relaxant effect of 17 alpha-estradiol in rat uterine smooth muscle behaving, presumably, as mediators of the transcriptional component involved in the effect of 17 alpha-estradiol.

Depolarization-dependent effect of flavonoids in rat uterine smooth muscle contraction elicited by CaCl2.

1. The effects of the flavonoids genistein (3-60 microM), kaempferol (3-60 microM) and quercetin (1-100 microM) on KCl (60 mM)-induced tonic contraction in rat uterus and their modifications with the inhibitor of cAMP-dependent protein kinases (TPCK, 3 microM), the inhibitor of ornithine decarboxylase [alpha-difluoromethyl ornithine (DFMO), 10 mM] and the polyamine spermine (1 mM) have been assayed. The effects of the three flavonoids were also studied on the contraction elicited by CaCl2 (30 microM to 10 mM) on rat uterus incubated in medium lacking calcium and supplemented with 33, 60 or 90 mM of KCl. For comparison, the effects of the calcium channel blockers nifedipine and verapamil and the activator of adenylyl cyclase forskolin were assayed on contractions induced by KCl and CaCl2. 2. Genistein (IC50: 20.2 +/- 1.0 microM, n = 11), kaempferol (IC50: 10.1 +/- 0.8 microM, n = 8) and quercetin (IC50: 13.2 +/- 0.5 microM, n = 8) relaxed the tonic contraction induced by KCl (60 mM) in a concentration-dependent way. Verapamil (IC50: 70.1 +/- 5.8 nM, n = 7), nifedipine (IC50: 8.4 +/- 0.7 nM, n = 6) and forskolin (IC50: 0.62 +/- 0.08 microM, n = 14) also relaxed the KCl-induced contraction. TPCK (3 microM) significantly antagonized the effect of quercetin, kaempferol and forskolin (P < 0.01) but did not modify the effect of genistein. 3. Spermine (1 mM) increased the effects of genistein and verapamil and antagonized the effect of quercetin but did not modify those of kaempferol and forskolin. DFMO (10 mM) did not modify the effect of quercetin but increased that of genistein and antagonized those of kaempferol and forskolin. The addition of spermine (1 mM) plus DFMO (10 mM) antagonized the effect of quercetin. Spermine counteracted the effect of DFMO on forskolin but not on genistein. 4. KCl (33, 60 or 90 mM) did not produce contraction in calcium-free solution, but CaCl2 (30 microM to 10 mM) induced concentration-dependent contraction after depolarizing with KCl. The EC50 values for CaCl2 were: 0.74 +/- 0.08 (n = 12), 0.34 +/- 0.03 (n = 14) and 0.48 +/- 0.02 (n = 12) mM in a medium with 33, 60 or 90 mM of KCl, respectively. 5. Genistein (20 microM), kaempferol (10 microM), quercetin (15 microM), verapamil (70 nM), nifedipine (10 nM) and forskolin (0.5 microM) inhibited the concentration-response curve to CaCl2 in medium supplemented with 33, 60 or 90 mM of KCl. The effect of kaempferol was independent of the concentration of KCl in the incubation medium. However, the inhibitory effect of genistein on CaCl2-induced contraction was inversely related to the concentration of KCl in the medium. On the contrary, the effect of quercetin was directly related to the concentration of KCl in the medium. 6. The antagonism of verapamil, nifedipine and forskolin on CaCl2-induced contraction seems to be related to the degree of depolarization because increasing the KCl in the medium counteracted their effects. 7. Our results suggest that (1) cAMP contributes to the relaxant effects of quercetin and kaempferol on KCl (60 mM)-induced tonic contraction; (2) polyamines are involved in the relaxant effects of forskolin and kaempferol on KCl-induced tonic contraction but not on CaCl2-induced contraction in the depolarized uterus, and (3) the flavonoids assayed also possess a calcium antagonist action but show a different behavior toward the calcium channel blockers and the cAMP enhancer forskolin.

Transcriptional mechanisms involved in the relaxant effect of zeranol on isolated rat uterus.

1. The effect of zeranol (3-100 microM) on rat uterus contractions induced by KCl (60 mM) and CaCl2 (30 microM-10 mM) has been assayed. 2. Zeranol relaxed the tonic contraction induced by KCl in a concentration-dependent manner (IC50 15.62 +/- 2.66 microM). CaCl2 (0.1-10 mM) did not counteract the relaxing effect of zeranol. 3. CaCl2 (30 microM -10 mM) produced a concentration-dependent contraction of rauuterus in medium lacking calcium plus KCl (60 mM) (EC50 0.34 +/- 0.03 mM). Zeranol (8 microM) displaced the CaCl2 concentration-response curve to the right and increased the EC50 to 1.27 +/- 0.57 mM (P < 0.05) without modifying the Emax. 4. The antiestrogen tamoxifen (1 microM) and the inhibitor of cAMP-dependent protein kinase TPCK (3 microM) did not modify the effect of zeranol. However, the inhibitors of transcription (actinomycin D, 4 microM), protein synthesis (cycloheximide, 100 microM), and ornithine-decarboxilase (alpha-difluoromethyl-ornithine, 10 mM)) antagonized the effect of zeranol, increasing the IC50 to 50.2 +/- 6.2 microM, 122 +/- 6.9 microM, and 23.51 +/- 1.14 microM, respectively. 5. Our results suggest that the relaxing effect of zeranol on rat uterus smooth muscle is produced by mechanisms unrelated to cAMP and estrogen receptors, but involves transcriptional effects and polyamine synthesis.

Effect of Rp diastereoisomer of adenosine 3',5' cyclic-monophosphothioate on the cAMP-dependent relaxation of smooth muscle.

The effect of Rp diastereoisomer of adenosine 3',5'-cyclic monophosphothioate (Rp-cAMPS) on relaxation elicited by histamine (1-100 microM), forskolin (1-60 microM), papaverine (1-100 microM), vinpocetine (1-100 microM), rolipram (0.1-1 mM), Sp-cAMPS (10-300 microM), 8-BrcAMP (10 microM - 1 mM) and 8-BrcGMP (3 microM - 1 mM) of the previous vanadate-induced contraction was assayed. The effect of Rp-cAMPS on the relaxing effect produced by forskolin, papaverine, vinpocetine, rolipram, Sp-cAMPS and 8-BrcAMP in KCl-induced tonic contraction was also assayed. Histamine, forskolin, papaverine, rolipram, Sp-cAMPS, 8-BrcAMP and 8-BrcGMP, but not vinpocetine, relaxed the vanadate-induced contractions in rat uterus incubated in medium lacking calcium plus EDTA in a concentration-dependent way. Rp-cAMPS (1-300 microM) had no effect on vanadate contraction. However, it antagonized the relaxation elicited by histamine and papaverine, but not that of forskolin, rolipram, Sp-cAMPS, 8-BrcAMP and 8-BrcGMP. Forskolin, papaverine, vinpocetine, rolipram and 8-BrcAMP, but not Sp-cAMPS, relaxed the KCl-induced contraction. Rp-cAMPS antagonized the relaxation elicited by forskolin, papaverine and vinpocetine, but not that of rolipram and 8-BrcAMP. Our results suggest that: a) Rp-cAMPS is an effective PKA inhibitor that could be used to study the involvement of cAMP on drug-induced response in smooth muscle, and b) the effects of Sp-cAMPS, 8-BrcAMP and rolipram were independent of the activation of protein kinases.

Pharmacological evidence for the contribution of polyamines as mediators of the transcriptional component involved in smooth muscle relaxation elicited by forskolin.

To study whether cAMP-dependent transcriptional effect and polyamines might play a modulatory role on smooth muscle, the effect of forskolin on KCl (60 mM)-induced contractions in isolated rat uterus and its modification by inhibitors of cAMP-dependent protein kinase (PKA) (Rp-cAMPS and TPCK), transcription (actinomycin D), protein synthesis (cycloheximide) and ornithine decarboxylase (alpha-difluoromethyl-ornithine, DFMO), and a polyamine (spermine) have been assayed. Forskolin (0.1 to 6 microM) induced concentration-dependent relaxation on KCl-induced tonic contractions in rat uterus (IC50: 0.55 +/- 0.12 microM) which was antagonized (p<0.05) by Rp-cAMPS (30 microM), TPCK (3 microM), cycloheximide (300 microM), actinomycin D (4 and 12 microM) and TPCK (3 microM) plus actinomycin D (12 microM). The IC50 values of forskolin in the presence of these drugs were 3.75 +/- 1.53 microM, 12.08 +/- 8.18 microM, 6.88 +/- 5.02 microM, 3.80 +/- 2.35 and 5.31 +/- 2.80 microM, and 4.26 +/- 3.65 microM respectively. Furthermore, DFMO (10 mM) also shifted the relaxation curve to forskolin to the right (IC50: 3.06 +/- 2.66 microM, p<0.05) but DFMO (10 mM) plus actinomycin D (12 microM) (IC50: 1.78 +/- 1.33 microM) did not. However, DFMO (10 mM) and actinomycin D (12 microM) did not antagonize the spermine (1-30 mM)-elicited relaxation (IC50s: 7.8 +/- 0.7 mM vs 7.28 +/- 1.4 mM and 4.67 +/- 0.44 mM in the presence of DFMO and actinomycin D, respectively). Moreover, spermine (1 mM) did not decrease the forskolin induced relaxation and counteracted the antagonism produced by actinomycin D and DFMO. Our results suggest that, in rat uterus, forskolin: a) produced cAMP-dependent relaxation, as this is antagonized by Rp-cAMP and TPCK, and b) increased the activity of ornithine decarboxylase, as this is inhibited by DFMO. Therefore, polyamines could be the mediator of the cAMP-dependent transcriptional component involved in forskolin relaxation, since, as mentioned, DFMO antagonized this relaxation and spermine counteracted the displacement produced by DFMO and actinomycin D. Thus, a plasma membrane-nucleus interaction might, at least partially, explain the mechanisms involved in forskolin induced relaxation in smooth muscle of rat uterus under the present experimental conditions.

Calcium and depolarization-dependent effect of pregnenolone derivatives on uterine smooth muscle.

1. The effects of several gestagens (pregnenolone [1 to 30 microM], 20 alpha-hydroxy-pregnenolone [1 to 30 microM], and 20 beta-hydroxypregnenolone [1 to 30 micro M]) on rat uterine contraction induced by KCl (60 mM) and CaCl2 (30 microM to 6 mM) have been assayed. 2. The three drugs relaxed the tonic contraction induced by KCl in a concentration-dependent way. The respective EC50 values were: 27.6 +/- 1.58 microM (pregnenolone), 4.1 +/- 0.12 microM (20 alpha-hydroxy-pregnenolone), and 11.2 +/- 1.04 microM (20 beta-hydroxypregnenolone). CaCl2 (1 to 10 mM) totally counteracted the relaxing effect of pregnenolone but only partially compared to that of 20 alpha- or 20 beta-hydroxy-pregnenolone. 3. CaCl2 (30 microM to 6 mM) produced concentration-dependent contraction of rat uterus in medium lacking calcium plus 30, 60, or 90 mM of KCl. The EC50 values of CaCl2 were: 0.38 +/- 0.072, 0.183 +/- 0.015, and 0.183 +/- 0.015 mM in a medium with 30, 60, or 90 mM of KCl, respectively. 4. Pregnenolone (10 microM) did not significantly modify the EC50 of CaCl2 in a medium with 30, 60, or 90 mM of KCl. However, 20 beta-hydroxypregnenolone (10 microM) antagonized, in a noncompetitive manner, the concentration-response curve to CaCl2. 5. 20 alpha-Hydroxypregnenolone (4 microM) antagonized the concentration-response curve to CaCl2 in a competitive manner. This antagonism was directly related to the concentration of KCl in the medium. 6. Our results suggest a different calcium antagonist effect of the three gestagens assayed.