Combined effect of pyrazinamide and ofloxacin within the human macrophage.

SETTING: Recent reports of outbreaks of multidrug resistant tuberculosis have raised questions as to the most appropriate therapeutic response for those exposed to such organisms. A recent Centers for Disease Control National Action Plan suggests the combination of pyrazinamide (PZA) and a quinolone as a potential preventive therapy regimen. OBJECTIVE: Prior studies in the ex-vivo human macrophage model have shown PZA to have only a bacteriostatic effect and, in addition, to diminish the bactericidal effect of rifampin. This study was designed to quantify the intramacrophage antimycobacterial effect of PZA when combined with a quinolone (ofloxacin). DESIGN: Forty micrograms/ml of PZA was combined with varying concentrations of ofloxacin and administered to human macrophages infected with virulent tubercle bacilli; drug sequencing was also studied. RESULTS: A clinically achievable level of PZA enhances the antimycobacterial effect of low, non-bactericidal levels of ofloxacin and does not impede the bactericidal effect of a higher clinically effective level of ofloxacin. Unlike the combination of PZA and rifampin, these interactive effects are not affected by the sequence of drug administration. CONCLUSIONS: Findings support the use of these agents as a potentially effective preventive therapy combination for individuals exposed to multidrug resistant tuberculous organisms.

Transferrin, iron, and serum lipids enhance or inhibit Mycobacterium avium replication in human macrophages.

Mycobacterium avium grows exponentially over 7 days in human macrophages when they are cultured in serumless medium. Normal serum inhibits this replication. When serum lipids were extracted using chloroform, the inhibitor was present in the lipid-free component. The lipid extract significantly enhanced M. avium replication. Iron (Fe2+) added at 8-80 micrograms/mL to infected macrophage cultures in serum resulted in enhanced mycobacterial replication. Serum-induced inhibition of bacterial growth in serumless medium could be duplicated with apotransferrin at 50-500 micrograms/mL. At 1000 micrograms/mL, apotransferrin no longer inhibited bacterial growth. Holotransferrin was not inhibitory, and at 500 micrograms/mL, it enhanced M. avium growth. Depletion of the transferrin in serum by affinity chromatography using goat anti-transferrin on protein G-Sepharose removed inhibitory activity. These results indicate that transferrin levels, transferrin saturation, iron levels, and serum lipids can profoundly alter the replication of M. avium in association with macrophages.

The combined effect of rifampin and pyrazinamide within the human macrophage.

A recent study in the murine model suggested that a combination of rifampin and pyrazinamide used as preventive therapy might shorten the duration of treatment time. Clinical trials using this combination have been initiated, but significant results will not be available for many years. The ex vivo human macrophage model has been instructive in expanding our knowledge of the activity of chemotherapeutic agents against intracellular virulent tubercle bacilli. Prior studies have shown rifampin to have a bactericidal effect in this model while even at clinically unachievable levels, pyrazinamide had only a bacteriostatic impact. This study finds an enhanced bacteriostatic effect when low, nonbactericidal levels of rifampin are combined with clinically achievable levels of pyrazinamide but not with higher bactericidal levels of rifampin. Adding pyrazinamide 2 days after the introduction of rifampin clearly enhanced the combined killing effect. However, reversing the order and adding rifampin 2 days after the introduction of pyrazinamide produced a result weaker than introducing the agents simultaneously. Our findings do not support the use of these agents as a potentially effective preventive therapy combination, but they suggest that the timing of the administration of these chemotherapeutic agents could be an important factor in their effectiveness.

Comparison of the abilities of Mycobacterium avium and Mycobacterium intracellulare to infect and multiply in cultured human macrophages from normal and human immunodeficiency virus-infected subjects.

Patients with AIDS commonly develop disseminated infections with Mycobacterium avium (MA) but not its close relative, M. intracellulare (MI). In non-AIDS patients who have these infections, the two species are about equally distributed. The higher incidence of infection with MA than with MI in AIDS patients might be due to the selective susceptibility of these patients to MA. This possibility was tested by comparing the abilities of MA and MI to infect and replicate in cultured macrophages from normal subjects and from patients with AIDS-related complex or AIDS. The macrophages were cultured in medium supplemented with 1 or 5% normal or patient sera or with 1% defined serum substitute. Replication of MA (serovar 4) or MI (serovars 16 and 17) in the macrophages was measured by CFU counts made from lysed samples of the macrophages taken at 0,4, and 7 days after macrophage infection. MA and MI in infected normal macrophages which were cultured in normal serum replicated in these macrophages at similar rates. MA but not MI multiplied abnormally rapidly in patient macrophages cultured in either normal serum or patient serum. The accelerated growth of MA in patient macrophages was macrophage dependent, because patient sera did not change the rate of MA replication in culture medium lacking macrophages. However, patient sera did increase the permissiveness of normal macrophages to MA but not MI. These results suggest that a selective increased susceptibility to MA compared with a retained normal resistance to MI in human immunodeficiency virus-infected patients as they progress from AIDS-related complex to AIDS accounts for the higher prevalence of MA than MI infection in AIDS patients. The results also indicate that the mechanisms of native resistance in human macrophages to MA and MI are different.

Characterization of inhibition of Mycobacterium avium replication in macrophages by normal human serum.

Serum from some AIDS patients permits the rapid multiplication of Mycobacterium avium in cultured human macrophages. Serum from human immunodeficiency virus-negative individuals inhibits replication. The characteristics of the serum-induced inhibition were examined here. M. avium 7497 serovar 4 grew exponentially in macrophages when they were cultured in serumless medium. Growth was measured by determining the CFU after infected macrophages were lysed at 0 to 7 days after infection. Normal AB serum (5 to 10%) added to infected macrophages resulted in an initial 4-day lag of bacterial growth followed by rapid replication from 4 to 7 days. Serum also inhibited bacterial replication in medium without macrophages. This inhibition was not biphasic but was sustained over 7 days. Macrophage-associated M. avium became less responsive to serum inhibitor within 24 h after infection of macrophages. Within 2 days of culture, M. avium no longer responded to inhibitor. Replication of macrophage-derived M. avium (Vi) was in some instances serum inhibitable and at other times was enhanced by serum, when it was used to infect fresh macrophages. The Vi phenotype remained serum inhibitable without macrophages. Preinfection of macrophages with heat-killed M. avium did not alter serum-induced bacterial inhibition or escape from inhibition.

Chlorpromazine: a drug potentially useful for treating mycobacterial infections.

Chlorpromazine (CPZ) is one of several phenothiazines known to have antimicrobial properties. It can inhibit mycobacteria, and was reported in the early literature to improve tuberculosis clinically. CPZ was tested here for its ability to inhibit the replication of Mycobacterium tuberculosis and Mycobacterium avium in cultured normal human macrophages, as determined by counts of viable bacteria at 0, 4, and 7 days after bacterial infection of the macrophages. CPZ inhibited the intracellular bacteria at a concentration range of 0.23-3.6 micrograms/ml, and was more effective intracellularly than extracellularly. It was further tested for its ability to cooperate with isoniazid, streptomycin, pyrazinamide, rifampin, rifabutin, penicillin and ethambutol (EMB) against intramacrophage M. tuberculosis and M. avium. CPZ enhanced the effectiveness of most of the drugs tested against intracellular mycobacteria. However, the combination of CPZ and EMB did not result in augmented antimycobacterial activity.

Evidence that vesicles containing living, virulent Mycobacterium tuberculosis or Mycobacterium avium in cultured human macrophages are not acidic.

Mycobacterium tuberculosis and Mycobacterium avium multiply in cultured human macrophages (MP) within membrane-enclosed vesicles. These vesicles are generally assumed to be acidic. The evidence most frequently cited for this assumption is that pyrazinamide, which requires an acid pH to be effective, is effective and streptomycin, which loses most of its activity at a low pH, is poorly effective against tubercle bacilli. This assumption was tested by using the two weak bases chloroquine and NH4Cl to raise the pH of acidic vesicles in MP experimentally infected with M. tuberculosis or M. avium. An immunocytochemical locator of acidic regions in the MP was used to monitor the association of intracellular bacilli with acidity. MP were infected with M. tuberculosis or M. avium and incubated with various combinations of the drugs and the weak bases. Replication of the bacteria in the MP was measured by culture counts. Intracellular associations of the mycobacteria with acidity were assessed by electron micrographs and by using the weak base 3-(2,4-dinitroanilino)-3'-amino-N-methyl dipropylamine, which was detected with colloidal gold-labeled antibodies. It was confirmed by immunocytochemistry that both chloroquine and NH4Cl raise the pH of acidic vesicles in the infected MP. However, neither caused any pH-related change in the antimycobacterial activities of pyrazinamide or streptomycin or of the pH-independent drug isoniazid. Immunochemical analyses showed acidity to be associated with killed but not living mycobacteria in the MP. These findings suggest that living M. tuberculosis and M. avium are located in human MP in vesicles which are not acidic.

Inhibition of tubercle bacilli in cultured human macrophages by chloroquine used alone and in combination with streptomycin, isoniazid, pyrazinamide, and two metabolites of vitamin D3.

Intracellular tubercle bacilli (TB) reside in vacuoles in infected human macrophages (MPs). The relative impotency of streptomycin against TB in MPs and the contrary greatly increased potency of pyrazinamide (PZA) have been attributed to the fact that these vacuoles are phagolysosomes and, therefore, acidic. Chloroquine (CQ) is a lysomotropic base which can be used to raise phagolysosomal pH. Consequently, it was tested for its ability to increase the anti-TB effectiveness of streptomycin and decrease that of PZA in cultured human MPs. MPs infected with virulent Erdman strain TB were incubated in medium with various combinations of the drugs. Samples were taken at 0, 4, and 7 days and lysed for CFU counts of viable TB on nutrient agar. As expected, CQ increased the effectiveness of SM, but unexpectedly, it did not decrease that of PZA. CQ alone was found to be able to inhibit intracellular TB. Because of this, it was also tested with isoniazid, 1,25(OH)2-vitamin D3, and 25-OH-vitamin D3. It significantly enhanced the anti-TB protectiveness of both isoniazid and 25-OH-vitamin D3. Some combinations of CQ and the various drugs tested were able to kill intracellular TB. These results suggest that CQ may be useful in the treatment of tuberculosis.

Pyrazinamide and pyrazinoic acid activity against tubercle bacilli in cultured human macrophages and in the BACTEC system.

Pyrazinamide (PZA) has become an essential component of current 6-month regimens for therapy of tuberculosis. Susceptible strains of tubercle bacilli convert PZA to pyrazinoic acid (POA) through pyrazinamidase (PZase), which resistant strains and Mycobacterium bovis bacille Calmette-Guérin lack. PZA susceptibility results obtained in cultured human macrophages were compared with those in the broth BACTEC system with 7H12 medium at pH 6.0 for strains known to be PZase-positive or -negative. Although added POA was unable to inhibit tubercle bacilli in cultured macrophages, it was able to inhibit them at very high concentrations in the BACTEC broth. Intracellularly formed POA would not be able to escape from the macrophage, and therefore would accumulate sufficiently to lower pH to toxic levels for tubercle bacilli. The results suggest that the cultured macrophages contribute actively or passively to the effectiveness of PZA, such as through the proposed mechanism of low pH generated by PZase in the phagolysosomes.

Comparative abilities of various metabolites of vitamin D to protect cultured human macrophages against tubercle bacilli.

Vitamin D metabolites have several biologic functions besides the best-known one of controlling mineral metabolism, one of which may be protection against tuberculosis. The chemical structures of the metabolites govern their functions. The most potent metabolite for regulating calcium metabolism is 1,25(OH)2-vitamin D3 (1,25-D3). This metabolite also is able to protect cultured human monocytes and macrophages (MP) against tubercle bacilli (TB). To determine whether these two functions are connected, 14 other analogs or metabolites of vitamin D were compared with 1,25-D3 for ability to protect cultured MP against TB. Blood-derived MP from 18 different donors were used in 70 experiments. The MP were infected with TB, then incubated for 7 days in medium containing 4 micrograms/ml of metabolite or synthesized analog. Growth of TB in the MP was measured by colony-forming unit counts from samples of lysed MP at 0, 4, and 7 days after infection. The metabolites, none of which inhibited TB in the absence of MP, varied from unprotective to bacteriostatic in the MP. Four of them were nearly as protective as 1,25-D3, and the metabolite 25S, 26(OH)2-vitamin D3 was consistently more protective. An analog synthetically designed for maximum ability to promote cell differentiation was unprotective. There was no correlation between metabolite ability to protect and known ability to stimulate calcium mobilization. These results suggest that antituberculosis protection of human MP by vitamin D metabolites or analogs can be separated from their functions of inducing cell differentiation and controlling mineral metabolism.

Relative permissiveness of macrophages from black and white people for virulent tubercle bacilli.

Epidemiological, clinical, and histopathological evidence suggests that black people are more susceptible to tuberculosis than are white people. The cellular basis of this putative susceptibility was investigated in vitro by comparing responses of blood-derived macrophages from black and white donors to experimental infection with virulent tubercle bacilli. Phagocytes from pairs of black and white donors were infected. The uptake and replication of the tubercle bacilli in these cells were measured by microscopic counts and by CFU counts of bacilli at 0, 4, and 7 days. The effects of donor serum, of 1,25-(OH)2-vitamin D3, and gamma interferon on the infection also were studied. Black-donor phagocytes killed more bacilli during phagocytosis than white-donor phagocytes did. However, the bacilli grew consistently and significantly faster in successfully infected macrophages from black than from white donors, especially in the presence of black-donor serum. 1,25-(OH)2-vitamin D3 gave significantly less protection against tubercle bacilli to macrophages from black donors than to macrophages from white donors. The permissiveness of the macrophages from the two races was affected equally by gamma interferon. These results demonstrate some inherent and environmental liabilities in the monocytic phagocytes and serum of black people compared with white people, which may contribute to their greater susceptibility to tuberculosis.

[Determination of the sensitivity of tuberculosis bacteria to pyrazinamide using human macrophage culture]. / Bestimmung der Empfindlichkeit von Tuberkulosebakterien gegenüber Pyrazinamid mit Hilfe humaner Makrophagenkultur.

Increasing interest is being shown in the antituberculous drug pyrazinamide. An in-vitro model using cultures of human blood macrophages was tested with 8 different Mycobacterium tuberculosis trains. A good correlation was found between the susceptibility of the strains to pyrazinamide and the Kinetics in the macrophage culture.

Enhancement of growth of Mycobacterium lepraemurium in macrophages by gamma interferon.

Gamma interferon, an immune lymphokine that protects mouse macrophages against infection by several parasites, was ineffective against Mycobacterium lepraemurium. On the contrary, it significantly stimulated multiplication of M. lepraemurium in the macrophages. Simultaneous treatment of macrophages with gamma interferon and interleukin-4 or interleukin-2 or a combination of all three did not enhance the macrophage resistance to infection with M. lepraemurium, but instead stimulated growth of M. lepraemurium.

Defects in sera from acquired immunodeficiency syndrome (AIDS) patients and from non-AIDS patients with Mycobacterium avium infection which decrease macrophage resistance to M. avium.

Some characteristics of the sera and macrophages (MP) of human immunodeficiency virus (HIV)-infected patients which might contribute to their unusual susceptibility to Mycobacterium avium infection were studied. Cultures of patient peripheral blood MP in medium supplemented with their sera or normal subject sera were infected with M. avium and compared with similar cultures of normal MP. Intracellular mycobacterial replication was measured in the infected MP by CFU counts of the bacteria made from lysed samples of the MP at 0, 4, and 7 days after MP infection. Sera from patients with chronic granulomatous infection with M. avium, but no HIV infection, also were studied. The sera from all of the patients with chronic granulomatous infection and from several HIV-infected patients were deficient or lacking in an inhibitor that in normal serum acts within normal MP to suppress intracellular growth of M. avium. Most of the HIV-infected patients also had MP that were abnormally permissive for M. avium because they responded poorly to the serum inhibitor. Elucidation of these associated defects in native defenses against M. avium may result in better prevention and therapy of M. avium infections.

Inhibition by normal human serum of Mycobacterium avium multiplication in cultured human macrophages.

Normal human serum used as a protein supplement in RPMI 1640 medium inhibited growth in blood-derived human macrophages (MP) of virulent Mycobacterium avium serovars 4 and 8, derived from patients with acquired immunodeficiency syndrome, but not virulent Mycobacterium tuberculosis. A defined serum substitute (SS) promoted the intramacrophage growth of M. avium but not of M. tuberculosis. The effects of serum or SS were measured by counting viable bacteria in lysates of the MP at 0, 4, and 7 days after their infection by the bacteria. Neither serum nor SS inhibited or enhanced M. avium growth in the absence of MP. The results suggest that a nutrient essential for intracellular replication of M. avium is made by MP from a pronutrient present in both SS and serum and that something in serum inhibits MP conversion of the pronutrient to nutrient. This inhibition may be an important mechanism of native resistance against M. avium in normal people.

Inhibition by retinoic acid of multiplication of virulent tubercle bacilli in cultured human macrophages.

The immunologically active vitamin retinoic acid (RA) was tested for the ability to increase the resistance of cultured human macrophages (MP) to experimental infection with virulent Mycobacterium tuberculosis Erdman (tubercle bacilli [TB]). It was added to MP in various concentrations and addition regimens. Protection against TB was measured by counting live TB (CFU) in lysates of samples of MP taken at 0, 4, and 7 days after MP infection. RA was protective when added after infection at the pharmacologic concentration of 10(-5) M and when added before infection at the physiologic concentration of 10(-7) M. The protection lengthened intracellular generation times for TB, occasionally caused bacteriostasis, and regularly kept CFU counts at 7 days (end of the period of infection) 1 to 2 log10 CFU below control values. Significant protection was seen in a series of 16 experiments with MP from seven different donors, but the degree of protection varied considerably. The protection depended partly on and was inversely proportional to concentrations of a serum substitute or autologous serum used as a supplement in the RPMI 1640 MP culture medium. It was strongest at concentrations of serum below 1%. RA at concentrations used in the MP cultures did not inhibit TB in the absence of MP. These results suggest that RA (vitamin A), like vitamin D, may have some immunoprotective role against human tuberculosis, as historically intimated by the regular use of vitamin A- and D-rich cod liver oil for the treatment of tuberculosis before the introduction of modern chemotherapy.

1,25(OH)2-vitamin D3 synergizes with pyrazinamide to kill tubercle bacilli in cultured human macrophages.

Pyrazinamide (PZA) is believed to be mycobactericidal in vivo. Because it is ineffective at neutral pH in vitro, it is thought to owe its in vivo activity at least partly to acting upon tubercle bacilli (TB) in the helpfully low pH of macrophage (MP) phagolysosomes. However, when it was tested in TB-infected cultured human MP, it was not bactericidal and was able only to slow intra-MP bacillary growth. Recent evidence has suggested that human MP need hormonal support from certain vitamin D metabolites to resist TB. This support was not provided in the culture medium of the earlier experiments in which the PZA was relatively ineffective. Here, PZA has been retested in MP cultured in medium supplemented with the hormonally active metabolite of vitamin D, 1,25(OH)2-vitamin D3 (1,25D3). The MP were infected with virulent TB and incubated in various concentrations of PZA. 1,25D3 was added to postinfection medium at 4 micrograms/ml. Inhibition or killing of intracellular TB was quantitated by counts of culturable TB from samples of lysed MP taken at zero, 4, and 7 days after MP infection. Previous evidence for the protectiveness of 1,25D3 alone for human MP against TB was confirmed. The weak inhibition of TB in MP by PZA alone also was confirmed. The two used together synergized to decrease concentrations of PZA which were inhibitory and to switch the action of PZA from weakly inhibitory to bacteriostatic or mildly bactericidal. 1,25D3 had no direct anti-TB effect, and it did not synergize with PZA in the absence of MP, as determined with acidified bacteriologic culture medium in the BACTEC radiometric system.(ABSTRACT TRUNCATED AT 250 WORDS)