Neonatal sepsis in a tertiary care center in central India: microbiological profile, antimicrobial sensitivity pattern and outcome.

INTRODUCTION: Neonatal mortality is increasingly recognized as an important global public health challenge. The spectrum of organisms that cause neonatal sepsis changes over time and varies from region to another. This study was conducted to determine the profile, antibiotic sensitivity pattern of bacterial isolates and outcome of confirmed neonatal sepsis in a tertiary care center. STUDY DESIGN: All blood culture reports (n = 285), obtained during the study period (January 2012-September 2012) from the neonatal intensive care unit were analyzed. RESULTS: Blood culture positivity rate was 22.1% (67/285). Seventy-three percent babies were outborn. Sixty-two percent babies were preterm and 80% were low birth weight. Thirty-six (57%) babies had early onset and remaining 27 (43%) had late onset neonatal sepsis. Blood culture isolates included Gram-negative bacilli (38/67, 56.7%), Gram-positive cocci (20/67, 29.8%), and Candida species (9/67, 13.4%). Staphylococci and Klebsiellae were the most common organisms responsible for infections, accounting for 25.4% (17/67) and 19.4% (13/67) of the isolates, respectively. All Gram positive isolates were sensitive to vancomycin, while 50-65% Gram negative isolates were sensitive to amikacin, ciprofloxacin and meropenem. Fifty-eight percent babies were discharged after completion of the antibiotic therapy, while 28.6% babies expired. CONCLUSION: Multidrug resistant Gram negative isolates pose serious challenge, particularly in setting of emerging resistance to fluoroquinolones and carbepenems.

Effect of atrial natriuretic peptide (8-33-Met ANP) in patients with hypertension.

In this pilot study we investigated the effects of a 4-h infusion of atrial natriuretic peptide (8-33 Met ANP) on hemodynamic, renal, and hormonal parameters in 12 patients with hypertension. Either 8-33 ANP in 5% mannitol (0.7 microgram/min [eight patients] and 1.05 micrograms/min [four patients]) or placebo (5% mannitol) was infused for 4 h on 2 consecutive days in a randomized double-blind crossover design. The plasma levels of ANP were not significantly different between the two doses of ANP and therefore the results from the two doses were combined. Plasma ANP increased from 61 +/- 24 pg/mL to 291 +/- 55 pg/mL after 2 h and to 288 +/- 40 pg/mL after 4 h. ANP caused a significant lowering of systolic blood pressure after 2 h of infusion from 148 +/- 5 mm Hg to 142 +/- 5 mm Hg (P less than .05) and to 128 +/- 6 after 4 h (P less than .01). Two hours after discontinuation of the infusion, systolic blood pressure was 126 +/- 6 and 135 +/- 7 mm Hg 4 h after the end of the infusion. Diastolic blood pressure did not change. Heart rate increased from 69 +/- 3 beats/min to 74 +/- 3 beats/min after 4 h and to 78 +/- 4 beats/min 2 h after termination of the infusion. Cardiac output did not change significantly. Urinary sodium and chloride increased significantly but creatinine clearance did not change. Plasma aldosterone decreased after 2 h of ANP infusion from 9.8 +/- 1.7 ng/dL to 6.7 +/- 0.9 ng/dL (P less than .01) and to 6.5 +/- 1.2 ng/dL after 4 h (P less than .05). Plasma renin activity decreased from 0.81 +/- 0.1 ng angiotensin I/mL/h to 0.57 +/- 0.1 after 2 h of infusion (P less than .05). There were no significant changes in plasma catecholamines or arginine vasopressin. Two patients developed severe hypotension and bradycardia and one of them had a sinus pause of 7.4 sec associated with loss of consciousness. Neither of these two patients had a significant increase in plasma catecholamines in response to the severe hypotension, suggesting that ANP may have inhibited their sympathetic response and increased their sensitivity to vagal cardioinhibitory reflexes. In conclusion, infusion of ANP in hypertensive patients causes prolonged lowering of systolic blood pressure with no change in diastolic pressure and cardiac output.(ABSTRACT TRUNCATED AT 400 WORDS)

Adverse effects of oral amiodarone therapy.

Oral amiodarone was administered to 38 patients (25 males, 13 females) with mean age of 43.6 years. Ventricular and supraventricular arrhythmias were present in 30 and 8 patients respectively. Amiodarone was given as 400-1200 mg/day for 1-2 weeks as loading dose and then it was maintained as 100-600 mg/day. The mean duration of therapy was 12.4 months. Adverse effects were noted in 21 (55.3%) cases. The commonest adverse effects observed were asymptomatic corneal microdeposits followed by gastrointestinal, cardiac, neurological and cutaneous disturbances. The drug was withdrawn in 2 (5.3%) patients because of nausea and vomiting. One patient died of pulmonary infiltrations. It is concluded that adverse effects are common with amiodarone but are tolerated well, making this drug an excellent choice for treatment of cardiac arrhythmias.

Evaluation of amiodarone free radical toxicity in rat hepatocytes.

The possible roles of free radicals and lipid peroxidation in the mechanism of toxicity of amiodarone (AD) [2-butyl-3-(3',5'-diiodo-4' alpha-diethylaminoethoxybenzoyl)benzofuran] and its principle metabolite, desethylamiodarone (DE), were examined in primary cultured Sprague-Dawley male rat hepatocytes. AD (20 and 40 micrograms/ml) and DE (10 and 25 micrograms/ml) killed hepatocytes in concentration- and time-dependent fashions. Several antioxidants [Cu,Zn-superoxide dismutase (200 U/ml), catalase (200 U/ml), N,N'-diphenylphenylenediamine (DPPD; 25 microM), butylated hydroxytoluene (0.1 mM), and N-acetylcysteine (5 mM)] were incapable of preventing AD and DE hepatocyte toxicity. Only vitamin E (VE, d,l-alpha-tocopherol acetate; 20-200 microM) prevented AD and DE toxicity. No correlation between the onset of hepatocyte death by AD and DE and hepatocyte lipid peroxidation was seen. Both drugs inhibited NADPH-dependent rat liver microsomal superoxide production. These results, excluding the preventive effects of VE, do not support a free radical/lipid peroxidation mechanism of hepatocyte toxicity by AD and DE. VE may have prevented hepatocyte toxicity through non-antioxidant effects.

The effects of antihypertensive agents on the quality of life in Indian hypertensives.

Effects of commonly used antihypertensive agents like nifedipine, atenolol, propranolol and captopril on quality of life was studied. Fourty-four patients with essential hypertension entered and 26 completed the full protocol of the study. Each drug was given separately in a random fashion in fixed dosage for 4 weeks with a washout period of 2 weeks in between the drugs. Assessment of quality of life was done under following measures: satisfaction with life and sense of well being, physical state, emotional state, intellectual function, social life and sexual life; each assessed on a prestandardized 5 point scale. All the 4 drugs resulted in significant and similar blood pressure control but the incidence of adverse effects was maximum with nifedipine (40.9%), followed by atenolol (18.4%), propranolol (14.3%) and captopril (3.6%). There was significant improvement in various aspects of quality of life with all the 4 drugs. Captopril and propranolol scored significantly better than atenolol and nifedipine on measures like sense of well being and satisfaction with life, physical state, intellectual function and emotional state. Improvement in sexual life was maximum with captopril, moderate with propranolol and nifedipine and least with atenolol. In conclusion, captopril closely followed by propranolol was the most acceptable drug with fewer adverse effects and improved sexual as well as other aspects of quality of life compared to nifedipine and atenolol.

Physical microenvironment of platelet membrane in acute myocardial infarction.

Patients with acute myocardial infarction have more reactive platelets than those from normal population. These pathological platelets had more viscous plasma membrane, as inferred from fluorescence polarisation studies, and a lower fusion activation energy (delta E) of the membrane, reflecting a higher degree of order within lipid-lipid interactions.

Cytotoxic interactions of cardioactive cationic amphiphilic compounds in primary rat hepatocytes in culture.

Hepatocytes from adult male Sprague-Dawley rats were isolated by the two-stage collagenase perfusion technique; 1 x 10(6) cells/plate were incubated in primary cell culture in Leibovitz's L-15 medium for 24 hr with or without various concentrations (12.5 to 400 mumol/L) of cardioactive cationic amphiphilic compounds such as propranolol, verapamil, sotalol, atenolol and procainamide. Propranolol and verapamil caused a significant release of lactate dehydrogenase (used as cytotoxic index in this study) in the culture media in a concentration-dependent manner, with LC50 values of 220 +/- 10 and 224 +/- 7 mumol/L, respectively. Atenolol, sotalol and procainamide had no effect on lactate dehydrogenase release. Electron microscopy of the hepatocytes showed that subtoxic concentrations of propranolol (12.5 to 125 mumol/L) and verapamil (12.5 to 100 mumol/L) induced multilamellar inclusion bodies after 24 hr of incubation. The two higher concentrations of propranolol (50 and 125 mumol/L) and 100 mumol/L of verapamil produced a significant decrease in the percentage of volume density of the mitochondria as quantitated by morphometrical analysis. An unusual feature of the electron microscopical changes with propranolol and verapamil was the presence of mitochondria within the multilamellar inclusion bodies. When these two drugs were used together or with subtoxic concentrations of amiodarone or desethylamiodarone, release of lactate dehydrogenase was significantly enhanced. No correlation was evident between the cytotoxic response and the volume density of cellular inclusions in hepatocytes treated with different concentrations of propranolol, verapamil, amiodarone or desethylamiodarone. Sotalol, atenolol and procainamide in concentrations up to 400 mumol/L did not produce any ultrastructural changes in hepatocytes after 24 hr of incubation. These results show that (a) cationic amphiphilic structure per se is not the only requirement for induction of multilamellar inclusions, (b) propranolol and verapamil can induce the formation of multilamellar inclusion bodies and cause a concentration-dependent release of lactate dehydrogenase from hepatocytes and (c) combination of different cationic amphiphiles in subtoxic concentrations can enhance cytotoxicity and increase the volume density of multilamellar inclusions.

Effect of aluminum hydroxide gel on quinidine gluconate absorption.

The effect of aluminum hydroxide gel on quinidine gluconate bioavailability was studied in eight nonsmoking healthy male volunteers. Subjects were randomized to receive quinidine gluconate 648 mg with and without 30 mL of aluminum hydroxide gel. The mean area under the concentration-time curve (AUC) (23.11 +/- 5.21 mg.h/L), time to reach maximum concentration (tmax) (3.13 +/- 0.64 h), maximum serum concentration (1.44 +/- 0.41 mg/L), and elimination rate constant (0.069 +/- 0.010-h) observed during the control phase of the trial did not differ significantly (p greater than 0.05) from values obtained during the coadministration of aluminum hydroxide with quinidine gluconate (23.91 +/- 4.48 mg.h/L, 4.13 +/- 2.12 h, 1.53 +/- 0.34 mg/L, and 0.077 +/- 0.013-h, respectively). There was considerable individual variation in AUC with one subject demonstrating an increase of 35 percent and one subject demonstrating a decrease of 18 percent. There was a trend toward aluminum hydroxide delaying tmax with only one subject experiencing an earlier tmax with the coadministration of aluminum hydroxide. The results of this single-dose trial suggest that, although statistically the concurrent administration of aluminum hydroxide gel with quinidine gluconate does not significantly alter the extent of quinidine absorption, clinically significant individual variations may occasionally occur.

Amiodarone- and desethylamiodarone-induced myelinoid inclusion bodies and toxicity in cultured rat hepatocytes.

Hepatocytes isolated from Sprague-Dawley rats were incubated with various concentrations of either amiodarone or desethylamiodarone for 0 to 96 hr. Both drugs produced a concentration-dependent increase of lactate dehydrogenase release in the culture medium, which correlated well with cell death as measured by trypan blue exclusion test. Desethylamiodarone was more toxic than amiodarone in the cultured hepatocytes. Incubation with subtoxic concentrations of either amiodarone (7.6 microM) or desethylamiodarone (8 microM) for 24 hr resulted in the development of myelinoid inclusion bodies in the hepatocytes without any excess release of lactate dehydrogenase. In experimental protocols where the hepatocytes were exposed to either amiodarone or desethylamiodarone for up to 96 hr, there was an increase in lactate dehydrogenase and the percent volume-density of multilamellar inclusion bodies with cumulative drug exposure with time. A linear correlation between hepatocyte drug concentration and multilamellar inclusion bodies was found for both amiodarone and desethylamiodarone. These results demonstrate that both amiodarone and its major metabolite, desethylamiodarone, induce lysosomal inclusions, which, under appropriate conditions, can be dissociated from cell death. Withdrawal of the drug after 24 hr exposure did not result in disappearance of the inclusion bodies from the hepatocytes for up to 96 hr of tissue culture. The concentrations at which amiodarone- or desethylamiodarone-induced electron microscopic changes and hepatotoxicity were only two to five times as high as the usual serum drug levels in patients given antiarrhythmic therapy with amiodarone.

Subcellular changes of rat myocardium after treatment with amiodarone or desethylamiodarone, studied with electron microscopy.

Amiodarone, an antiarrhythmic agent, has proven to be unique in its capability to control arrhythmias unresponsive to conventional drugs. However, its association with many undesirable side effects after chronic usage has become just as clear. Chronic clinical toxicity with amiodarone is associated with intracellular lamellar or myelinoid inclusion bodies (onionoid bodies or corpora cepiformia) in various organs (i.e. skin, cornea, lung, liver, and lymph nodes). Previous study has demonstrated formation of these inclusion bodies in canine myocardium following multiple doses of amiodarone. The present study was designed to develop a more convenient animal model, and to measure the concentration of amiodarone, as well as desethylamiodarone (its major metabolite) in this rodent model. The direct role of desethylamiodarone in formation of lamellar inclusion bodies in rat myocardium was also investigated. Amiodarone (50 mg/kg) or desethylamiodarone (25 mg/kg) was injected intraperitoneally daily for a period of 14 days. Myocardial sections revealed the presence of lamellar inclusion bodies, round or oval in appearance, in the form of laminated or concentrically arranged membranes after either amiodarone or desethylamiodarone treatment. This is the first reference to the induction of these myelinoid inclusion bodies with desethylamiodarone. Myocardial tissue concentrations of amiodarone and desethylamiodarone exceeding plasma concentrations were found in the present study and indicate the capability of these compounds to easily distribute and accumulate in the myocardium.

Inhibition of platelet aggregation by moxalactam and free N-methylthiotetrazole.

The effects of moxalactam and free N-methylthiotetrazole (N-MTT) in vitro on platelet aggregation induced by adenosine diphosphate (ADP), arachidonic acid, collagen, epinephrine, or ristocetin were determined. Moxalactam at concentrations of 1.9 mM and 5.7 mM inhibited platelet aggregation induced by ADP, arachidonic acid, epinephrine, and ristocetin. Although the aggregatory activity of collagen was not inhibited with 1.9 mM moxalactam, an increase in the concentration of moxalactam to 5.7 mM significantly inhibited collagen-induced platelet aggregation. Inhibition of platelet aggregation by free N-MTT was also concentration dependent. The lowest concentration of N-MTT used in this study, 5.7 mM, inhibited platelet aggregation induced by both arachidonic acid and ristocetin. At a concentration of 28 mM, N-MTT inhibited aggregation induced by ADP, collagen, epinephrine, and ristocetin, but not by arachidonic acid. At 57 mM N-MTT, almost complete inhibition of platelet aggregation occurred for all five agonists tested.

Cardiac changes in acute viral hepatitis in Varanasi (India): case reports.

Three cases of acute viral hepatitis are reported with various cardiac changes such as transient left ventricular hypertrophy, myocarditis and progressive cardiomegaly (cardiomyopathy). Extra-hepatic manifestations of acute viral hepatitis are rare but have been well documented. The aims of the present study are to highlight the cardiac involvement in acute viral hepatitis and to report the clinical implications of cardiac changes in acute viral hepatitis.

Basic and clinical pharmacology of amiodarone: relationship of antiarrhythmic effects, dose and drug concentrations to intracellular inclusion bodies.

Amiodarone is a unique class III antiarrhythmic drug with several unusual pharmacokinetic, pharmacodynamic, and toxicological actions which are quite distinct from those of the standard antiarrhythmic drugs. Extensive animal and clinical studies have demonstrated that amiodarone and its major metabolite, desethylamiodarone, both produce a marked increase in the duration of transmembrane action potential, which may be related to their antiarrhythmic as well as clinical electrophysiological activity. Unlike most other cardiovascular drugs, it has been recognized for more than 20 years that optimal antiarrhythmic effects may take several days to weeks after onset of oral therapy. Amiodarone is highly lipid soluble and exhibits at least three separate compartments of drug distribution, with a long elimination half-life of 14-120 days after chronic therapy. The pharmacokinetic profile of desethylamiodarone is qualitatively similar to that of amiodarone, but its elimination half-life is even longer and its tissue distribution may be slightly different. Although there may not be any correlation between serum drug levels and clinical toxicity of amiodarone during long-term therapy, recent animal as well as clinical data suggest that multilamellar intracellular inclusions can be dissociated from cell death or clinical toxicity. Thus, it is possible that amiodarone toxicity can be minimized with low doses or low serum drug concentrations. The metabolite(s) of amiodarone may play a major role in its pharmacological and toxicological actions.

Amiodarone and desethylamiodarone toxicity in isolated hepatocytes in culture.

Amiodarone, a class III antiarrhythmic drug, has been found to be effective in the management of patients with life-threatening ventricular arrhythmias. Recent reports describe the presence of myelinoid inclusion bodies following amiodarone therapy in liver, myocardium, white blood cells, lung, cornea, skin, and lymph nodes; their relationship to toxicity is unclear. The exact role of desethylamiodarone, the major metabolite, of amiodarone in systemic toxicity of the parent drug is not known. Concentration-response relationships for amiodarone and desethylamiodarone were investigated by adding 1-50 micrograms/ml of the compounds of dimethyl sulfoxide (controls) to hepatocytes isolated from Sprague-Dawley rats and cultured in Leibovitz L-15 medium. Using lactate dehydrogenase release into the medium to quantitate cell death, both drugs were found to cause cell death in a concentration-dependent manner within 24 hr of incubation; this data showed desethylamiodarone to be significantly more toxic than amiodarone. In experiments with 50-micrograms/ml concentrations of amiodarone or desethylamiodarone, we found desethylamiodarone to produce a significantly greater release of lactate dehydrogenase as compared with amiodarone within 2-4 hr. Electron microscopic studies indicated the presence of myelinoid inclusion bodies at early culture stages followed by progressive swelling of mitochondria and rough endoplasmic reticula, disruption of membranes, aggregation of subcellular structures, and ultimately cell death. Ultrastructural changes occurred sooner in the hepatocytes treated with desethylamiodarone than with amiodarone. These data demonstrate that (i) desethylamiodarone is more toxic than amiodarone; (ii) acute toxicity of desethylamiodarone and amiodarone can be quantitated by lactate dehydrogenase release; (iii) both desethylamiodarone and amiodarone can induce myelinoid inclusion bodies in cultured hepatocytes; and (iv) toxicity is characterized by progressive subcellular changes leading to cell death.