Treatment of hospitalized patients with complicated skin and skin structure infections: double-blind, randomized, multicenter study of piperacillin-tazobactam versus ticarcillin-clavulanate. The Piperacillin/Tazobactam Skin and Skin Structure Study Group.

We compared the efficacy and safety of two beta-lactam-beta-lactamase inhibitor combinations, namely, piperacillin-tazobactam and ticarcillin-clavulanate, in the treatment of complicated bacterial infections of skin that required hospitalization. The study was a randomized, double-blind, comparative trial involving 20 centers. The infections were classified as (i) cellulitis with drainage, (ii) cutaneous abscess, (iii) diabetic or ischemic foot infection, and (iv) infected wounds and ulcers with drainage. The clinical response rates were comparable for the two treatment regimens (61% of the patients were cured with piperacillin-tazobactam and ticarcillin-clavulanate and improvement was seen in 15 and 16% of patients treated with piperacillin-tazobactam and ticarcillin-clavulanate, respectively). Both regimens were found to be safe and well tolerated. These data support the use of piperacillin-tazobactam for initial empiric therapy of hospitalized patients with complicated skin and skin structure infections.

An unusual presentation of salmonellal aortitis.

Our patient represents what we believe to be the first documented case of Salmonella choleraesuis aortitis presenting as a salmonellal empyema in an elderly diabetic man. Although S choleraesuis often causes septicemia, its absence should not lead one to forget the pathogenic nature of and high mortality associated with this organism. Aggressive efforts must be made to search for endovascular infection, because cures can be achieved only with surgical intervention and prolonged antibiotic therapy.

CNS infection and bacteremia due to clostridium septicum.

Central nervous system infection with Clostridium septicum is rare. We report two fulminant cases of such infection with accompanying bacteremia. The presence of extensive brain necrosis was striking in our two cases. The association of C septicum bacteremia with hematologic disease, and with solid tumors, was present in our cases. We conclude that C septicum should be considered as a potential cause of life-threatening bacteremia and meningitis in the compromised host.

Clinical implications of large vegetations in infectious endocarditis.

Thirty-four patients with clinical infectious endocarditis were examined by M-mode and two-dimensional (2D) echocardiography. Vegetations were identified in 16 patients (47%) by M-mode and in 27 patients (87%) by 2D echocardiography. Vegetations identified by 2D echocardiography were categorized as small (less than 5 mm), medium (5 to 9 mm), or large (greater than or equal to 10 mm). Large vegetations were caused by a variety of organisms, had a higher incidence of surgery (44% v 0%), and had no increased incidence of stroke or death. The larger the vegetation, the more detectable it was by M-mode. Aortic valve vegetations were associated with a higher incidence of congestive heart failure (CHF) (67% v 14%) and stroke (44% v 9%). Four patients with large aortic valve vegetations had the highest complication rate; CHF developed in all four, two had valve replacement, one had a stroke, and two died.

Effects of dietary ascorbic acid and vitamin E deficiency on rat adrenal cholesterol ester metabolism and corticosteroidgoenesis.

The effect of dietary ascorbic acid (AA) and deficiency of vitamin E, alone and in combination, upon adrenal steroidogenesis in rats have been tested in vivo. High concentrations of AA blocked the normal stress-induced increase in plasma and adrenal corticosteroid concentration. Adrenal cholesterol ester hydrolase activity was also markedly inhibited by the high AA diet, while acylcoenzyme A:cholesterol acyltransferase was significantly increased. Vitamin E deficiency caused generally opposite effect, while simultaneous excess AA and vitamin E deficiency caused these parameters to return toward control values. Thus the role of AA in blocking adrenal steroidogenic response to stress is confirmed. It's mode of action may be at least partly through control of cholesterol availability for steroidogenesis.

Adrenocorticotropin-induced unresponsiveness in cultured adrenal tumor cells.

Our results demonstrate that adrenocorticotropin (ACTH)-induced refractoriness occurs in cultured adrenal tumor cells. Cells became 85% refractory to ACTH-induced cyclic AMP formation in 20 min and the effect persisted if the hormone remained in the incubation medium. Refractory cells gradually regained hormone-specific responsiveness within 24 h if cultures were incubated in fresh media containing serum. The observed effect is hormone specific since cyclic AMP could not induce unresponsiveness to ACTH. The addition of ACTH plus inhibitors of protein synthesis partially reversed hormone-specific refractoriness. However, preincubation with cycloheximide or diphtheria toxin led to superinduction of ACTH-induced cyclic AMP formation. These experiments suggest that unresponsiveness, following hormonal activation of adrenal cells, may be related to a decrease in hormone-specific binding sites or to synthesis of an adenylate cyclase inhibitor.

Factors influencing heat-labile Escherichia coli enterotoxin activity.

In this study, conditions for production, detection, and storage of heat-labile Escherichia coli enterotoxin (LT) in culture filtrates from E. coli H-10407 were defined by using the adrenal tumor cell assay system. An enriched medium containing 0.6% yeast extract, 2% Casamino Acids, and 0.25% glucose buffered at pH 8.5 produced the highest LT activity of the various test media. In E. coli strain H-10407, LT activity was markedly decreased if the initial pH of the culture media was reduced to pH 7.5 or less. In contrast to E. coli P-263, if strain H-10407 was grown in the presence of mitomycin C there was no increase in LT production. Crude-culture filtrates containing LT can be stored at 4 degrees C for several days without an appreciable loss of activity; however, for long-term storage lyophilization or freezing at -70 degrees C is recommended.

Toxigenic Escherichia coli and childhood diarrhea.

Stool specimens were examined from 40 children with diarrhea who were under three years of age to determine the incidence of enterotoxigenic Escherichia coli in endemic diarrhea. Heat-labile E. coli enterotoxin was assayed in the very sensitive and reproducible cultured adrenal tumor cell system. Toxigenic E. coli were isolated from only one stool specimen and in this case infection with Shigella dysenteriae was also present. None of the eight classic enteropathogenic E. coli isolates were positive in the adrenal assay. This study suggests that heat-labile enterotoxin-producing E. coli are not an important cause of endemic childhood diarrhea in Southern California.

Mode of action of Vibrio cholerae enterotoxin in cultured adrenal tumor cells.

The effects of Vibrio cholerae enterotoxin on steroidogenesis and on formation of adenosine 3':5'-cyclic phosphate (cyclic AMP) in two adrenal tumor cell lines were compared. Steroidogenesis was half-maximal at concentrations of 1 ng of cholera toxin/ml in the mutant OS-3 cells and 3 ng of cholera toxin/ml in the parent Y-1 cells. At the end of an 8-hr incubation, toxin-induced formation of cyclic AMP in the mutant cell line was reduced by 90%. A molar ratio of GM1 ganglioside (galactosyl-N-acetylgalactosaminyl [sialosyl] lactosyl ceramide; GGnSLC) to cholera toxin of 3:1 caused half-maximal inhibition of steroidogenesis in both cell lines. When equine antiserum to choleragenoid was added to adrenal cells 15 min after cholera toxin, there was marked inhibition of cyclic AMP formation and of steroidogenesis. Pretreatment of Y-1 cells with adrenocorticotropin rendered them unresponsive to hormonal induction of cyclic AMP formation, but these cells had an unimpaired response to cholera toxin. These studies, utilizing two adrenal cell lines, suggest important differences between the mode of action of cholera toxin and that of adrenocorticotropin in cultured adrenal tumor cells.

Interaction of cholera enterotoxin with cultured adrenal tumor cells.

In the adrenal tumor cell system ganglioside Gm1 inhibited cholera enterotoxin (CT)-induced steroidogenesis if it was preincubated with the toxin or added to adrenal cells 10 min before CT. In the preincubation studies a molar ratio of Gm1 to toxin of 3:1 was necessary for half-maximal inhibition of steroidogenesis. On the other hand, horse serum anticholeragenoid neutralized the steroidogenic response to cell-bound CT by 50% if it was added to adrenal monolayer cultures 15 min after the toxin. Specific antiserum was able to neutralized 20% of the toxin-induced activity even if it was added to adrenal cultures 2 h after CT. Phase contrast microscopy demonstrated that partial neutralization of the biochemical effect of CT by horse serum anticholeragenoid was accompanied by partial prevention of toxin-induced rounding of adrenal cells. Further studies showed that pretreatment of cultured adrenal cells with a maximal dose of CT increased cyclic adenosine 3'-5'-monophosphate formation in response to a maximal stimulating dose of adrenocorticotropin. This result suggested potentiation of hormonal activation of adenylate cyclase in intact adrenal tumor cells in response to CT.

Escherichia coli enterotoxin-induced steroidogenesis in cultured adrenal tumor cells.

A heat-labile, Pronase-sensitive factor has been partially purified from cell-free culture filtrates of enterotoxigenic Escherichia coli. The partially purified factor contains both protein and carbohydrate moieties and appears to be E. coli enterotoxin (ECT). ECT binds to cultured adrenal tumor cells rapidly and irreversibly leads to adenosine 3', 5'-cyclic monophosphate formation and steroidogenesis after a 60-min lag phase. Further studies indicate that it interacts with the cholera toxin receptor site on adrenal cells rather than the adrenocorticotropin receptor to activate adenyl cyclase. Mixed gangliosides block stimulation of steroidogenesis in response to both E. coli and cholera enterotoxin. In contrast to adrenocorticotropin, ECT has no additive effect on cholera toxin-induced steroidogenesis. The protein moiety of ECT is similar to cholera enterotoxin because horse serum anticholeragenoid prevented stimulation of steroidogenesis by either enterotoxin. Cultured adrenal cells provide a quantitative assay system that has facilitated the purification and characterization of E. coli enterotoxin.